Thursday, May 26, 2011

Women, Pain Relievers, & Suicide: An Epidemic?

Suicide With all the emphasis lately on the alleged epidemic of overdoses and deaths associated with prescription opioids an overlooked dark secret is that pain relievers — both Rx and over-the-counter — are increasingly used in suicide attempts, particularly by women. Better strategies than prescriber education and restricting access to these medications are needed for effectively dealing with this other “epidemic.”

A newly published nationwide study in the U.S. shows that from 2005 to 2009 (the most recent year with available data) emergency department (ED) visits for drug related suicide attempts by women of all ages increased from 92,682 to 120,418. Of particular concern, suicide attempts by women aged 50 and older rose by 49% — from 11,235 to 16,757 during the 5-year period — the greatest increase for any age group [SAMHSA 2011].

Data are from the Drug Abuse Warning Network (DAWN) report from the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA). DAWN is a public health surveillance system that monitors drug-related hospital ED visits reported throughout the nation. The data include only suicide attempts involving drugs (excluding alcohol as a sole agent), although the drug also may be present in a suicide attempt by other means (eg, cutting wrists after taking the drug).

During the 5-year study period, ED visits for suicide attempts among females involving pain relievers rose more than 30%, from 36,563 to 47,838. Within that general class of drugs, cases involving “narcotic” (ie, opioid) pain relievers overall increased 61%, with hydrocodone implicated to the greatest extent and increasing 67% from 4,613 to 7,715 cases. Interestingly, in 2009 alone there were 15,517 attempted suicides with acetaminophen and 11,192 involving ibuprofen — both sold over-the-counter in the U.S. — which, combined, exceeded the total 17,348 cases involving all opioids that year.

Significant numbers of ED visits for suicide attempts involving other prescription drugs also increased dramatically. For example, cases of suicide attempts by women involving drugs to treat anxiety and insomnia — such as clonazepam and zolpidem — increased 56% during 2005 to 2009. Other agents, including antidepressants and antipsychotic agents, also were involved in increasing incidences of suicide attempts by women across all age groups.

Importantly, DAWN data do not include information that might help to explain factors behind the suicide attempts, such as mental illness and/or intractable chronic pain. This might be of special concern in older women, who had the greatest increases in suicide attempts. The SAMHSA report does acknowledge, “The physical and mental health needs of women vary across the life span, and older women represent one of the Nation’s fastest growing populations.” However, the agency offers no solutions in the report, other than a call for “expanded research on women’s aging issues.”

COMMENTARY: Men have higher suicide death rates but women are treated for attempted suicide more often than men; for example, in 2009, females were involved in 3 out of 5 ED visits for drug-related suicide attempts. While the misuse and abuse of opioid analgesics has garnered much attention these days, suicide attempts involving these agents may relate to another epidemic — the undertreatment or mistreatment of pain.

A grim reality is that patients with chronic pain often stockpile prescribed opioid pain relievers for use if they cannot continue to access adequate pain care. This may be a special concern in aging persons with intractable pain, who have diminished quality of life, are depressed, and have lost hope of any recovery. They well know that opioids — and a host of other potent drugs they may have on hand — can be used for suicide. In this regard, efforts to further control prescribing and restrict access to opioids may be ultimately misguided; in fact, the suicide “epidemic” might be exacerbated due to more limited access to adequate pain care and increasing incidences of unrelieved chronic pain in all age groups.

In a news release, Pamela S. Hyde, JD, SAMHSA Administrator said, “The steep rise in abuse of narcotic pain relievers by women is extremely dangerous and we are now seeing the result of this public health crisis in our emergency rooms. Emergency rooms should not be the frontline in our efforts to intervene. Friends, family and all members of the community must do everything possible to help identify women who may be in crisis and do everything possible to reach out and get them needed help.”

Indeed, we have previously advocated for greater involvement by communities and families in addressing substance misuse, abuse, and diversion problems. And, this certainly also applies to suicide prevention. However, we also have questioned what the government is doing to help; other than their providing a variety of surveys and data, often out-of-date, that sound alarms about escalating troubles, and then looking for ways to curtail access to vital, albeit potentially harmful, medications. New mandates coming from federal and state agencies requiring practitioner education on the prescribing of opioids, and some limiting amounts that can be prescribed, are unlikely to address the suicide issues.

In fair balance, we must note that SAMHSA has funded a National Suicide Prevention Lifeline (1-800-273-TALK [8255]) that can be called for round-the-clock, immediate assistance anywhere in the U.S. Perhaps, other countries have a similar resource available, since the “epidemic” of suicides most likely related to unresolved pain is certainly not exclusively an American tragedy. In fact, one study in Canada spanning 14 years found that nearly a quarter of fatal overdoses involving opioids were suicides [see UPDATE here].

REFERENCE: SAMHSA. DAWN Report. Trends in Emergency Department Visits for Drug-Related Suicide Attempts among Females: 2005-2009. 2011(May 12) [PDF available here].