Suicide Risk in Addiction Recovery from Opiates and Alcohol

By Ebonie Williams, LPCC, Executive Director, Recovery Works Mayfield in Kentucky

What Interventions Can Reduce Suicide Risk During Recovery?

Suicide is a significant public health concern in the United States in 2022. If you have a family member, friend, or loved one who has an opioid or alcohol addiction problem, it’s important to understand that they’re at increased risk of suicide.

That’s not meant to scare you, but rather, to inform you of the facts, help you understand what to watch for, and encourage you to learn about the types of treatments and/or interventions that may reduce risk of suicide – because we live in a time when risk of suicide, especially for people with addiction and mental health issues, is higher than ever before.

The Pandemic Effect: Addiction and Suicide

The negative mental health consequences associated with two years of pandemic-related worry, uncertainty, and isolation have had a heavy toll on everyone. These secondary effects of the pandemic have had a disproportionate impact on our most vulnerable citizens, including those with alcohol use disorder (AUD), opioid use disorder (OUD), and mental health disorders. Many people with addiction and/or mental health problems were unable to access consistent and timely treatment, which exacerbated their conditions and increased suicide risk.

The combination of pandemic-related separation from mental health/addiction support and treatment, and an upward trend in rates of both addiction and suicide over the past twenty years, led a group of researchers to review and analyze the most effective known interventions that may reduce suicidality in people diagnosed with alcohol and opioid addiction. When they began their review, they noted, “…a dearth of research on pharmacological and psychosocial interventions for co-occurring AUD/OUD and suicidal ideation and behavior.” Therefore, the paper they published, Suicide Risk and Addiction: The Impact of Alcohol and Opioid Use Disorders, is now one of the first – and to date, the definitive – research effort on the topic. We’ll use data from that paper for the rest of this article.

Let’s take a look at what they found.

Alcohol Addiction, Opiate Addiction, and Suicide: What We Know

Evidence shows that alcohol and opioid use disorders (AUD/OUD) significantly increase risk for:

• Suicidal ideation
• Suicide attempts
• Completed (fatal) suicide

The study reviewed clinical recommendations for people with AUD/OUD and co-occurring suicidal ideation and behavior. Researchers identified the most effective types of:

• Inpatient care
• Medication
• Psychotherapeutic approached

First, they identified the big-picture consequences of chronic alcohol intoxication, chronic alcohol use, and both acute and chronic opioid use.

Evidence shows that chronic alcohol use and/or opioid use disorder (OUD) can:

• Increase maladaptive coping behaviors
• Hinder self-regulation

Both these consequences can increase the risk of suicide.

In addition, researchers identified evidence that chronic opioid and/or opioid use disorder (OUD) use can:

• Cause neurobiological changes, i.e. changes in brain structure and function
• Increases negative emotional states, e.g. depressive symptoms, anxiety symptoms, low self-esteem, feelings of hopelessness

These consequences can lead to continued opioid use and increased suicide risk.

As a whole, study authors conclude – and cite decades of evidence that show – chronic opioid use/addiction and chronic alcohol use/addiction can increase overall suicide risk.

But why, exactly?

Alcohol Use Disorder (AUD), Opioid Use Disorder (OUD), and Suicide

We’ll now discuss the reasons alcohol and opioid use increase risk of suicide, starting with alcohol.

After conducting their review of available data, study authors indicate the two forms of alcohol use most often implicated in elevated risk for suicidal thoughts and behavior are:

1. Acute Alcohol Intoxication

• • In the 24-hour period after intoxication, risk of suicide increases seven-fold
  • Intoxication is related to greater lethality of attempt methods, making suicide fatalities more likely
  • Over a third of people who die by suicide test positive for alcohol:
    • 5% had blood alcohol concentrations consistent with intoxication

2. Chronic Alcohol Use or Alcohol Use Disorder (AUD)

• • Compared to people without AUD, people with AUD have a ten-fold increased risk of suicide
  • After mood disorders, AUD is the second most common diagnosis in people who die by suicide

The study authors identified the primary reasons acute alcohol intoxication increases risk of suicide. Here’s what existing studies agree increases overall risk:

• Dysphoria
• Myopia
• Agitation
• Impaired perception
• Impaired motor control

These consequences “…render an individual prone to risk-taking or impulsive behavior and less likely to seek alternative solutions to self-regulate.”

Secondary reasons acute alcohol intoxication increases risk of suicide include:

• Self-medication to avoid unwanted emotions
• Behavioral disinhibition
  • Decreases fear of death
  • Increase risk taking an impulsivity

The researchers identified the primary reasons alcohol use disorder (AUD) increases risk of suicide. Studies on the relationship between AUD and suicide indicate AUD can:

• Promote social isolation
• Corrode relationships
• Degrade support systems
• Cause or aggravate psychosocial stressors, including:
  • Homelessness
  • Financial insecurity

In addition, existing peer-reviewed studies on chronic alcohol use and addiction associate AUD with:

• Aggressive behavior
• Intimate partner violence
• Economic hardship
• Job loss
• Increased cognitive deficits
• Impaired decision-making
• Decreased behavioral control

Finally, researchers have identified abnormalities in brain structure that are common to both people with AUD and people who die by suicide. These atypical changes include:

• Reduced gray matter in the prefrontal cortex, which is responsible for decision-making and inhibitory control
• Reduced gray matter in the limbic system, which is responsible for emotions, reward, and pleasure

The research clearly shows there are objectively identifiable emotional and behavioral consequences of AUD that increase risk of suicide, as well as measurable neurological impairments that increase risk of suicide.

We’ll now look at the types of interventions research indicates are most successful for decreasing suicide risk or preventing suicide for people who are acutely intoxicated (drunk) and for people diagnosed with AUD.

Alcohol and Suicide Risk: Interventions

First, we’ll examine effective approaches to prevent suicide in people who are acutely intoxicated, beginning with psychiatric hospitalization.

Inpatient Treatment for Alcohol-Related Suicidality

The study indicates that individuals who present – which means show up with – to emergency rooms or psychiatric hospitals as intoxicated and with suicidal plans or intent often stabilize quickly in inpatient care.

This means that for those who are acutely intoxicated, a relatively short time in inpatient care can often present a suicide attempt. At face value, this is logical: a person shows up intoxicated and suicidal, but when the alcohol wears off, they’re no longer intoxicated, and in most cases, no longer suicidal.

However, the situation for people with AUD is complicated.

A person who presents with acute intoxication and pre-existing AUD is at significantly higher risk of relapse and subsequent suicide attempts. For these individuals, suicide risk decreases when:

• They transfer to an inpatient, residential treatment center for addiction
• They transfer to an intensive outpatient or partial hospitalization treatment program for addiction
• Outcomes improve when individuals participate in dual-diagnosis treatment programs, which support patients with co-occurring addiction and mental health disorders

That makes sense: short-term inpatient treatment helps stabilize people in emergency situations, while longer-term inpatient treatment can help people address addiction problems and any mental health issues that may contribute to those addiction problems.

Pharmacological Interventions for Alcohol-Related Suicidality

Although there are an abundance of medications available to treat conditions that may contribute to alcohol-related suicidality, such as medication for mood disorders and/or anxiety, there are no known and/or approved medications “specifically indicated for suicidal ideation, urges, or behavior.”

However, medications to treat alcohol use disorder/alcohol addiction do exist. They include:

• Disulfram:
  • Produces very uncomfortable symptoms after alcohol use
• Acamprosate:
  • Mitigates alcohol withdrawal symptoms
• Naltrexone:
  • Reduces alcohol cravings

Research also shows that in some cases, naltrexone can also reduce withdrawal-related symptoms of anxiety and depression.

Psychotherapeutic Interventions for Alcohol-Related Suicidality

When an individual presents at an emergency room or psychiatric hospital intoxicated and displays suicidal thoughts and behaviors, clinicians stabilize them first, which may take as few two hours and as many as twelve. After stabilization, clinicians work with the individual to create a written list of suicide triggers, coping mechanisms, and potential sources of support and/or treatment: there is no real psychotherapeutic intervention for acute intoxication aside from a standard suicide crisis intervention protocol.

However, with regards to mitigating suicide risk for a person with AUD who is not acutely intoxicated, there are several effective, evidence-based, psychotherapeutic approaches available:

• Motivational enhancement therapy (MET). This approach applies techniques from motivational interviewing (MI) to help people to overcome resistance to treatment and create goals related to achieving sobriety and abstinence
• Cognitive behavioral therapy (CBT). When a person with AUD has a co-occurring mental health disorder, CBT helps them address the underlying emotional, psychological, and behavioral factors that may contribute to both AUD and suicidality
• Relapse prevention therapy (RPT). This technique helps people in recovery reduce the chances of relapse, which, in turn, can reduce suicidality

In some cases, a combination of antidepressant medication and cognitive behavioral therapy may also mitigate suicide risk in people with AUD – but the evidence on this is preliminary, and not yet conclusive.

That’s the end of the section on alcohol, alcohol intoxication, alcohol use disorder, and suicidality. For the rest of this article, we’ll focus our attention on opioids.

Opioid Use Disorder (OUD) and Suicide

After conducting their review of available data on opioid addiction and suicide, study authors identified two factors that are most often implicated in elevated risk for suicidal thoughts and suicidal behavior among people who use opioids and/or have OUD:

1. People with OUD experience a higher rate of social and environmental disadvantage, compared to people without OUD. These include:

• • Lack of family support
  • Unemployment
  • Homelessness
  • Childhood trauma, including:
    • Physical abuse
    • Sexual abuse

2. People with OUD experience a high rate of co-occurring mental health disorders.

• • 75% of people with OUD have another psychiatric diagnosis, including:
    • Mood disorders
    • Anxiety disorders
  • Self-medication with opioids in order to alleviate the emotions related to mood and anxiety disorders significantly increases suicide risk

The social and environmental disadvantages that are common to people with OUD increase risk of suicide in the same way adverse childhood experiences (ACEs) – also listed above – increase overall suicide risk. Lack of family support, unemployment, homelessness, and trauma all increase the likelihood an individual will develop:

• Addiction disorders
• Mental health disorders

This is where the factors related to OUD and suicidality begin to overlap. ACEs increases likelihood of both addiction and mental health disorders, which each increase likelihood of the other. In addition, researchers found that the neurophysiological changes caused by long-term exposure to opioids is associated with:

• Increased sensitivity to negative emotions
• Increased sensitivity to stress and pain
• Decreased response to natural rewards and pleasure

These changes are associated with:

• Reduced gray matter in the prefrontal cortex
  • Reduced gray matter in the prefrontal cortex is related to decreased:
    • Emotional regulation
    • Cognitive function
    • Impulse control
  • Damage to the limbic system, a.k.a. the reward system
    • Damage to the limbic system is associated with:
      • Increased emotional reactivity
      • Decreased cognitive control over emotions
      • Dysfunctional decision-making

All of the above – from increased sensitivity to negative emotions to dysfunctional decision-making – increase risk of suicidal behavior, including suicidal ideation and suicide attempts. We’ll now look at the types of interventions research indicates are most successful for decreasing suicide risk or preventing suicide in people with OUD.

Opioid Use Disorder and Suicide Risk: Interventions

As we did with interventions for people with alcohol use or addiction problems, we’ll examine effective approaches to prevent suicide in people with OUD and people in recovery from OUD.

Medication-Assisted Treatment (MAT) for Opioid-Related Suicidality

Current evidence shows the gold-standard treatment for people with OUD is called medication-assisted treatment (MAT). Studies show that MAT reduces the following:

• Opioid use
• Opioid overdose

In addition, studies show that MAT increases the following:

• Time-in-treatment
• Capacity to seek and gain employment
• Capacity to participate in family life
• Ability to engage in therapeutic activities associated with treatment

That last bullet point is salient: when a person with OUD enters and MAT program, they’re required to participate in drug counseling, therapy, and treatment for co-occurring disorders. Since co-occurring disorders are responsible for much of the suicidality associated with OUD, MAT is a powerful approach to treatment: it addresses both addiction and its underlying causes.

Pharmacological Interventions for Opioid-Related Suicidality

There are three medications approved by the FDA to treat OUD. These medications reduce the negative mental health consequences of OUD and enable an individual to engage in drug counseling and psychotherapy. Therefore, this means these medications also play an important role in decreasing opioid-related suicidality:

• Methadone: Reduces the symptoms of withdrawal, reduces cravings, and blocks other opioids
• Buprenorphine: Reduces the symptoms of withdrawal, reduces cravings, and blocks other opioids
• Naltrexone: Blocks other opioids and reduces cravings, but has no effect on withdrawal symptoms.

We’ll say it again, because it’s worth repeating, and anyone with a loved one or friend in treatment for or recovery from OUD needs to hear and read it: MAT is the gold-standard treatment for OUD. In addition, anyone with a friend, family member, or loved one in treatment for or recovery from OUD should also understand that MAT enables their friend, family member, or loved one to participate in the psychotherapeutic interventions we discuss next.

Psychotherapeutic Interventions for Opioid-Related Suicidality

Most of us understand that the disorder use of substances rarely appears out of nowhere, with no underlying emotional factors. It can happen, most certainly: during the ongoing opioid crisis, there are countless examples of people who develop OUD as the result of receiving a prescription for an opioid pain-relieving medication.

However, in most cases, addiction develops from a confluence of emotional, environmental, and behavioral factors. When a person is in treatment for addiction, psychotherapy helps them identify – or rule out – the presence of co-occurring mental health disorders. When a co-occurring mental health disorder is diagnosed alongside OUD, there are several effective, evidence-based, psychotherapeutic approaches available. In many cases, the approaches used for AUD are effective for OUD. These may include, but are not limited to:

• Motivational enhancement therapy (MET). As we describe above in the section on psychotherapeutic to suicidality in people with AUD, therapists use the same motivational question-and-answer approach in sessions with people with OUD to resolve their resistance to treatment. Once in treatment for OUD, MET helps people set goals related to treatment and recovery that help organize their behavior and point them in the direction of long-term, sustained recovery.
• Cognitive behavioral therapy (CBT). In the presence of a co-occurring mental health disorder, CBT help a person with OUD identify and work through the underlying emotional, psychological, and behavioral factors that play a role in OUD and any related suicidal behavior.

Psychotherapeutic components of treatment for OUD are as important as the medication-related interventions we list above. Medication helps people reduce the most destructive elements of OUD, while therapy helps people understand the factors that may have caused them to develop OUD. One way to look at it is that the medications help people with OUD stop taking opioids, while psychotherapy keeps them from relapse and helps them understand, prevent, and process the patterns of thought, emotion, and behavior that can lead to relapse.

Treatment for Addiction Reduces Suicide Risk

That’s the one thing we want anyone with a friend or loved on in recovery from or treatment or alcohol addiction or opioid addiction to understand: treatment improves everything. What we keep coming back to in this article is the presence of co-occurring disorders. When co-occurring disorders are not present, suicide risk decreases for people with AUD and OUD. When they are present, risk increases. That’s why evidence-based treatment for AUD and OUD decrease suicide risk. In both cases, the standard of care includes integrated treatment that includes individual psychotherapy, group psychotherapy, family involvement in therapy, community support, lifestyle changes, and, in some cases, medication.

For people with OUD, the medication component is crucial: it facilitates all the other elements of treatment, including the psychotherapeutic approaches that are pivotal in decreasing risk of suicide or relapse during recovery.

For people with AUD, OUD, and their families, we’ll end with this: according to the latest available peer-reviewed research, evidence-based treatment for AUD and/or OUD that follows the integrated treatment model is the most effective way to reduce suicide risk.