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Researchers: Some fatal overdoses may be misclassified as 'accidental'

The Day - 12/28/2018

Dec. 28--Researchers are looking into whether some fatal opioid overdoses are misclassified as "accidental" -- and why it can be hard to tell.

Fatal overdoses and suicides have been on the rise in the United States -- especially among adults ages 25 to 54 -- and have dropped life expectancy in two of the last three years, the Centers for Disease Control and Prevention said.

But researchers and clinicians who cover the topic think the number of suicides -- the CDC reported 44,965 in 2016, of which 15 percent were overdoses -- likely is even higher.

"When we study suicide, we define an attempt as causing injury or trying to with at least some intent to die," said Alexis May, an assistant professor of psychology at Wesleyan University. "Without a note or something that shows a very clear cause, a death likely could be left as an accidental overdose rather than a suicide."

Another issue, May said, is the country's haphazard system of classifying deaths. While some states use skilled medical examiners, others employ coroners with little to no training.

Connecticut Chief Medical Examiner Dr. James Gill said his team works with police to consider evidence from the scene and on phones, although sometimes the latter can't be unlocked. He said examiners look for a history of psychiatric illness and depression and ask families if a person had expressed suicidal thoughts.

Gill said to demonstrate that a person overdosed with the intent to die "is a very high standard." Sometimes, he said, examiners will certify a death as "undetermined" if they're suspicious of suicide but don't have enough evidence.

About 8 percent of overdose deaths are classified as undetermined in the United States, an August 2017American Journal of Public Health article said.

May, who spoke at a forum on the subject in Middletown earlier this month, said better data is needed.

"That isn't the sexiest place to put money toward," she said. "But in terms of root cause analysis, it seems critical to me that we understand why a person died."

In the meantime, May said clinicians should consider screening drug users for suicide risk, and people with suicidal thoughts for problems with addiction.

Treatment for one, she said, often doesn't address the other.

"We need to make sure we're pairing people with what they actually need," May said.

A fuzzy line

Janice Keeman, an addiction counselor who has assessed suicidal behavior in emergency department settings for more than 20 years, said opioid users often don't qualify for involuntary psychiatric commitment.

Some may have wanted to die but will tell physicians they were just trying to get high. Some say they don't want to die but don't care if they do. Others very much want to live, Keeman said.

A person must have psychiatric disabilities and be dangerous to himself or others or gravely disabled to be involuntarily committed.

"We know addiction is life-threatening, but the line between having a life-threatening disease and intentionally wanting to hurt yourself is one that is really fuzzy," said Keeman, who sat on a panel with May in Middletown.

Still, people who reported regular opioid use in the 2014 National Survey of Drug Use and Health were twice as likely to have attempted suicide as people who didn't use opioids.

Keeman said she would like to see a different standard that allows hospitals to commit drug users who are on the edge, though she acknowledged many hospitals already have a shortage of beds.

"It's rare to have somebody who is addicted who doesn't have a concurrent mental illness," Keeman said. "We need more options to pause the addiction process in order to provide help."

Keeman said sometimes videos or text messages that show a person is in danger can help make the case for commitment. She encouraged family members and friends to collect such evidence.

"Even though it's hard to not get jaded, the goal is to look with curiosity every time somebody comes in and say, 'This could be the time this person gets it,'" she said.

Preventing suicide

The overlap between addiction and suicidal thoughts is on the radar of Angela Duhaime, transition manager for the Southeastern Regional Action Council, or SERAC.

SERAC won a three-year, $116,810 grant from the Substance Abuse and Mental Health Services Administration in September to increase access to mental health services for at-risk youth and young adults.

Duhaime said her agency, which covers 39 towns, will use some of the money to include suicide prevention training each time it trains municipal employees, business owners or residents on how to use the overdose-reversal drug naloxone.

She hopes some funding also will go toward hosting a forum similar to the one in Middletown earlier this month, which was co-sponsored by health, higher education and business organizations in Middlesex County.

"In this day and age, suicide notes or expressions of those feelings look so different than even 20 years ago," Duhaime said. "People aren't writing notes. They might send a text, or post online."

"The question is, how do you catch those things?" she said. "I'm not saying every overdose is intentional, but it's something to consider."

l.boyle@theday.com

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(c)2018 The Day (New London, Conn.)

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