In lethal opioid overdoses, how do you differentiate between suicide by overdose and “accidental” overdoses?

Persons with opioid use disorder (OUD) and persons with chronic pain prescribed chronic opioid medications are at a significantly increased risk of death by opioid overdose as well as death by suicide. These groups are also known to underestimate and minimize their overdose risks. When an overdose occurs, figuring out whether the overdose was accidental or represents a suicide attempt can be complicated. Medical examiners and coroners will classify the death as accident or suicide if the absolute cause of death is evident. Otherwise, they will classify it as undetermined intent.

The term “accidental overdose” if often considered to generate apathy and carries the risk of de-emphasizing the need for treatment in high-risk groups.

An alternative to such uncertain classification for cause of death would be to classify it as Death from Drug Self-Intoxication (DDSI). This classification describes apparent premorbid behavior rather than decedent intent. It also circumvent problems of misclassification and mischaracterization related to (sometimes) competing functions of the epidemiologic and medicolegal paradigms.

DDSI prevention strategies include:

  1. Overdose/ suicide risk training for clinicians
  2. Overdose/suicide risk education for patients/families/public
  3. Structured suicide screening at evaluation, and longitudinally
  4. Elicit common overdose/suicide risk cognitions, develop safety planning around these
  5. Research/surveillance of risk cognitions, especially non-fatal overdose or suicide attempt

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