Introduction

Death by suicide has become an international public health crisis. Globally, more than 700,000 people die by suicide each year. The epidemiology of suicide varies widely by gender, age, income, geographic location, and other factors. Most suicides occur in low- and middle-income countries, and more than half occur in those under age 50. Suicide is the second leading cause of death worldwide in people aged 15–29 years. The risk of suicide is particularly elevated in individuals who experience heightened distress and traumatic events such as natural disasters, personal violence or abuse, and experience feelings of loneliness, isolation or perceived discrimination [1]. Suicide is associated with high health care utilization and societal burden; for each death by suicide there are on average, 4 hospitalizations for suicide attempts; 8 emergency department admissions related to suicidal behavior and 27 self-reported suicide attempts [2].

Recent data show that patient populations with chronic pain and those with substance use disorders (SUDs) have an increased risk of suicidal ideation and suicidal attempts [3]. A burgeoning literature underscores that the burden of suicide among patients with chronic non-cancer pain (CNCP) is significant. The prevalence of suicidal ideation among this population ranges from 20% to over 50% [4,5,6,7], and it has been estimated that between 5% and 14% of individuals with CNCP attempt suicide over their lifetime [3, 8].

In this narrative review of the literature, we describe the epidemiology of suicide in populations with CNCP and SUDs, risk factors for suicide, and modifiers of the association between pain-OUD and suicide, as well as pharmacologic and non-pharmacologic treatment strategies for these complex problems.

Epidemiology

A systematic review by Tang and Crane [5] discovered the risk of death by suicide was doubled among patients with chronic pain compared to those without chronic pain. In 2014, Campbell et al. [6] evaluated all legally closed cases of intentional death in Australia; 2,590 deaths were identified and individuals with CNCP represented 14.6% of all deaths. Individuals with CNCP who died by suicide were characterized as being older, having a higher rate of mental and physical morbidity, and more likely to die by drug overdose. This rate is remarkable, given the rate of actual death by suicide in the general population is less than 1% [2].

Individuals with SUDs are another population that is vulnerable to suicide. Studies of SUD populations show that 40% of patients receiving treatment for addiction reveal a history of suicide attempts [9,10,11]. Compared to the general population, persons with an alcohol use disorder and those who are injection drug users are approximately 10 times more likely and 14 times more likely to die by suicide, respectively [12]. Individuals with SUD and CNCP share similar suicide risk factors including feelings of loneliness and isolation, self-esteem issues and self-perceived burden, mood disorders, and difficulty coping with cumulative severe stressors like the loss of social and family relationships, valued life and work roles, mounting financial problems and multimorbidity related to pain and OUD burdens [13].

Receipt of long-term opioid therapy (LTOT) is associated with a potential risk of engaging in problematic drug use, misuse of opioids and developing an opioid use disorder (OUD); greater than 50% of patients receiving LTOT will engage in problematic use, approximately 21–29% will misuse opioids, and 8 to 10% of these patients will develop a subsequent OUD [14, 15]. Recent research suggests that both CNCP and OUD increase the risk of suicide [3, 16]. Archambault et al. [16] evaluated individuals entering a residential treatment program for opioid agonist therapy in Montreal who endorsed a history of suicidal ideations or suicide attempts. In multivariable analysis, an array of important sociodemographic and psychiatric covariates were examined. Adjusting for these covariates, the odds ratio (OR) of having suicidal ideation was 2.48 (95% confidence interval [CI] [1.01–6.11]) times higher among patients with SUD and a mood disorder, 2.41 (95% CI [1.01–5.81]) higher among patients with SUD and an anxiety disorder, and 2.59 (95% CI [1.06–6.35]) times higher among patients with SUD and concomitant CNCP. The OR of having an actual suicide attempt was 2.64 (95% CI [1.05–6.62]) times higher among patients with SUD and an anxiety disorder [16].

In a cross-sectional study of 609 patients with no prior SUD history treated with long-term opioid therapy for CNCP in ambulatory settings, 18.0% (n = 110) were at high risk for suicidal ideation measured on the Suicide Behavior Questionnaire-Revised (SBQ-R). Compared to those with only CNCP, individuals with both CNCP and OUD were 3.44 (95% CI [2.26–5.33]) times more likely to report suicidal ideation [3].

Suicide among Chronic Pain Populations: Risk Factors and Modifiers

Risk Factors

Identified risk factors for suicidal ideation among patients with CNCP include pain intensity and type, sleep disturbance, opioid prescribing patterns and opioid tapering.

Pain Intensity and Sleep Disturbance

Studies have evaluated associations among pain intensity, sleep disturbance, and suicide. Many patients with CNCP report chronic sleep disturbance which can cause an inflammatory response, lower pain threshold, and exacerbate anxiety and mood disorders [17]. Coping with both intense pain and sleep disturbance has been demonstrated to increase the risk of suicide in patients with CNCP. A sample of 221,817 U.S. veterans commencing pain treatment were evaluated by Ashrafioun and colleagues [18]. Participants were categorized into four groups: those having no/mild pain and no insomnia; mild-moderate pain and no insomnia; no/mild pain and insomnia; and moderate-severe pain and insomnia. Individuals experiencing both moderate-severe pain and insomnia had a significantly higher odds of having a history of suicide attempts and were at greater risk of a suicide attempt versus the other categories [18]. Suicide prevention should include improving pain reduction and managing co-occurring sleep disturbance in this patient population.

Pain Type

Individuals coping with certain pain disorders are more vulnerable to the risk of suicide. Jimenez-Rodríguez et al. [19] compared the risk of suicide in patients with fibromyalgia, chronic low back pain, and “no pain” controls. Patients with fibromyalgia had a higher level of suicidal ideation (OR, 26.89, 95% CI [5.72-126.42] p < 0.0001) and risk of suicide (OR, 48.00, 95% CI [12.93–178.20] p < 0.001) compared to patients with chronic low back pain (OR, 4.58, 95% CI [0.83–25.43] p = 0.082) and (OR, 4.73, 95% CI [1.30-17.21] p = 0.019) for suicidal ideation and risk of suicide, respectively. Research shows that patients with complex regional pain syndrome (CRPS) also have an elevated risk of suicide. Patients with CRPS experience severe pain and reduced function which is refractory to most interventions. Lee et al. [20] surveyed 251 patients with CRPS and discovered that 92.1% of patients endorsed having sleep disorders and 80.5% had a history of suicidal ideation.

Data show that individuals who experience recurrent headache disorders may have a heightened risk of suicide. In a big data study, Columbia-Suicide Severity Rating Scale (C-SSRS) scores were retrospectively reviewed from a cohort of 2,832,835 nonpsychiatric adult visits at a large county hospital. The authors found that presenting with a headache was positively associated with two specific aspects of suicidality measured on the C-SSRS: the ‘wish to be dead’ and suicidal action. Type of headache was also relevant—tension headache sufferers had a reduced risk of the desire for death compared to patients with more refractory migraine and cluster headaches [21]. In clinical practice, patients with poorly controlled headaches, especially refractory migraine and cluster headaches, should be closely monitored for suicidal ideation.

Opioid Prescribing and Opioid Tapering

Emerging research has evaluated opioid prescription patterns and opioid tapering and the elevated risk of suicide. Olfson and colleagues [22] conducted a retrospective study on geographic changes in opioid prescribing and the association with opioid-related total suicide deaths and specific suicide deaths by overdose. Two datasets (the IQVIA Longitudinal Prescription Database) and (the National Center for Health Statistics) provided claims data on prescriptions and mortality, respectively, and were analyzed from 2009 to 2017 (n = 886). The authors discovered that the number of opioid prescriptions per person, having any opioid prescription, having access to high-dose prescriptions, having long-term prescriptions, and having three or more prescribers of opioids were all positively associated with death by suicide. The authors concluded that regional changes in opioid prescribing (i.e., reduced prescribing of opioids) were associated with a decrease in total suicide deaths, including opioid-related fatal overdoses. In interpreting these data, it should be considered that the populations studied may have included “legitimate” pain patients on long-term opioid therapy but also individuals with non-medical use or OUD (e.g., having three or more opioid prescribers).

The current trend to taper opioids in patients with chronic pain has resulted in varied outcomes. For example, Havlik et al. [23] performed a retrospective cohort study evaluating the impact of rapid dose reduction among patients with chronic pain on high-dose, long-term opioid therapy (LTOT) on three outcomes: the risk of suicide, opioid-related overdoses, and other potential opioid related adverse effects. A large dataset of 14,596 patients on high-dose LTOT was evaluated. Patients were classified into 4 categories: opioid prescriptions were abruptly discontinued (28.7%); opioid dose was reduced prior to opioid discontinuation (11.3%); opioid dose was reduced but not discontinued (44.4%); patients were maintained on a stable dose/ the baseline dose was increased (15.6%). Results indicated that the risk of suicide was significantly increased among those with any opioid weaning, either abrupt or with dose reduction, versus stable or increasing dosing. However, those with opioid discontinuation or dose reduction had a reduced risk of overdose compared to patients on a stable or increasing dose. This finding for lower intentional overdose may reflect reduced access to prescription opioids, but patients completing an abrupt discontinuation were more likely to overdose on heroin (vs. prescription opioids) than patients in the other opioid prescription category. This transition to heroin is possibly related to the patient seeking relief from increased pain or opioid withdrawal symptoms, or an undiagnosed OUD, or an intentional overdose. It was concluded that patients receiving LTOT “require careful risk assessment and supportive interventions when considering opioid discontinuation or continuation at a high dose.”

Modifiers

Several identified modifiers of pain and suicide with relevance to SUDs include catastrophizing, social support, self-perceived burden, and mental defeat.

Catastrophizing

Some individuals with CNCP may engage in negative thought patterns, such as catastrophizing. Pain catastrophizing is characterized by three components: an exaggerated negative focus on pain experience, rumination about pain, and feeling overwhelmed by the pain, which can be a key factor in the development of depression and reduced function, and compound pain and suffering [24]. Brown et al. [25] conducted a longitudinal study in a cohort of patients with CNCP evaluating the association between two styles of pain coping, catastrophizing and hoping/praying, as predictors of the subsequent risk of suicide, as well as possible mediators of pain and suicide. At baseline, 6- and 12-months, measures of coping styles (catastrophizing and prayer/hope), depression, pain interference, and risk of suicide were assessed. Catastrophizing was a significant predictor of an increased subsequent risk of suicide, whereas hoping/praying did not protect against the future risk of suicide. The relationship between catastrophizing and future suicidal ideation was mediated by depression. These results support the importance of improving pain coping skills, in particular catastrophizing in patients with CNCP.

Social Support

It is well-recognized that perceived positive social support is a key factor in preventing relapse among individuals with SUD [26] and that poor social support and withdrawal from social interactions can greatly contribute to the risk of suicide.

Cheatle et al. [4] performed a retrospective chart review of 466 patients with CNCP treated in a behaviorally based pain program. There was a high rate of suicidal ideation (26%); a logistic regression model revealed a number of factors were predictive of suicidal ideation, including: being socially withdrawn (Beta = 0.48; p < 0.001; OR, 2.23, 95% [CI 1.41–3.51] [4]. Due to pain-related mood disorder and activity interference, many patients with pain can become isolated. Likewise, individuals coping with a SUD may have strained or limited relationships with their friends and family, lost social contacts due to their drug use behavior, and become socially avoidant and withdrawn, which can exacerbate a mood disorder and increase the risk of suicide.

Self-Perceived Burden

Another common perception among both patients with CNCP and SUDs is the belief that one is a burden to his/her family, social network, and community. For example, one cohort study of 303 patients with CNCP referred to a physical rehabilitation program evaluated potential risk factors for suicide, including specific measures of belongingness and burdensomeness. After adjusting for important covariates, including sociodemographic, pain severity, functional limitation, pain catastrophizing and depression, the researchers discovered that self-perceived burden to others was the strongest predictor of suicidal ideation [27].

Self-perceived burden and social isolation are key components of the Interpersonal Theory of Suicide by Joiner et al. [28]. This highlights that the desire for suicide is a confluence of feelings involving a lack of belonging and perceived burdensomeness, and the inclination for suicidal ideation and suicidal attempts develop in response to repeated exposure to physically/emotionally painful and/or fear-inducing experiences. Individuals with CNCP and SUD typically are confronted with repeated physical and psychological stressors that increase the risk of suicide.

Mental Defeat

Mental defeat is common among patients with CNCP and can be distinguished from the construct of catastrophizing, similar to learned helplessness but more specific to patients who suffer form CNCP. Mental defeat is a psychological state characterized by a profound loss of autonomy, self-agency, self-efficacy, and human integrity [29]. Phenomenological studies have observed that patients suffering from CNCP often report a sense of “defeat of the mind”, and that “the pain is ‘taking over’” resulting in them feeling “unable to cope with what [they are] supposed to do” and “feeling less like a human being” [30]. These thoughts are associated with greater symptom interference, distress, physical and psychosocial disability, breakdowns in the self-management of pain, and increased treatment seeking, which may precipitate suicidal ideation and suicidal attempts [31, 32].

Pharmacologic and Non-Pharmacologic Interventions

The complexity of CNCP and co-occurring SUD and the myriad of comorbidities associated with these conditions requires a thoughtful and rational multimodal approach that includes pharmacologic, non-pharmacologic, integrative, rehabilitative, and interventional therapies to mitigate the risk of suicide. This should include optimally managing depression and anxiety, improving sleep disturbance, managing pain, supporting abstinence and reducing the risk of relapse. Mitigating the risk of suicide for the vulnerable populations with CNCP and SUD relies on rational pharmacotherapy and evidence-based non-pharmacologic interventions.

Pharmacologic Interventions

In a subgroup of patients who are appropriately selected, the prescription of opioids and benzodiazepines may be ethically and medically necessary in a patient at risk for suicide (e.g., in managing poorly controlled pain and anxiety). These medications are potentially lethal (because of the increased risk of respiratory depression, means to intentional overdose, and prompting OUD relapse) and should be prescribed judiciously, preferably on a weekly basis, in small amounts and be held and administered by a responsible family member and closely monitored by the prescribing clinician (frequent urine drug testing, pill counts, etc.). These universal precautions are best practices for safe and effective drug therapy in patients with CNCP and also SUDs.

Adjuvant analgesics, including antiepileptic and antidepressant medications can be potentially useful as analgesics and mood stabilizers for populations with CNCP and SUDS. Antiepileptic medications, such as gabapentin, oxcarbazepine, and pregabalin are first line therapies in managing fibromyalgia, neuropathically mediated pain conditions (e.g., diabetic neuralgia, CRPS, and post-herpetic neuralgia) and have the added benefit of mood stabilization and improved sleep quality. Antidepressant medications are clinically indicated and efficacious in treating concomitant depression and pain which are highly prevalent in patients with CNCP and SUDs. Serotonin and norepinephrine reuptake inhibitors (SNRIs)—venlafaxine, duloxetine, milnacipran (not FDA-approved for the treatment of depression), and desvenlafaxine and tricyclic antidepressants have been demonstrated to improve pain and mood in clinical trials, with the strongest support for duloxetine [33]. Certain tricyclic antidepressants also have sedating qualities to improve sleep along with mood modulation (e.g., amitriptyline, nortriptyline, and doxepin) and there is evidence of the analgesic properties of tricyclics and specific SNRIs, which are similar to the action of opioids in modulating descending inhibitory pain pathways. Similar findings have been documented on the association between increased risk of suicide and antidepressant and anticonvulsant medications [34, 35] Clinicians should be cognizant and closely monitor for changes in mood and the increased risk of suicide when initiating antidepressant or anticonvulsant drug therapy.

Emerging research has identified the potential efficacy of buprenorphine and ketamine for improving pain and OUD in this patient population. Buprenorphine is a partial agonist at the mu-opioid receptors and an antagonist at the kappa receptors with formulations indicated for both OUD and pain. While there is strong support for the effectiveness of buprenorphine in improving pain and supporting abstinence in patients with OUD, there is also encouraging literature on the effect of buprenorphine in reducing suicidal ideation 36, 37].

Yovell et al. [36] conducted a randomized double-blind, placebo-controlled trial of ultra-low-dose sublingual buprenorphine in a cohort of severely suicidal patients with no history of SUD. Patients were randomly assigned to receive either buprenorphine or placebo (in a 2:1 ratio), in addition to their usual treatments for depression. Patients who received ultra-low-dose buprenorphine had a greater reduction in suicidal ideation assessed on the Beck Scale for Suicidal Ideation (BSSI) than those patients who were administered the placebo, and this positive response was sustained after 2 and 4 weeks [36]. In another trial evaluating the efficacy of buprenorphine in reducing suicidal ideation, 51 male inpatients who met the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) diagnostic criteria for both OUD and major depressive disorder and endorsed active suicidal ideation were randomized to three treatment conditions to receive a single, sublingual dose of buprenorphine either 32 mg, 64 mg, or 96 mg. Patients completed a 3-day, trial course. There was a significant reduction in BSSI scores within each of the three groups, p < 0.01, but no difference in the outcomes among the groups (i.e., no dose response effect), p = 0.408 [37].

A novel use of an older medication for pain relief, managing depression, and reducing suicidal ideation is ketamine. Ketamine is a Class III non-narcotic drug that was initially Food and Drug Administration (FDA)-approved as a general anesthetic. Subsequently, it was discovered that a sub-anesthetic dose can significantly relieve severe, refractory depression, which led to FDA approval for (S)-ketamine (also called S[+]-ketamine or esketamine) indicated for refractory depression and to reduce suicidal ideation. Ketamine produces strong analgesic responses in neuropathic pain disorders such as CRPS, likely by inhibition of the N-methyl-D-aspartate receptor (NMDA). For pain conditions with a neuropathic component, patients typically undergo a series of medically administered ketamine infusions. A recent study evaluated the efficacy of ketamine in reducing active suicidal ideation—the design was a prospective, double blind, superiority, randomized placebo-controlled trial. One hundred fifty-six patients acknowledging severe suicidal ideation were randomized to receive either placebo (n = 83) or ketamine (n = 73). Two 40-minute intravenous infusions of ketamine (0.5 mg/kg) or placebo (saline) were administered at baseline and 24 h later. Results indicated that a higher proportion of patients who received ketamine reached full remission of their suicidal ideation at day 3 vs. those receiving placebo (63.0% vs. 31.6%), and this reduction was maintained at 6-week follow-up [38]. While these initial results are promising, ketamine can have very serious adverse effects and use must be medically supervised. Patients must be closely monitored for signs of CNS, hemodynamic, renal, and hepatic symptoms, as well as the potential for abuse and misuse.

Non-Pharmacologic Interventions

Individuals experiencing CNCP, as well as those struggling with CNCP and OUD are susceptible to depression, anxiety disorders, sleep disturbance, poor quality of life, and an increased risk of suicide. A range of multimodal pharmacologic and non-pharmacologic therapies can be employed. Non-pharmacologic treatments for these conditions include psychotherapy (e.g., Cognitive Behavioral Therapy [CBT] and Acceptance Commitment Therapy [ACT]), rehabilitative therapies (e.g., activating physical therapy), and complimentary and integrative therapies (e.g., acupuncture, yoga, and mindfulness meditation) and interventional pain therapies (e.g., neuraxial analgesia). CBT and ACT are evidenced-based therapies that target improving pain coping, function, sleep and the psychological sequala of living with CNCP and SUD. Complementary and integrative medicine (CIT) involves both Western-style medicine and complementary health approaches with evidence of efficacy in managing pain and SUD. For the purpose of this article, the focus will be on psychotherapy.

CBT

It is well known that CBT is highly effective in improving mood, function, and quality of life across numerous health conditions, including pain disorders, sleep disturbance, and SUDs.

a) CBT For Pain

The objective of CBT for pain (CBT-pain) is to improve pain coping skills, mood, and function by targeting maladaptive thinking patterns; the latter commonly includes pain catastrophizing (conceptualized as a magnified, exaggerated negative focus on pain that involves feelings of helplessness and a ruminative component, which can contribute to depression and disability and in turn exacerbate an individual’s experience of pain and suffering). CBT-pain also focuses on addressing maladaptive behaviors (typically kinesiophobia or fear of movement). Patients may become ‘trapped’ in this cycle of pain, catastrophic thinking, and kinesiophobia, which can promote further deconditioning, development of secondary medical problems (e.g., obstructive sleep apnea and hypertension), and increased pain, which frequently exacerbate depression and social isolation, increasing the risk for suicide. As noted previously, pain catastrophizing has been identified as a significant risk factor for suicidal ideation in patients with chronic pain (Brown et al. 2020). A typical program of CBT-pain includes evidenced-based techniques which can include mindfulness-based stress reduction, progressive muscle relaxation training, pacing, effective communication, cognitive restructuring, followed by skill consolidation, rehearsal, and relapse training [39].

Cognitive restructuring is one technique to address catastrophizing; it involves the patient learning to recognize recurrent dysfunctional and irrational thoughts and narratives that contribute to emotional distress. The patient learns to challenge these irrational cognitions and to reframe and reconceptualize their pain perceptions. This approach supports and empowers the patient to become more proactive, rather than reactive to their pain; and reinforces a sense of competence, agency, mastery, and self-efficacy. There is persuasive literature supporting the clinical efficacy and cost-effectiveness of CBT in improving mood, anxiety, functionality quality of life across several pain conditions.

b) CBT-Insomnia

Sleep disturbance is highly prevalent among patients with CNCP; the relationship between pain and sleep is bidirectional [17] and sleep disturbance is a known risk factor for suicide in patients with CNCP [18]. CBT for insomnia (CBT-I) has been demonstrated to improve sleep disturbance, sleep efficiency, and sleep quality and is equal to or superior to sleep medications [40].

A program of CBT-I typically includes psychoeducation about sleep and insomnia; stimulus control; sleep restriction; sleep hygiene; relaxation training; and cognitive restructuring. CBT-I can be delivered in an individual, group, and computer-assisted formats with generally equal effectiveness. There have been recent efforts to combine CBT-Pain and CBT-I into a hybrid program to target both pain and insomnia with promising results in improving sleep, mood, and function [41].

c) CBT, Pain, and SUD

The non-medical use of prescription opioids peaked in the U.S. in 2010 and has declined since [42]. While the prevalence of developing OUD in patients with CNCP receiving opioid therapy is relatively low [14], and the current opioid-related overdoses and deaths are increasingly related to fentanyl contamination or non-medical use, there is still an increasing rate of unhealthy prescription opioid use and other substances of abuse (alcohol and nicotine) that is problematic in the CNCP population. There is new evidence that CBT has the potential to reduce the risk of unhealthy prescription opioid use in high-risk patients by providing non-opioid therapy targeted to improve mood, anxiety, sleep, and pain coping skills. Barry et al. [43] evaluated the feasibility and acceptability of CBT for opioid use disorder and chronic pain in a cohort of patients enrolled in a methadone maintenance program. Patients who received the CBT intervention compared to treatment as usual counseling had higher rates of abstinence. Improvements in pain outcomes were not statistically significant between groups, but had trend effects. Morasco et al. [44] evaluated the efficacy of CBT for patients with Hepatitis C who also experienced chronic pain and had a history of SUD. Patients were enrolled in an 8-session integrated group CBT program for chronic pain and SUD. Results revealed improvement in key outcomes, including pain-related interference, reduction in cravings for alcohol and other substances, and a decrease in past-month alcohol and substance use.

Acceptance and Commitment Therapy (ACT)

ACT is a form of therapy based on relational frame theory (proposition that human communication and cognition facilitates interpretation of the self, others, events, and world that is both directive and experiential). ACT encourages individuals to experience one’s life mindfully (i.e., a greater focus on what is happening in the current moment, while recognizing and accepting one’s thoughts, emotions, and reactions, whether these are positive or negative). The core processes of ACT include Present Moment Awareness (i.e., calmly noticing thoughts, feelings, or sensations in the current moment, without judgment); Self-as-context; Diffusion (i.e., detangling oneself from his/her negative thoughts and feelings); Acceptance (i.e., permitting unpleasant experiences to occur without trying to change them); Values; and Committed Action (i.e., engagement in meaningful goals and valued life and activities). The goal of ACT is for the patient to strive for ‘psychological flexibility’ to cope with pain more effectively. Several randomized clinical trials have demonstrated treatment efficacy and long-term durability of ACT in patients with CNCP. Vowles et al. [45] demonstrated improvement in physical and emotional well-being among a cohort of patients with CNCP that completed a course of ACT for pain. These improvements were maintained three years after treatment by 64.8% of these patients that received ACT. ACT has also been employed in treating SUDs; it is associated with reduced rates of relapse and improved quality of life compared to usual care [46]. Currently, there are pilot studies exploring the feasibility and efficacy of ACT for patients with pain and co-occurring problematic opioid use [47].

Conclusions

CNCP and SUD are complex conditions with significant medical, social, and psychiatric consequences. Individuals with CNCP and concomitant SUD are highly susceptible to the risk of suicide. The focus on the opioid crisis has overshadowed the silent epidemic of suicide among the vulnerable population of patients suffering from pain and SUD. There is a burgeoning literature identifying risk factors for suicide that are unique to patients with pain and SUD. Emergent research is informing the development of effective pharmacologic and non-pharmacologic interventions to mitigate the risk of suicide in this patient population. As part of best practices, clinicians who provide care for CNCP and SUD should assess the risk of suicide on an ongoing, dynamic basis, and develop a vetted plan of action if a patient is identified as being at risk for suicide.

Resources

https://afsp.org/ American Foundation for Suicide Prevention.

https://www.samhsa.gov/find-help/988 SAMSHA National Suicide Prevention Lifeline.

https://www.veteranscrisisline.net/24/7 hotline for veterans and families.

https://www.crisistextline.org/ Hotline to trained crisis counselor.