PKpix/Shutterstock
Source: PKpix/Shutterstock

Many, if not most, deaths resulting from prescription opioid and other drug overdoses are listed as “accidental” or “unintentional” on death certificates because information regarding the person’s state of mind prior to the overdose is unavailable. This designation is used even when there is a history of repeated, deliberate drug use and overdose, which clearly increases the potential for death. Many in the public health field believe that this results in an underestimation of poisoning suicides.

Ian Rockett and colleagues recently published a paper in JAMA Psychiatry that convincingly demonstrates an increase in self-injury mortality (SIM) over the last 15 years. Rockett and his team define SIM as a combination of suicides by any method and a predetermined percentage of deaths from drug overdoses for which causes were classified as either “accidental” or “undetermined” by medical examiners and coroners. The authors contend that about 80 percent of overdoses classified as “accidental” and 90 percent of overdoses classified as “undetermined” result from self-destructive behavior. Therefore, the term SIM includes deaths of those who intended to die as well as deaths by people who demonstrated self-destructive behavior for which death was a likely possible consequence.

In this study, Rockett and colleagues used data from the Centers for Disease Control and Prevention to compare SIM to mortality resulting from diabetes, kidney disease, and influenza and/or pneumonia between 1999 and 2014. Their analysis found that SIM increased dramatically during these 15 years: An estimated 40,289 deaths were attributed to self-injury in 1999 compared to 76,227 in 2014. This corresponds to an increase from 14.4 deaths per 100,000 persons due to SIM in 1999 to 23.9 deaths per 100,000 persons in 2014. In 2014, the mortality rate from self-injury equaled that from diabetes and substantially exceeded the mortality rates from kidney disease and influenza/pneumonia.

Not surprisingly, most self-injury deaths occurred in younger individuals. From 1999 to 2001, over 77 percent of SIM occurred in individuals younger than 55 compared to 6 to 11 percent of deaths related to the other three categories of illnesses. The numbers were similar for the period between 2012 and 2014. Since SIM occurs in younger persons, the total number of years of life lost is markedly higher for SIM than for the other three categories of illnesses.

The researchers also found that self-injury deaths were much more common in males than females. However, the increase in mortality rate was higher in women during the study period.

The number of overall deaths and the rapid rise in the death rate over time represent major public health crises.

Suicides often occur in the context of depression and/or substance use disorders. Deaths resulting from overdoses likely involve many causes including depression, addiction, and other psychiatric illnesses. Overdoses of minor tranquilizers (e.g., benzodiazepines) may reflect different issues than deaths resulting from overdoses of heroin or prescription opioids.

The rates of death in young and middle-aged individuals from self-injury are staggering. Hopefully, research such as this will alert policy makers to invest resources to reverse this disturbing trend.

This post was written by Eugene Rubin MD, PhD and Charles Zorumski MD.

References

Rockett, I.R.H., Lilly, C.L, Jia, H., et al. (2016). JAMA Psychiatry. 73: 1072-1081.

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