Maybe It's Time ft. Corey Taylor, Joe Elliott, Brantley Gilbert, Ivan Moody, Slash
"Every 15 minutes a baby is born suffering from opioid withdrawal."
"The opioid epidemic is deadlier than the AIDS epidemic at its peak."
"There are currently 22 million Americans in recovery from substance use disorders."
"There is hope, and a better life, in recovery."
Overdose Awareness Day
- August 31
Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic United States, June 2430, 2020
Source: Drug Overdose Deaths in the United States: 1999-2018
Source: Health, United States, 2018, table 8 pdf icon[ PDF 9.8 MB]
More data: reports and tables
More data: query tools
help: Drug overdoses are soaring during the
Anahi Ortiz, a medical examiner in Columbus, Ohio, and her staff recently moved into a facility three times the size of their old office. Theyre already out of space.
Anahi Ortiz, a medical examiner in Columbus, Ohio, and her staff recently moved into a facility three times the size of their old office. Theyre already out of space. (Ty Wright/For The Washington Post)
The bodies have been arriving at Anahi Ortizs office in frantic spurts as many as nine overdose deaths in 36 hours. Weve literally run out of wheeled carts to put them on, said Ortiz, a coroner in Columbus, Ohio.
In Roanoke County, Va., police have responded to twice as many fatal overdoses in recent months as in all of last year.
In Kentucky, which just celebrated its first decline in overdose deaths after five years of crisis, many towns are experiencing an abrupt reversal in the numbers.
Nationwide, federal and local officials are reporting alarming spikes in drug overdoses a hidden epidemic within the coronavirus pandemic. Emerging evidence suggests that the continued isolation, economic devastation and disruptions to the drug trade in recent months are fueling the surge.
Because of how slowly the government collects data, it could be five to six months before definitive numbers exist on the change in overdoses during the pandemic. But data obtained by The Washington Post from a real-time tracker of drug-related emergency calls and interviews with coroners suggest that overdoses have not just increased since the pandemic began but are accelerating as it persists.
Suspected overdoses nationally not all of them fatal jumped 18 percent in March compared with last year, 29 percent in April and 42 percent in May, according to the Overdose Detection Mapping Application Program, a federal initiative that collects data from ambulance teams, hospitals and police. In some jurisdictions, such as Milwaukee County, dispatch calls for overdoses have increased more than 50 percent.
When the pandemic hit, some authorities hoped it might lead to a decrease in overdoses by disrupting drug traffic as borders closed and cities shut down. The opposite seems to be happening.
As traditional supply lines are disrupted, people who use drugs appear to be seeking out new suppliers and substances they are less familiar with, increasing the risk of overdose and death. Synthetic drugs and less common substances are increasingly showing up in autopsies and toxicology reports, medical examiners say.
Social distancing has also sequestered people, leaving them to take drugs alone and making it less likely that someone else will be there to call 911 or to administer the lifesaving overdose antidote naloxone, also known as Narcan.
Making matters worse, many treatment centers, drug courts and recovery programs have been forced to close or significantly scale back during shutdowns. With plunging revenue for services and little financial relief from the government, some now teeter on the brink of financial collapse.
Even before the pandemic, experts note, the nations infrastructure for helping people with substance use disorders was underfunded and inadequate. Without government intervention, local officials and drug policy experts warn, overdoses and deaths will continue to climb during the pandemic and the existing system will be inundated.
Whats needed, advocates say, is emergency funding to keep afloat treatment programs, recovery centers and needle-exchange programs. Medical associations have also urged federal officials to relax restrictive barriers to opioid treatments such as buprenorphine and called for wider distribution of naloxone.
Have you had trouble accessing mental health or social services because of the coronavirus pandemic? We want to hear from you
President Trump and conservatives have repeatedly cited the possible rise of overdoses and suicides when calling for states and businesses to hurry their economic reopening. Yet, of the nearly $2.5 trillion approved for emergency relief, Congress and the Trump administration have designated only $425 million barely more than a hundredth of 1 percent for mental health and substance use treatment.
If it werent for covid, these opioid deaths are all wed be talking about right now, said Natalia Derevyanny, spokeswoman for the medical examiners office in Cook County, Ill., which includes Chicago.
Last year, the Cook County medical examiner recorded 473 overdose deaths from January to June. This year, the total through May reached 656, with more than 400 additional suspected overdoses pending investigation and toxicology reports. The countys forensic staff already inundated by the flood of coronavirus deaths has added shifts and longer hours to deal with the incoming corpses from both crises.
One epidemic began, Derevyanny said, but the other one never stopped.
The lonely silence
Addiction is a disease of isolation.
Its when you feel alone, stigmatized and hopeless that you are most vulnerable and at risk, said Robert Ashford, who runs a recovery center in Philadelphia and has been in recovery for seven years. So much of addiction has nothing to do with the substance itself. It has to do with pain or distress or needs that arent being met.
As the pandemic has pushed massive doses of fear, uncertainty, anxiety and depression into peoples lives, it has cut off the human connections that help ease those burdens.
Steven Manzo, 33, lost his job at an Irish pub in Mount Clemens, Mich., after it was forced to close just before St. Patricks Day. From the apartment he rented above the bar, he described the disquiet welling up inside of him, with nothing to do but stand on the balcony and watch the empty street below.
Everything looks normal, but it doesnt feel normal. I live downtown with bars and restaurants and nobody is here, he said on March 20. We have no idea how long it will be.
Manzo spent much of his early 20s struggling with a heroin addiction. It took huge effort and the help of family members, co-workers and two treatment programs for him to turn his life around. He secured a job as a cook and bartender and discovered a gift for making.customers laugh.
The pandemic took it all away, he said
Two weeks after Manzo talked to a Washington Post reporter about his sudden unemployment, he was found dead in his apartment from an apparent overdose.
His mother, JoAnne Manzo, fought back tears as she described the rainy night she drove to her sons apartment to recover his body.
Talking to his friends, she tried to piece together his last moments. He and a younger friend also in recovery had been drinking that weekend and got bored. They bought $40 worth of cocaine and heroin, telling themselves they would use just that one time. Shortly after midnight, Manzo saw his friend out the door. Manzos body was discovered two days later, sprawled out on the kitchen floor not far from his five guitars and drum set.
He was clean for eight years. He would always tell me, My trigger is depression. That is my trigger, his mother said.
The virus, she believes, took away one of the strongest forces in Manzos life the presence of people who loved him. If he had still been working, he would have been able to fight that urge, because he was busy. He loved that job. He loved people.
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Reason for the rise
Michigan where Manzo died now ranks third in the United States for the highest unemployment rate, with 1 in 5 workers out of a job. Nationwide, more than 20 million are unemployed as the nation faces its worst economic crisis since the Great Depression.
Research has established strong links between stagnating economies and increases in suicides, drug use and overdoses. In recent years, economists Anne Case and Nobel Prize-winner Angus Deaton have dubbed such increasing fatalities in declining blue-collar communities deaths of despair.
For months, the Trump administration and several governors have seized on such research as their central argument for reopening states and businesses at any cost.
We have to reopen for our health, Health and Human Services Secretary Alex Azar wrote recently in a Post op-ed. The economic crisis brought on by the virus is a silent killer. As evidence, Azar cited a study suggesting that for every one percentage point increase in the unemployment rate in past recessions, the opioid death rate appears to increase by more than 3 percent.
But in an interview, the lead researcher behind that study rejected Azars premise as a misuse and an oversimplification of his data.
Many factors not just job loss trigger opioid use, said Alex Hollingsworth, a health economist at Indiana University. Dont use opioid deaths as a reason to reopen.
Hollingsworth and other economists, including Case, who spearheaded much of the research on deaths of despair, point out that their findings are based on previous recessions that were wildly different from this one.
One big difference is how suddenly this downturn occurred causing tens of millions of Americans to lose their jobs almost overnight. Deaths of despair normally occur after years of hardship. The pandemic has also introduced unprecedented disruptions into individual habits and society, making it difficult to foresee the exact effect.
But the biggest objection to such arguments that tie the declining economy to an inevitable increase in overdoses is the implied assumption that nothing can be done to avert it.
The focus, many economists and health experts agree, should be on finding safe and sustainable ways to reopen the economy, while increasing access and funding for mental health and substance use care.
We need to multitask as a society, said Nora Volkow, director of the National Institute on Drug Abuse, a federal research agency.
The problem is a lack of political will, said Alex H. Kral, an epidemiologist at the nonprofit research institute RTI International.
We may not have a vaccine for covid, but we actually have very effective treatments for opioid use disorder, Kral said. We have medication and proven interventions. It doesnt have to play out the way we fear it will.
Cries for help
A van waits to transport a body from the morgue in Columbus, Ohio, to a funeral home. Theres just so many bodies, the medical examiner said.
A van waits to transport a body from the morgue in Columbus, Ohio, to a funeral home. Theres just so many bodies, the medical examiner said. (Ty Wright/For The Washington Post)
Before the pandemic hit, national efforts to stem the opioid crisis were just starting to show progress.
In January, the Centers for Disease Control and Prevention released 2018 data showing a slight decline in fatal overdoses for the first time in 28 years. But decades into the opioid epidemic, federal and state agencies still lack a system to collect overdose data in real or near-real time.
The closest thing that exists comes from the Overdose Detection Mapping Application Program, which receives county-level data from emergency agencies. Since it began in 2017, ODMAP has forged agreements with a patchwork of about 3,300 agencies in 49 states that voluntarily provide data.
Of the counties participating, 62 percent have reported increased overdoses since March. And among counties that took part in the program last year and this year, data provided to The Post by ODMAP show a 42 percent increase in May.
Ortiz, the coroner in Columbus and surrounding Franklin County, said that she and her staff just moved this year into a facility three times the size of its old office so they could handle exactly this kind of added volume. Theyre already out of space.
Theres just so many. And the bodies absolutely cant go on the floor, out of respect for the decedents, she said. Were trying to borrow carts that emergency management was saving for hospitals and the possible covid surge.
Ortiz and more than half a dozen other coroners nationwide described a dangerous trend from recent years that has accelerated during the pandemic: dealers mixing long-standing narcotics such as heroin and cocaine with much more powerful synthetic drugs, including fentanyl and carfentanil.
The American Medical Association recently issued a warning, citing reports from officials in 34 states about the increased spread of such synthetic drugs and rising overdoses.
Sandy Rivera, an emergency medical technician in Union City, N.J., said she saw an abrupt change in May in the types of cases her ambulance was responding to.
For weeks, it had been almost all respiratory illnesses and cardiac arrests related to the coronavirus. Then, suddenly, nearly half her cases became overdoses and suicide attempts, a ratio she has never encountered in 15 years working on ambulances.
One night, thats all I had, Rivera said. One patient took a bottle of Tylenol. Another took medication that belonged to her children. An elderly patient had been drinking and swallowed 10 pills of Benadryl.
They were cries for help, she said.
Kate Yoder, deputy chief of investigations, is among the staff members confronting a surge of autopsies in Columbus, Ohio.
Kate Yoder, deputy chief of investigations, is among the staff members confronting a surge of autopsies in Columbus, Ohio. (Ty Wright/For The Washington Post)
At a time when they are needed most, some treatment centers and addiction clinics are struggling to stay solvent and have begun closing programs.
In May, Austin Recovery Network, the oldest addiction treatment provider in Texas, shuttered its clinics. It is only a matter of time until we run out of money, the board of the nonprofit organization told staff members.
Lynn Sherman, chairman of the treatment providers board, said the decision to close the clinics was hard as hell.
The organization is still holding online support groups and running a shelter for parents and children, Sherman said, but, she added, I dont think our area will have enough capacity in the future to provide the help thats needed.
Even as Austin Recovery Network shut down its residential treatment programs for adults, it has seen an increase in people walking into its offices, begging for detox treatment and a place to stay amid the pandemic.
In normal times, most nonprofit behavioral health centers operate on extremely thin margins and rely on reimbursements from major government health programs such as Medicaid and Medicare and grants from local government.
During the pandemic, they have struggled to treat patients, leading to severe drops in reimbursement, said Chuck Ingoglia, president of the National Council for Behavioral Health, which represents 3,326 treatment organizations. In a recent survey, 44 percent of the councils members said they will run out of money in the next six months.
Many are bracing for deeper cuts in the coming year, as states grapple with budget crunches.
Mental health and substance use programs are often the first thing cut, said Tami Mark, a drug policy researcher at RTI International. The last recession decimated behavioral health funding so badly it took them 10 years just to get back to previous levels.
Failures of the system
When the Democratic-controlled House passed a $3 trillion coronavirus relief bill in May, the legislation, dubbed the Heroes Act, designated $3 billion for mental health and substance use disorders programs seven times more than the amount Congress approved in March.
But the White House and Republicans have declared the bill dead on arrival, leaving it unclear whether any additional funding will go toward programs for mental health and substance use disorders.
We as a society often have a tendency to stigmatize and blame those who use drugs, said Ashford, the recovery center director in Philadelphia. But if overdoses really increase during this pandemic, it will be because of failures of the system.
Since her sons death, JoAnne Manzo has asked herself the same question over and over: What exactly happened? I know in my heart he did not want to take his life, she said.
On Friday, she finally received the official death certificate. Under cause of death, it said: acute fentanyl and cocaine.
The autopsy took nearly three months because county officials were overwhelmed with covid-19 cases. The pandemic also made it impossible to hold a funeral, so she had her sons body cremated.
JoAnne Manzo took the ashes and put a small portion into a heart necklace she now wears every day.
She knows how lonely her son felt during the last days of his life. Since his death, she has tried to keep him as close as possible.
If you or someone you know is
struggling with addiction, the Substance Abuse and Mental
Health Services Administration can help you locate treatment
at www.findtreatment.gov or at this free helpline:
despair': Coronavirus pandemic could push suicide, drug
deaths as high as 150k, study says
"We see very troubling signs across the nation," said Dr. Elinore McCance-Katz, assistant secretary at Department of Health and Human Services and head of the Substance Abuse and Mental Health Administration. "There's more substance abuse, more overdoses, more domestic violence and neglect and abuse of children."
McCance-Katz said the agency wants more money for services to address an anticipated surge in need for mental health and addiction treatment, which was already in short supply. She cited HHS' own substance abuse and mental health research and a February report in the British journal The Lancet on the psychological effects of quarantine.
Drink alcohol in moderation.
The Lancet study said the effects can include post-traumatic stress disorder and suicide and are "wide-ranging, substantial, and can be long lasting." That's especially true if there isn't a clear end in sight, like now, said McCance-Katz.
"The impetus is COVID-19, but the need was there before and it's just been increased by what's happened as a result of the virus," she said.
The new study, released Friday by the Well Being Trust and the American Academy of Family Physicians, factored in isolation and uncertainty when it calculated the expected deaths from suicide, alcohol and drugs, based on nine unemployment scenarios.
The likely toll from these "deaths of despair" was the loss of an additional 75,000 lives, the study found. Death estimates ranged from 27,644 if the economy recovers quickly, to 154,037 if recovery is slow.
"We already had a major problem on our hands," said psychologist Benjamin Miller, the Well Being Trust's chief strategy officer. "Now people are disconnected and lonely with a level of uncertainty, fear and dread."
Alcohol sales have spiked since shelter in place orders were imposed. Aside from economy security, having a job provides boundaries for potential problem drinkers that help them self regulate, Miller said.
McCance-Katz also noted reports of more people seeking treatment for alcohol problems in regions where coronavirus has hit the hardest, including the Northeast. Addiction treatment centers report far higher call volumes and outpatient treatment, now typically conducted on video.
"There's a level of powerlessness with the economy, retirement funds, unemployment and trying to get unemployment checks," said Doug Tieman, CEO of Caron Treatment Centers in Pennsylvania. "All of them are anxiety-causing, and people feel lousy and then dont see a light at the end of the tunnel."
Virus dreams:The coronavirus pandemic interrupted our lives. It may explain why you're having vivid dreams.
Psychiatrist Elinore McCance-Katz is the first assistant secretary of Health and Human Services for mental health and substance abuse.
Adults and even teens with substance abuse disorders struggle to reconcile often crushing addictions with their fears of contracting COVID-19. The chance of coronavirus transmission compounds parents' concerns when teens sneak out to buy drugs, especially when grandparents live in the home, said Dr. Joseph Lee, medical director of the Hazelden Betty Ford Foundation's youth continuum.
While April residential admissions at Hazelden were down about 2% over April 2019, intensive outpatient admissions soared 17%, thanks to virtual services launched in March, Lee said.
Don't detox alone:Quitting alcohol can be deadly: Hundreds in the US die each year
The stories leading to treatment can be startling.
New Hazelden patients include "multiple kids who drank everything in the house," and others who inhaled household products including the "air dusters" used to clean computer keyboards, Lee said.
Dr. Joseph Lee, is a psychiatrist and the medical director of the Hazelden Betty Ford Foundation youth continuum, where he is hearing from many parents worried about their children's now very apparent addictions.
A teenage girl addicted to heroin told her mother that she would kill herself if her mother didn't buy her heroin. The girl was afraid of contracting the virus, Lee said, so the mother complied.
Recovery goes virual:'The only thing missing are the hugs': How people fight addiction amid coronavirus social distancing
Lee said the girl is entering treatment despite her fear of flying to get there. As with other out of state patients, Lee said he talked through the risks of both coronavirus and addiction to help the family "problem solve."
"For anyone who didnt believe addiction was addiction, we are seeing it in all its glory now," said Lee, who works with 14- to 25-year-olds. "You see the power of the compulsive drive and this learned pathological conditioning."
Bob Poznanovich, Hazelden's vice president of business development, added: "The needs are growing, and were fully expecting and prepared for a surge in demand soon,"
To prevent "a disastrous wave of deaths of despair," the new Well Being Trust and AAFP report recommends an increased focus on reducing unemployment, easier access to treatment and more mental health and addiction services integrated into the healthcare system.
More resources for mental health is a good thing," Miller said.. "Lets just make sure that we are investing in strategies we know work for communities and that integrate mental health into the places people want it."
SAMHSA got $425 million from the Coronavirus Aid, Relief, and Economic Security Act to boost mental health and addiction services. That compares with more than $100 billion for hospitals and is far from what critics say is needed.
"Its embarrassing the lack of attention our Congress places on mental health in a crisis," Miller said.
The SAMHSA funding is being used for services in Certified Community Behavioral Health Clinics, which were defined in 2017 by the Excellence in Mental Health and Addiction Act as a way to boost addiction treatment services and coordinate health care to disadvantaged individuals.
The clinics offer mental health and addiction treatment, along with primary care in the same facilities. Crisis intervention services are available around the clock to keep people experiencing breakdowns out of emergency rooms.
McCance-Katz said they are an example of "where the successes are" in behavioral health and she hopes to expand them further.
"We are given the opportunity to tell the administration what we think is needed," McCance-Katz said. "I do believe theyre listening, so Im hoping that we will get more resources."
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Suicides and Overdose Deaths Have More Than Doubled from
2000 to 2017
Suicides and drug overdoses kill American adults at twice the rate today as they did just nearly two decades ago, and opioids are a key contributor to that rise, a new review and analysis finds.
Reversing this deadly double trend will take investment in programs that have been shown to prevent and treat opioid addiction, University of Michigan researchers say.
Writing in the New England Journal of Medicine, the authors also call for more research to identify who is most at risk of deliberate or unintentional opioid overdoses so these individuals can get better pain management, mental health care and medication-assisted therapy for opioid addiction.
Using Centers for Disease Control and Prevention data, U-M researchers found deaths from suicides and unintentional overdoses rose from 41,364 in 2000 to 110,749 in 2017.
When they calculated a rate per 100,000 Americans to account for the increase in population over time the team discovered the combined rate of these two causes of death had more than doubled, rising from 14.7 to 33.7 per 100,000 people.
And when the numbers were refined to include only opioid-related suicides and overdoses, they found these causes accounted for about 41 percent of such deaths in 2017, up from 17 percent in 2000.
Opioids were cited in more than two-thirds of unintentional overdose deaths in 2017 and one-third of overdose-related suicides, CDC data show.
Widespread problems examined
In their article, U-M researchers Amy Bohnert, Ph.D., and Mark Ilgen, Ph.D., review the evidence around the links between overdoses, suicides, chronic pain and opioids of all kinds, from those prescribed by doctors to the types purchased on the street.
They also look at the current evidence for what works to identify a patients risk of suicide or overdose, and ways to treat people with chronic pain, opioid use disorders and mental health conditions.
"Our goal was to highlight the fact that these adverse outcomes likely go together, and effective efforts to help those with pain will likely need to simultaneously consider both overdose and suicide risk." - Mark Ilgen, Ph.D.
Bohnert and Ilgen point out that suicide notes are found in only about one-third of overdose deaths, making the motivations behind other overdose deaths less clear. Thats why grouping overdoses and known suicides by overdose together makes sense, they say.
Unlike other common causes of death, overdose and suicide deaths have increased over the last 15 years in the United States, Bohnert says. This pattern, along with overlap in the factors that increase risk for each, supports the idea that they are related problems and the increases are due to shared fundamental causes.
Both researchers have previously studied these issues in depth, and potential ways to address them. Bohnert co-directs the U-M Program for Mental Health Innovation, Services and Outcomes and is an associate professor of psychiatry at the U-M Medical School.
Ilgen, who directs the U-M Addiction Treatment Services program and is an associate director of the U-M Addiction Center, is a professor of psychiatry. Both researchers also work for the VA Center for Clinical Management Research and are members of the U-M Institute for Healthcare Policy and Innovation and the U-M Injury Prevention Center.
Supply or demand?
The rise in overdose and suicide death rates over the past two decades paralleled the rise in opioid painkiller prescriptions and, later, the rise in use of heroin and illegally manufactured fentanyl.
The researchers look at the competing theories of whether an increased supply of opioids from legal and illegal sources or an increased demand for them because of social and economic factors was more likely to blame.
Although the paper notes that evidence from Australia suggests the supply theory has more credible support for an increase in overdoses, it maintains that both theories have validity and deserve to be addressed through policy solutions.
Because of the common factors involved, researchers say, the U.S. may be able to reduce the death toll from both overdose and suicide through increased use of proven prevention and treatment strategies.
Whos most at risk
For both suicide and unintentional overdose, men had death rates twice as high as women in 2017, according to the researchers analysis of CDC data.
Rates of suicide deaths were highest for white men and American Indian/Alaska Native men, and they were lower across the board for women.
When it came to unintentional overdoses, white men younger than 40 had the highest rate, with nearly 50 deaths per 100,000. But the rate among black men rose in middle and older age, surpassing those of white and Native American men.
For women, unintentional overdose death rates were much higher than suicide rates among white, black and Native American women under age 65.
But Bohnert and Ilgen cite research on racial biases among medical examiners in ruling deaths as suicides or overdoses. They also note studies about the increased risk of suicide and overdose among people with mental health conditions and substance use disorders.
Proven treatments identified
People with chronic pain are at clear elevated risk for both unintentional overdose and suicide a connection that hospitals and providers might not properly acknowledge.
To date, many system-level approaches to address overdose and suicide have addressed these as if they are unrelated outcomes, Ilgen says. Our goal was to highlight the fact that these adverse outcomes likely go together, and effective efforts to help those with pain will likely need to simultaneously consider both overdose and suicide risk.
To bring down the risk of suicide or overdose among those most at risk of dying from these causes, Bohnert and Ilgen lay out an array of potential interventions based on the evidence available from recent research.
For instance, they call for people who are on high-dose regimens of prescription opioids, or who are showing signs of prescription opioid misuse, to receive care that could reduce their suicide and overdose risk which includes a slow, patient-centered tapering of their opioid use.
Reducing prescription opioid doses gradually may actually reduce patients pain, research has shown, and reducing the amount of opioid painkillers prescribed at any time could also help keep at-risk patients from having the means for suicide or unintentional overdose on hand.
The U-M team also notes that naloxone, which can reverse an opioid overdose whether intentional or not should be prioritized for the friends and family of such patients.
The researchers also call for greater availability of medication-assisted treatment for anyone with an opioid use disorder.
This could involve the use of methadone, buprenorphine or naltrexone, depending on the person and the availability of treatment, offered in concert with counseling around overdose and suicide prevention, treatment for any mental health conditions and naloxone distribution.
Medication-assisted treatment for opioid use disorders has been repeatedly proven to reduce overdose deaths relative to no treatment or nonmedication treatment, Bohnert says.
Reducing the severity of opioid
use disorder through medications will also improve mental
health. Reducing barriers to use of these medications is
essential to addressing both overdose and suicide.
New National Data
Present a Mixed Picture: Some Drug Overdoses Down but Others
are Up, and Suicides Rates are Increasing - 1/30/20
Key findings from todays reports:
Risk of Drug
Overdose Lethality Ranked by Drug Class
The researchers conducted a cross-sectional study using data from state censuses and national samples including 421,466 suicidal drug overdoses. Rather than condense drug poisoning into a lumped category as previous analyses have, the researchers sought to investigate the risk of lethality by drug class.
We estimated what proportion of people who died of suicidal acts involving specific drugs may have survived their overdose if their drug mix had omitted a given drug class. For example, we analyzed what portion of completed suicides that involved opioids might not have been fatal if opioids were not involved, the researchers wrote.
Overall, 21,594 deaths resulted from the studied 421,466 drug poisoning suicidal acts. Of these deaths, 19.6% to 22.5% involved benzodiazepines, and 15.4% to 17.3% involved opioids. Opioids were associated with a 5.20 times greater relative risk (RR) of suicide completion than the mean for suicide involving other drug classes. Opioids were followed by barbiturates (RR, 4.29; 95% CI, 3.35-5.45), antidepressants (RR, 3.22; 95% CI, 2.95-3.52), and antidiabetics (RR, 2.57; 95% CI, 1.94-3.41). Calcium channel blockers were also found to have a high RR (2.24; 95% CI, 1.89-2.61) when using the updated toxin diagnosis coding in International Statistical Classification of Diseases and Related Health Problems, Tenth Revision.
These findings suggest that preventing access to lethal means for patients at risk for suicide should extend to drugs with high case fatality rates. Blister packing and securely storing lethal drugs seems advisable, the authors concluded.Michael Potts
Miller TR, Swedler DI, Lawrence BA, et
al. Incidence and lethality of suicidal overdoses by drug
class [published online March 23, 2020]. JAMA Netw
Action: How to Intervene During an Overdose
The Rise of an Overdose Epidemic
Ambulance rushing to hospitalUnfortunately, over the last four years, drug overdose deaths have significantly spiked in 26 states an alarming trend that still continues today.
While policymakers and health officials search for solutions, its important to realize that we all possess the power to help save lives. Awareness is the key to survival during most medical emergencies; thats certainly true in the case of a drug overdose.
If you find a loved one has overdosed, or even a complete stranger, knowing how to react could mean the difference between life and death.
Anatomy of an Overdose
An overdose occurs when your body cannot handle the amount of foreign substances in your body. Although signs and symptoms vary depending on the type of drug abused and the persons tolerance, its best to choose caution over discernment.
Simply put; if you feel something is wrong, it probably is.
Signs and Symptoms by Drug
Lets take a look at the steps you should take when someone has overdosed.
Opiates and benzodiazepines (heroin, Oxycontin, Valium, Xanax) are all depressants, meaning they significantly slow your breathing and heart rate. When an overdose occurs, the victim runs a significant risk of respiratory failure, which could lead to a coma, permanent brain damage and death.
Signs of a depressant overdose include:
Alcohol is also a depressant and affects the central nervous system similar to opiates and benzodiazepines. While some people may not generally consider alcohol an overdose risk, extreme cases can lead to respiratory failure, cardiac arrest, and choking. Mixing alcohol with other depressants also amplifies the effects of both, increasing the risk of an accidental overdose.
Signs of alcohol poisoning include:
While overdosing on stimulants (cocaine, speed, methamphetamine) is not as deadly, statistically speaking, as overdosing on depressants, it is still very dangerous. Overdosing on stimulants can cause heart attacks, strokes, seizures and psychosis.
Signs of a stimulant overdose include:
What Actions Should You Take?
If you believe someone is suffering from alcohol poisoning or stimulants, call 911 immediately. Home intervention will be inadequate in these cases.
Saving someone from an opiate overdose, however, requires quick reaction. According to the CDC, over half of all overdose deaths are directly related to prescription opioids and the National Institute on Drug Abuse reports heroin-related deaths have increased five-fold over the last 10 years. Since both of these opiates have a depressant effect, the same intervention tactics are applicable in the event of an overdose.
Step #1 Check Responsiveness
If someone is unconscious with shortness of breath or not breathing, rub your knuckles hard over their chest bone. If they are still unresponsive, call 911 immediately.
Step #2 Perform Rescue Breathing
A majority of overdose deaths are due to respiratory failure, so rescue breathing is crucial when dealing with an overdose. Tilt the head, lift the chin, and pinch the nose. Seal their lips and give two quick breaths into their mouth. Then give one long breath every five seconds.
Step #3 Administer Naloxone
Naloxone (Narcan) is a life-saving drug that reverses the depressing effects of opiates on the central nervous system. Naloxone kits are available in two forms: intranasal and injectable.
Intranasal Naloxone: Pry off yellow caps on the plastic delivery device (needleless syringe), and pry off the red cap of the cartridge. Screw the naloxone cartridge into the barrel of the syringe. Tilt head back and spray half of the naloxone (1cc) into each nostril.
Injectable Naloxone: Pry the orange top off the naloxone vial. Draw 1cc of naloxone into syringe and inject into a major muscle (buttocks, thighs or shoulders).
If need be, continue rescue breathing while the naloxone takes effect. If the person is still unresponsive after three to five minutes, administer another dose of naloxone.
Dont Let Fear Prevent Intervention
Too often, drug overdose deaths occur because a person is hesitant to call an ambulance due to a fear of police involvement. However, 20 states and Washington, D.C. have enacted Good Samaritan Laws to encourage seeking medical help.
The Good Samaritan Laws provide
limited immunity for minor drug violations, drug
paraphernalia and being under the influence at the time of
the medical emergency. Without the threat of legal
retribution, drug users are more likely to step in and call
911 to request assistance.
Portrait of the
American Overdose: Do You Fit the Profile?
Statistics show that the profile many Americans envision when conjuring up images of a typical overdose victim is far from accurate. According to a 2014 study, drug users most at risk of overdose are white, middle-aged, suburban men. Even more surprising is their age. The CDC reports that the highest overdose death rate in 2015 represented people between the ages of 45 and 54.
Digging Into the Overdose Details
Since 1999, the number of opioid prescriptions handed out by doctors has quadrupled. The Surgeon General reports that 78 Americans die every day from an opioid overdose. These painkillers, such as hydrocodone and oxycodone, accounted for nearly a fourth of drug-related deaths in 2015.
Heroin is responsible for another fourth of all fatal overdoses. Between 2010 and 2015, heroin overdose deaths tripled.
Ranking third on the list are semi-synthetic opioids, which account for 18 percent of overdoses. This family of drugs includes the potent compound fentanyl. Exponentially stronger than typical opiates, dealers often mix these synthetics with other drugs, unbeknownst to the user. The unexpected potency often has fatal results.
These deaths are not limited to back alleys and poor neighborhoods. In fact, a growing number of overdoses now occur in suburban and non-urban settings often in affluent neighborhoods.
Wondering which states have been hardest hit by fatal overdoses? According to the numbers, New Hampshire, Ohio, West Virginia, and Kentucky have seen the highest death toll in recent years.
Overdose Risk Factors You Should Consider
Tolerance: About half of all the people in recovery will ultimately suffer a relapse. When this happens, drug overdose is a serious concern. When they havent been using for a while, their drug tolerance drops. Unaware of this drop, they take a normal dose of the drug, which has a high potential for causing an overdose.
Mixed Substances: Taking more than one type of drug at a time also increases the risk of overdose. For example, combining opiates with alcohol can cause respiration to slow to a lethal rate. Mixing heroin with pain pills can have similar effects.
Are You at Risk?
Do you or a loved one fit any of these profiles? If so, you should be concerned about a potentially deadly overdose.
The good news is, overdoses are 100
percent preventable. Consider the risks. Get help if you
need it. Addiction and recovery resources are available
across the country. Dont let yourself or someone you
love become an overdose statistic.
A new data analysis funded by the National Institutes of Health finds patients who visited the emergency department for an opioid overdose are 100 times more likely to die by drug overdose in the year after being discharged and 18 times more likely to die by suicide relative to the general population. Additionally, in the year after emergency department discharge, patients who visited for a sedative/hypnotic overdose had overdose death rates 24 times higher, and suicide rates nine times higher, than the general population. The findings, published in the American Journal of Preventive Medicine, highlight the need for interventions that reduce suicide and overdose risk that can be implemented when patients come to the emergency department.
We knew that nonfatal opioid and sedative/hypnotic drug overdoses were a major cause of disease. What these new findings show is that overdose patients also face an exceptionally high risk of subsequent death not just from an unintentional overdose, but also from suicide, non-suicide accidents, and natural causes, said Sidra Goldman-Mellor, Ph.D.(link is external), lead study author and assistant professor of public health at the University of California, Merced.
Drug-related mortality is an ongoing public health problem. Deaths by drug overdose increased 225% between 1999 and 2015, with prescription drugs and heroin overdose accounting for the majority of these deaths. Although previous studies have detailed trends in emergency department visits related to opioid and sedative/hypnotic drug overdose, less is known about the risk of death in the year following emergency care for a drug overdose.
We have tracked and reported patient survival for health concerns such as cancers and heart surgery for decades, said paper co-author Michael Schoenbaum, Ph.D., a senior advisor for mental health services, epidemiology, and economics at the National Institute of Mental Health (NIMH), part of the NIH. We improve what we measure and should be doing the same type of tracking for people with overdose or suicide risk to inform our prevention and treatment programs.
To learn more about the risks for death that follow a nonfatal opioid overdose, a research team led by Dr. Goldman-Mellor examined discharge data for all visits to emergency departments in California between 2009 and 2011. These data were matched with death records from the California Department of Public Health, which provided information about the date and cause of death for all individuals who died between 2009-2012.
The researchers focused on patients who visited the emergency department for an opioid overdose (e.g., heroin, methadone) or for a sedative/hypnotic drug overdose (e.g., barbiturate, benzodiazepine) at least once during the 2009-2011 study period.
The data showed that for those who had visited for sedative/hypnotic drug overdose, the death rate in the following year was 18,080 per 100,000; for those who had visited for an opioid overdose, the death rate in the following year was 10,620 per 100,00 patients. The death rates for these groups were significantly higher than the death rate observed in a demographically matched group of Californians (3,236 per 100,000 people).
Eighty-eight percent of the unintentional deaths among patients who had visited for opioid overdose were caused by an unintentional overdose (1,863 per 100,000)a rate 100 times higher than that of the general population. The suicide rate for this group (319 per 100,000 patients), which included some deaths by intentional drug overdose, was 18 times higher than that of the general population.
Sixty percent of unintentional deaths among patients who had visited for sedative/hypnotic overdose were caused by an unintentional drug overdose (342 per 100,00 patients)a rate 24 times higher than that of the general population. Among those who had previously experienced a sedative/hypnotic drug overdose, the rate of death by suicide (174 per 100,000 patients) was almost nine times higher than the general population
There are already promising emergency department-based interventions that could reduce overdose and other mortality risks, such as suicide, among these patients, but such interventions need to be much more widely implemented, said Dr. Goldman-Mellor. Moreover, those interventions should target not just patients overdosing on opioids, but also those overdosing on sedative/hypnotic drugs, since their mortality risks were also very high.
Dr. Goldman-Mellor indicated that although this study provides important information about the outcomes of individuals presenting to emergency departments after an overdose, the findings should be replicated in other parts of the U.S. using more recent data, as patterns of opioid and sedative/hypnotic use (and related mortality) have changed substantially over time.
About the National Institute of Mental Health (NIMH): The mission of the NIMH is to transform the understanding and treatment of mental illnesses through basic and clinical research, paving the way for prevention, recovery, and cure. For more information, visit the NIMH website.
About the National Institutes of
Health (NIH): NIH, the nation's medical research agency,
includes 27 Institutes and Centers and is a component of the
U.S. Department of Health and Human Services. NIH is the
primary federal agency conducting and supporting basic,
clinical, and translational medical research, and is
investigating the causes, treatments, and cures for both
common and rare diseases. For more information about NIH and
its programs, visit www.nih.gov
vs. Unintentional Overdose Deaths
When overall drug overdoses are reported, intentional and unintentional overdoses are counted, along with drug poisonings inflicted by another person with intent to injure or kill, and overdoses in which the intent to harm cannot be determined.
The World Health Organization defines the codes for these categories as "the disease or injury which initiated the train of events leading directly to death, or the circumstances of the accident or violence which produced the fatal injury." For drug overdose, the international classification of diseases (ICD-10) codes for these categories are:
For more information about
cause-of-death data, visit wonder.cdc.gov/wonder/help/mcd.html
Findings In this cross-sectional study of state censuses and national samples that included 421?466 medically identified suicidal drug overdoses, the risk that an overdose would be fatal was highest if an opioid or barbiturate was involved. Lethality increased with age, whereas youth overdoses often involved toxins with low lethality.
Meaning These findings suggest that drugs that are lethal in overdose when combined should be stored securely in homes, and lethal drugs should be blister packed
Importance Prior lethality analyses of suicide means have historically treated drug poisoning other than alcohol poisoning as a lumped category. Assessing risk by drug class permits better assessment of prevention opportunities.
Objective To investigate the epidemiology of drug poisoning suicides.
Design, Setting, and Participants This cross-sectional study analyzed censuses of live emergency department and inpatient discharges for 11 US states from January 1, 2011, to December 31, 2012, as well as Healthcare Cost and Utilization Project national live discharge samples for January 1 to December 31, 2012, and January 1 to December 31, 2016, and corresponding Multiple Cause of Death census data. Censuses or national samples of all medically identified drug poisonings that were deliberately self-inflicted or of undetermined intent were identified using diagnosis and external cause codes. Data were analyzed from June 2019 to January 2020.
Main Outcomes and Measures Distribution of drug classes involved in suicidal overdoses. Logistic regressions on the state data were used to calculate the odds and relative risk (RR) of death for a suicide act that involved a drug class vs similar acts excluding that class.
Results Among 421?466 drug poisoning suicidal acts resulting in 21?594 deaths, 19.6% to 22.5% of the suicidal drug overdoses involved benzodiazepines, and 15.4% to 17.3% involved opioids (46.2% men, 53.8% women, and <0.01% missing; mean age, 36.4 years). Opioids were most commonly identified in fatal suicide poisonings (33.3%-47.8%). The greatest RR for poisoning suicide completion was opioids (5.20 times the mean for suicide acts that did not involve opioids; 95% CI, 4.86-5.57; sensitivity analysis range, 3.99-6.86), followed by barbiturates (RR, 4.29; 95% CI, 3.35-5.45), antidepressants (RR, 3.22; 95% CI, 2.95-3.52), antidiabetics (RR, 2.57; 95% CI, 1.94-3.41), and alcohol (conservatively, because 30% of death certifiers do not test for alcohol; RR, 2.04; 95% CI, 1.84-2.26). The updated toxin diagnosis coding in International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, used to code the 2016 data revealed that calcium channel blockers also had a high RR of 2.24 (95% CI, 1.89-2.61). Translated to attributable fractions, approximately 81% of suicides involving opioids would not have been fatal absent opioids. Similarly, 34% of alcohol-involved suicide deaths were alcohol attributable.
Conclusions and Relevance These findings suggest that preventing access to lethal means for patients at risk for suicide should extend to drugs with high case fatality rates. Blister packing and securely storing lethal drugs seems advisable.
Suicide researchers and prevention specialists use the phrase means matter to highlight that the mechanism used strongly influences a suicidal acts lethality.1 Through this line of research and practice, means restriction has become a public health focus for population-level suicide prevention.2 Analyses of means, however, usually lump almost all drug overdoses into a single category.2-7 The partial exception is alcohol; a study of fatal and hospital-admitted cases8 estimated that people were 5.1 times more likely to attempt suicide when consuming alcohol than when sober. Another small but robust study9 estimated that people were 9.6 times more likely to attempt a medically treated suicide during hours when they were intoxicated. Even these studies did not assess how alcohol involvement affected lethality. A few studies on suicide prevention by means focused on restricting access to specific, easily accessible toxins,10 such as pesticides, barbiturates, paracetamol (acetaminophen), or antidepressants. Evaluations found that restricting access to these lethal means through prescription practices and sales regulation was associated with declining suicide rates.10-12 Thus, drug suicide prevention efforts will benefit from a systematic investigation of suicide lethality by drug class that assesses the separate and interactive risks of varied drugs.
This study examined the association of drug classes consumed with the lethality of intentionally self-inflicted drug overdoses. We estimated what proportion of people who died of suicidal acts involving specific drugs may have survived their overdose if their drug mix had omitted a given drug class. For example, we analyzed what portion of completed suicides that involved opioids might not have been fatal if opioids were not involved.
This cross-sectional analysis combined mortality and hospital data. Its centerpiece is a tabular and regression analysis of hospital data we previously purchased for unrelated research.13 We used mortality data matched by state and year from deidentified, restricted-access Multiple Cause of Death (MCOD) data sets14 that recorded the state where the individual died. We restricted analyses to individuals 6 years and older because determining suicidal intent in younger children is often difficult. Most medical examiners do not classify a childs death as a suicide if the child is younger than 10 years15; however, suicide cases have been identified in children aged 5 to 9 years.16 This secondary analysis of deidentified data was exempted by the institutional review board of the Pacific Institute for Research and Evaluation, and the need for informed consent was waived. We followed the reporting requirements of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.
We had censuses of deidentified hospital inpatient and emergency department (ED) live discharges from January 1, 2011, through December 31, 2012, from Arizona, Iowa, Nebraska, and Utah for 2012 only; California for 2011 only; and Florida, Kentucky, New Jersey, New York, North Carolina, and Rhode Island for both years. These states accounted for 37% of US residents, 34% of total suicides,17 and 39% of drug poisoning suicides in 2012.18
To assess the consistency of the 11 states with the nation, we compared their tabular findings vs 2012 Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS) and Nationwide Emergency Department Sample (NEDS) tables. To ensure that our findings were current, we compared them with 2016 NIS and NEDS tables (the most recent).
Radically different sampling strategies and the absence of state identifiers in HCUP national samples preclude regressions on pooled MCOD, NIS, and NEDS data. The HCUP NIS builds on a 20% sample of discharges from every community hospital in 46 states plus Washington, DC. The HCUP NEDS 2016 sampled discharges from 953 hospitals in 36 states plus Washington, DC; the HCUP NEDS 2012 sampled discharges from 950 hospitals in 30 states. Neither NIS nor NEDS reveals a cases state of origin. It would be impossible to calculate standard errors (SEs) accurately in a pooled data set regression.
We largely restricted our analysis to deaths and live discharges in which drug poisoning was the mechanism of injury and intent was purposefully self-inflicted or, except in sensitivity analysis, undetermined (hereafter collectively labeled suicidal). International Classification of Diseases (ICD) intent codes do not differentiate suicidal from nonsuicidal self-inflicted intentional injury. Including drug poisonings of undetermined intent was a conservative correction for documented differential undercounting of drug poisoning suicides across states.19 The opioid epidemic is severely stressing underresourced emergency health care and medicolegal death investigation systems across the nation. Drug poisoning suicides are especially difficult for death certifiers to ascertain relative to suicides by more behaviorally and forensically overt methods, such as gunshot and hanging.20,21Undetermined is the manner-of-death category most susceptible to obscuring these suicides.22,23
We used diagnosis data to determine what drugs, if any, were present in each hospital-treated or fatal poisoning. Presence of alcohol and other drugs was determined using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) for 2011-2012 hospital data, International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) for 2016 hospital data, and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) for deaths. We identified drug poisonings of suicidal or undetermined intent by any listed diagnosis/intent code in ICD-10 or external cause code in ICD-9-CM. Except in sensitivity analysis, we then excluded cases that also included another suicide mechanism (eg, fall). We classified the drugs involved into the following categories: 4-aminophenol derivative (eg, acetaminophen), alcohol, antiallergic or antiemetic (a single ICD code), antidepressant, antipsychotic (ie, tranquilizers other than benzodiazepines), barbiturate, benzodiazepine, cocaine, hallucinogen, opiate, other nonsteroidal anti-inflammatory drug (eg, ibuprofen), muscle relaxant, psychostimulant, salicylate (eg, aspirin), other specified drug, and unknown drug. Because testing only detects components of combination drugs such as acetaminophen and hydrocodone bitartrate, acetaminophen and oxycodone hydrochloride, or cough medicine with codeine, these drugs were counted both as an opioid and as 1 or more other drug classes. The 2016 analysis differentiated additional drug classes identifiable only in ICD-10. eTable 1 in the Supplement lists the codes included in each drug class. A maximum of 8 classes were involved in 1 case. Data management and descriptive statistics were conducted with SAS, version 9.4 (SAS Institute Inc) and RStudio, version 1.2.5033 (RStudio Inc).
Drugs involved in suicide acts were not always tested or identifiable. Fewer than 10% of nonfatal poisonings but almost 45% of fatal poisonings included unknown drugs. If the record identified any drugs, we ignored the unknown drugs. For fatalities with all drugs unknown, we used a published regression method24 to infer the presence of frequently involved drug classes, that is, opioids, benzodiazepines, and stimulants (with probabilities >0.33 counted as present). We followed a similar strategy for nonfatal cases but could only use victim sex, age group, and rurality as explanators.
We tabulated the data. By time period, we computed the percentage of cases that were fatal (ie, the case fatality rate) and the risk of suicide due to drug poisoning involving each drug class relative to drug poisonings that did not involve that class (ie, the incidence rate ratio or the risk ratio).
Data were analyzed from June 2019 to January 2020. Our 2011-2012 state fatality and hospital data were censuses suitable for regression analysis after pooling. Using Stata, version 15.0 (StataCorp LLC), we ran a series of logistic regressions on them. The regressions estimated the odds that a poisoning suicidal act was fatal, with fatal cases equal to 1 and nonfatal cases equal to 0.
Covariates included victim age group (detailed in Table 1) by sex, 3-category urbanicity (large metropolitan/fringe, medium/small metropolitan, and micropolitan/noncore), and state. The HCUP data include urbanicity; we generated comparable categories from state and county information in the MCOD. The ED data offered no other demographic characteristics.
Regressions included the presence of comorbidities as a covariate. We searched the record for the 30 Elixhauser comorbid conditions.25 Hospitals assiduously code comorbidities, which can affect treatment choices or require maintaining a medication regimen or diet. Conversely, death certifiers only record comorbidities that contributed to the death.26 Therefore, we treated comorbidity as an absent-present variable rather than a count.
Three overarching regression models covered all drug classes. Model 1 included binary variables indicating the drug classes involved. Models 2 and 3 were sensitivity analyses that paralleled model 1. Model 2 omitted cases in which none of the drug classes involved were known or inferable. Model 3 omitted cases of undetermined intent. Because exploratory data tabulations suggested youths used different drug mixes than adults, we also ran model 1 separately for those 21 years or older and younger than 21 years.
Additional regressions further probed the lethality of the 9 classes of drugs with at least 100 deaths in the 2011-2012 sample. These regressions (model 4) added a set of interaction terms between the binary indicator variable for the drug class of interest and the indicator variables for the other drug classes. We calculated the increased lethality if a focal drug class was involved in a suicide act in 2 steps.27 First, we summed the regression coefficients for the drug class indicator and its interaction terms multiplied by the percentage of a drug class cases that involved each interaction. Then we exponentiated the sum to generate the adjusted odds ratio. Model 4 provides our best estimates. Model 1 is best for drug classes with too few deaths to calculate model 4 reliably. By including cases with only unknown drugs and cases of undetermined intent, these models should reduce the biases resulting from differential coding in the fatal and nonfatal data.
Model 5 paralleled model 1 but included suicidal acts from all mechanisms, with binary variables indicating the primary mechanism. The findings appear in eTable 2 in the Supplement.
We converted the odds ratios to relative risks (RRs) using a correction formula that derives directly from the definitions of the 2 terms.28 That formula is apropos because we have a census of cases. For RRs exceeding 1.00, we computed the fraction of deaths involving the focal drug class that would not have been fatal if no drugs in that class had been present. We calculated this drug-attributable fraction among the exposed by subtracting the base risk of 1.00 from the RR and then dividing by the RR.29,30
A total of 421?466 drug poisoning suicidal acts resulted in 21?594 deaths (46.2% men, 53.8% women, and <0.01% missing; mean age, 36.4 years). Table 1 and Table 2 as well as eTable 3 in the Supplement describe the suicidal acts and drug classes analyzed in the 3 populations: 246?362 events in the 2011-2012 state censuses (including 5081 deaths), 102?946 events (unweighted) in the 2012 national data (including 9693 deaths, with 48?340 nonfatal events and 1211 deaths also in the state censuses), and 73?369 events in the 2016 national data (including 10?525 deaths). In 2016, a nonfatal act treated in the ED involved a mean (SE) of 1.45 (0.01) drug classes; an admitted act, 1.21 (0.003) drug classes; and a fatality, 1.40 (0.004) drug classes, excluding alcohol. Across the 3 measurements, benzodiazepines were involved in 19.6% to 22.5% of the suicidal overdoses (Table 2). They were the drug class most often involved in nonfatal acts. Among fatalities, opioids (33.3%-47.8% of cases), antidepressants (16.3%-16.7%), and benzodiazepines (12.8%-15.9%) were most often involved.
The case fatality rate (eTable 3 in the Supplement) measures lethality. It was higher for males (2.6%-4.8%) than females (1.7%-2.6%) and increased with age group (6-14 years, 0.1%-0.2%; =60 years, 4.8%-9.0%). It consistently was highest for opioids (4.5%-9.5%), followed by antidepressants (2.9%-3.6%) and barbiturates (5.8%-12.2%). eTable 4 in the Supplement shows the percentage of cases within a given drug class for which that drug class was the only class identified for fatal and nonfatal cases. Among fatalities, antidiabetics (81.8%) and salicylates (60.3%) were the 2 drug classes that often were taken alone.
Opioids (RR, 5.20; 95% CI, 4.86-5.57) and barbiturates (RR, 4.29; 95% CI, 3.35-5.45) consistently had the highest unadjusted RRs in all periods. That pattern persisted in the regression-adjusted RRs shown in Table 3. The risk of a suicide act resulting in death was highest if opioids were involved, with a best estimate that death was 5.18 (95% CI, 4.81-5.58) times more likely. Across sensitivity analyses, this estimate ranged from 3.99 to 6.86. As Table 3 shows, this estimate translates as 75% to 87% of the suicide deaths involving opioids would not have been fatal if opioids were not involved.
Relative to the fatality risk for all other drugs combined, antiallergics or antiemetics (RR, 3.94; 95% CI, 3.48-4.45), antidepressants (RR, 3.22; 95% CI, 2.95-3.52), and alcohol (RR, 2.04; 95% CI, 1.84-2.26) had high RRs in the linear model (model 1), but their association was attenuated in a cross-product model (model 4) that accounted for the presence of other drugs. Too few cases involved barbiturates to test whether its high RR would attenuate. The RR for antidiabetics almost certainly would not attenuate because more than 80% of those deaths involved no other drugs. Besides opioids (81%), the attributable fraction of deaths involving another drug only exceeded 0.5 for barbiturates (77%), antidepressants (64%), and antidiabetics (61%). Among alcohol-involved deaths, 34% were alcohol attributable.
eTable 2 and eTable 5 in the Supplement provide the full regression models that produced the results in the sensitivity analysis column in Table 3. eTable 6 in the Supplement displays the regressions underlying the interaction models.
Table 4 as well as eTable 7 and eTable 8 in the Supplement compare drug suicide patterns of youths and adults. After controlling for drugs chosen, lethality was lower for youths than adults. The drug mixes chosen by youths and adults contrasted markedly. Youth poisoning suicide acts were more likely to include nonopioid pain relievers (eg, acetaminophen, aspirin, or ibuprofen), antidepressants, and antiallergic or antiemetic drugs. In contrast, attempts in adults were more likely to include alcohol, benzodiazepines, cocaine, opioids, and drugs to treat chronic conditions (eg, epilepsy, Parkinson disease). The adult regression yielded almost identical odds ratios by drug to the all-age model. The youth regression was hampered by sample size. With a broad 95% CI, the RRs of death for opioids (8.36 [95% CI, 5.36-13.00] vs 5.07 [95% CI, 4.73-5.42]) and barbiturates (9.43 [95% CI, 1.26-62.26] vs 4.22 [95% CI, 3.31-5.36]) were larger for youths than adults. Conversely, alcohol involvement only was associated with increased risk among adults (RR, 2.06 [95% CI, 1.86-2.29] vs 0.25 [95% CI, 0.03-1.85]).
The 2012 patterns for the 11 states and the nation shown in Table 2 were similar. The 2012 and 2016 national data were similar as well, except opioid-involved fatalities increased from 33.3% to 47.8%. Probing the data revealed that this resulted exclusively from deaths involving fentanyl and other synthetic opioids more than tripling from 516 to 1798 deaths.
A few drugs frequently involved in suicide acts are identifiable in ICD-10 but not ICD-9-CM. Relative risks for those drugs, based on 2016 data unadjusted for demographic characteristics and comorbidities, appear in eTable 9 in the Supplement. The attributable fraction of involved deaths for calcium channel blockers was high at 55% (RR, 2.24; 95% CI, 1.89-2.61).
This analysis found that including opioids or barbiturates in a suicidal drug mix increased the risk that a suicide attempt would prove lethal. The increase in lethality of suicidal opioid overdoses from 2012 to 2016 paralleled the rise in unintentional overdose deaths, which resulted from the spread of nonpharmaceutical fentanyl and analogues.31
Adults were much more likely than youths to include highly lethal drugs in their suicidal mix. The descriptive data suggest that youths took whatever was at hand, including nonopioid analgesics, allergy medications, or anything easily accessible.32 This finding emphasizes the importance of locking up drugs prescribed to any family member if they can be lethal in overdose.33 Parents of children with depression or who have multiple risks probably would be wise to compile a list of all their familys medications and ask their pharmacist to check for drugs that are likely to be lethal if combined in an overdose. Disposing of leftover drugs may also help prevent a fatal suicide attempt.34
Limiting access to lethal means is a proven way to prevent suicides.35-38 Smaller pack size and blister packaging proved protective against suicide by paracetamol.11,39 To reduce suicide risk, we recommend blister packing all opioids and other potentially lethal drugs.40,41 Suicidal acts often are impulsive, and once underway, the individual is impatient.42 Youths, in particular, are likely to simply choose a different bottle rather than patiently empty blister packs.
Adults used more considered drug mixes than youths. Their mixes increased lethality. It is unclear why adults had higher mortality rates than youths when they included alcohol in their mix. Possibly they took more drugs that interacted adversely with alcohol. Conversely, alcohol use disorder is a known risk factor for suicide.43-45 Therefore, alcohol involvement among adults might serve as a marker for alcohol use disorders that focused attempters on more lethal drug mixes. Antidepressant involvement might provide a similar signal.
The opioid-involved suicide rate more than doubled from 1999 and 2009, then stabilized.46 In reporting the death toll from the opioid epidemic, analysts routinely include these opioid-involved suicides.47-49 Our analysis confirms the wisdom of including them.47 It suggests that 75% to 87% of these deaths would not have occurred if the decedent had lacked access to opioids. Suicide acts often are impulsive and use readily accessible, often previously ideated means, so those who intentionally overdosed on opioids would be likely to try a drug overdose even if opioids were not readily available.35,36 However, without opioids in the mix, it appears that they probably would survive.
Reducing opioid involvement could save lives beyond the short term. A meta-analysis of predominantly drug poisoning cases found only 2.1% of suicide survivors died by suicide in the following 2 years.50 Indeed, means matter.
This study has some limitations. Our analysis was hampered by coding deficiencies in mortality and hospital data. First, only a subset of drug self-intoxication cases coded as undetermined intent were suicidal.47 Of the fatalities in Table 1, 27.6% were of undetermined intent, whereas none of the drugs involved were identified in 14.6% of cases. For nonfatal cases in Table 1, these percentages were 27.1% and 8.5%, respectively. Furthermore, 30% of death certifiers would not have tested for alcohol in drug poisonings, so our alcohol-attributable fraction is probably an underestimate.51 Our regression-based estimates of the attributable fractions omitting cases with undetermined intent and unknown drug were similar to estimates including them. Second, we unavoidably omitted fatal and nonfatal suicide acts that were deliberately miscoded as unintentional to avoid stigma or insurance problems. Third, we unavoidably omitted suicide acts among the 8.3% of ICD-9-CM drug poisoning cases that lacked external cause codes. Although poisoning intent cannot be omitted in ICD-10-CM, coders are encouraged to code as unintentional rather than undetermined. The net effect of these omissions and overinclusions is unclear. Nevertheless, some readers may prefer to view the results omitting undetermined intent (model 3) as primary.
Differences in drug coding between ICD editions and sparse counts also limited our analysis. The ICD-9-CM, which underpinned our regression-adjusted estimates, lumped other drugs with cannabis, ß-blockers, and calcium channel blockers. We had too few cases involving most drugs to use cross-product regressions that adjusted for drug interactions. Consequently, we could only provide 2016 unadjusted RR estimates for those drugs. For some other drugs, we saw dramatic declines in RR from unadjusted or linear regression to cross-product regression estimates. Regressions using pooled 2016 and 2017 state census data would improve our estimates.
Our data also lack recency. Comparing 2012 and 2016 data, however, suggested that the risk pattern has been stable for all drugs except opioids.
Our regression results may not be nationally representative. We used 2011-2012 data from a convenience sample of states that made affordable hospital discharge censuses available. Although we lack data from the Appalachian states that were hard hit by the opioid epidemic, we have state data from the coasts and heartland, as well as populous and sparsely populated states. Furthermore, the data sets lacked important demographic explanators, including race, ethnicity, and income. Our concerns about representativeness are softened by the consistency of the RRs in the 2011-2012 data before regression adjustment with the national RRs for 2012.
The suicide prevention concept of
means matter extends to drug class within
poisoning suicides. This study appears to reemphasize the
need to control access to drug classes that increase the
risk of dying of a suicidal overdose. This study suggests
that lethal drug access is particularly an issue for youths
because they rarely take a targeted set of drugs, seemingly
opting for whatever is accessible.
Few studies have focused on the characteristic features of drug overdose in children and adolescents who have attempted suicide in Korea. The present study examined the characteristics of drug overdose in children and adolescents who visited the emergency room following drug ingestion for a suicide attempt.
The medical records of 28 patients who were treated in the emergency room following a drug overdose from January 2008 to March 2011 were analyzed. Demographic and clinical variables related to the suicide attempts were examined.
The mean age of the patients was 16.6±1.7 years (range 11-19 years), and 20 of the patients (71.4%) were female. Most of the patients (n=23, 82.1%) overdosed on a single drug; acetaminophen-containing analgesics were the most common (n=12, 42.9%). Depression was the most common psychiatric disorder (n=22, 78.6%), and interpersonal conflict was the most common precipitating factor of the suicide attempts (n=11, 39.3%). This was the first suicide attempt for approximately 80% of the patients. About one fourth of the patients (n=7, 25%) had follow-up visits at the psychiatric outpatient clinic.
Early screening and psychiatric intervention for depression may be an important factor in preventing childhood and adolescent suicide attempts. Developing coping strategies to manage interpersonal conflicts may also be helpful. Moreover, policies restricting the amount and kind of drugs purchased by teenagers may be necessary to prevent drug overdose in this age group.
Suicide is a leading cause of death among children and adolescents in many countries.1,2) The World Health Organization estimated that suicide was the second highest cause of mortality in 10-24-year-olds, and the rate continues to increase. The Centers for Disease Control and Prevention reported an 8% increase in suicide among youths in the US, the largest 1-year increase in 15 years.3) This large worldwide challenge requires a multilateral approach and more prevention studies.
Many previous studies have investigated the epidemiological phenomena and the risk factors associated with suicidal behavior. Tang et al.4) investigated 10,233 adolescent students in southern Taiwan and reported that variables including female gender, weekly alcohol use, illicit drug use, depression, significant family conflict, poor family functioning, reduced interest in school, low rank in school, low acceptance in the peer group, and dropping out of school are associated with adolescent suicide attempts. In Finland, where youth suicide rates are among the highest in the world, Lahti et al.5) investigated suicides in individuals under 18 years of age from 1969 to 1989. A significant increase in more lethal suicide methods (e.g., hanging) among young females was noted, and the authors suggested that alcohol consumption, depression, and outward-directed violent behavior may be associated with suicide.5) In a study on suicide rates in England and Wales conducted from 1970 to 1998, suicide rates among 15-19-year-old males increased substantially between the 1970s and the 1990s. These results were associated with an increase in hanging and self-poisoning with vehicle exhaust gas in the 1980s, both of which continued to increase into the 1990s.6) The change in suicide attempt methods has directly affected suicide rates. In the US, substantial changes in suicide methods have occurred in youths, particularly among females. From 2003 to 2004, rates of suicide rates from hanging/suffocation in females aged 10-14 years increased by 119%.7) Despite the overall results of these studies, the typical characteristics of suicidal behavior in youths have yet to be clearly defined.
In Korea, few studies have investigated the characteristics of drug overdose and suicidal behavior by age group. Lee et al.8) investigated the risk factors of suicidal behavior in college students and concluded that depression, probability of bipolar disorder, and academic achievement were the most important predictors of suicide ideation. The identified risks for suicide attempts were socioeconomic status and probability of bipolar disorder in their study. Kim et al.9) examined self-poisoning in the elderly and found that older individuals tended to choose more lethal suicide methods (e.g., pesticides) compared with young people. Im and Kim10) found four core component of the meaning of suicide in older people: conflict with family, powerlessness and despair about their lives, decline in self-esteem, using internal and external resources to resolve their troubles, and awareness of an imminent crisis.
A few studies in Korea have examined drug overdose in children and adolescents. Kim11) investigated 122 adolescents who visited the emergency room for accidental or intentional drug poisoning. Analgesics were to the most common drugs used for intentional self-poisoning, whereas pesticides were the most common drugs in cases of accidental ingestion. However, this study included both accidental and intentional poisoning and focused on the medical, not the psychological aspects of suicidal behavior.
The present study examined the pattern of drug overdose and the characteristics of children and adolescents who attempted suicide by drug overdose in Korea.
Data were obtained from a retrospective medical and psychiatric chart review of patients who were admitted to emergency room at Uijeongbu St. Mary's Hospital, the Catholic University of Korea, from January 2008 through March 2011.
Of the 30 patients who were treated in the emergency room following a drug overdose, two children who overdosed by mistake were excluded. Therefore, data from 28 patients were analyzed.
Age, sex, past psychiatric history, number of previous suicide attempts, impulsivity of suicide attempts, precipitating events, and the type of drug used were evaluated. Psychiatric evaluation and diagnosis were carried out by psychiatry residents using the criteria from the Diagnostic and Statistical Manual of Mental Disorders-IV Text Revision.12) The patients were assessed in the emergency room using the Brief Emergency Room Suicide Risk Assessment (BESRA), which was constructed by the authors and has been explained elsewhere in detail.9) In brief, the BESRA consists of domains related to the patient's demographic factors, clinical diagnosis, and psychiatric resources, as well as detailed information about the present suicide attempt including the method of suicide attempt, whether the attempt was planned or impulsive, the reason for the attempt, and risk and rescue rating scores. To measure the medical severity of the suicide attempts, the appropriate section of the Suicide Attempt Self-Injury Interview developed by Linehan et al.13) was used. The scores used to measure medical severity ranged from 1 to 6 (1=very low, 2=low, 3=moderate, 4=high, 5=very high, 6=severe). The risk/rescue rating scale developed by Weisman and Worden14) was used. The risk and rescue ratings consisted of five variables used to assess risk (i.e., the method used and the actual damage sustained during a single attempt) and five variables to assess the likelihood of rescue (i.e., the observable circumstances and available resources present at the time of the attempt). The institutional review board approved this study.
Demographic and clinical variables were summarized and are presented as mean±standard deviation or as frequency and percentage depending on the type of variable. All statistical analyses were performed using SAS/PC version 9.2 (SAS Institute Inc., Cary, NC, USA).
Demographic and Clinical Characteristics
Table 1 shows the overall characteristics of the patients. The mean age of the patients was 16.6±1.7 years (range 11-19 years). Most of the subjects (n=26, 92.8%) were adolescents over age 13. Twenty patients (71.4%) were female, and 8 (28.6%) were male. The female-to-male ratio was 2.5:1. Depression was the most common psychiatric disorder (n=22, 78.6%) among the patients, and adjustment disorder was the second (n=2, 7.1%). Six (21.4%) patients reported a past history of psychiatric disorders.
Most of the patients (n=23, 82.1%) overdosed using a single drug. Acetaminophen-containing analgesics were the most common drugs used (n=12, 42.9%). Aspirin and antihistamines (e.g., diphenhydramine, doxylamine) were the second-most common (n=6, 21.4%; n=6, 21.4%, respectively). Other drugs were pesticides (n=2, 7.1%), hydrocarbons (n=1, 3.6%), and antidepressants (n=1, 3.6%).
Precipitating Events of Suicide Attempt
Interpersonal conflict was the most common precipitating event for the suicide attempt (n=11, 39.3%); academic stress was second (n=4, 14.3%). Interpersonal loss, physical illness, and parental separation/divorce were also reported as precipitating events by three patients (n=1 each, 3.6%). Other causes included feelings of hopelessness, feelings of exhaustion, and avoidance of legal problems.
Twenty patients (71.4%) attempted suicide for the first time, and about one-third of the patients (28.6%) reported multiple suicide attempts. Most patients (78.6%) attempted suicide impulsively, but some patients (17.9%) had planned the suicide attempt. Fourteen patients (50%) regretted their attempts, whereas 7 (25%) denied any regret. The mean medical severity score was 3.1±1.0, the mean risk rating score was 7.5±2.0, and the mean rescue rating score was 12.1±2.4. About one fourth of the patients (n=7, 25%) had follow-up visits at psychiatric outpatient clinics.
The present study showed the characteristic features of drug overdose among youths who attempted suicide in Korea. In the current study, most of the subjects used a single drug as the method of suicide. Acetaminophen-containing analgesics, aspirin, and antihistamines (e.g., diphenhydramine, doxylamine) were the most commonly used drugs. These drugs are inexpensive and readily available at local pharmacies without any prescription or restriction in Korea. Moreover, popular use among the general population might make the patients insensitive to the risk of these drugs. Indeed, many studies have revealed that even among adults, Tylenol (Janssen Korea, Hwasung, Korea) is used frequently without accurate knowledge15) of the risks involved.16) Such findings emphasize the significance of drug accessibility in the choice of drugs for suicide attempts among children and adolescents.
The pattern of drugs used for suicide attempts is quite different from that found in older people in a previous study.9) Elderly patients tended to ingest more lethal drugs, especially pesticides. Therefore, different approaches for controlling the accessibility of available over-the-counter (OTC) drugs for youths should be taken into consideration as a preventive measure against suicide attempts in children and adolescents. Lubin et al.17) studied the importance of policy making in interventions directed at adolescent suicidal behavior. After the Israeli Defense Forces to changed their policy to reduce adolescent access to firearms, the suicide rates decreased significantly, by 40%.17) In New Zealand, after more restrictive firearms legislation was introduced in 1992, the mean annual rate of firearm-related suicide decreased by 46% for the total population, 66% for youth, and 39% for adults.18) The impact of policy was also evident among youth in this study. In Korea, there are laws limiting access to narcotics, cannabis, and psychotropic agents to protect adolescents from abusing these drugs. Additionally, many laws including the Minor Protection Law and the Toxic Chemicals Control Law are intended to protect adolescents from using alcohol, nicotine, hallucinogens, and so forth. However, there is no legal restriction on access to OTC drugs for adolescents. Furthermore, a new law that permits the sale of certain quasi-drugs in supermarkets took effect in July 2011 in Korea. A revised version of the Pharmaceutical Affairs Law permitting the sale of some OTC drugs including Tylenol and cold medicines in supermarkets is planned to be submitted to the National Assembly in Korea. Thus, more consideration should be given to the impact of these policies on the risk of suicide in youths.
The most probable reason for the increase in suicide rates in adolescents is pubertal onset of depression and substance abuse, which aggravates the risk of suicide.19) The present study showed that depression was the most common psychiatric disorder in patients who attempted suicide. This is consistent with many other studies that have investigated the relationship between suicide and mood disorders. Children with mood disorders display a 4-to 5-fold higher likelihood of suicide attempts compared with children without mood disorders. Furthermore, even some symptoms of mood disorders, such as those apparent in adjustment disorder, were associated with an increased risk of suicidal behavior.20) In adolescents, depression is highly associated with violence,21) school refusal and truancy,22) and substance abuse.23) These factors are related to suicide behavior. Depressive symptoms such as avolition, irritability, and social isolation may negatively affect youths' potential for maintaining positive interpersonal relationships, which is a powerful protective factor during times of crisis. Therefore, prevention, early screening, and treatment of depression are effective ways to prevent suicidal behavior.24-26)
Moreover, increased impulsivity and immature decision-making ability are other possible factors in the increase in youth suicide. The decision-making process requires adequate maturation in the striatum (mediating approach), amygdala (representing avoidance), and prefrontal cortex (providing behavioral regulation).27) These brain regions are known to be fully matured in young adulthood, which means that these regions remain immature during adolescence. Thus, behavior can be impulsive and uninhibited and may lack adequate consideration of the consequences of behavior.28) By showing that 78.6% attempted suicide impulsively and 50% regretted their attempts, the present study suggests a role for biological vulnerability in suicide among adolescents.
In the present study, we also found that interpersonal conflict was the most common precipitating factor for suicidal behavior. This result is consistent with previous studies.29) Dieserud et al.30) investigated all general hospital-treated suicide attempters between 13 and 19 years of age (n=254) from 1984 to 2006 living in the municipality of Bærum, Norway. The most commonly reported antecedent was a relationship conflict (50.2%), and the most commonly reported underlying reason was a dysfunctional family situation (43.6%). In Taiwan, conflict with parents (25%) was the most common, and conflicts with teachers or classmates (14%) was the second-most common reason for suicide attempts.31) For Turkish young people, negative social status among females, as evidenced by forced marriage, young marital age, low literacy, and honor killings, was a possible causative psychosocial factor.32) These studies suggest that the precipitating factors for suicide may be different among cultures because of different psychosocial environments.
Our final point of discussion has to do with the lethality of the attempt. In the present study, the mean medical severity score (3.1±1.0) was moderate. The risk score among these subjects (7.5±2.0) corresponded to level 2 (low- moderate risk). The rescue score (12.1±2.4) corresponded to level 4 (high-moderate likelihood of rescue). Thus, the lethality of subjects' scores included relatively low risk and high likelihood of rescue. This finding contrasts with findings in older groups, which showed more lethal suicidal behaviors.9,33,34) This discrepancy might be due to differences in the choice of suicide methods between the two groups. As shown by the present study, children tend to choose less lethal drugs (e.g., acetaminophen-containing analgesics, aspirin, anti-histamines) compared with older groups (e.g., pesticides).
There are some limitations to the present study. Due to the small sample size, caution is advised when interpreting the findings of the present study. Adolescents and children constitute a relatively small part of the overall population who visit the emergency room for suicide attempts. Some attempters were excluded because the psychiatric interview was not possible or because they were poisoned by mistake and had no intention of committing suicide. Additionally, the present study only included suicide attempts involving drug overdose. Therefore, the findings cannot be generalized to suicide attempts using other methods. Finally, because the authors did not use structured diagnostic tools, the evaluation of psychiatric diagnosis may be limited even though trained psychiatry residents conducted the assessments.
In conclusion, children and adolescents who attempt suicide by overdosing with drugs tended to have depressive disorder, to experience interpersonal stress, and to choose easily accessible nonprescription drugs. They also tended to use less lethal methods and to have a high likelihood of being rescued. Specific policy efforts and social education programs are warranted.
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expectancy down; drug overdose, suicide up sharply
The latest CDC data show that the U.S. life expectancy has declined over the past few years. Tragically, this troubling trend is largely driven by deaths from drug overdose and suicide, said CDC Director Robert Redfield, MD, in a statement.
Two subreports that looked specifically at suicide mortality and drug overdose deaths mapped out where, when, and for whom the sharpest increases in mortality are being seen.
For suicide, though rates have increased by 33% overall for both men and women since 1999, the greatest annual increases in suicide rates have happened since 2006, according to a new report from the CDCs National Center for Health Statistics (NCHS).
Overall, suicide rates have climbed from 10.5 to 14.0 per 100,000 individuals, with statistically significant increases in suicide rates among all age groups except those aged 75 years and older.
Suicide rates rose more steeply in the most rural counties. The age-adjusted increase in the most rural counties was 53%, compared with an increase of 16% in suicide rates for the nations most urban counties over the 1999-2017 time period.
Over the entire period studied, men were more likely than women to experience suicide, as rates rose among most age groups. For example, the rates of suicide for men aged 15-24 years rose from 16.8 to 22.7 per 100,000; for women in that age group, suicide rates went from 3.0 to 5.8 per 100,000.
Though suicide has remained the 10th leading cause of death overall in the United States, suicide was the second leading cause of death for adolescents and young adults (aged 10-34) in 2016, and the fourth leading cause of death for those aged 35-54 in that year.
These increases come despite a goal set by the CDC and a national coalition of health partners to reduce suicide rates to 10.2 per 100,000 by 2020, as part of the Healthy People 2020 initiative, noted Molly Hedegaard, MD, of NCHS, and her coauthors, in the suicide mortality data briefing.
Drug overdoses increased by nearly 10% in one year, with the highest rates seen in adults aged 25-54 years, according to a second CDC data briefing.
The number of people who died of drug overdoses in the United States in 2017 was 70,237. This represents a year-over-year age-adjusted increase of 9.6%, from 19.8 to 21.7 per 100,000 individuals, said Dr. Hedegaard and the coauthors of the drug overdose mortality report.
Reflecting known national trends in opioid use disorder, age-adjusted drug overdose deaths were highest in the states of West Virginia, Ohio, and Pennsylvania, where rates were 57.8, 46.3, and 44.3 per 100,000 residents, respectively. The District of Columbia had the fourth-highest age adjusted drug overdose death rate, at 44 per 100,000.
Twenty states, clustered primarily in the Eastern half of the United States, had age-adjusted drug overdose death rate that were statistically higher than the national rate, wrote Dr. Hedegaard and her coauthors.
Compared with 1999, more than six times as many adults in older midlife (aged 55-64 years) died from drug overdoses in 2017 (4.2 versus 28 per 100,000).
Adults aged 25-34 years, 35-44 years, and 45-54 years also had significant increases in drug overdose rates; in 2017, rates were 38.4, 29, and 37.7 per 100,000, respectively. Adolescent and young adults died from drug overdoses at a rate of 12.6 per 100,000, and those over 65 years old had a death rate of 6.9 per 100,000.
Deaths attributable to synthetic opioid use, excluding methadone, rose by 45% in just one year, going from 6.2 to 9.0 per 100,000 nationally. In 1999, synthetic opioids other than methadone were implicated in just 0.3 per 100,000 deaths. Synthetic opioids include fentanyl and fentanyl analogs, such as carfentanyl.
Deaths involving heroin remained stable from 2016 to 2017, at 4.9 per 100,000. Deaths attributable to natural and semisynthetic prescription opioids, such as oxycodone and hydrocodone, also were the same in 2017 as 2016, at 4.4 per 100,000.
Looking at trends over time since 1999, the rate of increase in drug overdose deaths had risen slowly since 1999 and stabilized in the mid-2000s. However, beginning in 2012, rates have increased steeply, particularly for males.
Male rates were significantly higher than female rates for all years, reported Dr. Hedegaard and her coauthors (P less than .05). Though female drug overdose death rates have climbed from 3.9 to 14.4 per 100,000 since 1999, the male death rate has gone from 8.2 to 29.1 per 100,000 during the study period.
Life expectancy gives us a
snapshot of the nations overall health and these
sobering statistics are a wakeup call that we are losing too
many Americans, too early and too often, to conditions that
are preventable. CDC is committed to putting science into
action to protect U.S. health, but we must all work together
to reverse this trend and help ensure that all Americans
live longer and healthier lives, said Dr.
be Treated as Attempted Suicides?
Overdoses and Suicide
We are becoming more informed about the link between overdoses and suicide. According to the New England Journal of Medicine (NEJM), accidental drug overdose deaths and suicide have increased at an extreme rate.
In the United States, deaths due to suicide and unintentional overdose pose a major, and growing public health concern. The combined number of deaths among Americans from suicide and unintentional overdose increased from 41,364 in 2000 to 110,749 in 2017 and has exceeded the number of deaths from diabetes since 2010 both suicide and unintentional overdose have been the focus of large-scale prevention efforts, such as the National Strategy for Suicide Prevention and the State Targeted Response to the Opioid Crisis grant program of the Substance Abuse and Mental Health Services Administration. (NEJM).
The researchers who are investigating the links between drug overdose and suicide have learned that both problems have connections with pain and opioid use. The neurocircuitry in the human brain that activates neurotransmitters linked to pleasure and reward is affected by pain. The same is true for people who are addicted to opioids. Persons with Opioid Use Disorder (OUD), are also more prone to dangerous behavior because of the dysfunction of their neurocircuitry and may consider suicide as a way out of their addictions.
The distinction between unintentional and volitional deaths may be blurred among people with OUD, whose motivation to live might be eroded by addiction. Such erosion can have a range of effects, from engagement in increasingly risky behaviors despite a lack of conscious suicidal intent to frank suicidal ideation and intent. This entire spectrum can lead to opioid-overdose deaths, but little attention has been given to its contribution to overdose mortality (NEJM).
Drug Overdoses and Mandatory Holds
Several states are now considering implementing laws for mandatory holds and commitment time to be standard if a person is at risk for suicide due to a drug overdose. All states have laws that can legally commit a person to be held in a psychiatric facility if he or she is at risk for suicide or harming others. What some professionals are suggesting is that the same policies be in place for people with severe substance abuse histories, particularly with drugs that a person can easily overdose on such as heroin and other powerful opioids. Family members are often fear that their relative who is addicted to drugs will not live to the end of the week or day because it is apparent that their brain function and normal decision making has been directly impaired by drug use.
Radical changes need to occur to make
any difference in the number of people addicted to drugs
that die from accidental overdoses. It is encouraging that
public officials and well-respected medical journals are
studying internal and external influences that could
contribute to preventing suicide as well as linking the
opioid addiction crisis to help create better laws and
increase awareness about the substance abuse problem.
Patients admitted to
ED for drug overdose at increased risk for suicide
Thus, ED-based interventions may reduce these patients overdose and other mortality risks, researchers noted.
Our findings support widespread implementation of ED-based interventions aimed at reducing future overdose risk and not just among ED patients presenting with opioid overdose, but also among those who have overdosed on sedative/hypnotic drugs," Sidra Goldman-Mellor, PhD, of the department of public health at University of California, Merced, told Healio Psychiatry. EDs can serve as important partners in implementing harm-reduction strategies, including initiating buprenorphine treatment when opioids are involved, as well as providing warm handoffs to mental health care providers. The findings also suggest the need for integrated models of care that will comprehensively address overdose patients' broad mortality risks.
The investigators aimed to compare 12-month incidence of fatal unintentional drug overdose, suicide and other mortality among ED patients who presented with nonfatal opioid or sedative/hypnotic overdose using statewide, longitudinally linked ED patient record and mortality data from California. They analyzed data of all residents who presented to a licensed ED at least once between 2009 and 2011 with nonfatal unintentional opioid overdose or sedative/hypnotic overdose, as well as of a 5% random sample that did neither. Goldman-Mellor and colleagues followed participants for 1 year following index ED presentation and used ICD-10 codes to assess death due to unintentional overdose, suicide or other causes. They calculated absolute death rates per 100,000 person-years and standardized mortality ratios relative to the general population.
The researchers reported unintentional overdose death rates per 100,000 person-years following the index ED visit as follows:
Results also showed suicide mortality rates per 100,000 of 319, 174 and 32 following opioid overdose, sedative/hypnotic overdose and reference visits, respectively. Natural causes mortality rates per 100,000 were 8,058 for patients with opioid overdose, 17,301 for patients with sedative/hypnotic overdose and 3,097 for reference patients, according to Goldman-Mellor and colleagues.
We were surprised at the
magnitude of opioid overdose patients' increased risk for
drug overdose death, which was 100-fold higher compared with
the demographically matched underlying population,"
Goldman-Mellor told Healio Psychiatry. "The extremely high
death rates among both patient groups, but especially among
the sedative/hypnotic overdose patients, were also
surprising and concerning." by Joe Gramigna
Objectives: Overdoses account for a quarter of all suicides in England. The number of people who survive the immediate effects of their overdose long enough to reach medical attention, but who subsequently die in hospital is unknown. The aim of this study was to determine the proportion of overdose suicides dying in hospital and describe their sociodemographic characteristics.
Method: Cross sectional analysis of routinely collected Hospital Episode Statistics data for England (1997 to 1999) to identify hospital admissions for overdose among people aged 12+ and the outcome of these admissions.
Results: Between 1997 and 1999 there were 233 756 hospital admissions for overdose, 1149 (0.5%) of these ended in the death of the patient such deaths accounted for 29% of all overdose suicides and 7% of total suicides. The median time between admission and death was three days (interquartile range one to nine days). The most commonly identified drugs taken in fatal overdose were paracetamol compounds, benzodiazepines, and tricyclic/tetracyclic antidepressants.
Conclusion: Around a quarter of all overdose suicide deaths occur subsequent to hospital admission. Further more detailed research is required to discover if better pre-admission and inhospital medical management of those taking serious overdoses may prevent some of these deaths.
Suicide is a leading cause of premature mortality and, in recognition of this, recent health improvement strategies in Britain have set targets for its reduction.12 One of the most commonly used methods of suicide is the deliberate ingestion (overdose) of excessive quantities of prescribed or non-prescribed substances. Of the 5292 suicides in England in 2000, around a quarter (n?=?1312) were from overdose (personal communication, Office for National Statistics, January 2002).
Unlike the two other commonly used
methods of suicidehanging and carbon monoxide
poisoning from car exhaust gasesthe lethal effects of
drug overdose may not occur for several hours or days after
the attempt. For this reason most people who take overdoses
reach hospital alive and the medical interventions they
receive in hospital are likely to prevent a proportion of
deaths. While the need for improved medical management of
deliberate self poisoning in developed countries has been
highlighted,2a little attention has been given in the
suicide prevention policies of industrialised countries to
the inhospital medical management of people who have taken
life threatening overdoses.3 Indeed, the proportion of
overdose suicides who survive the immediate effects of their
overdose long enough to reach medical attention, but who
subsequently die, is unknown. Using routinely collected
national hospital admissions data we have investigated the
characteristics of overdose deaths occurring subsequent to
hospital admission and assessed the contribution of such
deaths to overall suicide rates.
Suicide and fatal
drug overdose in child sexual abuse victims: a historical
cohort study Dated
Design: A historical cohort linkage study of suicide and accidental drug-induced death among victims of child sexual abuse (CSA).
Setting and patients: Forensic medical records of 2759 victims of CSA who were assessed between 1964 and 1995 were obtained from the Victorian Institute of Forensic Medicine and linked with coronial data representing a follow-up period of up to 44 years.
Main outcome measures: Rates of suicide and accidental fatal drug overdose recorded in coronial databases between 1991 and 2008, and rates of psychiatric disorders and substance use recorded in public mental health databases.
Results: Twenty-one cases of fatal self-harm were recorded. Relative risks for suicide and accidental fatal overdose among CSA victims, compared with age-limited national data for the general population, were 18.09 (95% CI, 10.9629.85; population-attributable risk, 0.37%), and 49.22 (95% CI, 36.1167.09; population-attributable risk, 0.01%) respectively. Relative risks were higher for female victims. Similar to the general population, CSA victims who died as a result of self-harm were predominantly aged in their 30s at time of death. Most had contact with the public mental health system and half were recorded as being diagnosed with an anxiety disorder.
Conclusion: Our data highlight that
CSA victims are at increased risk of suicide and accidental
fatal drug overdose. CSA is a risk factor that mediates
suicide and fatal overdose.
In a review of pediatric hospital
emergency room admissions over 7 yrs, 505 621 yr olds
who had attempted suicide were identified. There were 3
times as many girls as boys, and the boys were significantly
younger. Features that distinguished them from 505 matched
controls were religion, living situation, substance abuse,
current psychiatric illness, prior psychotherapy, and
current medical illness. Their families had more psychiatric
illness (primarily drug or alcohol abuse), suicide, paternal
unemployment, and paternal and maternal absence than the
controls' families. The suicide attempts usually occurred in
the winter, after school or in the evening, at home with
someone nearby, and by drug overdose. (31 ref) (PsycINFO
Database Record (c) 2016 APA, all rights reserved)
Balancing on the edge of death:
suicide attempts and life-threatening overdoses among drug
Aims. Assessment of prevalence of
non-fatal overdoses and suicide attempts and predictors of
and co-variation between such behaviours among drug addicts.
Design. Cross-sectional survey. Setting. Inpatient and
outpatient treatment units in Norway. Participants. National
sample of 2051 drug addicts admitted to treatment in Norway
Measurements. Self-reports of suicide attempts and of
life-threatening overdoses from structured interviews with
therapists. Findings. Almost half (45.5%) the clients
reported having experienced one or more life-threatening
overdoses. A third (32.7%) reported one or more suicide
attempts. Suicide attempts were more often reported among
those who had overdosed (odds ratio (OR) = 6.3), and the
number of life-threatening overdoses and number of suicide
attempts were positively and moderately associated
(Pearson's r = 0.39). Drug addicts who had exhibited both
life-threatening behaviours were characterized by polydrug
use, poor social functioning and HIV risk-taking behaviour.
Suicide attempters were also characterized by psychiatric
problems. Conclusions. The substantial co-variation between
suicide attempts and drug overdose suggests some common
underlying causal factors. These seem to be related to heavy
drug use and poor social integration.
There is a lack of international research on suicide by drug overdose as a preventable suicide method. Sex- and age-specific rates of suicide by drug self-poisoning (ICD-10, X60-64) and the distribution of drug types used in 16 European countries were studied, and compared with other self-poisoning methods (X65-69) and intentional self-injury (X70-84).
Data for 2000-04/05 were collected from national statistical offices. Age-adjusted suicide rates, and age and sex distributions, were calculated.
No pronounced sex differences in drug self-poisoning rates were found, either in the aggregate data (males 1.6 and females 1.5 per 100,000) or within individual countries. Among the 16 countries, the range (from some 0.3 in Portugal to 5.0 in Finland) was wide. 'Other and unspecified drugs' (X64) were recorded most frequently, with a range of 0.2-1.9, and accounted for more than 70% of deaths by drug overdose in France, Luxembourg, Portugal and Spain. Psychotropic drugs (X61) ranked second. The X63 category ('other drugs acting on the autonomic nervous system') was least frequently used. Finland showed low X64 and high X61 figures, Scotland had high levels of X62 ('narcotics and hallucinogens, not elsewhere classified') for both sexes, while England exceeded other countries in category X60. Risk was highest among the middle-aged everywhere except in Switzerland, where the elderly were most at risk.
Suicide by drug overdose is preventable. Intentional self-poisoning with drugs kills as many males as females. The considerable differences in patterns of self-poisoning found in the various European countries are relevant to national efforts to improve diagnostics of suicide and appropriate specific prevention. The fact that vast majority of drug-overdose suicides came under the category X64 refers to the need of more detailed ICD coding system for overdose suicides is needed to permit better design of suicide-prevention strategies at national level.
Choice of suicide method is influenced by such factors as availability of means, cultural acceptance, suicidal intent and individual preference . The methods chosen have a major bearing on differential outcomes of suicidal acts. Lethal methods (firearms, drowning and hanging) predominantly characterise suicide while less lethal ones (cutting and poisoning) are often used for suicide attempts [1, 46]. Females' preferred method is drug overdose, which is not usually lethal, whereas males tend to prefer more lethal methods [2, 5]. Methods thus partially explain the sex paradox: although females are more commonly diagnosed as depressed and their suicide attempts are registered more frequently [6, 7], males' suicide rates are considerably higher in most countries .
Research into suicide methods has mostly explored drug self-poisoning as one of several method categories [1, 9, 10]. Use of specific drugs has prompted proposals to restrict their availability . Some studies have observed an association between rates of suicide and/or attempted suicide and sale of specific medicines or classes of drugs [1416, 1921]. Studies exploring other forms of self-poisoning, such as charcoal-burning  and pesticide ingestion [23, 24] focusing mainly on Asian countries, have helped somewhat in formulation of medical management guidelines. Comparative European research on suicidal self-poisoning acts using drugs is lacking.
Previous studies based on data from member countries in the 'European Alliance Against Depression' (EAAD) [25, 26] have shown that self-poisoning is the second or third most frequent suicide method for females and males alike. It accounts for a quarter of all female suicides overall and almost half of all female suicides in some countries studied, including Finland, Iceland, England and Scotland .
Our study examined rates of sex- and age-specific self-poisoning suicide (ICD-10, X60-64) and determined the category composition of drugs used in 16 European countries. Comparisons were made with other means of self-poisoning (X65-69) and intentional self-harm (X70-84).
Data for 2000-04/2005 were collected from 16 member countries in the EAAD project funded by the European Commission. Since data on method-specific suicides are not available from the WHO databank, male and female suicide numbers in 10-year age groups and the respective population data were compiled from the participants' national statistical offices. For the UK, English and Scottish data were collected separately. Belgium is represented by Flanders. A detailed description of the data sources is given elsewhere [9, 10].
Data based on the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10, WHO 1992) were available from Belgium, Estonia, Finland, France, Germany, Hungary, Iceland, Luxembourg, the Netherlands, Portugal, Scotland, Slovenia, Spain and Switzerland. Self-poisoning with drugs and other substances (codes X60-64 and X65-69) and self-harm (X70-84) were analysed separately. Fatal self-poisoning was identified using ICD-9 (WHO 1978), codes E950-E959, for England in 2000, Portugal in 2000-01 and Ireland for the entire study period. Table 1 lists the five ICD-10 categories of intentional self-poisoning with drugs. No category breakdown was possible for Ireland because the relevant ICD-9 and ICD-10 classifications were not comparable.
Table 1 Male and female age adjusted suicide rates per 100 000 and rate ratios, distributed by poisonings and injuries in 16 European countries, means of the years 2000-2004/5
Annual age- and sex-specific suicide rates were calculated for the 16 countries individually and as a combined EAAD dataset, with age-adjusted rates per 100,000 based on a European standard population . To assess linear correlation (+1 to -1) between national male and female rates of fatal, intentional drug overdose, Pearson correlation coefficients were calculated.
Overall, annual self-poisoning suicides averaged 2,511 for males and 2,580 for females in 2000-04/2005. As Table 1 shows, the 16 countries' data indicate that male suicides are much more likely to be due to self-harm (including hanging, drowning, shooting and jumping). Male rates of self-poisoning not involving drugs also exceeded female rates in all countries studied. Intentional drug overdoses were almost equally frequent among males and females: 1.6 and 1.5 respectively per 100,000 in the 16 countries combined. Finland had the highest rates for both sexes.
The male-to-female ratio of suicide by drug self-poisoning in the aggregate data was 1.1, ranging from 0.8 (Estonia) to 1.4 (Iceland) in individual countries. For other self-poisoning the aggregate male-to-female ratio was 3.7, and for self-harm 3.9. Males' and females' drug-overdose rates in the countries studied were strikingly similar (r = 0.97). Rates of male and female self-injury (r = 0.88) and self-poisoning not involving drugs (r = 0.67) also showed high positive correlation.
As Table 2 shows, for both sexes in the combined data set, the vast majority of drug-overdose suicides were registered as X64 ('Intentional self-poisoning by and exposure to other and unspecified drugs, medicaments and biological substances'), followed by X61 ('antiepileptic, sedative-hypnotic, antiparkinsonism and psychotropic drugs, not elsewhere classified'). The X63 category ('other drugs acting on the autonomic nervous system') was least frequently used. Category proportions of drugs used for overdose varied widely, but were similar for both sexes in each country. In France, Luxembourg, Portugal and Spain, X64 drugs accounted for more than 70% of overdoses. Finland showed low X64 and high X61 figures. Scotland had high levels of X62 ('narcotics and psychodysleptics [hallucinogens], not elsewhere classified') classification for both sexes, while England exceeded other countries in category X60 ('nonopioid analgesics, antipyretics and antirheumatics').
Table 2 Percent distribution of drug poisoning suicides (X60-X64 by ICD-10) in 16 European countries by gender, means of the years 2000-2004/5
The highest rates of drug self-poisoning suicide in the combined dataset were found in males aged 35-54 and females aged 45-54 (Table 3). The 15-24 age group had the lowest rates for both sexes. For males, rates fell off in the 55-64 age group but were slightly elevated among those aged 65+. For females, rates in both the 55-64 and the older (65+) age group were consistently lower.
Table 3 Male and female suicide rates per 100 000, poisoning by drugs (X60-X64 by ICD 10) by age groups in 16 European countries, means of 2000-2004/5
Scotland had the highest drug-overdose suicide rates in the 15-24 age group. Among people aged 25-34 Finland, Iceland and Scotland had the highest rates. For the 65+ age group, remarkably high rates of suicide by drug self-poisoning were found in Switzerland (females 12.31, males 12.25 per 100,000) and the lowest for females in Spain (0.2/100,000) and males in Estonia (0.2/100.000) (Table 3).
This study focused on drug-overdose suicides (ICD-10, X60-64) in recent years, comparing their prevalence and effects of sex and age in the 16 member countries of the European Commission's 'European Alliance Against Depression' (EAAD) project.
Sex and country differences
Sex is clearly a major demographic factor in choice of suicide methods [1, 10, 28]. The recent EAAD study showed that more than a quarter of female suicides involved intentional self-poisoning with drugs, while for males drug self-poisoning accounted for less than 10% . Several factors explain why females ingest drugs for suicidal purposes relatively often. Townsend  suggested that females' weaker intention to die may contribute to their high rates of drug overdose. Lester  associated the female preference for drug use in suicidal acts with greater concern for bodily appearance after death, and painlessness as one reason for this preference. Shapira  stressed males' greater propensity to violence. Regarding availability of means, Moller-Leimkuhler  cited the association between females' greater propensity to major depression and availability of prescription drugs, while linking males' higher suicide rate with their more frequent gun ownership.
Despite the sexes' different rates of drug overdose, the present study highlights the similarity of drug self-poisoning rates in most countries and in the aggregate data (1.6 and 1.5 respectively). This similarity is independent of the countries' overall suicide rates and male-to-female ratios. Males' far higher overall suicide rates are due to injury deaths, which were nearly four times higher than in females, while for drug overdoses the male-to-female ratio was very close to 1.
For parasuicide, unlike completed suicide, drug self-poisoning is a high-ranking method for both sexes, indicating its low lethality. The WHO/EURO Multicentre Study on Parasuicide reported that in 14 European countries, 73% of male and 84% of female suicide attempts were due to drug overdoses . The conclusion was that, in the context of overall suicidality, drugs warrant great attention as means. The relatively rarity of fatal outcomes may be due to effective toxicological aid; thus, many suicide attempters using drugs survive and are excluded from suicide statistics. Nevertheless, the WHO/EURO study showed striking differences in drug-overdose rates between countries. This is consistent with the present study's findings on completed suicides.
The country comparisons showed striking variations in sex rates, with implications for preventive policies. In Finland, rates of intentional drug-overdose death are particularly high for both sexes; drug overdoses cause half of the female suicides. Iceland, Scotland, Hungary and Switzerland are other high-risk countries in terms of both sexes' overdose rates, perhaps reflecting the availability of certain drugs, such as antidepressants and psychotropics . Improving depression treatment may lower suicide rates, but prescription drugs can be used for suicidal purposes. More attention should therefore be paid to preventive measures in medical management.
Subcategories of drugs involved in self-poisoning
Combined data from the countries studied show that, in more than half the cases of male and female suicide by overdose, drugs from the X64 category predominate. Since this category includes 'other and unspecified drugs', data recording is likely to be poor. It may be suspected that doctors issuing death certificates are unwilling to work on detecting drugs taken by the deceased or, in the event of multiple drug use, whether an X64 drug was included. Overall, this category needs refining in terms of, for example, drug combinations, unidentified drugs and biological substances.
Efforts should be made to improve recording systems and investigation procedures, especially in France, Luxembourg, Portugal and Spain, where category X64 drugs are implicated in more than 70% of overdose suicides. The small proportions of X64 drugs in Finland and Scotland reflect careful diagnostics of drugs used for overdoses.
The second most prevalent drug category, X61, is also heterogeneous. Antiepileptic, sedative-hypnotic, anti-parkinsonism and psychotropic drugs are prescribed by different specialists, making it difficult to develop specific strategies to prevent these suicides by systematically limiting access to these medicines. The greatest potential for prevention may be predicted in Finland and Switzerland.
Previous studies, reporting on sex differences in suicide by drug overdose in such countries as Denmark, England and Australia [11, 12, 21, 30, 31], suggested that drugs in categories X61 and X60 (non-opioid analgesics etc) predominate as means of suicide. The results of the present study show also that X60 drugs are the most frequently ingested in fatal overdoses in Scotland and England , and a much higher rate of self-poisoning with analgesics is reported in the UK than elsewhere in Europe [3, 14].
Scotland and Finland, on the other hand, show high rates of suicide using narcotics (X62). Interpretation is difficult; whether these cases are related to drug addicts' deaths not listed as suicides in other countries is unknown. Drug suicide may be difficult to distinguish from accidental death by overdose.
A comparison of the present study's findings with those of the WHO/Euro Multicentre Parasuicide Study  shows country-specific similarities in the drugs chosen. For attempted and completed suicides alike, overdose rates for some drugs, such as analgesics (X60) in England and Scotland, and psychotropic drugs (X61) in Finland, are high.
Age-specific drug overdose
The overall age distribution of suicide rates is not uniform. They peak around age 50 in males and 60 in females. Countries differ, but within each country male and female patterns are highly similar. In Finland and Scotland, high youth suicide rates cause concern [28, 32]. Several drug-related studies, subject to limitations of geographical area and size, have highlighted the frequency of drug overdose in the elderly. Since drug overdose is the predominant suicide method among people aged 60 and over, careful prescription is imperative in this age group [2, 33].
This study found exceptionally high rates of suicide by drug self-poisoning among the over-65s of both sexes in Switzerland . This partially reflects assisted suicides among the elderly there, and may indicate a need to review the legal basis for assisted suicide, currently offered by two private organisations (EXIT and DIGNITAS) . However, the present study also indicates that both Switzerland and Hungary need to improve suicide prevention among the elderly, perhaps through efforts to enhance their quality of life.
Compared with highly lethal methods, prevention of drug-related suicide across the lifespan has attracted little attention , because using drugs is among the least lethal methods [4, 10]. Intentional drug overdose, widely used by suicidal individuals, is relatively non-lethal partly because of its distinctive delay between initiation of the suicidal act and death. This delay offers ample scope for prevention: better potential for detection and intervention, and anticipated advances in medical toxicology. Success in these endeavours could turn potentially fatal suicides into suicide attempts. Preventive measures, being far more cost-effective, should nonetheless be given priority.
The number of intentional lethal self-poisoning acts may be underestimated because a sizeable proportion of those who commit them reach hospital alive, but then die from complications. These deaths are not reported as suicides in mortality statistics. The long-term impact of chronic liver damage from paracetamol poisoning is also worth mentioning [14, 16, 18]. A further factor contributing to underestimation may be that since death by poisoning lacks a dramatic visible outcome (unlike hanging or firearm use), families can conceal the real cause of death.
Preventing drug use in suicidal acts involves careful and appropriate prescription, particularly to treat mental illnesses. This can be achieved through training of GPs, other physicians and pharmacists [36, 37]. Overdose safety should be a key criterion for selecting drugs for psychiatric treatment, for example choosing between tricyclic antidepressants and newer, safer antidepressants such as selective serotonin reuptake inhibitors (SSRIs) .
Key strategies to reduce self-harm from intentional drug overdose include a public-health approach: informing patients and their families about the dangers of medicines; controlling their availability; and making it easier to dispose of unused tablets . Governments and agencies should be obliged to regulate access to lethal substances, promote training programmes and define international standards. Future development should be based on other countries' best practices, especially those incorporating effective monitoring and evaluation strategies . One such practice may be the 'e-clinic' system being introduced in Estonia, enabling all physicians to share information about their patients' state of health and coordinate prescriptions. However, the e-clinic approach presents real ethical problems regarding extended access to sensitive data.
Contrary to the 'method substitution hypothesis', which suggests that restricting access to some means of suicide results in substitution of alternative methods, numerous studies have demonstrated that such restrictions can reduce the number of completed suicides [36, 37, 39, 40]. Mortality from drug self-poisoning has decreased because of measures to make barbiturates less readily available in Australia , England and Wales , reduce the size of analgesic packs sold over the counter in the UK , improve safety in therapy with psychotropic drugs in Hungary , prescribe less toxic medication and smaller amounts of toxic drugs in Denmark , and withdraw co-proxamol in Scotland . Mann et al.  found that for common methods, restricting means has reduced overall suicide rates, but that it does not entirely discount the method-substitution theory.
Study strengths and limitations
To our knowledge this is the first time that comparative international data on intentional drug overdose have been analysed in separate categories. The data are not publicly available and were collected separately by each country's project participants. They permitted comparison of the countries by sex, age and categories of drugs used for intentional overdose, and reveal that drug ingestion also causes male suicides. The data could be used to improve suicide diagnostics and suicide prevention programmes. The study revealed also the need to redefine the ICD-10 X60-64 codes in more detail.
This study's limitations include its ecological design and aggregate data level, which rule out detailed investigation of the various drug categories, such as drug names or doses taken in overdoses. The ICD-10 X60-64 codes are clearly an inadequate classification for detailed use and lethality detection. Designing prevention programmes calls for a refined coding system. Further research must focus on specific drugs in national samples.
The study years chosen, 2000-04/05, imposed another limitation. Since the ICD-9 and ICD-10 classifications are not comparable, Ireland -- where ICD-9 was used throughout the study period -- is excluded from the category breakdown of overdose drugs presented in Table 2. England was included after ICD-10 superseded ICD-9 in 2001, and Portugal after its mortality registration system was restructured in 2002.
Both sexes use drug self-poisoning, a
preventable suicide method, equally. Overdose patterns vary
widely among the countries, but within them no substantial
divergence in sex and age patterns in drug choice are found.
The comparative data are relevant for improving suicide
registration, designing suicide prevention strategies at
national or regional level and learning best practices of
drug management in countries where drug overdose is
relatively unusual. These data show that drug self-poisoning
merits attention from clinical and public-health viewpoints.
This requires a more detailed ICD coding system for overdose
What is already known about this topic?
Communities have faced mental health challenges related to COVID-19associated morbidity, mortality, and mitigation activities.
What is added by this report?
During June 2430, 2020, U.S. adults reported considerably elevated adverse mental health conditions associated with COVID-19. Younger adults, racial/ethnic minorities, essential workers, and unpaid adult caregivers reported having experienced disproportionately worse mental health outcomes, increased substance use, and elevated suicidal ideation.
What are the implications for public health practice?
The public health response to the COVID-19 pandemic should increase intervention and prevention efforts to address associated mental health conditions. Community-level efforts, including health communication strategies, should prioritize young adults, racial/ethnic minorities, essential workers, and unpaid adult caregivers.
The coronavirus disease 2019 (COVID-19) pandemic has been associated with mental health challenges related to the morbidity and mortality caused by the disease and to mitigation activities, including the impact of physical distancing and stay-at-home orders.* Symptoms of anxiety disorder and depressive disorder increased considerably in the United States during AprilJune of 2020, compared with the same period in 2019 (1,2). To assess mental health, substance use, and suicidal ideation during the pandemic, representative panel surveys were conducted among adults aged =18 years across the United States during June 2430, 2020. Overall, 40.9% of respondents reported at least one adverse mental or behavioral health condition, including symptoms of anxiety disorder or depressive disorder (30.9%), symptoms of a trauma- and stressor-related disorder (TSRD) related to the pandemic (26.3%), and having started or increased substance use to cope with stress or emotions related to COVID-19 (13.3%). The percentage of respondents who reported having seriously considered suicide in the 30 days before completing the survey (10.7%) was significantly higher among respondents aged 1824 years (25.5%), minority racial/ethnic groups (Hispanic respondents [18.6%], non-Hispanic black [black] respondents [15.1%]), self-reported unpaid caregivers for adults§ (30.7%), and essential workers¶ (21.7%). Community-level intervention and prevention efforts, including health communication strategies, designed to reach these groups could help address various mental health conditions associated with the COVID-19 pandemic.
During June 2430, 2020, a total of 5,412 (54.7%) of 9,896 eligible invited adults** completed web-based surveys administered by Qualtrics.§§ The Monash University Human Research Ethics Committee of Monash University (Melbourne, Australia) reviewed and approved the study protocol on human subjects research. Respondents were informed of the study purposes and provided electronic consent before commencement, and investigators received anonymized responses. Participants included 3,683 (68.1%) first-time respondents and 1,729 (31.9%) respondents who had completed a related survey during April 28, May 512, 2020, or both intervals; 1,497 (27.7%) respondents participated during all three intervals (2,3). Quota sampling and survey weighting were employed to improve cohort representativeness of the U.S. population by gender, age, and race/ethnicity.¶¶ Symptoms of anxiety disorder and depressive disorder were assessed using the four-item Patient Health Questionnaire*** (4), and symptoms of a COVID-19related TSRD were assessed using the six-item Impact of Event Scale (5). Respondents also reported whether they had started or increased substance use to cope with stress or emotions related to COVID-19 or seriously considered suicide in the 30 days preceding the survey.§§§
Analyses were stratified by gender, age, race/ethnicity, employment status, essential worker status, unpaid adult caregiver status, rural-urban residence classification,¶¶¶ whether the respondent knew someone who had positive test results for SARS-CoV-2, the virus that causes COVID-19, or who had died from COVID-19, and whether the respondent was receiving treatment for diagnosed anxiety, depression, or posttraumatic stress disorder (PTSD) at the time of the survey. Comparisons within subgroups were evaluated using Poisson regressions with robust standard errors to calculate prevalence ratios, 95% confidence intervals (CIs), and p-values to evaluate statistical significance (a = 0.005 to account for multiple comparisons). Among the 1,497 respondents who completed all three surveys, longitudinal analyses of the odds of incidence**** of symptoms of adverse mental or behavioral health conditions by essential worker and unpaid adult caregiver status were conducted on unweighted responses using logistic regressions to calculate unadjusted and adjusted odds ratios (ORs), 95% CI, and p-values (a = 0.05). The statsmodels package in Python (version 3.7.8; Python Software Foundation) was used to conduct all analyses.
Overall, 40.9% of 5,470 respondents who completed surveys during June reported an adverse mental or behavioral health condition, including those who reported symptoms of anxiety disorder or depressive disorder (30.9%), those with TSRD symptoms related to COVID-19 (26.3%), those who reported having started or increased substance use to cope with stress or emotions related to COVID-19 (13.3%), and those who reported having seriously considered suicide in the preceding 30 days (10.7%) (Table 1). At least one adverse mental or behavioral health symptom was reported by more than one half of respondents who were aged 1824 years (74.9%) and 2544 years (51.9%), of Hispanic ethnicity (52.1%), and who held less than a high school diploma (66.2%), as well as those who were essential workers (54.0%), unpaid caregivers for adults (66.6%), and who reported treatment for diagnosed anxiety (72.7%), depression (68.8%), or PTSD (88.0%) at the time of the survey.
Prevalences of symptoms of adverse mental or behavioral health conditions varied significantly among subgroups (Table 2). Suicidal ideation was more prevalent among males than among females. Symptoms of anxiety disorder or depressive disorder, COVID-19related TSRD, initiation of or increase in substance use to cope with COVID-19associated stress, and serious suicidal ideation in the previous 30 days were most commonly reported by persons aged 1824 years; prevalence decreased progressively with age. Hispanic respondents reported higher prevalences of symptoms of anxiety disorder or depressive disorder, COVID-19related TSRD, increased substance use, and suicidal ideation than did non-Hispanic whites (whites) or non-Hispanic Asian (Asian) respondents. Black respondents reported increased substance use and past 30-day serious consideration of suicide in the previous 30 days more commonly than did white and Asian respondents. Respondents who reported treatment for diagnosed anxiety, depression, or PTSD at the time of the survey reported higher prevalences of symptoms of adverse mental and behavioral health conditions compared with those who did not. Symptoms of a COVID-19related TSRD, increased substance use, and suicidal ideation were more prevalent among employed than unemployed respondents, and among essential workers than nonessential workers. Adverse conditions also were more prevalent among unpaid caregivers for adults than among those who were not, with particularly large differences in increased substance use (32.9% versus 6.3%) and suicidal ideation (30.7% versus 3.6%) in this group.
Longitudinal analysis of responses of 1,497 persons who completed all three surveys revealed that unpaid caregivers for adults had a significantly higher odds of incidence of adverse mental health conditions compared with others (Table 3). Among those who did not report having started or increased substance use to cope with stress or emotions related to COVID-19 in May, unpaid caregivers for adults had 3.33 times the odds of reporting this behavior in June (adjusted OR 95% CI = 1.756.31; p<0.001). Similarly, among those who did not report having seriously considered suicide in the previous 30 days in May, unpaid caregivers for adults had 3.03 times the odds of reporting suicidal ideation in June (adjusted OR 95% CI = 1.207.63; p = 0.019).
Elevated levels of adverse mental health conditions, substance use, and suicidal ideation were reported by adults in the United States in June 2020. The prevalence of symptoms of anxiety disorder was approximately three times those reported in the second quarter of 2019 (25.5% versus 8.1%), and prevalence of depressive disorder was approximately four times that reported in the second quarter of 2019 (24.3% versus 6.5%) (2). However, given the methodological differences and potential unknown biases in survey designs, this analysis might not be directly comparable with data reported on anxiety and depression disorders in 2019 (2). Approximately one quarter of respondents reported symptoms of a TSRD related to the pandemic, and approximately one in 10 reported that they started or increased substance use because of COVID-19. Suicidal ideation was also elevated; approximately twice as many respondents reported serious consideration of suicide in the previous 30 days than did adults in the United States in 2018, referring to the previous 12 months (10.7% versus 4.3%) (6).
Mental health conditions are disproportionately affecting specific populations, especially young adults, Hispanic persons, black persons, essential workers, unpaid caregivers for adults, and those receiving treatment for preexisting psychiatric conditions. Unpaid caregivers for adults, many of whom are currently providing critical aid to persons at increased risk for severe illness from COVID-19, had a higher incidence of adverse mental and behavioral health conditions compared with others. Although unpaid caregivers of children were not evaluated in this study, approximately 39% of unpaid caregivers for adults shared a household with children (compared with 27% of other respondents). Caregiver workload, especially in multigenerational caregivers, should be considered for future assessment of mental health, given the findings of this report and hardships potentially faced by caregivers.
The findings in this report are subject to at least four limitations. First, a diagnostic evaluation for anxiety disorder or depressive disorder was not conducted; however, clinically validated screening instruments were used to assess symptoms. Second, the trauma- and stressor-related symptoms assessed were common to multiple TSRDs, precluding distinction among them; however, the findings highlight the importance of including COVID-19specific trauma measures to gain insights into peri- and posttraumatic impacts of the COVID-19 pandemic (7). Third, substance use behavior was self-reported; therefore, responses might be subject to recall, response, and social desirability biases. Finally, given that the web-based survey might not be fully representative of the United States population, findings might have limited generalizability. However, standardized quality and data inclusion screening procedures, including algorithmic analysis of click-through behavior, removal of duplicate responses and scrubbing methods for web-based panel quality were applied. Further the prevalence of symptoms of anxiety disorder and depressive disorder were largely consistent with findings from the Household Pulse Survey during June (1).
Markedly elevated prevalences of reported adverse mental and behavioral health conditions associated with the COVID-19 pandemic highlight the broad impact of the pandemic and the need to prevent and treat these conditions. Identification of populations at increased risk for psychological distress and unhealthy coping can inform policies to address health inequity, including increasing access to resources for clinical diagnoses and treatment options. Expanded use of telehealth, an effective means of delivering treatment for mental health conditions, including depression, substance use disorder, and suicidal ideation (8), might reduce COVID-19-related mental health consequences. Future studies should identify drivers of adverse mental and behavioral health during the COVID-19 pandemic and whether factors such as social isolation, absence of school structure, unemployment and other financial worries, and various forms of violence (e.g., physical, emotional, mental, or sexual abuse) serve as additional stressors. Community-level intervention and prevention efforts should include strengthening economic supports to reduce financial strain, addressing stress from experienced racial discrimination, promoting social connectedness, and supporting persons at risk for suicide (9). Communication strategies should focus on promotion of health services§§§§,¶¶¶¶,***** and culturally and linguistically tailored prevention messaging regarding practices to improve emotional well-being. Development and implementation of COVID-19specific screening instruments for early identification of COVID-19related TSRD symptoms would allow for early clinical interventions that might prevent progression from acute to chronic TSRDs. To reduce potential harms of increased substance use related to COVID-19, resources, including social support, comprehensive treatment options, and harm reduction services, are essential and should remain accessible. Periodic assessment of mental health, substance use, and suicidal ideation should evaluate the prevalence of psychological distress over time. Addressing mental health disparities and preparing support systems to mitigate mental health consequences as the pandemic evolves will continue to be needed urgently.
Disorders classified as TSRDs in the Diagnostic and Statistical Manual of Mental Disorders (DSM5) include posttraumatic stress disorder (PTSD), acute stress disorder (ASD), and adjustment disorders (ADs), among others.
§ Unpaid adult caregiver status was self-reported. The definition of an unpaid caregiver for adults was a person who had provided unpaid care to a relative or friend aged =18 years to help them take care of themselves at any time in the last 3 months. Examples provided included helping with personal needs, household chores, health care tasks, managing a persons finances, taking them to a doctors appointment, arranging for outside services, and visiting regularly to see how they are doing.
¶ Essential worker status was self-reported. The comparison was between employed respondents (n = 3,431) who identified as essential versus nonessential. For this analysis, students who were not separately employed as essential workers were considered nonessential workers.
** A minimum age of 18 years and residence within the United States as of April 28, 2020, were required for eligibility for the longitudinal cohort to complete a survey during June 2430, 2020. Residence was reassessed during June 2430, 2020, and one respondent who had moved from the United States was excluded from the analysis. A minimum age of 18 years and residence within the United States were required for eligibility for newly recruited respondents included in the cross-sectional analysis. For both the longitudinal cohort and newly recruited respondents, respondents were required to provide informed consent before enrollment into the study. All surveys underwent data quality screening procedures including algorithmic and keystroke analysis for attention patterns, click-through behavior, duplicate responses, machine responses, and inattentiveness. Country-specific geolocation verification via IP address mapping was used to ensure respondents were from the United States. Respondents who failed an attention or speed check, along with any responses identified by the data-scrubbing algorithms, were excluded from analysis.
The surveys contained 101 items for first-time respondents and 86 items for respondents who also participated in later surveys, with the 15 additional items for first-time respondents consisting of questions on demographics. The survey instruments included a combination of individual questions, validated questionnaires, and COVID-19-specific questionnaires, which were used to assess respondent attitudes, behaviors, and beliefs related to COVID-19 and its mitigation, as well as the social and behavioral health impacts of the COVID-19 pandemic.
§§ https://www.qualtrics.com/external icon.
¶¶ Survey weighting was implemented according to the 2010 U.S. Census with respondents who reported gender, age, and race/ethnicity. Respondents who reported a gender of Other, or who did not report race/ethnicity were assigned a weight of one.
*** Symptoms of anxiety disorder and depressive disorder were assessed via the four-item Patient Health Questionnaire (PHQ-4). Those who scored =3 out of 6 on the Generalized Anxiety Disorder (GAD-2) and Patient Health Questionnaire (PHQ-2) subscales were considered symptomatic for these respective disorders. This instrument was included in the April, May, and June surveys.
Symptoms of a TSRD attributed to the COVID-19 pandemic were assessed via the six-item Impact of Event Scale (IES-6) to screen for overlapping symptoms of PTSD, ASD, and ADs. For this survey, the COVID-19 pandemic was specified as the traumatic exposure to record peri- and posttraumatic symptoms associated with the range of stressors introduced by the COVID-19 pandemic. Those who scored =1.75 out of 4 were considered symptomatic. This instrument was included in the May and June surveys only.
§§§ For this survey, substance use was defined as use of alcohol, legal or illegal drugs, or prescriptions drugs that are taken in a way not recommended by your doctor. Questions regarding substance use and suicidal ideation were included in the May and June surveys only. Participants were informed that responses were deidentified and that direct support could not be provided to those who reported substance use behavior or suicidal ideation. Regarding substance use, respondents were provided the following: This survey is anonymous so we cannot provide direct support. If you would like crisis support please contact the Substance Abuse and Mental Health Services Administration National Helpline, 1-800-662-HELP (4357), (also known as the Treatment Referral Routing Service) or TTY: 1-800-487-4889. This is a confidential, free, 24-hour-a-day, 365-day-a-year, information service, in English and Spanish, for persons and family members facing mental and/or substance use disorders. Regarding suicidal ideation, respondents were provided the following: This survey is anonymous so we cannot provide direct support. If you would like crisis support please contact the National Suicide Prevention Lifeline, 1-800-273-TALK (8255, or chat line) for help for themselves or others.
¶¶¶ Rural-urban classification was determined by using self-reported ZIP codes according to the Federal Office of Rural Health Policy definition of rurality. https://www.hrsa.gov/rural-health/about-us/definition/datafiles.htmlexternal icon.
**** Odds of incidence was defined as the odds of the presence of an adverse mental or behavioral health outcome reported during a later survey after previously having reported the absence of that outcome (e.g., having reported symptoms of anxiety disorder during June 2430, 2020, after not having reported symptoms of anxiety disorder during April 28, 2020).
Adjusted for gender, employment status, and essential worker status or unpaid adult caregiver status.
§§§§ Disaster Distress Helpline (https://www.samhsa.gov/disaster-preparednessexternal icon): 1-800-985-5990 (press 2 for Spanish), or text TalkWithUs for English or Hablanos for Spanish to 66746. Spanish speakers from Puerto Rico can text Hablanos to 1-787-339-2663.
¶¶¶¶ Substance Abuse and Mental Health Services Administration National Helpline (also known as the Treatment Referral Routing Service) for persons and families facing mental disorders, substance use disorders, or both: https://www.samhsa.gov/find-help/national-helplineexternal icon, 1-800-662-HELP, or TTY 1-800-487-4889.
***** National Suicide Prevention Lifeline (https://suicidepreventionlifeline.org/external icon): 1-800-273-TALK for English, 1-888-628-9454 for Spanish, or Lifeline Crisis Chat (https://suicidepreventionlifeline.org/chat/external icon).
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Abbreviations: CI = confidence
interval; COVID-19 = coronavirus disease 2019; PTSD =
posttraumatic stress disorder; TSRD = trauma- and