Suicides Among Opioid Overdose Deaths

April 14, 2020 Paul S. Nestadt, MD¹ Author Affiliations Article Information JAMA. 2020;323(14):1409-1410. doi:10.1001/jama.2020.1446

To the Editor Dr Olfson and colleagues¹ examined trends in the rates of opioid-related mortality, stratified by intentionality. Concerns about whether a significant proportion of opioid overdose suicides have been misclassified, and therefore that the suicide component of the opioid epidemic is underestimated, cannot be answered with death certificate data.

The Centers for Disease Control and Prevention has been struggling with the difficulty of classifying suicides among overdose deaths for years.² Several studies have estimated the proportion of misclassification in the National Violent Death Reporting System, using suicide notes or advanced statistical methods, and have generally agreed on a figure ranging between 21% and 33%.^3,4 Therefore, it seems likely that a significant number of suicides is hidden within deaths from the opioid epidemic.

The authors stated that “the sensitivity of death certificates for suicide is high.”¹ However, death investigation experts^2,5 suggest that the specificity for suicide is high, but the sensitivity is low, particularly for overdose deaths. For a variety of reasons, including stigma and evidentiary standards, suicides may be more likely than unintentional deaths to be left undetermined. This is supported by the authors’ statement that “[u]ndetermined overdose deaths tend to more closely resemble suicides than unintentional deaths.”¹ In a recent study, machine learning techniques were used to estimate that, based on this resemblance, 33% of Utah’s undetermined overdose deaths were likely suicides.⁴ These estimates may be improved with psychological autopsies (in-depth interviews with trained investigators) on a subset of decedents to validate coroner-cataloged manner of death.

The authors found that few (4%) opioid overdose deaths were classified as suicides. However, the validity of the classification of overdose deaths as suicide vs undetermined or unintentional deaths was inadequately questioned. Given the increasing prevalence of opioid use and the particular lethality of opioids as a suicide method, their role in suicide demands better measurement, recognition, and attention. Those caring for persons at risk of suicide should be counseled to treat opioids as they would a firearm: removed whenever possible, stored safely inaccessible from those in crisis, and kept only with safeguards (such as Narcan) readily available.

Section Editor: Jody W. Zylke, MD, Deputy Editor.

Article Information

Corresponding Author: Paul S. Nestadt, MD, Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, 600 N Wolfe St, Baltimore, MD 21287 (pnestadt@jhmi.edu).

Conflict of Interest Disclosures: None reported.

References

1.Olfson  M , Rossen  LM , Wall  MM , Houry  D , Blanco  C .  Trends in intentional and unintentional opioid overdose deaths in the United States, 2000-2017.   JAMA. 2019;322(23):2340-2342. doi:10.1001/jama.2019.16566
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2.Stone  DM , Holland  KM , Bartholow  B ,  et al.  Deciphering suicide and other manners of death associated with drug intoxication: a Centers for Disease Control and Prevention consultation meeting summary.   Am J Public Health. 2017;107(8):1233-1239. doi:10.2105/AJPH.2017.303863PubMedGoogle ScholarCrossref

3.Rockett  IRH , Caine  ED , Stack  S ,  et al.  Method overtness, forensic autopsy, and the evidentiary suicide note: a multilevel National Violent Death Reporting System analysis.   PLoS One. 2018;13(5):e0197805. doi:10.1371/journal.pone.0197805PubMedGoogle Scholar

4.Liu  D , Yu  M , Duncan  J , Fondario  A , Kharrazi  H , Nestadt  PS .  Discovering the unclassified suicide cases among undetermined drug overdose deaths using machine learning techniques.   Suicide Life Threat Behav. Published online September 19, 2019. doi:10.1111/sltb.12591PubMedGoogle Scholar

5.Goodin  J , Hanzlick  R .  Mind your manners: part II: general results from the National Association of Medical Examiners manner of death questionnaire, 1995.   Am J Forensic Med Pathol. 1997;18(3):224-227. doi:10.1097/00000433-199709000-00002PubMedGoogle ScholarCrossref

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