Opioid Use and Misuse and Suicidal Behaviors in a Nationally Representative Sample of US Adults

Hillary Samples; Elizabeth A. Stuart; Mark Olfson


Am J Epidemiol. 2019;188(7):1245-1253. 

In This Article

Abstract and Introduction


Prior research has shown associations between opioid misuse and suicidal behaviors, but the relationship between medical opioid use and suicidal behaviors is not known. We assessed associations of opioid use and misuse with suicidal ideation, suicide plans, and suicide attempts among adults aged 18–64 years (n = 86,186) using nationally representative cross-sectional data from the 2015 and 2016 administrations of the National Survey on Drug Use and Health. We used logistic regression to estimate associations between opioid use/misuse and suicidal behaviors and propensity score–weighted logistic regression analysis to examine the counterfactual scenario in which persons with misuse had instead not misused opioids. In propensity score–weighted analyses, compared with opioid misuse, opioid use without misuse was associated with lower odds of suicidal ideation (odds ratio (OR) = 0.57, 95% confidence interval (CI): 0.45, 0.72) and suicide plans (OR = 0.53, 95% CI: 0.35, 0.80), and no use was associated with lower odds of suicidal ideation (OR = 0.62, 95% CI: 0.49, 0.80), suicide plans (OR = 0.56, 95% CI: 0.39, 0.79), and suicide attempts (OR = 0.54, 95% CI: 0.33, 0.89). These findings suggest that opioid misuse is associated with greater odds of suicidal behaviors, but opioid use without misuse is not. Compared with persons with opioid misuse, similar persons without misuse have a reduced risk of suicidal behaviors. Clinical and public health interventions should focus on preventing misuse of opioids.


For the first time in decades, US life expectancy declined 2 years in a row from 2014 to 2016.[1,2] While mortality from 7 of the 10 leading causes of death decreased, mortality from suicide and unintentional injuries—including drug overdoses—increased. Unintentional opioid overdose is now a leading public health and clinical concern, and evidence further suggests that the national opioid epidemic has also contributed to the recent increase in suicide. The proportion of suicides directly attributable to opioids approximately doubled from 1999 to 2014.[3] Suicide also contributes to excess mortality among persons with opioid use disorder (OUD)[4,5] and among persons who die within 1 year of experiencing a nonfatal opioid overdose.[6]

These national trends focus attention on the complex relationships between opioid use and suicidal behaviors. One study using nationally representative epidemiologic data found no association between suicide attempts and opioid misuse but revealed a positive association between suicidal ideation and former misuse, persistent misuse, and prescription OUD.[7] However, persons who began misusing opioids in the past 2 years were not at increased risk of suicidal ideation.[7] Another study showed an association between suicidal ideation and past-year opioid misuse,[8] and a third study found that more frequent opioid misuse was associated with suicidal ideation, suicide plans, and suicide attempts.[9]

To our knowledge, no studies have examined the association between opioid use without misuse (i.e., medical opioid use as directed by a physician) and suicidal behaviors, yet this relationship is potentially important because of the strong association between suicidal behavior and chronic pain, which is the primary clinical indication for use of prescription opioids. Surveys of US,[10] Canadian,[11] Australian,[12] and multinational[13] samples have demonstrated a relationship between chronic pain conditions and increased risk of past-year and lifetime suicidal behaviors. Prospective research has also revealed that pain is strongly associated with suicide death.[14] However, little is known about the relationship between medical opioid use and suicidal behaviors. In a 2015 national survey, among adults with suicidal ideation who had used opioids in the past year, nearly 70% were medical opioid users who did not misuse opioids,[15] but it is unclear whether and to what extent medical use of opioids independently contributes to risk of suicidal behaviors. We addressed this knowledge gap by analyzing risk factors associated with suicidal behaviors in adults with no past-year opioid use, adults with past-year use but no misuse (i.e., medical use as directed by a physician), and adults with past-year misuse (i.e., use in any way not directed by a physician). Our goal was to inform efforts to prevent suicidal behaviors within the opioid-using population by evaluating whether the increased risk of suicidal behaviors associated with opioids extends to opioid use without misuse.[16]