The finding: A sample of ~124,000 VHA patients were assessed for opioid dosing for the treatment of chronic noncancer pain in 2004-2005 and suicide in the successive five years. Increasing daily opioid doses were associated with increased risk of suicide, as detailed in the abstract. The majority of suicides involved firearms; overdose accounted for about 20% of the suicides and it did not appear that increased access to opioids was associated with an increased risk of intentional overdose. Comorbid psychiatric diagnoses did not sufficiently account for the increased risk associated with higher opioid doses.

Strengths and weaknesses: This is the first study to attempt an examination of the relationship between opioid dosing (rather than degree or type of chronic pain) and suicide. It is not able to shed light on whether it is possible to view suicide as an adverse outcome of increased opioid use, or if the latter’s relevance is more as a marker for severity and/or duration of pain, or the suboptimal application of collateral non-pharmacologic pain management strategies. The study population was overwhelmingly male (>95%) and it is not known to what extent these results can be generalized to the population at large.

Relevance: Every consultation psychiatrist is familiar with requests to see patients who either threaten suicide if their demands for higher opioid dosing are not met, or who express their conclusion that life is no longer worth living given the degree of pain they are experiencing. While the characteristics of these groups of patients may differ, the common denominator is that both groups may eventually secure increasing opioid doses. Despite the many unanswered questions, this study reminds the consultation psychiatrist to attend carefully to suicide risk assessment in vulnerable individuals who are receiving increased (>20 mg daily of morphine-equivalent) opioid doses.