Clients in substance abuse treatment should be screened for suicidal thoughts and behaviors routinely during intake and at specific points during treatment. For this approach to be effective, providers must implement a treatment plan and coordinate the plan with other providers and with their clients and family members. For this to be effective:

• Make sure referral appointments are kept
• Be empathic and nonjudgmental
• Understand how your own attitudes and experiences impact your clients
• Understand ethical and legal principles as well as potential areas of conflict (CSAT, 2017)

Abstinence should be a primary goal for every client with a substance use disorder and suicidal thoughts or behaviors. For most clients, abstinence reduces risk, although some individuals remain at risk even after achieving this goal. These can include clients experiencing independent depression or unresolved difficulties that promote suicidal thoughts. It can also include:

• Clients with a personality disturbance such as borderline personality disorder
• People with trauma histories such as sexual abuse history
• Individuals with a major psychiatric illness (CSAT, 2017)

In a review of men and women who received care in 8 large integrated healthcare systems spanning a variety of regions across the U.S., results suggested that SUDs are associated with significantly increased risk of suicide even after adjusting for other factors that are known to increase risk of suicide, such as psychiatric conditions or physical health comorbidity (Lynch et al., 2020).

Researchers also examined the association of SUDs with risk of suicide for males and females separately. The results indicated that all categories of SUD are associated with significantly increased risk of suicide for both males and females although men were more likely than women to have died from suicide. Having multiple SUDs was associated with significantly greater risk of suicide mortality than any of the other SUD categories (Lynch et al., 2020).

To improve outcomes, co-occurring mental disorders associated with suicidal thoughts and behaviors should be assessed and treated. The most common risk factors are:

1. Depression
2. Anxiety disorders
3. Severe mental illness
4. Personality disorders
5. Anorexia nervosa (SAMSHA, 2021)

Individuals at acute risk for suicidal behavior who appear to be under the influence of alcohol or other drugs, either based on clinical presentation or objective data (breath or laboratory tests), should be maintained in a secure setting until intoxication has resolved. Risk assessment needs to be repeated once the patient is sober to determine appropriate next steps. Risk management options include, but are not limited to, admitting the patient for inpatient hospital care, making a referral for residential care, detoxification, ambulatory care, or scheduling outpatient followup (DVA/DOD, 2019).

Unintentional vs. Intentional Overdose

The continuum of suicidal behavior includes death wishes, suicidal ideation, suicidal attempt, and suicide. Suicidal ideation is the best predictor of an attempt and subsequently attempt is a predictor of suicide. Attempters who show persistent suicidal ideation with high intent to die are at high risk of re-attempting suicide (Rezapur-Shahkolai et al., 2020).

Suicidal intent is an important factor contributing to suicide and defined as the desire for death and suicide attempt. The degree of suicide intention can predict the method used and the lethality of suicide attempts. The level of suicidal intent is a powerful predictor of death from attempted suicide (Rezapur-Shahkolai et al., 2020).

The possibility that an overdose was intentional should always be considered. Differentiating between unintentional and intentional overdose is generally straightforward in patients who are forthcoming. However, many patients will insist an overdose was not intentional even if it was.

Risk factors for suicide attempt (compared to unintentional overdose) include female sex, comorbid depression, interpersonal distress or disruption, and use of substances other than one’s drug of choice. Prior suicide attempts also increase the likelihood that a recent overdose event was intentional.

A risk factor for unintentional overdose is a recent loss of tolerance, for example due to incarceration or detoxification. Individuals using recreational drugs with high potential for miscalculation are more likely to experience unintentional overdose. Obtaining additional information from sources such as family members, treatment providers, and medical records, can be invaluable in making the determination between intentional and unintentional overdose (DVA/DOD, 2019).

Although not typical, there are instances when intentionality is unclear or ambiguous even among substance abusers who are forthcoming, for example a case where the individual was experiencing suicidal ideation and overdosed but appeared not to have intended to attempt suicide, or when a distressed person knowingly pushed the limits of dosage and stated “I didn’t care if I lived or died” but seemed to have no clear agenda for suicides.

Coordinating Services for Patients with SUDs

All patients at acute risk for suicide who are under the influence of drugs or alcohol should be evaluated in an urgent care setting and be kept under observation until they are sober. They should be reassessed for risk for suicide when no longer acutely intoxicated, demonstrating signs or symptoms of intoxication, or experiencing acute withdrawal (DVA/DOD, 2019).

Intoxicated or psychotic patients who are unknown to the clinician and who are suspected to be at acute risk for suicide should be transported securely to the nearest crisis center or ED for evaluation and management. These patients can be dangerous and impulsive; assistance in transfer from law enforcement may be necessary (DVA/DOD, 2019).

Use of drugs or alcohol should routinely be assessed with all persons at any risk for suicide. Psychiatric and behavioral comorbidities (mood, anxiety disorder, aggression) should be assessed in patients with substance use disorder at risk for suicide. Social risk factors such as disruptions in relationships and legal and financial difficulties should also be considered (DVA/DOD, 2019).