The answer is, unequivocally, YES.

Suicide is now the eleventh leading cause of death in the United States, accounting for 34,000 deaths per year. Community based surveys by the CDC reveal that approximately 5% of adults have made a serious suicide attempt.

At the same time, deaths from Substance Use Disorder are skyrocketing. According to the Substance Abuse and Mental Health Service Administration (SAMHSA), opioid overdose deaths have increased 265% among men and 400% among women since 1999. At the same time, cannabis use has increased among adults and adolescents, in lock step with ongoing legalization efforts.

Although the correlation between Substance Use Disorder and suicide risk has been established, the progression from sadness, depressed mood, anhedonia and major depression is not clear. The relationship between substances used, age of onset, cause and effect of drugs of abuse on suicidal ideation, as well as the onset cause and effect of suicidal ideation with the use and/or dependence upon intoxicants, is quite complicated and really, has not been adequately examined.

Suicidal Ideation and Substance Use Disorder

To shed light on this question, Agrawal and colleagues (2017) studied a prospective cohort (N=3277) of the Collaborative Study of the Genetics of Alcoholism (COGA), adjusting for covariates such as depression, family history of alcohol use disorder, other pathologies, and environmental factors and stressors. The analysis revealed that suicidal ideation was related (OR 0.71–0.77) to subsequent alcohol, nicotine and cannabis use. Suicide attempts were associated with (OR 1.44–1.61) later alcohol, nicotine and cannabis dependence, even after accounting for covariates. Interestingly, the evidence for early substance use as a risk factor for the onset of suicidal ideation or attempt was limited. I suspect this is likely due to limited availability of specific data regarding depression and other co-occurring mental illness, as well as the potential for survivor bias.

Why Does This Matter?

Those of us who have worked with addicts understand that there are levels of suicidality that do not fit into government statistical categories. For example, taking a handful of pain pills with a fifth of vodka to numb the feelings associated with addictive disease, all the while knowing there is chance of never waking up, is a common, albeit, more subtle form of suicide among addicts—but nonetheless grievous. In many ways, it is like the analysis we did on speeding and teens as part of a spectrum of gambling, risk taking and suicidality.

In addition, previous analysis from psychological autopsies reveal that 63% of all suicide completers suffer from Substance Use Disorder, primarily alcohol use disorder (Edwards, et al, 2012). Lastly, the concordance rate between Substance Use Disorder and depression is 45-60%, and the relationship is bi-directional.

What To Do

Persons hospitalized for overdose or in treatment for depression should be evaluated for Substance Use Disorder. Patients with a Substance Use Disorder should be evaluated for co-morbid psychiatric illness and active and passive suicidal thinking. Likewise, whether a patient is seen in an outpatient, detox or MAT program does not appear predictive of who has depression, anhedonia and suicidal ideation or behavior. Individuals seen for Substance Use Disorder should be evaluated for psychiatric illness, suicide ideation, family history of depression and suicide, and if necessary, treated aggressively because the cost of failure is simply unacceptable.