Suicide deaths missing from opioid overdose data, experts say
Today, Chacku Mathai is the CEO of the Mental Health Association of Rochester.
But at 15, he wanted to die.
Describing himself as an immigrant kid with dark skin in a largely white neighborhood, he said he felt misunderstood and targeted at school. He attempted suicide by overdosing on alcohol and other drugs.
To this day, though, he doesn’t know how Monroe County officials recorded his overdose. He doubts it went into their database as a suicide attempt, he said. More likely, he believes, it was ruled an accident, because evidence of his intent didn’t turn up right away.
“I would bet that it was not determined intentional, because my family found a note later,” Mathai said.
Mathai’s experience decades ago is still playing out today, said Pauline Stahlbrodt, the clinic manager at Rochester Regional Health’s Evelyn Brandon Health Center.
Even as the opioid death toll continues to climb, it remains difficult to determine the intent behind an overdose, Stahlbrodt said, and officials often default to calling it unintentional.
Stahlbrodt said she regularly gets cause-of-death information from Monroe County when a person dies from an overdose, and they’re almost always listed as accidental.
Still, even she was surprised to learn of county data obtained by WXXI News showing that only three of the 220 opioid-overdose fatalities – just over 1 percent – last year were ruled intentional.
“That seems unbelievably small,” Stahlbrodt said.
Lisham Ashrafioun, who works on suicide prevention for the Veterans Administration in Canandaigua and teaches psychiatry at the University of Rochester Medical Center, laughed incredulously at the statistics. “That’s pretty striking to me,” he said. “That seems pretty low.”
The problem with undercounting intentional overdoses, Ashrafioun said, is it leads the public and medical professionals to ignore the high risk of suicide in people with opioid use disorder who are addicted to prescription or illegal drugs.
“There are practices for suicide prevention that may never get enacted because no one ever asked if the person was suicidal,” said Ashrafioun.
People are killing themselves, Ashrafioun and Stahlbrodt said, and their families and communities have no idea.
Stahlbrodt, Ashrafioun and other mental health and addiction experts acknowledged two major obstacles that make getting an accurate count of opioid-overdose suicides difficult.
One is the problem of determining intent.
“If you shot yourself, it’s no mistake. Hanging is no mistake. There’s no question about that being a suicide attempt,” Stahlbrodt said. “Overdose is certainly more ambiguous.”
The other difficulty in gathering accurate data is an often unconscious desire on the part of medical examiners, coroners and families to remove intention from a person’s death.
“It makes people feel better, because then the burden isn’t ‘I didn’t do enough,’” said Stahlbrodt. “There’s so much stigma around suicide, and on top of that, now you’re adding substance abuse to it; that has its own stigma, too.”
“It’s just easier to label the death as accidental, rather than suicide,” Ashrafioun said.
Monroe County strongly disputes the idea that it’s mislabeling overdose deaths as accidental. In an emailed statement, Jesse Sleezer, the county’s communications director, said that “Medical Examiner Dr. Nadia Granger is a preeminent expert in the field of forensic pathology” and “her office’s work stands for itself.”
The county declined to make Granger available for an interview.
Experts at the University of Rochester Medical Center said they saw “no reason to question the validity” of the county’s data. Becky Baker, whose son died of an overdose in 2016 and who today helps people looking for addiction treatment get connected with local providers, said she thinks the county’s data accurately reflects the influx of fentanyl into Rochester’s heroin supply.
According to local law enforcement, dealers lace their heroin with fentanyl, which is cheaper. Fentanyl is up to 100 times more potent than morphine, and a small amount of the substance can be deadly. Baker said fentanyl increases the risk of drug users overdosing accidentally.
“They’re not aware of what they’re getting,” Baker said. “That’s why I don’t believe these deaths are intentional.”
But national experts, including Maria Oquendo, the past president of the American Psychiatric Association, and Nora Volkow, the current director of the National Institute on Drug Abuse, said miscategorizing opioid deaths is common across the country, and there are no consistent standards from county to county, or state to state.
The federal Centers for Disease Control is pushing for more consistency, saying a standard protocol is needed.
Monroe County, however, said its procedure is “entirely case-specific – there is no blanket approach” to how the medical examiner’s office determines if an opioid fatality was accidental or intentional.
Missed chances for treatment
Oquendo said inconsistency and lack of resources could be resulting in bad data. “The only way you can determine if an overdose is a suicide death without a suicide note is by doing an investigation,” Oquendo said. “That requires a lot of funding.”
When researchers did have the funding, Oquendo said, they found a much higher rate of suicide attempts than were officially documented. They set up a study to evaluate people who ended up in the emergency room after an overdose. With the resources to fully investigate the intent behind those overdoses, Oquendo said, they found up to 40 percent were suicide attempts.
We have to either figure out a way to get the data more accurate, or assume that the data is not accurate. —Pauline Stahlbrodt
But data from other counties across New York state mirror Monroe County’s findings. In Orange County, 94 percent of opioid overdose deaths were ruled accidental in 2017. In Suffolk County, it was 97 percent.
In Onondaga County, the number of fatal opioid overdoses ruled intentional last year was so small, county spokesperson Melanie Drotar said, that it can’t be publicly disclosed for fear of identifying that person, or those people.
The Ontario County Coroner and the Erie County medical examiner’s office both said they do not track which overdose deaths are suicides and which are accidental. “That information doesn’t exist,” said Janinne Blank, who directs the Erie County office.
Mathai, the leader of Rochester’s Mental Health Association, said trying to collect this data might actually be counterproductive. If you ask people whether they just tried to kill themselves, he said, you probably won’t get an honest answer. And you might lose the chance to address any other mental health concerns.
“That shuts a person down,” Mathai said. “You lose the chance to have an exploration of someone’s trauma. People don’t start out by saying, ‘I have something unspeakable to say.’”
Still, Mathai said, good data are necessary for good policy.
Stahlbrodt took it a step further. “We have to either figure out a way to get the data more accurate, or assume that the data’s not accurate and start screening for suicide risk,” she said.
Stahlbrodt said the tendency to think of all opioid overdoses as accidents means mental health workers might be asking the wrong questions and missing the chance to get the right counseling to people whose lives are at risk.
Oquendo agreed, saying the treatment for an overdose needs to be different if it was intentional or if it was an accident.
“If someone had an accidental overdose, you might hand them naloxone,” to reverse the effect of the drugs, Oquendo said.
“But if they’re suicidal, giving them an antidote doesn’t make a difference. If a person is suicidal, you have to give them an anti-suicidal intervention.”
This story is part of “New York’s Opioid Crisis,” a partnership of public broadcasting stations across the state working to draw attention to this public health crisis. Learn more at wxxi.org/opioids.