
- Vol 30 No 6
- Volume 30
- Issue 6
Pain and Suicide
The rise in suicides and lethal overdoses of opioid analgesics is probably not coincidental. In most overdose deaths, we have no way of knowing with any degree of certainty whether they were accidental deaths or intentional suicides.
Readers of this column are well aware that I am a vociferous advocate of more
There is continuing research that makes me still believe that I am right-and that those who view pain management as fitting far better under the purview of other specialties, most notably anesthesiology, are mistaken.
One of the things that makes me believe my view is correct is the growing literature on the association between pain and suicide. With increases in prescriptions for opioid analgesics, the rise in lethal overdoses and in suicides is probably not coincidental.
Drug overdose is the most common method of suicide attempts and of completed suicide in women (in men, firearms and suffocation/hanging are more common). In most cases of overdose deaths, we have no way of knowing with any degree of certainty whether they were accidental deaths or intentional suicides. Many who survive after taking overdoses are unable to aid us in elucidating reasons for the overdose. Patients may be so frustrated that they are willing to take potentially lethal doses to relieve their pain; some may feel that they would be better off dead unless the pain is alleviated. Opioids have sedative effects and can impair thought processes, so individuals who overdose may not be clear about why they overdosed.
Adding to this mix is the
Opioid analgesics are well recognized as depressants, so while their use can provide marked relief of pain and thereby reduce comorbid depression, they can also exacerbate or even precipitate depression. Weighing the mental health risks and benefits of these drugs can be, to say the least, quite difficult and requires trained caregivers. Physicians who prescribe opioids for chronic pain but fail to evaluate the mental health of their patients are not providing anything close to optimal care.
SNRIs and antiepileptic drugs (AEDs) are excellent analgesics for many forms of
A recent review of suicidality highlighted that AEDs, too, can carry a risk for suicidal ideation and suicidal attempts. Although the literature on this effect among patients with chronic pain who are taking these medications is limited, the researchers conclude that “in deciding whether to initiate or continue AED treatment in chronic pain patients, especially those with risk factors for suicidality (beyond the increase risk conferred by having chronic pain), careful evaluation is necessary to determine whether treatment benefits outweigh risks.”6(p348)
To be practical, many, if not most, non-psychiatrists (apart perhaps from
We can either train non-psychiatrists to be experts in recognizing and evaluating mental health problems or train psychiatrists to be experts in managing pain. Because psychiatrists are already experienced in using many of the most common analgesic medications and psychotherapeutic interventions that have been demonstrated to be effective for the management of pain, I think that the answer is obvious.
Disclosures:
Dr King is in private practice of pain medicine in New York, and he is Clinical Professor of Psychiatry at the New York University School of Medicine, New York.
References:
1. Governale L. Outpatient prescription opioid utilization in the US, years 2000-2009. July 22, 2010.
2. Centers for Disease Control and Prevention. Primary Care and Public Health Initiative. Balancing pain management and prescription opioid abuse: educational module. October 24, 2012.
3. Centers for Disease Control and Prevention. Suicide among adults aged 35-64-United States, 1999-2010. MMWR Morb Mortal Wkly Rep. 2013;62:321-325.
4. Bair MJ, Robinson RL, Katon W, Kroenke K.
5. Ilgen MA, Zivin K, Austin KL, et al.
6. Pereira A, Gitlin MJ, Gross RA, et al. Suicidality associated with antiepileptic drugs: implications for the treatment of neuropathic pain and fibromyalgia. Pain. 2013;154:345-349.
Articles in this issue
over 12 years ago
The Family Guide to Mental Health Careover 12 years ago
“PRN” Medication for Alcohol Dependence May Reduce Harmover 12 years ago
No Mortality Increase With Antipsychotics in Prospective Studyover 12 years ago
Epidemiology and Treatment of Substance Use and Abuse in Adolescentsover 12 years ago
Bias Against Schizophrenic Patients Seeking Medical Careover 12 years ago
Shared Risk Factors in Multiple Psychiatric Disordersover 12 years ago
Genetics and Pharmacogenetics of Schizophrenia: Recent ProgressNewsletter
Receive trusted psychiatric news, expert analysis, and clinical insights — subscribe today to support your practice and your patients.