It is Pain Awareness Month and it is Suicide Prevention Month. That makes a lot of sense when you consider chronic pain. Pain itself is a suicide risk if you have no pain management and management is tricky. It differs from person to person and it can take so much time to find what works for that person. And then we can have comorbid mental illness and that complicates the issue of pain management and suicide risk factors at the same time.
we found robust evidence that chronic pain itself, regardless of type, was an important independent risk factor for suicidality. (Science direct)
In fact, chronic pain alone increases the risk of suicidal behaviours twice as much as the rest of the population. However, there are many factors involved in this, including depression. And later I will discuss some of the factors of the pain experience that lead to suicidal ideation and behaviour we have to be aware of because that is where intervention can lie.
Let’s start with some basic pain facts.
- 100 million Americans have chronic pain
- 1.5 billion worldwide have experienced chronic pain
This is not a minor problem. There is, in fact, a pain epidemic.
Most common forms of pain
- 27% low back pain
- 15% headache and migraine
- 15% neck pain
- 4% facial pain
What we feel with chronic pain
- 77% feel depressed due to the pain
- 51% feel they have little to No control over the pain
Neither of those points suggests pain is sunshine and rainbows, does it? Pain is relentless and difficult to cope with. It is a hard road.
At least 10% of all suicides are from chronic pain (Pain Awareness month)
Now with this statistic we know is more but you have to remember it is skewed by what they label a suicide. If there is no note, no suicide. Or do they think it was an accidental overdose opposed to suicide? Or do they just list it as overdose? Lots of factors influence this statistic. Which is important because since the guidelines on opiate have change we know in the pain community suicides have increased but how much we will never know.
We would like to blame it all on depression. And certainly 6.7 American adults have Major Depressive disorder and I can tell you it does really compromise our capacity to cope with chronic pain. And a risk factor for depression is chronic illnesses. Something about them… depressing.
Today the CDC released a new report estimating that 50 million Americans – just over 20 percent of the adult population – have chronic pain. About 20 million of them have “high-impact chronic pain” — pain severe enough that it frequently limits life or work activities. The estimates are based on the 2016 National Health Interview Survey of over 33,000 adults…. “By differentiating those with HICP, a condition that is associated with higher levels of anxiety, depression, fatigue, and cognitive difficulty, we hope to improve clinical research and practice,” said co-author M. Catherine Bushnell, PhD, scientific director at NCCIH. PainNewNetwork
We know depression complicates the situation. It needs to be treated along with the pain as its own entity. And yes, it accounts for some of the suicidal ideation and behaviours… but not all.
Opiates are by no means the only solution to the complex problem of chronic pain. But they are one factor for some people’s pain management. So we cannot ignore the impact of taking those away from people’s pain management and suicide risk factors. We have all heard so many people lost to suicide when the medication that helped them function just a little bit was taken from them. It is frankly, horrific.
CDC changed its guidelines in response to the opiate epidemic
New guidelines and restrictions surrounding the prescription process are intended to make opioid use safer for patients. The latest guidelines from the Centers for Disease Control and Prevention (CDC) do note the difficulty of treating chronic pain.
According to an abstract published in the Journal of the American Medical Association (JAMA), the CDC notes the importance of the guidelines, stating, “Evidence of long-term efficacy of opioids for chronic pain is limited. Opioid use is associated with serious risks, including opioid use disorder and overdose.”
The CDC notes that doctors need to do a better job of explaining potential side effects to patients, and to really weigh the risks versus the benefits in prescribing this class of drug.
According to their guidelines, “Non-opioid therapy is preferred for treatment of chronic pain. Opioids should be used only when benefits for pain and function are expected to outweigh risks.” Healthline
What happened when the CDC guidelines were changed:
“The fallout from the CDC’s guidelines – which were released a little over two months ago – was in many ways predictable. In our survey of over 2,200 pain patients last fall, many predicted there would be unintended consequences if the guidelines were adopted.”
- 90% thought more people will suffer than be helped by the guidelines
- 78% thought there would be more suicides
- 76% thought doctors would prescribe opioids less often or not at all
- 60% thought pain patients would get opioids through other sources or off the street
- 70% thought use of heroin and other illegal drugs would increase (Pain News Network)
However, opiate treatment is not the treatment for everyone. As I said, treatment is diverse and tricky and complicated. We are lucky if we find someone that realizes that and puts the time to find the treatment that works for us. Or we find it because they won’t help us. So removing opiates from those that need them certainly is a major suicide risk factor. Depression is definitely a suicide risk factor.
But what inherently about the pain experience is a suicide risk factor that we have to watch out for and need to get intervention for to help ourselves?
How can we prevent suicidal ideation and thoughts… and plans? I can tell you, I had a real problem with it and I am lucky to be alive. I wish I knew then what I knew now. But also a) I am on slow-release tramadol which helps me function and b) I am on depression medication for Major Depressive Disorder. Tag me on both my points so far. If I was not treated for both I would be back where I was… and where I was, I was ardently suicidal. So those two factors do actually mean quite a bit. But what is it about pain itself, because I can tell you before I was depressed I still had suicidal ideation and I can tell you it is very common to have it. So common a psychologist will make the distinction are you having ideation… or Intent? But what underlays the depression and the opiate issue…
Risks factors for suicide with chronic pain (Source)
- Desire to escape from the pain– Many of us have this thought. We don’t want to die, we want to escape the pain
- Duration of pain-People with chronic enduring pain 6-12 months or more has an increased risk of suicide compared to acute pain.
- Hopelessness– When we lose hope that nothing will ever help us then we are at increased risk.
- Insomnia– Which is a very common symptom of ours (painsomnia) also increases our risk factors
- Passive coping strategies– wishing or hoping the pain will just stop increases risk (because it doesn’t, does it?)
- Pain catastrophizing– (my favourite apparently) feeling the worst about pain, helpless about it, magnifying it is linked to suicide and even intentional overdose
- Pain interference– So even after controlling depression pain interference, the degree to which pain interferes i engaging in everyday life can increase suicide ideation.
- Pain severity– studies indicate a link between pain severity and suicide and death. However, if depression is managed another study suggests this may be altered (mixed results on that study)
- Perception of being a burden– When we feel like we have simply become a burden to our loved ones it increases suicidal ideation
- Specific pain conditions– some conditions come with them a higher risk. Migraines for example do- see chronic migraine and suicide awareness. And also back pain and psychogenic pain also have increased risk factors.
- Access to certain medications– When pain and mood disorders are present as well as alcohol use or other factors as well as access to pain medications and anxiety medications can increase the risk of suicide in chronic pain patients.
When we look at this list First thing, it is very familiar isn’t it? It is like a checklist for my brain anyway. Hit most of these. Not all. But most. Because PAIN comes with certain emotional and mental impacts.
#7 and #8 are the ones that need some sort of medical intervention- medication, botox, nerve blocks and yes Opiates- whatever helps manage the pain because that is an important factor. Maybe opiates. And that is why taking away opiates tips this scale of pain management because there goes 7 and 8 out of control and then all the others like feeling hopelessness… fall down as well. Those two cannot be ignored. And you cannot take what was working for someone without replacing with something that works equally well. If you replace it with nothing then, yes, you have tipped the scales on all those other factors and yes that is why suicides have increased with the sharp cut-off of opiate treatment. My opinion on that (Don’t steal lives, doc)
The ones that cannot be managed by medication, if we are at a pain clinic, can be managed by pain management intervention classes, pain group therapy, treatment with a psychologist.
And at my worst, yeah, I really felt some of these intently. And I would say they were the driving factors along with 7 and 8. And depression. The perfect storm really. Now the pain is being managed somewhat, the depression is managed, and I have seen a psychologist a long time so that the others do not impact me in the same way that they did.
I think they always do impact us. In one way or another. I think the problem is when the pain is severe and it affects all aspects of our lives and then the factors get More Intense and Real. You lose hope. You feel like a burden. You do catastrophize. You can’t sleep. You can’t escape the pain… ever. The duration of pain can be years or decades at that point. And then it becomes a massive problem. A problem we don’t even notice right away.
Other times when we are coping better and the pain is being managed, the other factors are less Loud. And we hear them, yeah, we hear them. But they do not hurt us so much. But we have to be wary. At any time the pain management we have… could be gone.
We know though that through long term pain it alters our perspective on life, on the pain, on our very identity and self-worth. Sometimes I say we are broken and remade… but not just once. What Charles Bukowski said in one of his poems was “what matters most is how well you walk through the fire.” Maybe that is true. But I sometimes have not walked so well through this fire. And sometimes better. Because coping is a process and it isn’t something we are aces at all the time. And sometimes it takes time to piece back together our fractured self-worth and reform and new self-identity.