Editor’s note: This story focuses on suicide, self-harm and other topics related to psychiatric distress. If you or a loved one is in crisis, resources are available here.
Nathan Lerner was at an Auburn emergency room with a swollen hand and feet around 2 a.m. on Jan. 6, 2021. The pain had begun a few days before and was blooming into a serious infection.
He was no stranger to discomfort. But on this night, Nathan really needed help.
Nathan grew up in a small town in upstate New York, where he loved to play hockey, taught himself guitar, had a gaggle of friends who often crowded into his family’s home — and where, around age 12, depression crept in.
Now, he was 30 years old, newly arrived in the Seattle area, and had returned to using heroin after nearly two years of hard-earned sobriety. At the ER, staff gave him a cocktail of drugs for nausea, infection and fever — and two doses of hydromorphone, an opioid pain reliever at least twice as potent as morphine. He was discharged sometime after 6 a.m., then a few hours later, took a call from his mom, Miriam Lerner. He sounded high, Miriam recalled.
“Then,” she said, “we didn’t hear from him.”
Five days later, finally, a call: Nathan’s car was found near a bridge on a rural Pierce County road. He had died by suicide.
People with substance use disorders have a significantly heightened risk of suicide. Compared with the general population, risk of suicide is about 14 times higher among people addicted to heroin and prescribed opioids and about five to 10 times higher among those dependent on alcohol or meth. The statistics are staggering, experts agree. And yet they likely underestimate the overlap between addiction and suicide.
Substance use disorders and suicide share many risk factors, such as a history of mental illness, feelings of hopelessness and a loss of connection. Substances can loosen a person’s inhibition to kill themselves, said Jennifer Stuber, associate professor of social work at the University of Washington, and raise their risk of suicide by causing shame or isolation.
But the strong connection between these two highly stigmatized health concerns isn’t acknowledged or treated as such in many addiction, psychiatric or general health treatment settings.
And several experts interviewed for this story agree this lack of coordination between addiction treatment and mental and physical health care has contributed to skyrocketing overdose deaths and associated suicidality. In Washington, overdose deaths are up at least 22% from last year, according to federal data, and rose 15% nationwide from 2020-21 and 30% from 2019-20.
“If you are in the addiction treatment business, you are also in the suicide treatment business,” said Dr. Richard Ries, professor of psychiatry and addictions at the University of Washington.
Ries is among a small group of medical professionals now arguing for better suicide prevention efforts across the health care system, including in substance use treatment programs.
They’re also raising concerns about ingrained structural problems, such as the inconsistent way people with substance use disorders are screened for suicide and connected with resources to keep them safe. Right now, there are disincentives to thoroughly screen people for suicidality since next steps — like mental health resources — aren’t always available, said Dr. Hilary Connery, assistant professor of psychiatry at Harvard Medical School.
“It’s sort of the ugly reality that nobody wants to talk about,” Connery said. “We need to make people aware of just how real this risk is.”
Warning signs
Nathan became addicted to heroin around 2010, while living in Colorado and working at a ski resort. He spent about eight years in and out of treatment, prison and halfway houses before getting sober.
Before the pandemic hit, he was sober and living in Alaska, working as a kayaking guide. The tourism industry quieted when COVID-19 arrived, and several of his friends left. One day, Nathan told his parents he didn’t think he could handle another lonely Alaskan winter. He’d adopted a dog, and decided to move to Seattle, where he’d found a job. But his parents suspected he was using again.
At the ER that night in 2021, Nathan told the hospital staff he was homeless. He hadn’t had thoughts of suicide, he said in response to a short ER questionnaire.
He’d relapsed only a few weeks before, but he wasn’t seen by a social worker and wasn’t given immediate access to substance use treatment. He’d been flagged for hyponatremia, or low sodium, which is tied to opioid use and can lead to serious symptoms, like confusion. His second dose of potent hydromorphone was delivered shortly before he was discharged on his own, without someone to drive him. And he was allowed to leave before all his blood results — which would ultimately show he was positive for strep — came back.
The typical warning signs of suicide — a serious shift in mood, severe insomnia, hopelessness — are the same in people with substance use conditions. But relapsing after a long period of stability, as Nathan had, is also a serious signal.
The last time Nathan’s parents saw him, in fall 2020, he was headed back to Alaska after visiting family in Vermont. On the drive to the airport, something was wrong, but Nathan didn’t want to talk about it. Miriam remembers a familiar, heavy silence. Like one she’d experienced years earlier before another loved one who was addicted died by suicide: her mother.
Said Miriam: “Suicide isn’t just that momentary act, when it ends. It’s everything leading up to it.”
Incomplete picture
The data on suicide and addiction is imperfect — and what information does exist paints a complex picture.
Nearly 108,000 people in the U.S. died from a drug overdose in 2021, twice as many as just six years before. At the same time, national suicide rates have dipped slightly since the start of the pandemic, defying predictions that a surge in mental health concerns would be accompanied by a rise in suicides. Local data fits this national trend: In King County, for instance, fatal overdoses are spiking, but suicides tied to drugs and alcohol have since 2010 steadily decreased from 15% to 4% of all drug-related deaths.
This could be a hopeful sign that suicide prevention efforts are working, experts like Connery say.
But it could also indicate that many suicides are going undetected or masked within overdose data.
It can be extremely difficult to confirm whether a drug overdose was motivated by suicidal intentions; without a note or other evidence, medical examiners will likely label an overdose as “accidental,” or undetermined, said Caleb Banta-Green, professor at the University of Washington School of Medicine’s Addictions, Drug & Alcohol Institute.
Fentanyl, in particular, is largely to blame for rising overdose deaths, potentially obscuring suicide statistics since those using fentanyl might not have a home, family or friends that could provide evidence for suicide, Banta-Green said.
Emerging research, however, suggests a desire to die is common before nonfatal opioid overdoses. In two recent studies from Connery and her colleagues, about 45% of people reported they had some desire to die just before their most recent overdose; in one of the studies, 20% reported having some intention to die and 5% said they were trying to kill themselves.
Ian Rockett, an epidemiologist who spent much of his career working on suicide classification, said there’s no big outcry for better data on drug-related suicides, in part because of the shame and rejection that are often tied to suicide and addiction.
But there should be, he said.
“If you’re not measuring something properly, it’s very difficult to prevent it.”
Prevention first
For people with opioid use disorder, like Nathan, experts say the most effective approach to addressing substance use and preventing suicide is medication-assisted treatment such as buprenorphine or methadone. A large national study from April confirmed this: Among 60,000 veterans, they were nearly half as likely to die by suicide while they were in stable, medication-assisted treatment compared to when they weren’t.
Medication is a “huge step in the right direction,” said Sean Soth, director of health integration and innovation at the Seattle-area addiction center Evergreen Treatment Services.
Counseling is also a mandatory part of addiction treatment in Washington, Soth pointed out, and the law requires that many substance use counselors undergo some level of suicide prevention training. Suicidal thoughts aren’t something his clients regularly report, he said, but lots of things could explain this. Staff aren’t necessarily asking hard questions about suicide, and clients may be reluctant to open up.
He and others agree physical and mental health services — including suicide prevention — should be integrated more seamlessly into substance use treatment programs, and that staff need better training to help prevent suicidal behavior.
It’s an idea Ries, the addiction psychiatrist, is trying to spread. Through a partnership with 15 Washington community health agencies, he recently developed a three-hour suicide prevention treatment that can easily slide into certain addiction treatment programs.
The program involves educating about suicide, having a group conversation about loved ones who have attempted or died by suicide and creating a safety card to identify warning signs of suicide — and resources to stay safe.
“There’s been this crevasse between the addiction world and mental health world,” Ries said. “That’s really why I created that (intervention).”
Connery quickly lists off several ideas that apply to both drug relapse and suicide prevention: You educate the patient about risk. You teach patients to recognize early warning signs. You teach them to understand their personal patterns. And then you do safety planning.
Miriam and Kenny Lerner, Nathan’s father, have additional ideas.
Their son isn’t someone she ever worried would die by suicide, Miriam said, and although he had said he was depressed, he seemed excited about his new chapter in Seattle. But that night in the ER, Miriam says, Nathan was, “really, really sick. He was in pain.”
In August, after more than a year of filing grievances with the state and the hospital, the pair flew from their home in New York to Washington in hopes of meeting with administrators at MultiCare Auburn Medical Center. They were convinced the hospital made several errors the night of Nathan’s ER visit, ones that may have set him up to find relief from pain on his own, without the promise of additional help from mental health or medical professionals.
The Lerners picketed for a few hours outside the hospital before their request for a meeting was granted.
In the office of the hospital’s chief medical officer, they finally said their piece. It should be standard for a social worker to evaluate people who are recently relapsed, vulnerable and homeless, they said. If someone is given a narcotic pain reliever, don’t discharge them so quickly, or by themselves. If someone wants to initiate detox and transfer to a rehabilitation facility, they should have that option.
In the end, the hospital agreed that many of the Lerners’ suggestions make sense — and in response, a hospital spokesperson said, has already changed its discharge process for patients who receive narcotics.
The Lerners also got an apology, Kenny said.
“That’s the only ‘win,’ with a very, very, very small-font ‘w,’ like the smallest font there is,” Miriam said. “The only win in this is that it shook things up and maybe some things will change.”