Opioid Discontinuation increases the risk of suicide by as much as 6.8 times. The failure to treat people with opioids is also a risk, since untreated chronic pain itself can quadruple the risk of suicide, even in people without depression.

Prescription opioid restrictions helped fuel the doubling of suicide and accidental overdose deaths between 2000 to 2017. Research published in 2020 and funded by the Veteran’s Administration found vets forced to discontinue opioids were 4 to 6.8 times more likely to die by suicide or accidental overdose than vets who continued treatment (Oliva). Similarly, a 2017 VA study found stopping opioid treatment following signs of substance use put vets at 2.4 times the risk for suicidal ideation and 6 times the risk for self-harm and suicide. Substance use itself was “insufficient to to precipitate these suicidal thoughts and behaviors” (Demidenko).

In 2019, researchers reported that primary-care providers tripled their patients’ risk of suicide by discontinuing opioid therapy. Patients whose providers initiated discontinuation were at increased risk, and providers initiated discontinuation in at least 77% of cases (James). The 2020 VA team, led by their National Opioid Overdose Education Coordinator, attributed higher overdose rates following discontinuation to “unmanaged pain, or symptoms of opioid withdrawal and mood instability, which could have driven other risky strategies to obtain relief (eg, illicit opioids, sedating medications, self-harm)” (Oliva). Researchers who studied discontinuation in primary-care patients also identified “poorly managed chronic pain” as a probable cause of the rise in deaths (James).

Reports of “serious harm” following opioid discontinuation led the Food and Drug Administration to add warnings against rapid tapers and sudden discontinuation to the official prescribing information for all opioids. The FDA cautions patients directly, “do not suddenly stop taking your medicine” before formulating a plan with providers “to slowly decrease the dose of the opioid and continue to manage your pain.” The Agency urges patients to “contact your health care professional if you experience increased pain, withdrawal symptoms, changes in your mood, or thoughts of suicide.” These warnings do no good when providers push patients off opioid analgesics, often without warning or taper, in more than three-quarters of cases.

In Vermont, for example, hundreds of Medicaid recipients were forced off established opioid scripts above 120 MME with no taper. Half of the 490 affected patients were stopped cold; 86% were tapered in under 3 weeks, at least 13 times faster than CDC now recommends. It’s little wonder that half “subsequently had an adverse opioid-related health care event”: 91% were seen in Emergency Departments, 9% required hospitalization (Mark). But as Kertesz notes in “Outcomes After Opioid Dose Reductions and Stoppage,” this study “could only capture the first harm detectable in a payer database. Under-detection of harm is likely. If an ED visit was followed by worsening disability, for example, that’s not in these data.” No one tracks whether patients like Vermont’s Medicaid recipients die after being forced down or off opioids. But because the National Committee for Quality Assurance (NCQA) demarcated opioid scripts above 120 MME as “poor care,” by the “metrics put forward by NCQA, any reduction in this number indicates an improvement in care” (Kertesz).

The authors of 2019 research published in the Journal of the American Medical Association found dose fluctuation puts patients at such “significant risk” of unintentional overdose that they recommend practitioners “seek to minimize dose variability when managing long-term opioid therapy” That’s exactly the opposite of what states, practices, hospitals, and insurers now recommend or mandate. The authors note that the rise in overdoses caused by dose fluctuations helps explain why “substantial reductions in opioid prescribing” have not led to “significant decreases” overdoses (Glanz). The policy itself is killing people.

The answer is not to stop prescribing opioids in the first place. A 2016 paper funded by the Veteran’s Administration and published in the journal Pain cites 10 studies linking chronic pain to an increased suicide risk, noting the association “remains significant even after controlling for other psychiatric disorders, consistent with the interpretation that pain increases suicide risk above and beyond the association between pain and depression” (Ilgen).

Indeed, chronic pain at least doubles a person’s risk for suicide, and half the risk factors identified by a highly-cited review are pain-specific, including the type, intensity, and duration of pain and the presence of pain-related insomnia. “Sleep-onset insomnia severity alone explained 67% of the variance” between people with suicidal ideation from depression and those with somatic symptoms like pain and insomnia. Feelings of helplessness and hopelessness increase the likelihood of self-harm and suicide (Tang).

Two FDA-approved classes of medicines can protect patients with chronic pain and insomnia from sucide: benzodiazepines (like Ativan) and opioids. The CDC Guideline urges primary-care providers (its intended audience) to consider offering naloxone when factors increase risk for opioid overdose, such as concurrent benzodiazepine use, judicious advice for prescribers who may be unfamiliar with the possible risks of prescribing an opioid for pain and Ativan for insomnia or seizures, two conditions often comorbid with painful diseases like migraine. Instead, patients like the woman whose case we profile below are told to “choose between pain and sleep,” that is, between an opioid or a benzodiazepine. She added, “Then, they tell me they are taking my sleep meds as well. Guess it wasn't really a choice.”

Specific painful diseases also increase the risk of pain even without comorbid depression or anxiety. Migraine and severe headache, for example, quadruple a person’s risk for suicide, a risk that increases by 17% with each 1-point rise in average pain intensity on the standard 10-point scale. That means a 30% decrease in pain from an opioid analgesic can cut a migraine patient’s risk of suicide in half (Breslau). Importantly, mere access to opioid medicines does not increase the risk of suicide. Patients with pain are no more likely to choose overdose as their means of death than those without pain (Ilgen).

Pain expert B. Eliot Cole asks, “If an individual patient has no problems associated with the use of 120, 180 or 240 mg of morphine equivalent on a daily basis, why do we need to reduce that dose? If an individual patient is functioning well with opioid therapy after 90 days, and there is no better treatment available, why would we stop treatment and inflict worsening pain?”

The duty to do no harm must compel doctors to put the lives of their patients above the goal of lowered scripts and lowered dosages. People’s lives are on the line.

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Annotated List of Sources

Dasgupta N, Funk MJ, Proescholdbell S, Hirsch A, Ribisl KM, Marshall S. Cohort study of the impact of high-dose opioid analgesics on overdose mortality. Pain Medicine. 2016 Jan 1;17(1):85-98. https://academic.oup.com/painmedicine/article/17/1/85/1752837

Demidenko MI, Dobscha SK, Morasco BJ, Meath TH, Ilgen MA, Lovejoy TI. Suicidal ideation and suicidal self-directed violence following clinician-initiated prescription opioid discontinuation among long-term opioid users. General Hospital Psychiatry. 2017 Jul 1;47:29-35.

https://www.suicideinfo.ca/wp-content/uploads/gravity_forms/6-191a85f36ce9e20de2e2fa3869197735/2017/10/opioid-users.pdf

12% of vets had suicidal ideation (SI) or suicidal self-directed violence (SSV) in the year following opioid discontinuation (9.2% with SI; 2.4% with SSV), 2.4 times the rate of ideation and 6 times the risk of self-harm when compared to a community sample of vets. The study’s authors think it’s “likely” that they “underestimated the actual proportion of patients who experienced SI or SSV in the year following discontinuation of opioid therapy.”

“Substance use disorder diagnoses in general were unrelated to SI/SSV in the current study. Among veterans, substance use disorder diagnoses have been shown to be unrelated to suicide outcomes after controlling for mental health variables.” Source for that final sentence is Dobscha. See also Oliva.

Dobscha SK, Denneson LM, Kovas AE, Teo A, Forsberg CW, Kaplan MS, Bossarte R, McFarland BH. Correlates of suicide among veterans treated in primary care: Case–control study of a nationally representative sample. Journal of general internal medicine. 2014 Dec 1;29(4):853-60.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4239287/

Researchers “did not detect significant relationships” between “substance (including alcohol) use disorder diagnoses, the psychosocial context variables, and suicide.” See also Demindenko and Oliva.

Fink DS, Schleimer JP, Sarvet A, Grover KK, Delcher C, Castillo-Carniglia A, Kim JH, Rivera-Aguirre AE, Henry SG, Martins SS, Cerdá M. Association between prescription drug monitoring programs and nonfatal and fatal drug overdoses: a systematic review. Annals of Internal Medicine. 2018 Jun 5;168(11):783-90.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6015770/

“Evidence that PDMP implementation either increases or decreases nonfatal or fatal overdoses is largely insufficient”: “Low-strength evidence from 10 studies suggested a reduction in fatal overdoses with PDMP implementation,” but 3 studies “found an increase in heroin overdoses after PDMP implementation.”

Fishbain DA, Bruns D, Disorbio JM, Lewis JE. Risk for five forms of suicidality in acute pain patients and chronic pain patients vs pain-free community controls. Pain Medicine. 2009 Sep 1;10(6):1095-105.

https://academic.oup.com/painmedicine/article/10/6/1095/1843570

24.85% of people with acute pain and 34.9% of those with CP reported a history of wanting to die; the risk for such lifetime passive suicidal ideation was 1.38 (acute), 1.93 (CP). 5.83% of people with acute pain and 9.38% with CP reported frequent active ideation; the risk was 1.84 (acute), 2.97 (CP).

7.06% and 7.92% reported having a suicide plan; the risk was 4.26 (acute), 4.78 (CP) times that of healthy people. 14.11% (acute) and 20.53% (CP)--one-fifth--had attempted suicide; the risk was 2.23 and 3.25 times higher than healthy controls.

Fishbain DA, Goldberg M, Rosomoff RS, Rosomoff H. Completed suicide in chronic pain. The clinical journal of pain. 1991 Mar;7(1):29-36. https://europepmc.org/article/med/1809412

1st paper on the association of CP & suicide found rate of completed suicide among CPPs was two to three times that of the general population.

Glanz JM, Binswanger IA, Shetterly SM, Narwaney KJ, Xu S. Association Between Opioid Dose Variability and Opioid Overdose Among Adults Prescribed Long-term Opioid Therapy. JAMA Network Open. 2019;2(4):e192613. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2730786

“Attempts to discontinue opioid therapy to reduce the risk of overdose and adhere to prescribing guidelines may lead patients to be exposed to variability in opioid dosing. Such dose variability may increase the risk of opioid overdose” by greater than 3-fold “even if therapy discontinuation is associated with a reduction in risk.”

“Although practice guidelines have led to substantial reductions in opioid prescribing across the United States, significant decreases in pharmaceutical opioid overdose have not been documented. It is thus possible that unexamined prescribing practices or unintended consequences of prescribing policies are contributing to persistently elevated pharmaceutical opioid overdose rates.”

Ilgen MA, Bohnert AS, Ganoczy D, Bair MJ, McCarthy JF, Blow FC. Opioid dose and risk of suicide. Pain. 2016 May;157(5):1079.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4939394/

James JR, Scott JM, Klein JW, Jackson S, McKinney C, Novack M, Chew L, Merrill JO. Mortality after discontinuation of primary care–based chronic opioid therapy for pain: a retrospective cohort study. Journal of General Internal Medicine. 2019 Dec 1;34(12):2749-55. https://link.springer.com/article/10.1007/s11606-019-05301-2

“Discontinuation of chronic opioid therapy was associated with a hazard ratio for death of 1.35 and for overdose death of 2.94.” 4.9% of discontinued patients died of overdose, while 1.75% of retained patients died of overdose. Most patients had at least one provider-initiated reason for COT discontinuation.

Mark TL, Parish W. Opioid medication discontinuation and risk of adverse opioid-related health care events. Journal of Substance Abuse Treatment. 2019 Aug 1;103:58-63. https://www.sciencedirect.com/science/article/abs/pii/S0740547219300376

Oliva EM, Bowe T, Manhapra A, Kertesz S, Hah JM, Henderson P, Robinson A, Paik M, Sandbrink F, Gordon AJ, Trafton JA. Associations between stopping prescriptions for opioids, length of opioid treatment, and overdose or suicide deaths in US veterans: observational evaluation. BMJ. 2020 Mar 4;368. https://www.bmj.com/content/368/bmj.m283.long

Patients are at up to 6.8 times the risk of suicide or overdose after stopping opioid treatment. 2,887 veterans died from overdose or suicide after their opioid medicines were discontinued in FY 2013. “Stopping treatment was associated with an increased risk of death from overdose or suicide regardless of the length of treatment, with the risk increasing the longer patients were treated.” Death rates “increased immediately after starting or stopping treatment with opioids, with the incidence decreasing over about three to 12 months.”

Tang NK, Crane C. Suicidality in chronic pain: a review of the prevalence, risk factors and psychological links. Psychological Medicine. 2006 May 1;36(5):575.

Tang-Crane full text

2006 paper reviews and integrates 12 studies on suicide & suicidal ideation in people with chronic pain. “The risk of death by suicide appeared to be at least doubled in chronic pain patients” (575). Suicidal ideation is 3 times more common in people with chronic pain compared to healthy individuals with a lifetime prevalence of about 20% in people who live with pain (576).

Eight risk factors for suicidality in chronic pain were identified, half of which are physical, including the type, intensity and duration of pain and sleep-onset insomnia co-occurring with pain, which appeared to be pain-specific. Helplessness and hopelessness about pain, the desire for escape from pain, pain catastrophizing and avoidance, and problem-solving deficits were highlighted as psychological processes relevant to the understanding of suicidality in chronic pain” (575).

Rates of suicide attempts vary widely based on the location of pain, ranging from 5% in those with muscloskeletal pain to 14% in people with chronic abdominal pain. A 1995 study found farmers with back pain were 9 times more likely to die by suicide than those without back pain (576).

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