On Oct. 26, 2003, two patients of mine, Randy and Helen—a married couple in middle age and both weary with chronic pain—attempted a dual suicide. Randy succeeded by overdosing on the methadone that was prescribed for his pain. His wife was either lucky or unlucky, depending on your point of view. She survived and was afterward confined to a psychiatric ward for several days.

The social worker who walked into their house that fatal weekend found not only Halloween balloons bobbing eerily but also Christmas presents neatly wrapped. Did this couple always shop early for presents, or had they determined that their plans to exit this life shouldn’t cheat the grandchildren out of holiday presents?

A pile of papers, suicide notes and a will left for family and authorities to find seemed to indicate that the plans had been percolating for several months at least. After the fact, Helen’s daughter conveyed to me her belief that the couple had been talking it over between themselves for at least a year.

After Helen was discharged from the psychiatric hospital, she returned to the clinic where I worked for further treatment of her pain. She opened up about the reasons why she and Randy wanted to die. Randy, she said, had 18 diagnoses and “his pain was outrageous.” Multiple illnesses are correlated with higher suicide risk, and multiple medical problems are common in patients with chronic pain.¹ The pain turned to anger for Randy, Helen said. “Lots and lots of anger.”

“At whom?” I asked.

Everyone, Helen said. Everyone whom Randy believed had let him down. For instance, Randy was angry with the doctors who he believed were undertreating his pain. When I asked Helen for her reasons for trying to end her own life, she pointed to an abusive first marriage and a stressful relationship with Randy. Her own pain played a major role, too. She said, “I didn’t have anything to lose. I didn’t have anything to look forward to except pain.” She had fibromyalgia and cervical disk herniation with neck pain, causing constant headaches. She also wanted to be with Randy in the afterlife where they both would be free of pain.

How common is it for people with chronic pain—people such as Helen and Randy—to attempt or complete suicide? It’s difficult to know with any degree of certainty. A potential deficit in our ability to understand the real prevalence of suicides in people with chronic pain is the way the Centers for Disease Control and Prevention (CDC) classifies opioid overdoses. The source of the CDC data comes from medical examiners and coroners. In most states, if an opioid is believed to have contributed to the death but there is no suicide note or other overt evidence that the death was intentional, such as copious amounts of opioids in the stomach at autopsy, it will be classified as unintentional or intent undetermined. In the absence of concrete evidence, it is difficult to know whether the death was truly accidental or intentional. However, an unintentional or undetermined classification allows for civil insurance claims to proceed against the prescriber and for collection on life insurance. Although not a prime reason for classifying deaths as unintentional, such considerations may be factors on occasion. However, the reality of the decedent’s intention may be different in some instances.

A problem results in understating the prevalence of pain-associated suicides, thereby concealing the effect that pain has on the suicide rate. By not understanding the true contribution of pain to the prevalence of suicides, we tragically miss an opportunity to reduce the rate. Intentionality is obvious when someone uses a firearm to end one’s life, but it is less obvious when a person in pain chooses to end his or her life with the medications prescribed for pain.

It is hard to prove the correlation of opioid overdose deaths and pain, so we need to triangulate the data. One interesting observation is that the most common age for suicides from poisoning in the United States (namely, 45-64 years of age) corresponds to a similar age for unintentional overdose deaths (45-54 years of age).² Furthermore, the CDC reported more than a 400% increase in opioid-related overdose deaths from 1999 to 2010.³ During that same period, the reported suicide rate for adult men increased almost 30% for 35- to 64-year-olds. This is the same age range with the highest prevalence of opioid overdose deaths.⁴ It is unlikely that we are looking at coincidence.

In addition, the means to end life when pain overwhelms is close at hand, because medications used to treat pain can also be used for the purpose of suicide. The CDC reports that, in 2013, there were approximately 1 million suicide attempts and nearly 40,000 completed suicides in the United States.⁵ The suicide rate has been increasing in parallel with the number of opioid prescriptions, just as the rate of opioid overdoses has paralleled opioid prescribing. This, too, is probably not coincidental.

People with chronic pain are at high risk for suicide for many reasons. In a recent registry study from Denmark involving 1,871 people with chronic pain, 6% had attempted suicide.⁶ The authors stated that this reflected a 3.76-fold increased risk for suicide attempts versus people without chronic pain. Risk factors included mental health disorders, social separation or isolation, substance use disorders and “intractable” pain.

Nicole Tang has recently reported that the most significant predictor for suicide attempts in people with pain is “mental defeat.⁷” Mental defeat is a state of mind marked by a sense of a loss of autonomy, agency and human integrity. It occurs when the fight just doesn’t seem worth it anymore. It is a person’s retreat from his or her battle with pain.

As with Randy and Helen, people may just find that there is no reason to live. If they have been dealing with a chronic pain problem, prescription drugs are likely close at hand. Feelings of hopelessness, seeing “no way out,” social isolation, mental defeat and severe pain intensity are all present in many with intractable pain. It is intuitive that some of the overdoses classified as unintentional are actually intentional, or at least the result of willingness to accept death in an attempt to escape pain.

The effects of suicide on family, friends and communities are devastating and far reaching even long after a loved one has taken his or her life. People in pain who take their lives have usually struggled with shame, the stigma of pain, marital problems and financial problems, and have been treated as if they are drug addicts or lowlifes unworthy of respect, attention or love. Unfortunately, public policy supporting our ability to collect data that could help us understand and prevent many of the tragic deaths has not been a priority. In fact, too often the finger points to the agent (drug) rather than the underlying cause (pain). Defining an overdose as unintentional when it may not be may mislead and conceal an epidemic of suicide.

There are important steps that we should take to address this lack of awareness and data:

• First, we need to acknowledge that the CDC data may be incomplete and imperfect in defining the intentionality underlying the death.
• Second, we must recognize that providing opioids to people with severe pain may be providing them the means to commit suicide.
• Third, and most importantly, we should agree that pain not adequately relieved is a major public health problem that deserves more equitable research funding so that lethal drugs are not a necessary treatment.

It is time that people in pain, and we who have devoted our careers to helping them, demand better treatments. Lives depend on it.

References

1. Juurlink DN, Herrmann N, Szalai JP, et al. Medical illness and the risk of suicide in the elderly. Arch Intern Med. 2004;164:1179-1184.
2. Centers for Disease Control and Prevention. Ten leading causes of injury deaths by age group highlighting unintentional deaths, United States-2013. www.cdc.gov/​injury/​images/​lc-charts/​leading_causes_of_injury_deaths_highlighting_unintentional_injury_2013-a.gif.
3. Centers for Disease Control and Prevention. Unintentional drug poisoning in the United States. July 2010. www.cdc.gov/​HomeandRecreationalSafety/​pdf/​poison-issue-brief.pdf.
4. King SA. Pain and suicide. Psychiatric Times. June 13, 2013. www.psychiatrictimes.com/​suicide/​pain-and-suicide.
5. Centers for Disease Control and Prevention. Featured topic: World Health Organization’s (WHO) report on preventing suicide. www.cdc.gov/​violenceprevention/​suicide/​who-report.html.
6. Stenager E, Christiansen E, Handberg G, et al. Suicide attempts in chronic pain patients: a register-based study. Scand J Pain. 2014;5:4-7.
7. Tang NK, Beckwith P, Ashworth P. Mental defeat is associated with suicide intent in patients with chronic pain. Clin J Pain. 2015 Jul 21. [Epub ahead of print]