Oct 30, 2019
Mark S. Gold, MD,
Norris, MD, host of the MDedge Psychcast and editor in chief of
MDedge Psychiatry, to discuss the intersection between the rise in
suicide and the opioid crisis in the United States.
Dr. Gold is adjunct professor of psychiatry at Washington
University in St. Louis. He also serves on the editorial advisory
board of MDedge Psychiatry. Previously, Dr. Gold served as
distinguished professor and chairman of the psychiatry department
at the University of Florida, Gainesville.
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- This week in Psychiatry (01:11)
- Interview with Dr. Gold (03:40)
This week in Psychiatry
Demeaning patient behavior takes
an emotional toll on physicians
by Steve Cimino
Suicide and the opioid
- In 2017, more than 70,000 people died from overdose, and 47,600
of those deaths involved prescription or illicit opioids. Most
coroners list the deaths as “accidental” unless there is a suicide
note or the deceased spoke about an intent to die.
- Chronic opioid self-administration changes the brain. The
person becomes less high and more depressed over time.
- The prevalence of depression is at least 50% in those with
opioid use disorder. Some experts estimate that up to 30% of opioid
overdoses are intentional and count as suicide. A person with
opioid use disorder has 13 times the risk of attempting and
completing suicide, compared with the general population.
- Until recently, psychiatric evaluations and suicide assessments
were not routine in the chain of events from opioid use to overdose
to transition to medication-assisted treatment (MAT).
- People whose overdoses are reversed by naloxone are prime
candidates to ask whether an overdose was accidental. In an
emergency department in Flint, Mich., 30% of overdose patients
rescued with naloxone described their overdose as a suicide
- Although some people revived with naloxone are angry, it is
important to consider irritability and anhedonia that come from
giving an opioid antagonist during a high.
Future of treatments in the opioid crisis
- Much is still unknown. For example, there are no MAT options
for either stimulant or cannabis use disorders, which are
implicated in the morbidity and mortality of the overdose crisis.
More research is needed to determine how long patients should be on
MAT and when their brains “reset” after addiction.
- Also, in the pipeline is advanced imaging showing how drug use
changes a person’s neurocircuitry and genetics. The OPRM1 gene, for example,
is a polymorphism whose presence predicts whether a person is more
likely to become addicted after their first use of opiates and
determines treatment resistance to recovery.
- In the next year, efforts aimed at preventing overdoses and
investigating the risk and rates of suicide are likely to
- If every patient with a high-dose opioid prescription were
offered naloxone, nearly 9 million more naloxone prescriptions
could have been dispensed in 2018. So, we might see state-level
policies that seek to increase naloxone prescriptions to patients
based on morphine equivalents.
- Looking beyond overdoses and relapse prevention, the National
Institute on Drug Abuse (NIDA)
has identified novel targets focused on regenerating the reward
system in order to return the brains of people with addictions to
premorbid function after years of abuse.
Volkow N and Gordon J.
Suicide deaths are a major component of the opioid crisis.
NIDA. 2019 Sep 19.
Oquendo MA and Volkow ND. Suicide: A silent contributor to
New Engl J Med. 2018;378:1567-9.
5-point strategy to combat the opioid crisis. U.S. Department
of Health & Human Services.
not enough naloxone where it’s most needed. Centers for Disease
Control and Prevention. 2019 Aug 6.
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