Question:
Are people suffering from opioid use disorder (OUD) at elevated risk for suicide? Does MAT reduce that risk?
Answer:
The first answer is yes, people suffering from OUD are at increased risk for suicide for several reasons. A recent study released in 2023, for example, examined the prevalence of and identified factors associated with suicidality in 244 adults with OUD who initiated office-based buprenorphine treatment. It found that 37.7% reported significant thoughts of suicide over their lifetime, and 27.46% reported suicide attempts over their lifetime. This compares to 4.9% of the general population having significant thoughts of suicide over their lifetime and only 0.5% having attempted suicide over their lifetime. Also, as the researchers advise, these suicide rates excluded individuals who were judged to be psychiatrically unstable, too intoxicated to provide consent, or at immediate risk for suicide.
The study population included 68% males, 38.5% White, 38% Black, and 25% Hispanic or Latinx. The mean age at enrollment in the treatment programs was 43.23 years. A little over a third suffered from chronic pain. To be enrolled, none displayed evidence of psychiatric instability.
Among the 27.46% with OUD who had attempted suicide, those who also had a history of anxiety were 7.49 times more likely to attempt suicide and 4.01 times more likely if they had a history of depression. Odds were also increased but less so for those with a history of sexual abuse (2.89), being Latino/a/x ethnicity (4.01), or having chronic pain (2.43). [Lent, M.R., Dugosh, K.L., Hurstak, E. et al. Prevalence and predictors of suicidality among adults initiating office-based buprenorphine. Addict Sci Clin Pract 18, 37 (2023). https://doi.org/10.1186/s13722-023-00393-y]
The answer to the second is more complicated.
Buprenorphine has been found to be associated with reductions in suicide risk. [Medication-Assisted Treatment (MAT). Samhsa.gov. 2022. Accessed Oct 7 2022; Watts BV, Gottlieb DJ, Riblet NB, Gui J, Shiner B. Association of medication treatment for opioid use disorder with suicide mortality. Am J Psychiatr. 2022.] However, the researchers of this study, still advise: “Given the very high prevalence of lifetime suicidality in our sample, regular screening and monitoring for suicidality may be warranted in individuals initiating MOUD given the challenges in multiple life domains that can accompany both OUD and recovery.”
There are studies that hypothesize how buprenorphine reduces suicide risk. One hypothesized that observed reductions in suicide risk were associated with buprenorphine’s potential to minimize pain-induced aversive moods. [Cameron CM, Nieto S, Bosler L, Wong M, Bishop I, Mooney L, et al. Mechanisms underlying the anti-suicidal treatment potential of buprenorphine. Adv Drug Alcohol Res. 2021.] This is significant because chronic pain is common among individuals with OUD, with estimates ranging from 30–60% of patients. [Hser Y-I, Mooney LJ, Saxon AJ, Miotto K, Bell DS, Huang D. Chronic pain among patients with opioid use disorder: results from electronic health records data. J Subst Abuse Treat. 2017;77:26–30.]
Another suggests that buprenorphine’s activity as a kappa opioid antagonist may be responsible for its ability to lower suicide risk quickly, as brain studies suggest that the kappa receptor plays a role in dysphoria. [Mann J, Rizk MM. A brain-centric model of suicidal behavior. Am J Psychiatry. 2020.]
Still, an alternative theory is that buprenorphine’s efficacy in lowering suicide risk relates to the medication’s ability to foster engagement in medical care, as it is typically prescribed in an office-based, primary care setting. [Lent, M.R., Dugosh, K.L., Hurstak, E. et al. Prevalence and predictors of suicidality among adults initiating office-based buprenorphine. Addict Sci Clin Pract 18, 37 (2023). https://doi.org/10.1186/s13722-023-00393-y]
Other studies have similarly found mortality risk, including suicide risk, to also be reduced during methadone use [See, e.g., Degenhardt L, Randall D, Hall W, Law M, Butler T, Burns L. Mortality among clients of a state-wide opioid pharmacotherapy program over 20 years: risk factors and lives saved. Drug Alcohol Dependence. 2009;105(1–2):9–15.]
Another study concluded, “Overall, MOUD, including buprenorphine, methadone, and naltrexone, was associated with a greater than 50% reduction in risk of suicide mortality during periods of stable treatment.” Buprenorphine stood out as superior with a 65% reduction in suicide mortality risk. [Watts BV, Gottlieb DJ, Riblet NB, et al.: Association of medication treatment for opioid use disorder with suicide mortality. Am J Psychiatry 2022; 179:298–304]
The research on OUD suicide risk is compromised because it is acknowledged that a high percentage of opioid overdoses that are diagnosed as “accidental” are, in fact, “intentional”—attempted or successful suicides. The many studies that confirm that MAT reduces the risk of lethal overdoses, therefore, may be underassessing their role in reducing the risk of suicide.
However, it should also be noted that when people stop taking medication for OUD, their risk for suicide may increase. Studies have also found that MOUD retention rates are a major challenge, especially for justice-involved people.