RRies Addiction and Suicide
Richard Ries MD rries@u.washington.edu
Harborview Medical Center and the
University of Washington
Seattle, Washington


Dr Ries is on Speaker’s bureaus for
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Janssen, and Alkermes
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Dr Ries has Grant funding from:
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NIH- NIDA
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Contingency Management Meth in Mentally Ill
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Preventing Addiction Related Suicide
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Brief Interventions of Drug Abuse in Prim Care
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CSAT
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National Co-occurring Center of Excellence
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DOD- Suicide Prevention grant

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30,000 die by suicide in USA each year
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More die by suicide than homicide (1.7 times more)
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Third leading cause of death in those 15-24 ….more than cancer, AIDS, heart, and lung disease combined
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Males die 4x more often, but females make more attempts
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60% die by firearm
CDC web site

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500,000 ER visits for attempts in 1997
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Four times as many US citizens died by suicide during the Viet Nam War period than died as soldiers.
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Rates increase with age ( as do other causes of death)
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Often Drug/Alcohol related
CDC web site

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Risk of Attempt
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Previous attempt
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Family History of Suicide
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Psychiatric disorder
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Alcohol/Drug disorder
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Alcohol/Drug Intoxication
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Loss
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Hopelessness/end of rope
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Risk of Lethality
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Male 4/1 over females
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Guns 70%
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Access
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Older >70
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Alone/Loss of support
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Alcohol
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Serious illness
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Medical

Psychiatric

2009, United States
Suicide Injury Deaths and Rates per 100,000
All Races, Both Sexes, All Ages
ICD-10 Codes: X60-X84, Y87.0,*U03
USA Number of
Suicide Deaths
36,909
Population
307,006,550
Crude
Rate
12.02
698,473
698,473
20.47
20.47
Age-Adjusted
Rate**
11.77
19.39
Alaska
143
143
Idaho
304
304
Washington
921
921
1,545,801
1,545,801
6,664,195
6,664,195
19.67
19.67
13.82
13.82
20.42
13.38
Oregon
644
644
3,825,657
3,825,657
16.83
16.83
16.11

Homicide
Combat
3%
4%
Undetermined
1%
Suicide
17%
Illness
25%
Accident
50%
Suicide accounted for an average of nearly 1 in 5 deaths among regular and reserve U.S. military personnel between
October
1998 and
September
2003.
Source: U.S. Armed Forces
Medical Examiner, 2004

J Sch Health. 2004 May;74(5):177-82.
Attempted Suicide and associated health risk behaviors among Native American high school students
. Shaughnessy L, Doshi SR,
The study included students in BIA-funded high schools with 10 or more students enrolled in grades 9-12. Overall, 16% of BIA high school students attempted suicide one or more times in the 12 months preceding the survey.
Risk Factors:
> unintentional injury and violence behaviors,
> sexual risk behaviors,
> tobacco use, and
> alcohol and other drug use.


Lifetime Suicide risk for Schizophrenic,
Affective and Addiction Disorders:

Method: review of 83 mortality studies:
 Schizophrenia…………4%
 Affective Disorders……6%
 Addiction Disorders…...7%
Inskip HM: Br J Psych 1998

 Alcohol strongest predictor of completed suicide over 5-
10 years after attempt, OR= 5.18…vs. demog or psych disorders ( Beck J Stud Alc 1989)
 40-60% of completed suicides across USA/Europe are alcohol/drug affected (Editorial: Dying for a Drink: Brit
Med J. 2001)
 Higher suicide rates (+8%) in 18 vs. 21yo legal drinking age states for those ages (Birckmayer J: Am J Pub
Health 1999)

40%
30%
20%
10%
0%
N=60,952
25%
17%
20%
13%
18%
11%
20%
13%
IP OP MM Detox
% Thoughts % Attempted

N=60,952 40%
30%
20%
10%
0%
8%
2%
5%
1%
4%
1%
9%
2%
% Thoughts % Attempted

What do we know about Suicide Attempts in
Prospective Age-Matched Alcoholic Populations
 4.5% of alcoholics attempted suicide within 5 years of DX
 ( age 40.. n=1,237)
 0.8% in non-alcoholic matched comparison group
 ( age 42..n=2,000)…
 p< .001……….. 700 % increased risk of Suicide Attempts
Preuss/Schuckit Am J Psych 03

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Rate = 4.5% attempted suicide
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Prior attempts
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Earlier onset and more severe dependence. Other drug dependence
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Separated or divorced
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More likely to have had treatment ( more severe)
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More Panic
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More Substance Induced Psych Disorder
Preuss/Schuckit et al Am J Psych03

1: Drug Alcohol Rev. 2005 May;24(3):203-8.
Alcohol and suicide at the population level--the
Canadian experience.
Ramstedt M.
Studies suggest that the population level link between alcohol and suicide differs across countries and between men and women. The aim of this paper was to estimate the relationship between alcohol consumption and suicide in
Canada and to put the results in a comparative perspective.
The total suicide rate in Canada increased significantly by around
4% as alcohol consumption increased by one litre per capita, suggesting that approximately 25 - 30% of Canadian suicides were related to alcohol.

Standardized suicide mortality rates in men and women with mean annual alcohol consumption in liters per capita.
Russia 1965-99.
Men Women
Alcohol Consumption

Mean annual consumption with BAC-positives and BAC-negatives for
8 Russian Regions 1981-1990.
BAC Positive Suicides
BAC Negative Suicides
Alcohol Consumption


Henriksson, et al (1993)- 43% of completed suicides had alcohol dependence. 48% of these were also depressed.
42% had a personality disorder.
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Elliot, et al (1996)- patients with medically severe suicide attempts had a statistically higher prevalence or substanceinduced mood disorder.
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Pages K et al (1997)- Higher degrees of Sub Dep related to higher severity suicide ratings

METH ADDICTS : LIFETIME SUICIDE ATTEMPTS, BEHAVIOR PROBLEMS, AND
FELONY CHARGES, BY GENDER
ASI Item Overall Males Females
Test
Statistic*
Attempted Suicide (%) 27% 13% 28% 35.42**
Violent behavior problems (%) 43% 40% 46% 3.29***
Assault Charges (mean number) 0.29
0.46
0.15
4.46**
Weapons charges (mean number) 0.13
0.21
0.07
4.09**
*Mantel-Haenszel chisquare was used to test differences in proportions by gender, df=1; Student’s two-group t-test (two-sided) was used to test differences between males and females in continuous dependent variables reflecting the number of charges, df=1013.
**p < 0.00001 ***0.1 < p <0.05
Zweben, et al., 2004

Do Antidepressants treat OR decrease “Suicidality
Am J Psychiatry. 2003 Apr;160(4):790-2.
Suicide rates in clinical trials of SSRIs, other antidepressants, and placebo: analysis of FDA reports.
Khan A, Khan S, Kolts R, Brown WA.
RESULTS: Of 48,277 depressed patients participating in the trials, 77 committed suicide. Based on patient exposure years, similar suicide rates were seen among those randomly assigned to an SSRI (0.59%, 95% confidence interval [CI]=0.31%-0.87%), a standard comparison antidepressant
(0.76%, 95% CI=0.49%-1.03%), or placebo (0.45%, 95% CI=0.01%-0.89%).
CONCLUSIONS
: These findings fail to support either an overall difference in suicide risk between antidepressantand placebo-treated depressed subjects in controlled trials or a difference between SSRIs and either other types of antidepressants or placebo.

Cohort suicide attempts
Adults Year Prior Year After
> 25 yo (n=3524) 23%...........................4%
18-24 yo (N=651) 28%...........................4%
Adoles (n=236) 23%...........................7%
Karageorge: National Treatment Improvement Evaluation study 2001

Alcohol Consumption, Alcoholics Anonymous membership, and Suicide Mortality
Rates, Ontario, 1968-1991 .
Mann RE, Zalcman RF, Smart RG, Rush BR, Suurvali H.
Method: We studied the impact of alcohol consumption levels, AA membership rates, and unemployment rates on suicide mortality rates in Ontario from 1968 to
1991.
Results:
Total alcohol consumption was significantly and positively related to total and female suicide mortality rates .
AA membership rates were negatively related to total and female suicide rates .
(J. Stud. Alcohol 67: 445-453, 2006).

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Opiates and Opioids have the highest death rates of any psychoactive illicit-substances


Accidental deaths from Prescription Opioids now
Outnumber Traffic deaths in many states

The 2010 CDC report, Unintentional drug poisoning in the United states , sites heroin and prescription painkillers as the two leading causes of overdose death in the US
Hulse, English, Mline, &
Holman, 1999; Seymour et al.
2000, CDC 2010, 2012

Fully accidental
Just blot out worries
Who cares if I wake
Lethal Plan

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Mortality rate of opioid users 14 times that of general population
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46% to 70% of opioid users experience one or more non-lethal overdoses during their lifetime
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Opiate users who were recently released from prison were at even higher risk of overdose, and this risk may also exist post “Detox”

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1 in 5 (20%) of suicide victims have opiates in their bodies at time of death, including heroin, and prescription painkillers
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Opioid dependent adults are 14 times more likely that their non-drug using counterparts to die by suicide Between 33% and 50% of drug users have a history of suicide attempts
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Suicide accounts for an estimated 3% to 35% of deaths among heroin users
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Spectrum of Volition —

Accidental -- Risky -- Passive SI -- Planned Suicide
Harris and Barraclough, 1997; Darke and
Ross, 2002, Ries SPOT unpub

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Risk Factors for Suicide in Opiate Abusers
Parallel Risk Factors for Accidental
Overdose (Darke and Ross, 2002)
Accidental
Overdose
Male gender
Depression
Previous overdose
Homelessness
Previous attempt
Personality
Disorder: CCD ASPD
Social isolation
Poly-substance abuse Genetic predisposition
Hx. of childhood sexual trauma
Suicide

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Methadone: opiate replacement therapies reduce opiate overdose risk by 75%
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Naloxone: ER administered Naloxone, peer administered
Naloxone (I.M., I.V., S.Q., intranasil).
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Medically supervised injection facilities: report 0 fatal overdose deaths.
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Educational programs: presented at needle exchange programs
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Protocols: limiting police intervention in during overdose emergencies
Gunne and Gronbladhm, 1981; Bammer, 2000;
McGregor, Ali Christie, Darke, 2001

NIDA R21
Ries, Voss, Comtois,
Addictions staff and directors
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Designed to be a single 3 hour IOP session integrated into typical outpt
Addictions Treatment programs—for all patients in treatment
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To enhance positive changes in Attitudes, Knowledge, and Adaptive
Skills for suicidal issues in both patients and those around them, workbook based,
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Needing only a single 3 hour staff training session—using same guide they then use to perform and guide group.
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Designed iterively with REAL WORLD addictions staff, administrators, and patients for feasabiity
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RETRAINS STAFF EACH TIME USED IN IOP, OR OTHER FORMAT

Pre-test In the past 30 days, have you asked for help because you were having suicidal thoughts/feelings.
No
97%
(n=60)
1 month follow-up
YES
3%
(n=2)
90%
(n=56)
10% (n=6)
P=.000
In the past 30 days, have you asked a friend to get help because you were worried that he or she was having suicidal thoughts/feelings.
Pre-test
1-month follow-up
NO
94%
(n=59)
78%
(n=49)
YES
6%
(n=4)
22%
(n=14)
P=.009

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American Association of Suicidology: www.suicidology.org
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American Foundation for Suicide Prevention: www.afsp.org
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National Strategy for Suicide Prevention: www.mentalhealth.org/suicideprevention/
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National Suicide Prevention Strategy www.sg.gov/library/calltoaction/
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CDC

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Suicide Prevention Advocacy Network (SPAN) www.spanusa.org
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QPR institute: www.qprinstitute.com
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Substance Abuse and Mental Health Services
Administration: www.samhsa.gov
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Tip 50- Addiction and Suicide www.CSAT.gov

YOUR

Suicide Assessment
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Suicide prevention
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Suicide Treatment