A virtual avalanche of articles has appeared in the medical literature recently discussing opioid analgesics for chronic pain. Almost without exception, the news and views are disparaging; in some cases reflecting a poor quality of evidence and, in others, conveying biases of the authors. Ongoing concerns about opioid misuse, abuse, and fatalities may be obscuring a problem of equal or greater importance — intentional self-harm, suicide, by drug overdose among persons with chronic pain. It may be time for a rational reassessment of this problem before it is too late.
A prior Pain-Topics UPDATE article [here] cited U.S. government data indicating that drug-related suicide attempts by women specifically involving pain relievers rose more than 30%, to 47,838, between 2005 and 2009. Cases involving opioid analgesics increased 61%; although, suicide attempts involving non-opioid analgesics — acetaminophen and ibuprofen — were even greater in number.
Most recently, the government released comparable data on drug-related suicide attempts by men during 2005 to 2009 [SAMHSA 2011]. In 2009, there were a total of 77,971 emergency department (ED) visits for drug-related suicide attempts among males of all ages; 27,700 involving pain-reliever medications. ED visits for suicide attempts among males aged 35 to 49 involving “narcotic pain relievers” (ie, opioids) almost doubled from 2005 to 2009, while the numbers almost tripled among men aged 50 and older.
Of some importance, there were more than 27,000 cases of attempted suicide by men using drugs that treat anxiety or insomnia. And, while overall numbers of suicide attempts are less in men than in women, suicide ranks as the 7th leading cause of death in males, nearly 4 times the rate of females.
As usual, the government made no attempt to assess how many of the persons attempting suicide were suffering unresolved chronic pain. The biased assumption is that the incidents were a result of substance abuse, as SAMHSA Administrator Pamela S. Hyde states: “While we have learned much about how to prevent suicide, it continues to be a leading cause of death among people who abuse alcohol and drugs. The misuse of prescription drugs is clearly helping to fuel the problem.”
Other reports have more clearly depicted a connection between chronic pain and suicide. Writing in a special supplement to the journal Pain Medicine, Martin D. Cheatle, PhD, observes that comorbid conditions that pose risks for suicide, especially depression, are prevalent in people living with chronic pain [Cheatle 2011]. The true numbers of failed attempts and successful suicides are unknown and may never be determined, he says; yet, “risk factors for suicidal ideation are so high in the chronic pain population that it must be assumed that some proportion of those who die of drug overdoses might have intended to end their lives, not just temporarily relieve their pain.”
Cheatle notes that many persons with pain experience hopelessness and isolation, and they endure many losses, including work and family roles. Some fear that their pain symptoms will be minimized or considered as evidence of any underlying mental disorder. One survey found that half of patients with chronic pain had serious thoughts of committing suicide, another found that roughly 1 in 5 had current passive suicide ideation, 13% had active thoughts, 5% had a plan for suicide, and 5% reported a prior suicide attempt. Drug overdose was the most commonly reported plan for committing suicide.
The recently released Institute of Medicine (IOM) report on “Pain in America” also paid special attention to the effects of chronic pain on suicide risks [IOM 2011, also see UPDATE here], as had earlier reports [Tang and Crane 2006]. Relative to controls, risk of death by suicide is at least doubled in patients with chronic pain. The lifetime prevalence of suicide attempts was between 5% and 14% in individuals with chronic pain, with the prevalence of suicidal ideation being approximately 20%. Suicidality is particularly problematic in persons with chronic severe headaches, and people with more than one type of chronic pain are almost 3 times more likely to attempt suicide. One study found that military veterans with severe pain were one-third more likely to die by suicide than those without pain or with only mild-to-moderate pain.
Eight risk factors for suicidality in chronic pain have been proposed [Tang and Crane 2006]. Four are pain-related: the type, intensity, and duration of pain, and sleep-onset insomnia co-occurring with pain. Four factors are psychological: helplessness and hopelessness about pain, the desire for escape from pain, pain catastrophizing and avoidance, and coping or problem-solving deficits.
The ugly truth may be that suicide is often an unintended consequence of undertreated or mistreated chronic pain in America, and opioids are only one of several involved drug classes. Cheatle recommends that healthcare providers should be alert to the presence of depression and the risk of suicide in patients with long-term, chronic pain. Routine screening for depression or other mental disturbance is advised. Mental status of the patient should be taken into account when prescribing large amounts of potentially lethal medications; opioids, certainly, but also non-opioid analgesics, benzodiazepines, and other psychotropic drugs. For patients determined to be at high and/or immediate risk of self-injury, referral to emergency psychiatric services is recommended.
REFERENCES:
> Cheatle MD. Depression, Chronic Pain, and Suicide by Overdose: On the Edge. Pain Medicine. 2011(Jun);12(Suppl s2):S43-S48 [abstract here].
> IOM (Institute of Medicine). Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC; National Academies Press, 2011 [access report here].
> SAMHSA. DAWN Report. Trends in Emergency Department Visits for Drug-Related Suicide Attempts among Males: 2005 and 2009. 2011(June 16) [PDF available here].
> Tang NK, Crane C. Suicidality in chronic pain: a review of the prevalence, risk factors and psychological links. Psychol Med. 2006;36(5):575-86 [abstract here].
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15 comments:
Stewart,
Your comments are much appreciated in this issue on pain, opioids and suicide. For years I have been convinced many of the unintentional overdose deaths are actual suicides. I have had 1-2 deaths per year that are clear suicides, some of which used guns and left notes. They could not live with their pain any longer. In addition many, many of my patients who have been warned of not overusing their medications or they "will die" tell me that in complete seriousness that dying would be better than living with their pain. Patients will sometimes overuse their opioids and sleeping medication because they are tired of hurting. They accept the risk of possible overdose just like soldiers accepts the risk when they go to battle. Fighting pain is a never-ending battle for many patients. I consider some of these tragic events to be rational suicides while others accept death as a possible outcome of seeking adequate pain relief.
We need much more attention to this issue as a possible explanation to the rise in unintentional overdose deaths. Substance abuse is a problem with some patients but the larger and more serious issue is are failure to sufficiently help relieve pain, leaving suicide as the only escape for some. As we focus on substance abuse and overdose deaths among pain patients we must not accept that the problem is too much pain medications but rather to little pain relief.
Lynn Webster, M.D.
Medical Director, Lifetree Clinical Research
(801) 892-5140
LRWebsterMD@gmail.com
Twitter: http://twitter.com/LynnRWebsterMD
www.yourlifesource.org
The fact that the number of suicide attempts in the chronic pain population has increased does not mean that the percentage of that population attempting suicide has increased. Vastly more people with chronic pain are prescribed opioid drugs today. That is a confounding factor.
Also confounding is the fact that not all apparent suicides are intended. Many pain patients self-prescribe by using too much medication, using it too often and by combining it with other dangerous drugs and alcohol. Some medications interact poorly with opioid. All of these can appear to manifest as attempts at suicide, but only on the surface.
One can hardly disagree that prescribing physicians should be alert to signs of depression. But taking it a step farther and requiring patients to submit to a depression index survey or to be cleared by a psychiatrist or psychologist before receiving medication would make a bad problem (inadequate treatment) much worse. Many patients would give up, rather than deal with such issues.
The data clearly reveals that patients with chronic severe pain and multiple forms of chronic severe pain are at higher risk of suicidal ideation. What we apparently haven’t measure very carefully is how much suicidal ideation is decreased with appropriate treatment, including opioid medications. If the severity of pain is a robust risk factor for suicidal ideation, then it follows that removal or reduction of that pain (including with powerful medications) will lead to reduced suicidal ideation. If so, then making it more difficult to obtain appropriate medication will increase the rate of suicide. If chronic severe pain leads to depression, which leads to suicidal ideation, then reducing pain should lower suicide attempts.
In conclusion, while making physicians alert to signs of depression is reasonable; the most appropriate way to lower pain-induced suicide lies in making pain medications and non-medication pain treatments more readily available to patients. Conversely, placing additional barriers between pain patients and the drugs and treatments they require will increase suicidal ideation.
Right on the nail! Great post! I am sick of hearing how the FDA wants to pull these medications due to supposed abuse and yet studies are never done to determine what are the ramifications to untreated pain. As an ra sufferer, I for one hear everyday the relentless pain of ra patients and how that facet is not treated or grossly undertreated. And add the catch 22 that rheumatologist are afraid to prescribe regulated pain meds while pain management specialist don't want to treat ra patients...they say it is the rheumatologists responsibility..leaving the patient to suffer.
Finally, "The ugly truth".."that suicide can be an unintended consequence of undertreated or mistreated chronic pain" Wow, talk about hitting the nail on the head! This is so true, I have been suicidal for many years, depression, all that goes along with being a chronic pain sufferer...I now have dx of "FBSS"-"failed back surgery syndrome. This is common for those that have had spinal fusions.
I am undertreated, misunderstood, living day to day as so many more do the same.
I am a little encouraged by this article, maybe, just maybe, someday we will be set free from pain.
I hope that research is funded in this country.
Something that I think is being overlooked is that the association between pain and depression is not unidirectional, i.e., the second is always caused by the first. In fact, it is well documented that pain is a very common presenting symptom of depression, in fact, one of the most common. Unfortunately, because these patients are complaining of pain and because many doctors including many pain specialists have limited knowledge and training in the recognition and treatment of mental disorders the depression is often overlooked or dismissed as being of secondary importance.
Steven A. King, M.D.
I think the last line of Dr. Webster’s comments (above at top) speaks volumes, “As we focus on substance abuse and overdose deaths among pain patients we must not accept that the problem is too much pain medications but rather to little pain relief.” So, perhaps it is time to change the dialogue and focus on effective pain management, WITHOUT so much emphasis on the very small percentage of person who misuse and abuse prescription medications.
Dr. King’s comments (immediately above) are also noteworthy. The interactions of pain and depression (and, anxiety and stress) are important to consider, and research has found this to be especially important in older persons with persistent pain. Most opioid analgesics have some antidepressant qualities, as do SSRIs or SNRIs, of course, used for some pain conditions; so, treating one syndrome with these agents also benefits the other. This is often overlooked or not taken fully into account in treatment plans. -- SB. Leavitt
I suffer from FBSS as "anonymous" above does, I also have been diagnosed with Major Depressive Disorder with suicidal ideation. Iam also being treated with opiods for chronic pain. The only time I would consider abusing my medications wouild be to actually use them to commit suicide. Were there different and better ways to treat my chronic pain, I would gladly accept it. However, until then I live with a daily battle of pain and suicidal thoughts.
Were the Government (FDA) put more energy into chronic pain research and more varied treatment options rather than opiod abuse and misuse they might help resolve the problem. As the article points out the "the government made no attemept to assess how many of the persons attempting suicide were suffering from unresolved chronic pain." It appears all they want to discuss is the abuse of opiods with no regard for chronic pain.
In fact the government only adds to the problem by the constant pointing of fingers that everyone who takes opiods abuses or misusses them. Because you are a chronic pain patient on opiods you are immediately labled an addict, a drug abuser and more by anyone who knows that you are on the medication. The government has successfully added to the problem of suicidal thoughts by creating this stigma that if you use it you abuse it.
Dr. King, your comments that depression can cause pain is well known. But we're not talking about depression related pain that can often be easily addressed, we're talking about people suffering from failed back surgery, arachnoiditis, severe arthritis pain, and more. We're talking about the kind of pain that disables people. More distressing in your comment is, once again, "You need psychotherapy, the pain is all in your head. I cannot tell you how often I heard this destructive, ill informed comment coming from a physician with little or no pain treatment education. I would advise you to look at the pain for what it is, PAIN. I suspect you'll find dealing with people like me who suffer from multiple sources of pain that it is by no means in my head, it's in my body where it's been for 47 years!
This article and remarks by other doctors was a much needed breath of fresh air. I'm a victim of how our system treats or rather doesn't treat pain and how it views addiction as the worst evil while being indifferent to suffering. I lived with an unknown pain for over a decade which worsened with time. Being into natural healing and health I began to aggressively try to cure myself. After years of no success and the pain worsening my husband and I decided to contact doctors. We were turned down by EVERY doctor we called because being self employed we had no insurance and they all required thousands up front to start testing. We were not poor just could not afford to pay the high costs in full as we went. None would take payments.
Finally bedridden and suicidal I learned I could order prescription pain meds online. I did and got my life back.. for a while. Till last November when a twenty man SWAT team broke my door down and took me away to jail in handcuffs. All for less than one months worth of medicine. I'm now a convicted felon for life. A 52 year old mother, grandmother, wife of 34 years, voter, business owner, and student who has always been a good citizen and tried to make a positive difference. I am now labeled an "addict" though I only took the meds for pain, and though I finally found a doctor a year ago who would see me and diagnose me (I have 3 degenerative back conditions) he will not truly "treat" me or ease my suffering. I'm given Tramadol and Robaxin which does little. And I still can't afford the costs of more tests such as MRI and other things he said he would do if I had insurance.
I continue to try and heal myself as I know that will be the only way I will get help. Treating people like this is beyond unconscionable. Thank you so much for these words and making me aware that there are some doctors who "get it."
Nancy Rector
Author of "A Painful Truth - The Entrapment of America's Sick"
www.apainfultruth.com
nancy@apainfultruth.com
What a bunch of idiots...clueless! Yep IHave chronic pain and have had foy years, gEtting worse and yes I have reached my limit, and yes I am going to do something abuot it. I worked in mental health and what a scam. Doctor after Doctor, test after test, hour after hour and nothing but flat broke. I don't want your pain meds but most of all I do not want your Lecture on pain meds. Shut up and treat the patient. I've tried western and eastern medicine and I think your all poor at guessing. I'm now homeless and living with my best friend ( should not be his problem), all my pay for medical and meds and no company insurance. For God sake I'm a Paramedic, I took care of everyone else. I'm hurting and tired and yes I have a plan and no it does not involve your pain meds. Soon, very soon.
I have CRPS/RSD and fibromyalgia, and have suicidal ideation daily. I am near the end of the pain meds, as I am nearly maxed on the 3 I use. Medical Marijuana is not legal in my state, and I can’t move with my mortgage underwater.
I have suffered from depression since puberty, but it well controlled for decades. Now, I am disabled and unable to work - and I love my profession. I am generally inactive. I can’t show my dogs, ride a horse (I finally sold my mare), take long walks, or anything else that involves using my legs. At this point, the antidepressants are not working - which is no surprise. I go to bed every night hoping not to wake up. When I hear that others have died, or been given a terminal diagnosis, I wish it were me.
I have two more dosage increases on the fentanyl, so I expect another 4 years or so before the meds will be there to combat increasing pain. With soldiers coming home with RSD, I am hoping that there will be some breakthroughs in research, and maybe more successful treatments. If not, my ideation may become action. I would not want to prolong this kind of suffering in one of my pets - and my vet would agree and euthanize the animal. WHy is it that the same care and consideration is not available to people? After our family vet’s mom had died after prolonged suffering, he said he did not understand why we, as a society, are so much more compassionate with our pets than with people. The fact that we can understand what ails us should not mean we have to accept it, to keep up with society’s idea that being alive is the most important thing.
To anonymous immediately above... I would urge you to seek an appointment with a mental health professional -- a psychologist, pyschiatrist, or counselor. Do it today! Pain is a physical reality; whereas, mental torment and suffering can often be brought under one's own control.
I suffered from a spinal chord injury as a college athlete, that involves C4, C5, & C6 almost 28 years ago. My spinal canal is significantly narrowed at C4 & C5, and narrowed at C6. I live with constant pain down my right arm and hand, my left hand ( and arm at times), migraines, and radiating pain down both legs at times. I occasionally bruise my spinal chord causing increased pain, and temporary loss of use in my right arm. Lastly for disclosure purposes, I have been diagnosed with major depressive disorder, with suicidal ideation after the spinal chord injury.
I personally have found that the use of steroids and strong opioids allows me to knock the pain down quickly. It allows me to survive episodes of extremely high pain. With out this, I surely would not be here. I have found that it is when my pain is not controlled for extended periods of time, I begin to despair. I am not sleeping, and I find myself begging for either the pain to end or death. But, once the pain is under control, or once it is back to a tolerable level (with the use of exercise, antidepressants and muscle relaxers). I can participate in life again, and be happy.
Hence from my experience, I believe that the issue of under treated pain and suicide is critical. If I can knock the severe pain down, sleep again, regain a rational state, and participate in life. I always find a reason to be here, even with a fair amount of day to day pain.
I appreciate the doctors who have tried to help pain patients but am sad that they think are not truthful.
The doctor who first prescribed oxycontin retired 2 hrs ago without finding someone else to take care of me. I finally found another MD who is elderly + will soon retire at which time, I will be unable to continue
To live a "normal" life. I will become unemployed due to severe pain and will suffer economic consequences.
Prior to that, I will take
Care of the problem myself without overdosing
On the pain meds that were prescribed by the physicians trying to help me . I would not want to cause them
To suffer as they tried to help me.
The best way to solve the problem is to take care of it without hurting anyone else. No one has the right to OD or abuse prescription meds. Why harm the professional careers of physicians trying to help others lead better lives. It doesn't help the rest of the
Unfortunate patients trying to find someone to help them.
If we would respect each other , maybe the MDs would be willing to help more patients. I can understand why they are afraid.
I need help. I need a doc to listen to me. I am 24 so everyone disregardes my cries for help. I am in pain. Its been 2 yrs untreated. I self medicate. I can't do this anymore. I need someone to pls help me. Mother of.2beautiful children who r the only reason I haven't solved this problem myself. Pls help me
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