Pain, Addiction, and Suicide: Recognition and Response

I think we’ve been so focused on this opioid crisis that we have forgotten that these are very brittle people who have significant psychiatric co-morbidities, including depression, anxiety, sleep disorders, substance use disorders. I think that suicide is really a silent epidemic that has not been focused on  because of our concern about opioid misuse and abuse. If you look at the data, anywhere from 15 to 50 percent of patients with chronic non-cancer pain have daily suicidal thoughts.  40% of people with substance use disorders endorse having suicidal thoughts. If someone has an alcohol use disorder, they’re 10 times more likely to take their life than the general population. If they have an injection use disorder, they’re 14 times more likely to commit suicide than the general population. So people who have pain and a substance use disorder are particularly vulnerable to committing suicide. And there are some pain-specific risk factors. Pain intensity is one, pain duration is another risk factor. People who tend to catastrophize, as patients with pain do, are at increased risk of suicide and sleep disorders.

We have to be more aware of these risk factors. I think that every person who takes care of patients with chronic pain should have an action plan. Physicians don’t want to ask two questions of patients – what’s your pain level and are you suicidal? These are patients that are brittle and need to be assessed and monitored for their risk of suicide. They should have a very good hotline to local mental health facilities and crisis units because, again, the statistics speak for themselves. Some of these risk factors you can’t change. You can’t change the genetic predisposition. You can’t change your gender or your age. But other risk factors are treatable. Cognitive behavioral therapy for pain catastrophizing can lower the risk for suicide. In my practice, I tell patients I am not going to take on their case unless they do something to break the cycle of isolation and burdensomeness that they are feeling. They can volunteer; talk to their priest, their minister, their rabbi; get involved in the community; attend AA, NA, OA, whatever A, but they need to break that cycle because I think that’s one factor that’s going to lead them into this rabbit hole of no return. And PAINWeek is a great opportunity for clinicians to learn the skills of how to assess these patients, how to intervene at their level, how to refer to the right people in their community.