This research explores the link between the use of prescribed opioids and harm, including non-accidental fatalities. This is an important topic to investigate, as there is a widely held belief that individuals prescribed opiates are at increased risk of self-harm and suicide. There is research to support this view, and it is easy to see why a powerful, potentially toxic group of drugs like opiates could be used by those who want to inflict harm on themselves or wish to end their life. However, it is crucial to dig deeper into the association between prescribed opiates and self-harm to try to understand the relationship.
Although the study took place in Australia, many Western countries, including the United Kingdom, have seen a rapid expansion in the prescribing of opiates in recent years. In 2019, the UK had the world’s highest rate of opiate consumption, which was also associated with a significant rise in opiate related mortality (Roberts et al 2023). Since then, the United States of America has experienced a surge in opiate consumption and hundreds of thousands of fatalities that, unfortunately, dwarf those recorded in the UK. With increasing access to these powerful drugs, there has been concern that this elevates the risk to those who are vulnerable to self-harm.
Do opiates prescribed for pain actually put patients at greater risk of self-harm, or is the assumption more dangerous than the drug?
Methods
The research team explored 15 years of retrospective cohort data drawn from an existing study of over three million Australian adults. These were adults who started a prescription of opioids between 2003 and 2018. Measured outcomes were hospital admissions due to self-harm and suicides.
In this study, the type of opiates included were drugs such as Tramadol, Fentanyl, Codeine, Methadone and Morphine, for example. It is important to note that the researchers excluded those who were prescribed opiates for dependence, as the aim was to investigate non-opiate dependent links with self-harm and suicide.
Opiate exposure was defined in three ways:
- On/Off opioid – current, recent and former use of opioids was individually identified.
- Cumulative exposure – the number of days an individual used opioids over a 180-day time interval. 180 days was chosen as it matched measures used in previous research.
- Daily opioid dose – the estimated daily dose of an opiate was calculated by converting the specific opiate to an oral morphine equivalent (OME), this is a standard and recognised of unifying opiates to calculate a daily dose.
Results
There were slightly more females than males observed in the research. The mean age at the start of the study was 51.25 years. One in five of the cohort had anxiety or depression. The team found that those taking the lowest dose of opiates, as measured using the oral morphine equivalent (OME), represented the highest number of person-years, in other words, the most common group.
Two factors were found to be associated with an increased risk of suicide, a seven fold increase in suicide deaths among those taking opiates for the longest period and an eight fold increase for those on the highest dose of opiates.
The results for self-harm poisoning revealed the majority did not involve an opiate; with opiate poisoning accounting for only 16% of all self-harm events.
There were 3.086 suicides recorded during the study period. The majority (81%) did not involve an opiate; instead, they were attributed to firearms, gas, hanging or drowning.
Overall, the cohort spent more time off opiates than on them on average.
84% of self-harm events and 81% of suicides in this cohort did not involve an opiate.
Conclusions
The authors stress how complex the relationship is between opiate prescribing and self-harm. They argue that increasing the availability of prescribed opiates does not simply provide the means to a greater risk of self-harm and suicide involving these drugs.
Greater access to prescribed opiates does not straightforwardly translate into greater risk of self-harm or suicide.
Strengths and limitations
The sample size and duration of the study are considerable strengths of this research. Likewise, by excluding people who are dependent on opiates, the researchers ensured that there was a clear focus on how, if at all, opiates might increase self-harm and suicide.
The authors were unable to identify patients accessing opiates due to chronic pain, which was due to a limitation in the data sets used. It is well known that those experiencing chronic pain have an elevated risk of other problems, including poorer mental health, which could result in self-harm.
As the authors acknowledge, private prescriptions were not included in this study. This is a common limitation as public data is more accessible than that held by the private sector. Sadly, it is those in society with the greatest resources who are afforded the greatest privacy at the expense of those with the least. This results in a collective blind spot about what we know about the wealthy, specifically the problems they have with opiates and how they navigate these challenges. This is not just unfair; it denies us any insights and intelligence that this group might offer, which could benefit those who have the least.
The study’s scale is impressive, but the inability to identify chronic pain patients leaves an important gap in understanding who is most at risk.
Implications for practice
The belief that increasing use of opiates also increases the risk of self-harm has proved to be a sticky perception; this study challenges that. This is so important for clinicians to understand, as they could be tempted to discourage some people from abstaining from prescribed opiates as a way of protecting them from self-harm. Not only is this unlikely, but it could deny an individual analgesia at a time when they need it. Although well-intended, it is not good for someone’s mental as well as physical health to be suffering pain.
The only caveat based on this study is that the higher the dose of opiate and the longer a person is exposed to these drugs, the more there is an elevated association with self-harm. But this needs to be viewed as the exception rather than the rule for most people who are prescribed an opiate. Unfortunately, for too long, the reverse has been the widely held view, which has inadvertently denied too many people the treatment they needed, and which opiates would have helped with.
The stigma associated with opiates has endured for too long; hopefully, this study will help reverse the out-of-date view that opiates are all harmful and promote self-harm.
Clinicians who withhold opiates to protect patients from self-harm may be doing more harm than good; is it time to retire this outdated assumption?
Statement of interests
Ian Hamilton has no conflicting interests.
Edited by
Dr Dafni Katsampa
Links
Primary paper
Gabrielle Campbell, Duong Thuy Tran, Chrianna Irene Bharat, Louisa Degenhardt, Brian Draper, Sallie-Anne Pearson, Natasa Gisev and Alys Havard (2025). Risk of self-harm and suicide associated with the use of opioid analgesics. The British Journal of Psychiatry, pp.1-9.
Other references
Hamilton, I. Opioid agonist treatment associated with 50% lower risk of mortality, but political epiphany still needed to reduce drug-related deaths. Mental Elf, 18th August 2021.
McPhee, I. Only junkies how stigma and discrimination link to rise in drug deaths among Scotland’s poor. The Conversation, 22nd February 2021.
Roberts, A.O. and Richards, G.C., 2023. Is England facing an opioid epidemic?. British journal of pain, 17(3), pp.320-324.
