September 7, 2022
Toolkit

Substance use disorder and suicide

Centre for Suicide Prevention

Updated September 2022

Expert reviewer

Dr. Kenneth Conner Psy.D., M.P.H., Professor, Department of Emergency Medicine, University of Rochester Medical Center

Dr. Conner is a noted researcher on alcohol and drug use and suicidal behaviours.

Introduction

Substance use disorder is the second most frequent risk factor for suicidal behaviour after depression.

People who are experiencing a mental health disorder, like depression or anxiety, may use drugs or alcohol to cope with the symptoms of their disorder, and substance use disorder may develop. Suicide risk increases if an individual has substance use disorder in addition to a mental health disorder.

What to expect

This resource is a brief introduction into substance use disorder and suicide for people interested in learning more about the topic. You’ll learn about statistics, warning signs for suicide, why substance use disorder increases suicide risk and how these suicides can be prevented. You’ll also learn how to have a conversation with someone you’re worried about.
If you know someone who is actively thinking about suicide and immediately at risk, or if you’re thinking about suicide, call your local crisis line. In Canada, call or text 9-8-8.

Statistics

  • 40% of patients seeking treatment for substance use disorder report at least one suicide attempt in their lives (Pompili et al., 2010).
  • 25% of Canadian suicides that had autopsies performed showed alcohol ingestion (Orpana et al., 2021).
  • 27-50% of young people who die by suicide have a substance use disorder (Canadian Centre on Substance Use and Addiction (CCSA), 2016).
  • 30% of opioid poisoning hospitalizations are the result of self-harm, including suicide attempts. There has been a 53% increase in opioid poisoning hospitalizations since 2005 (Chan et al., 2018).

What is substance use disorder?

Substance use disorder refers to varying degrees of excessive use of a substance (American Psychological Association, 2021). A ‘substance’ refers to any legal or illegal drug, including medication, alcohol, and opiates (Mood Disorders Society of Canada, 2009).

According to the DSM-5, substance use disorder exists when two or more of the following are present:

  • Taking larger amounts of substance over a longer period of time than intended
  • Trying repeatedly yet unsuccessfully to control use
  • Spending significant time obtaining, using or recovering from effects of substance
  • Craving or having a strong desire or urge to use substance
  • Failing to fulfill obligations at work, school or home due to recurrent use
  • Experiencing social or interpersonal problems due to recurrent use
  • Eliminating or reducing social, occupational or recreational activities because of substance use
  • Using in physically hazardous situations
  • Continuing to use despite knowledge of having a physical or psychological problem caused or exacerbated by substance
  • Increasing amounts of substance to achieve desired effects or intoxication, diminished effect with continued use of the same amount of substance (tolerance affected)
  • Experiencing withdrawal

The severity of the disorder is based on how many symptoms are experienced (American Psychiatric Association, 2013).

Alcohol and suicide 

Alcohol has both disinhibiting and sedating effects. Disinhibiting effects include impulsivity and aggression, while the sedating effects may lead to feelings of sadness and despair as well as impaired cognition. All of these effects can increase suicide risk, making alcohol extremely harmful to someone experiencing suicidality (Orpana et al., 2020).

Why do people develop substance use disorder?

People develop substance use disorder in a variety of ways. For example, some people use substances to cope with unbearable physical and/or psychological pain caused by trauma, mental health disorders (possibly undiagnosed), and/or physical health issues. When people rely heavily on substances to cope with their pain, substance use disorder can develop, further increasing vulnerability to suicidal behaviour.

In this scenario, people experiencing physical or psychological pain use substances because they are very effective at masking pain – but they do not address its root causes. Holistic forms of treatment such as trauma informed care can more effectively address pain so that the person’s healing and recovery process can begin.

Trauma-informed care
“The greater the trauma, the greater the risk for alcohol abuse, illicit drug use, depression, suicide attempts, and other negative outcomes” (Rosenberg, 2011, p.428).

Trauma-informed care (TIC) is key to addressing substance use disorders in people who have experienced trauma. A TIC approach differs from a traditional 12-step model of recovery (as used in Alcoholics Anonymous). The former focuses on ‘what happened to you?’ whereas the latter focuses on ‘what’s wrong with you?’ If someone is not able to abstain from substances as prescribed by a 12-step model they are trying to follow, it may be because past trauma is driving their behaviour. To learn more about this, read our article about trauma, substance use and suicide prevention and our toolkit on trauma and suicide.

Minnesota Alternatives in Spring Lake Park, Minnesota and The Sunshine Coast Health Centre in Powell River, British Columbia, are two such TIC-based, alternative recovery programs. Both institutions also specialize in working with trauma survivors with substance use disorder.

Why does substance use disorder increase suicide risk?

There are several reasons why a person who has substance use disorder may also have an increased risk of suicide:

  • People under the influence of substances, including alcohol, may become more impulsive, have impaired judgment, and lose their inhibitions, all of which increase the chance that suicide may occur.
  • Substances may be used to ease the distress of the act of suicide itself.
  • Substance use disorder may lead to changes in the brain that result in depression over time, and suicide risk increases if a person has substance use disorder in addition to a mental health disorder.
  • Substance use disorder can result in disruption to relationships, causing a person to become isolated from their supports and lose their social connections – this outcome may also increase suicide risk.

(Centers for Disease Control and Prevention, 2020; Pompili et al., 2010)

Warning signs

Warning signs for suicide include any significant change in behaviour. For people with substance use disorder, some warning signs include:

  • Talking about suicide
  • Making statements to indicate hopelessness
  • Increasing substance use
  • Withdrawing from friends, family
  • Raging, having uncontrolled anger
  • Engaging in risk-taking behaviour (driving drunk, taking more drugs than usual)
  • Lacking a reason for living, no sense of purpose in life

(American Association of Suicidology, 2019)

What to do if you recognize warning signs

If someone you know is exhibiting warning signs, or if you’re just generally worried about them, have an open, non-judgmental conversation. If they’re considering suicide, connect them with support.

Before beginning the conversation, decide what role you will play. Are you their ongoing caregiver? Friend? Acquaintance? You can enlist others to help, including your local crisis centre.

  • Mention your concerns.
    “I’ve noticed you’ve been drinking more than usual and driving drunk… that’s not like you. Are you okay?”
  • Listen to their response for expressions of hopelessness, melancholy, or desperation, for example, “I’ve been feeling really down lately… I feel like such a failure.”
  • Avoid offering solutions. If you’re still concerned after hearing their response, explore further. Ask them about their situation or feelings. If you’re worried they’re thinking about suicide, ask them directly: “It sounds like you’re going through a lot right now. Sometimes, when people are struggling, they think about suicide. Are you thinking about suicide?”
  • If they say yes, give them your local crisis line number (in Canada, 9-8-8) and offer to make the call together. Make sure the person knows what role you are playing. Be direct. Enlist others to help, for example, family members, friends, or the crisis centre.
  • If they have imminent plans to die, contact the crisis centre or 911 and ensure they are not left alone.
  • Other ways you can support the person:
    • connect them to mental health resources (ca)
    • offer to be their support person to call when they need
    • create a safety plan with them

Risk Factors

Suicide is complex; there are multiple contributing factors. Certain factors can place people at a higher risk for suicide, while other factors build resilience and protect a person from thinking about suicide. It is the combination of factors, and especially risk factors that outweigh protective factors, that can put a person at risk of suicide. These factors can contribute to suicide risk:

  • Substance use disorder with co-occurring disorders such as depression, PTSD, and anxiety
  • Feelings of hopelessness
  • Stressful life events
  • Lack of social support
  • Living alone
  • Chronic pain
  • History of childhood abuse
  • High aggression/impulsivity
  • Belonging to a sexual or gender minority
  • Previous suicide attempt

(Sher, 2006; Substance Abuse and Mental Health Services Administration, 2017)

Protective Factors

Certain factors or circumstances can guard a person against considering suicide, increase resiliency, and promote hope, belonging, meaning and purpose. Here are some protective factors that promote life in those with a substance use disorder:

  • Identified reasons for living
  • Active recovery
  • Trusting relationship with a counsellor, physician, or other service provider
  • Employment
  • Presence of a child in the home and/or childrearing responsibilities
  • Stable relationship with a partner
  • Attendance at religious or spiritual gatherings
  • Attendance at a support group
  • Optimistic perspective on life

(Substance Abuse and Mental Health Services Administration, 2017)

The opioid epidemic and suicide 

The opioid crisis in North America has brought new challenges to prevention efforts in substance use and in suicide. In Canada, between January 2016 and March 2020, 16,364 people died from opioid use, and in the US, 450,000 people have died between 1999 and 2018 (Government of Canada, 2021; Centers for Disease Control and Prevention, 2020). For many of these deaths, it is uncertain whether the death was intentional (suicide) or unintentional (overdose), however, it is probable that a large number of these deaths are suicides though not counted as such. Opioid use has become prevalent since 2000, when doctors began prescribing opioids more frequently. It was thought that pain was severely under-treated, and many pharmaceutical companies aggressively promoted the use of opioids to reverse this. Each year between 1997 and 2007 saw a 600% increase in prescribed opioid dosage per person. Suicide attempts and fatal and nonfatal overdoses have all increased with the prescription of opioids (Bohnert et al., 2019).

Groups most affected by substance use disorder

Adolescents

Young people with substance use disorder may have a heightened risk for suicide in both the long and short term. Poor impulse control, characteristic of adolescence, is one factor that may contribute to the likelihood that a young person may use substances (Dawes et al., 2008). Young people may also use substances to cope with a mental health disorder, like depression, or a stressful life event, like a break-up. If they continue to rely on substances to cope, they may develop substance use disorder. Many youth who have substance use disorder have an additional disorder, such as depression. Therefore, young people who appear to be at risk for substance use disorder should be screened for all other psychiatric disorders as well as suicidality to ensure they receive necessary treatment and reduce suicide risk (Makjija & Sher, 2007).

Since the factors that may lead to substance use disorder (poor impulse control, co-occurring disorders, stressful life events) are all risk factors for suicide, young people with a substance use disorder are at heightened risk for suicide.

Adolescent cannabis use

Regular consumption of cannabis by adolescents has been shown to interfere with the complex and extensive development of the brain that occurs during youth. There are several studies which show that regular cannabis use during adolescence is also associated with increased risk of depression, worsening symptoms of depression if already present, anxiety disorder, bipolar disorder, eating disorders and suicidal behaviours (CCSA, 2015).

Middle-aged males

Middle-aged and older men have some of the highest rates of suicide, and those with substance use disorder are at particularly high risk for suicide (Sher, 2006).

Men are often socialized not to talk about their emotions and therefore men as a group may mask their stress and deal with emotional pain through harmful behaviours and actions, including substance use. If men do not receive help and instead rely on substances to mask their emotions, they may develop substance use disorder (ibid, 2006).

Older adults

25–50% of older adults have a substance use disorder and a mental illness (Mood Disorders Society of Canada, 2009).

Older adults may become dependent on substances as an attempt to ‘self-medicate’ (Osgood, 1992) and drink in response to stressors caused by losses such as the death of loved ones, retirement, and deteriorating physical or mental health.

How can suicide in people with substance use disorder be prevented?

  • Checking in with the people in our lives

We all have a role to play in preventing suicide and we can be alert to the warning signs of suicide. If we notice someone is struggling, we can ask if they’re okay and if they’re thinking about suicide. We can then support them and connect them to help.

  • Treating people with suicidality and substance use disorder for both, not just one, of these issues

People with substance use disorder and suicidal behaviours often receive treatment for only one of these issues, though they often co-occur. Mental health and addiction services need increased collaboration to ensure people are treated for both issues.
A well known and efficacious treatment plan was devised by the Center for Substance Abuse Treatment. It is called Addressing suicidal thoughts and behaviors in substance abuse treatment, Treatment Improvement Protocol Number 50 (TIP 50). It can be accessed here: https://store.samhsa.gov/sites/default/files/d7/priv/sma15-4381.pdf.

(An evaluation of its efficacy can be found in the references under Conner et al.).

  • Training healthcare providers to identify and address signs of suicide risk and substance use disorder

Healthcare providers must be trained to identify and address the signs of both suicide risk and substance use disorder. Studies show that the majority of people who die by suicide have had contact with their healthcare provider in the months before their death; 45% had contact within the last month (CCSA, 2016).

  • Offering a variety of treatment options to ensure the root cause of substance use disorder is addressed

Traditional 12-step models of recovery are successful for some people, while other people may need a method of treatment that is more personalized to meet their unique needs (Substance Abuse and Mental Health Services Administration, 2012). Holistic ‘bio/psycho/social’ models of treatment treat the ‘whole person,’ acknowledging root causes of substance use instead of treating the substance use disorder alone. Learn more in our article, ‘What does successful recovery look like?’

  • Adopting the view that recovery from both substance use disorder and suicidality is possible, and being realistic about what the recovery process looks like

Recovery needs to be thought of as “a way of living a satisfying, hopeful, and contributing life even with the limitations caused by illness” (Mental Health Commission of Canada, (MHCC), 2009, p.27). Recovery needs to be realistic and meet people where they’re at in the present moment, instead of prescribing idealized outcomes that might be unattainable.

What can people with substance use disorder do?

People who have substance use disorder can prioritize their healthy relationships, ensuring they have a support system of people around them that they can reach out to for help when they’re struggling.

They can also seek out treatment options, including holistic treatment, that will address the issues underlying their substance use.

Resources for self-help and peer support

12 Step Groups

Alcoholics Anonymous
“Alcoholics Anonymous is a fellowship of men and women who share their experience, strength and hope with each other that they may solve their common problem and help others to recover from alcoholism.”

Narcotics Anonymous

Cocaine Anonymous 

A.A. Agnostica
A.A. for atheists and agnostics.

Alternative Groups

Women in Sobriety
A non-profit dedicated to helping women overcome alcoholism and other addictions through self-help programs which help achieve sobriety and sustain ongoing recovery.

Smart Recovery
Face-to-face meetings and online. “SMART (Self Management and Recovery Training) recovery participants learn tools for addiction recovery based on the latest scientific research and participate in a worldwide community which includes free, self-empowering, science-based mutual help groups.”

HAMS Network
HAMS is a peer-led, free-of-charge support and informational group for anyone who wants to change their drinking habits for the better. The acronym HAMS stands for Harm reduction, Abstinence, and Moderation Support.

LifeRing
“LifeRing is an abstinence-based, worldwide network of individuals seeking to live in recovery from addiction to alcohol or to other non-medically indicated drugs.” Offers peer-to-peer support in ways that encourage personal growth and continued learning through personal empowerment.

Rational Recovery
“A worldwide source of counseling, guidance, and direct instruction on self-recovery from addiction to alcohol and other drugs through planned and permanent abstinence.”

Other resources

Rehab.ca
A listing of rehabilitation centres in Canada.

211.ca
Canadian mental health and addiction services listing.

References

American Association of Suicidology. (2019). Warning signs. https://suicidology.org/resources/warning-signs/

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, (DSM-5). Washington, D.C.: American Psychiatric Association.

American Psychological Association. (2021). Substance Use Disorder. https://www.apa.org/pubs/highlights/substance-use

Bohnert, A., & Ilgen, M. (2019). Understanding links among opioid use, overdose and suicide. New England Journal of Medicine. https://doi.org/10.1056/NEJMra1802148

Canadian Centre on Substance Use and Addiction (CCSA). (2015). The effects of cannabis use during adolescence.  https://www.ccsa.ca/sites/default/files/2019-05/CCSA-Effects-of-Cannabis-Use-during-Adolescence-Summary-2015-en.pdf

Canadian Centre on Substance Use and Addiction (CCSA). (2016). Substance use and suicide among youth: Prevention and intervention strategies.  https://www.ccsa.ca/sites/default/files/2019-04/CCSA-Substance-Use-Suicide-Prevention-Youth-Summary-2016-en.pdf

Centers for Disease Control and Prevention, (2020). Opioids: Understanding the epidemic. https://www.cdc.gov/opioids/basics/epidemic.html

Chan, E., McDonald, B., Brooks-Lin, E., Jones, G., Klein, K. & Svenson, L. (2018). The role of opioid toxicity in Alberta, 2000-2016. Health Promotion and Chronic Disease in Canada, 38(9). DOI: org/10.24095/hpcdp.38.9.07

Dawes, M., Mathias, C., & Richard, D. (2008). Adolescent suicidal behaviour and substance use: Developmental mechanisms. [HTML] Substance Abuse: Research and Treatment, 2, 13-28. https://doi.org/10.1016/j.jsat.2012.01.008

Conner, K. R., Wood, J., Pisani, A. R., & Kemp, J. (2013). Evaluation of a suicide prevention training curriculum for substance abuse treatment providers based on Treatment Improvement Protocol Number 50 (TIP 50). Journal of Substance Abuse Treatment, 44, 13-16.

Government of Canada. (2021). Data, surveillance and research on opioids and other substances. https://www.canada.ca/en/health-canada/services/opioids/data-surveillance-research.html

Makhija, N. & Sher, L. (2007). Preventing suicide in adolescents with alcohol use disorders. International Journal of Adolescent Medicine and Health, 19(1), 53-59. https://doi.org/10.1515/ijamh.2007.19.1.53

Mental Health Commission of Canada. (2009). Toward recovery and well being. https://www.suicideinfo.ca/wp-content/uploads/2022/08/FNIM_Toward_Recovery_and_Well_Being_ENG_0_1.pdf

Mood Disorders Society of Canada. (2009). Quick Facts: Mental illness and addiction in Canada.  https://mdsc.ca/documents/Media%20Room/Quick%20Facts%203rd%20Edition%20Eng%20Nov%2012%2009.pdf

National Center for Injury Prevention (NCIJ). (2010). Suicides Due to Alcohol and/or Drug Overdose: National Center : A Data Brief from the National Violent Death Reporting System. https://stacks.cdc.gov/view/cdc/11981

Orpana, H., Giesbrecht, N., Hajee, A., & Kaplan, M. (2021). Alcohol and other drugs in suicide in Canada: Opportunities to support prevention through enhanced monitoring. BMJ Injury Prevention, 27(2), 194-200. https://doi.org/10.1136/injuryprev-2019-043504

Osgood, N. (1992). Suicide in later life: Recognizing the warning signs. New York: Lexington Books.

Pompili, M., Serafini, G., Innamorati, M., Dominici, G., Ferracuti, S., Kotzalidis, G. D., Serra, G., Girardi, P., Janiri, L., Tatarelli, R., Sher, L., & Lester, D. (2010). Suicidal behavior and alcohol abuse. International journal of environmental research and public health, 7(4), 1392–1431. https://doi.org/10.3390/ijerph7041392

Rosenberg, L. (2011). Addressing trauma in mental health and substance use treatment. The Journal of Behavioural Health Services & Research, 38(4), 428-431. https://doi.org/10.1007/s11414-011-9256-9

Sher, L. (2006). Alcohol consumption and suicide. Quarterly Journal of Medicine, 99(1), 57-61. Suicide Prevention Resource Center (SPRC). https://academic.oup.com/qjmed/article/99/1/57/1523792

Substance Abuse and Mental Health Services Administration. (2012). Working definition of recovery.  https://store.samhsa.gov/product/SAMHSA-s-Working-Definition-of-Recovery/PEP12-RECDEF

Substance Abuse and Mental Health Services Administration. (2017). Addressing Suicidal Thoughts and Behaviours in Substance Abuse Treatment: TIP 50.  http://store.samhsa.gov/ shin/content/SMA09-4381/TIP50.pdf