Incidence and Lethality of Suicidal Overdoses by Drug Class | Psychiatry and Behavioral Health | JAMA Network Open | JAMA Network
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    Original Investigation
    March 23, 2020

    Incidence and Lethality of Suicidal Overdoses by Drug Class

    Author Affiliations
    • 1Pacific Institute for Research and Evaluation, Calverton, Maryland
    • 2Curtin University School of Public Health, Perth, Australia
    • 3School of Public Health, West Virginia University, Morgantown, West Virginia
    • 4American Counseling Association, Alexandria, Virginia
    • 5Education Development Center, Waltham, Massachusetts
    JAMA Netw Open. 2020;3(3):e200607. doi:10.1001/jamanetworkopen.2020.0607
    Key Points español 中文 (chinese)

    Question  What is the association between classes of drugs consumed and the lethality of suicidal drug overdoses?

    Findings  In this cross-sectional study of state censuses and national samples that included 421 466 medically identified suicidal drug overdoses, the risk that an overdose would be fatal was highest if an opioid or barbiturate was involved. Lethality increased with age, whereas youth overdoses often involved toxins with low lethality.

    Meaning  These findings suggest that drugs that are lethal in overdose when combined should be stored securely in homes, and lethal drugs should be blister packed.


    Importance  Prior lethality analyses of suicide means have historically treated drug poisoning other than alcohol poisoning as a lumped category. Assessing risk by drug class permits better assessment of prevention opportunities.

    Objective  To investigate the epidemiology of drug poisoning suicides.

    Design, Setting, and Participants  This cross-sectional study analyzed censuses of live emergency department and inpatient discharges for 11 US states from January 1, 2011, to December 31, 2012, as well as Healthcare Cost and Utilization Project national live discharge samples for January 1 to December 31, 2012, and January 1 to December 31, 2016, and corresponding Multiple Cause of Death census data. Censuses or national samples of all medically identified drug poisonings that were deliberately self-inflicted or of undetermined intent were identified using diagnosis and external cause codes. Data were analyzed from June 2019 to January 2020.

    Main Outcomes and Measures  Distribution of drug classes involved in suicidal overdoses. Logistic regressions on the state data were used to calculate the odds and relative risk (RR) of death for a suicide act that involved a drug class vs similar acts excluding that class.

    Results  Among 421 466 drug poisoning suicidal acts resulting in 21 594 deaths, 19.6% to 22.5% of the suicidal drug overdoses involved benzodiazepines, and 15.4% to 17.3% involved opioids (46.2% men, 53.8% women, and <0.01% missing; mean age, 36.4 years). Opioids were most commonly identified in fatal suicide poisonings (33.3%-47.8%). The greatest RR for poisoning suicide completion was opioids (5.20 times the mean for suicide acts that did not involve opioids; 95% CI, 4.86-5.57; sensitivity analysis range, 3.99-6.86), followed by barbiturates (RR, 4.29; 95% CI, 3.35-5.45), antidepressants (RR, 3.22; 95% CI, 2.95-3.52), antidiabetics (RR, 2.57; 95% CI, 1.94-3.41), and alcohol (conservatively, because 30% of death certifiers do not test for alcohol; RR, 2.04; 95% CI, 1.84-2.26). The updated toxin diagnosis coding in International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, used to code the 2016 data revealed that calcium channel blockers also had a high RR of 2.24 (95% CI, 1.89-2.61). Translated to attributable fractions, approximately 81% of suicides involving opioids would not have been fatal absent opioids. Similarly, 34% of alcohol-involved suicide deaths were alcohol attributable.

    Conclusions and Relevance  These findings suggest that preventing access to lethal means for patients at risk for suicide should extend to drugs with high case fatality rates. Blister packing and securely storing lethal drugs seems advisable.