Something for the Pain
Suicide and opioid use/addiction have something in common: they are attempts to solve the problem of pain, both physical pain and psychological pain (also known as “psychache”) (Shneidman 1998). Last summer the Centers for Disease Control (CDC) released a report indicating that death by suicide in the US increased by 24% between 1999 and 2014, translating to 44,193 lives lost each year to suicide–a rate of 13.26 per 100,000 individuals. And this year, in 2017, we have learned that deaths from drug overdoses have increased 2.5 times the rate in 1999, to a rate of 16.3 per 100,000 individuals (Hedegaard, Warner, and Miniño 2017). Of the drug overdose deaths in 2015, 25% involved heroin–triple the percentage of heroin overdoses in 2010. While there is a declining mortality among most diseases in the US, deaths from suicide and drug overdose have dramatically increased since 1999. Pain of one sort or another is often at the root of both suicide and addiction.
How might we think about the many causes of pain and the treatments for deadly symptoms that emerge in relation to pain? There are a host of environmental, epidemiological, social, and cultural factors that have been studied in relation to both phenomena, and yet understanding the mind of the individual who dies by suicide or drug overdose requires careful attention to how they subjectively experience and manage physical and psychological pain. The problem in the US for both suicide and opioid addiction is so severe that public health interventions are needed to dramatically decrease the death rate. Studies support the effectiveness of public health interventions that go beyond treating the individual’s symptoms and aim to intervene through environmental and social engineering, treating the larger contexts in which these problems are embedded (Barber, Hemenway, and Miller 2016); (David-Ferdon et al. 2016).
For suicide, one avenue of change is to restrict access to lethal means. In the United States, more than 50% of suicide deaths occur through the use of a firearm, and research supports the idea that sensible gun laws restricting access to lethal means would reduce the rate of suicide (Anestis and Houtsma 2017). For those who do own guns, increased “lethal means counseling” around suicide and firearm safety may also reduce the risk of suicide (Barber, Hemenway, and Miller 2016). Similarly, with opioid use/addiction, the over prescription of opioid medication for the past 15 years has contributed to the problem of opioid addiction in the US. As Jennifer Michaels, MD, and Eric Plakun, MD, write in their earlier blogs (Dr. Michaels’ blog, Dr. Plakun’s blog), this situation has occurred because physicians were worried about undertreating pain, pharmaceutical companies vigorously marketed opioid medication to consumers and physicians, and prescribing medicine for pain in the short-term can appear easier than understanding the causes and full symptoms of a pain disorder.
Building healthy communities and addressing sources of psychic pain such as poverty, mental illness, lack of access to care, addiction, and violence are all needed in order to reduce the premature death of many of our citizens. One analogy that supports this approach is car safety. In the past fifty years, deaths from motor vehicle accidents have been dramatically reduced. This did not occur because we as individuals have become better drivers. Rather, the death rate has decreased because we have lowered the speed limit, passed seatbelt laws, built safer cars with air bags and other collision protection, and strengthened our efforts to reduce drunk or impaired driving. The lesson from this public health strategy might be useful for reducing deaths by drug overdose and suicide. In a country where our individual freedoms and liberties are cherished, social engineering is often viewed with skepticism or suspicion. But the data are clear: to reduce deaths by suicide and by opioid overdose, restriction of lethal means is a proven and effective approach we can take.
Anestis, Michael D., and Claire Houtsma. "The Association Between Gun Ownership and Statewide Overall Suicide Rates." Suicide and Life-Threatening Behavior (2017). doi: 10.1111/sltb.12346.
Barber, Catherine, David Hemenway, and Matthew Miller. “How Physicians Can Reduce Suicide–Without Changing Anyone’s Mental Health.” The American Journal of Medicine 129 no. 10 (2016): 1016-17.
Curtin, Sally, Margaret Warner, and Holly Hedegaard. “Increase in Suicide in the United States, 1999–2014.” NCHS Data Brief 241 (2016). https://www.researchgate.net/profile/Sally_Curtin/publication/301564377_Increase_in_Suicide_in_the_United_States_1999-2014/links/571a31dc08ae408367bc84d6.pdf.
David-Ferdon, Corinne, Alex Crosby, Eric Caine, Jarrod Hindman, Jerry Reed, John Iskander. “CDC Grand Rounds: Preventing Suicide Through a Comprehensive Public Health Approach.” Morbidity and Mortality Weekly Report (MMWR) 65 (2016): 894-897.
Hedegaard, Holly, Margaret Warner, and Arialdi M. Miniño. "Drug Overdose Deaths in the United States, 1999-2015." NCHS Data Brief 273 (2017): 1-8.
Shneidman, Edwin S. "Further Reflections on Suicide and Psychache." Suicide and Life-Threatening Behavior 28, no. 3 (1998): 245-250. doi: 10.1111/j.1943-278X.1998.tb00854.x.