Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2024 Jan 1.
Published in final edited form as: Subst Use Misuse. 2022 Dec 8;58(1):1–10. doi: 10.1080/10826084.2022.2125271

The Association of Opioid Misuse and Suicidality among People with Disabilities

Keith T Chan 1, Christina N Marsack-Topolewski 2
PMCID: PMC9792431  NIHMSID: NIHMS1846328  PMID: 36476221

Abstract

Background/Purpose:

Past research has linked non-medical prescription opioid use with suicide, though less focus has been placed among people with disabilities impacted by the opioid epidemic. This study examined the relationship of non-medical prescription opioid use and suicidality among people with and without disabilities while controlling for sociodemographic and other variables.

Method:

Using the 2019 National Survey on Drug Use and Health, weighted logistic regression analyses were conducted on a cross-sectional sample of 38,088 respondents 18 and older to examine the effect of opioid misuse and disability on serious thoughts of suicide, having a suicide plan, and making a suicide attempt.

Results:

Findings indicated opioid misuse was associated with 37% higher odds for having a suicide plan in the past year (OR = 1.37, p < 0.05). The main results indicated the people with disabilities had 30% higher odds for having a suicide plan (OR = 1.30, p < 0.05) and 73% higher odds for a suicide attempt in the past year (OR = 1.73, p < 0.001). Interaction analysis found that opioid misuse was associated with higher odds for having a suicide plan (OR = 1.89, p < 0.01), and having a suicide attempt among those with disabilities (OR = 2.57, p < 0.01).

Conclusion:

Results indicated that opioid misuse is a risk factor for suicide, and people with disabilities were at greater risk. Health workers can serve as a nexus point in effectively engaging at-risk people with disabilities in substance use and mental health prevention and recovery services.

Keywords: opioids, substance use, disability, suicide

Non-medical prescription opioid use (NMPOU) has contributed to decreased life expectancy in the United States (Illgen et al., 2016). Research has indicated that the increase in suicide rates may be linked to the opioid epidemic (Bohnert & Ilgen, 2019; Streck et al, 2022), specifically in regard to the association of opioid misuse with suicidal behaviors (Baiden et al., 2019; Guo et al., 2016) and other risk behaviors among adolescents (Clayton et al., 2019). Past research has examined the association of opioid misuse with mental health problems and increased risk for suicide (Chan et al., 2019), especially for vulnerable populations such adolescents and young adults (McCabe et. al, 2017; SAMHSA, 2018), older adults (Carew & Comiskey, 2018; Husain-Krautter, 2019; West & Dart, 2016), and ethnic minority groups (Chan et al., 2019). Limited research has explored NMPOU and its association with mental health outcomes for people with disabilities who may have specific vulnerabilities due to the ongoing opioid epidemic.

Opioids and People with Disabilities

According to the Centers for Disease Control and Prevention (CDC, 2018), approximately 61 million individuals in the United States reported having a disability. Past research has found that adults with disabilities were more likely to be prescribed opioids (Hong et al., 2019; Lauer et al., 2019). People with disabilities also reported higher rates of opioid misuse compared to those without a disability (Ford et al., 2018). Findings from a report from the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) indicated that individuals with disabilities were more likely to misuse opioids, be diagnosed with an opioid use disorder, but were less likely to receive treatment (Kennedy et al., 2018; NIDILRR, 2018). In addition, people with disabilities may face a number of barriers such as inaccessible entrances, inadequate insurance coverage, and lack of other chronic pain management options (NIDILRR, 2018).

Past research has found that Medicare beneficiaries who have a disability are one of the fastest growing populations hospitalized for opioid or heroin poisoning (Song, 2017). Trend analysis indicated that the use of opioids among Medicare beneficiaries has become commonplace for those with a disability, with any use of opioids reported at 43.7% and chronic use at 23.1% (Morden et al., 2014). Among adults who misused opioids, those with disabilities were more likely to report misuse to help with difficult feelings or emotions, compared to those without disabilities (Reif et al., 2021). As such, this population may seek treatment for pain management and be prescribed opioids at a higher rate than those without disabilities (Bohnert & Ilgen, 2019; Morden et al., 2014).

People with Disabilities and Suicide

Past research has highlighted that people with disabilities may experience a higher risk for suicide (Meltzer et al., 2012; Russel et al., 2009). Individuals with physical disabilities and other disabling health conditions, such as multiple sclerosis, were among specific disability populations with increased suicide risk (Khazem eg al., 2017; Lewis et al., 2017). Individuals with disabilities often experience deleterious health consequences and comorbid physical conditions (Kennedy et al., 2018; NIDILRR, 2018). In addition, past research has indicated that disability status was associated with a higher likelihood for mental health conditions (CDC, 2021; Cree et al., 2020). The increased risk for comorbid health and mental health challenges may heighten suicide risk for individuals with disabilities. Despite these risks and realities, there is a lack in the extant literature examining both the prevalence and linkages between opioid misuse and suicidality for individuals with disabilities.

Disability Framework & Stress and Coping Theory

Disability and the opioid epidemic

Under a person and environment framework, disability has been defined as difficulty performing and engaging in activities due to a health or physical problem resulting in the gap between personal capability and environmental demand (Verbrugge & Jette, 1994). Chronic health conditions that limit personal capability may lead to difficulties participating in work and social activities and performing activities of daily living (ADLs), which can then lead to increased risks for mental health problems (CDC, 2021; Cree et al., 2020). People with disabilities often have specific risk factors for opioid use due to increased risk for poverty, poorer health, new and/or chronic pain, higher rates of prescription medication use, and comorbid health issues related to their conditions (Bohnert & Ilgen, 2019; Kennedy et al., 2018; Morden et al., 2014; NIDILRR, 2018). These factors exacerbate the risk of poor mental health and suicidality for people with disabilities who face barriers in participating in daily life and accessing mental health services.

The historical context of the opioid epidemic warrants consideration in regard to its impact on people with disabilities. Beginning in the late 1990s, opioids were commonly prescribed and marketed as an effective and non-addictive drug for pain management (Vadivelu et al., 2018; Volkow & McLellan, 2016). However, the prevalence of NMPOU and opioid-related deaths continue to rise despite public policy and clinical interventions to limit its usage (Baumgarter & Radley, 2022; Han et al., 2015). The pain management needs of people with disabilities are often treated with prescription opioids, which are associated with increased risk for symptoms of depression and other mental health conditions (Mazereeuw et al., 2018; Scherrer et al., 2016; Sullivan, 2018). Examining the impact of having one or more disabilities in the context of NMPOU is paramount for understanding how the opioid epidemic affects people with disabilities and its consequences for their mental health and risk of suicide.

Stress and coping theory

In conjunction, this study used the stress and coping theory from Lazarus and Folkman (1984) to understand the relationship of NMPOU and suicidality for people with disabilities. The stress and coping theory provides a framework to examine emotion-focused and problem-focused coping mechanisms (Folkman et al., 1986). Coping can be conceptualized as a causal factor for emotional or psychological outcomes, which may be adaptive or maladaptive (Lazarus, 1993). Because people with disabilities often have co-occurring medical conditions often requiring chronic pain management, they may also cope with their stress through the use of prescription opioids. As such, people with disabilities may experience prescription opioid use and non-medical use in the context of stress and coping. Stressors experienced by people with disabilities while coping with pain are likely multifaceted and complex. Opioid use to manage pain can become an added stressor, leading to increased risk for suicide for an already vulnerable population.

Aims and Hypotheses of the Present Study

The purpose of this study was to examine the relationship of NMPOU and suicidality among people with and without disabilities. It was hypothesized that (H1) NMPOU will be associated with higher risk of suicidality as measured by (H1a) serious thoughts of suicide, (H1b) making a suicide plan and (H1c) making a suicide attempt in the past year, even when controlling for socio-demographic, mental health and other substance use variables. Furthermore, we hypothesized that (H2) differences will be found for people with disabilties compared to those without disabilities in the association of NMPOU and suicide, as measured by (H2a) thoughts of suicide, (H2b) having a suicide plan, and (H2c) having a suicide attempt, and disability status will have a moderating effect on this relationship. Specifically, the association of past-year NMPOU with (H2a) serious thoughts of suicide, (H2b) having a plan for suicide and (H2c) making a suicide attempt will be stronger for people with disabilities compared to people without disabilities.

Methods

Data and Sample

Data from the 2019 National Survey on Drug Use and Health (NSDUH) Public Use File (Center for Behavioral Health Statistics and Quality, 2020) were used for this study. The study sample consisted of a community-based, non-institutionalized population aged 12 and older. The survey was collected by the Substance Abuse and Mental Health Services Administration (SAMHSA) using an independent, multi-stage area probability sampling design. This dataset has been used to conduct analyses by federal, state, and local government agencies to study substance use problems and trends, assess the need for treatment services, and develop funding strategies and prevention measures in the United States. Computer assisted personal interviewing (CAPI) and audio computer-assisted self-interviewing (ACASI) were used to enhance data collection protocols. Field interviewers used CAPI for screening and to collect and record demographic data. For more sensitive questions regarding substance use and mental health, ACASI was used where respondents read questions on a computer screen or listened to questions on headphones, and recorded their answers without the interviewer knowing their responses.

Imputation of missing values was conducted using predictive mean neighborhoods (PMN). Sampling design weights were generated to account for non-response, demographics of the state of residence, poststratification steps, and these weights were calibrated based on the U.S. Census from 2010. The full sample in the Public Use File included 56,136 persons 12 years and older. The adolescent data were excluded from this study because this portion of the data was designed specifically for 12 to 17 year old respondents, and contained different variables from those 18 and older. The final sample in this analysis included 38,088 adults aged 18 and older.

Measures

Suicidality (Dependent variable)

Suicidality was measured using three variables: serious thoughts of suicide, making a suicide plan, and attempting suicide in the past year. Individuals were asked, “At any time in the past 12 months, that is from [date of one year ago from interview] up to and including today, did you seriously think about trying to kill yourself?” Responses of “yes” were coded ‘1,’ and responses of “no” were coded ‘0.’ Respondents who indicated “yes” to the previous question were then asked, “During the past 12 months, did you make any plans to kill yourself?” Responses of “yes” were coded ‘1,’ and responses of “no” were coded ‘0.’ Respondents who indicated “yes” to having a suicide plan were then asked, “During the past 12 months, did you try to kill yourself?” Responses of “yes” were coded ‘1,’ and responses of “no” were coded ‘0.’

Disability status

Disability status was measured using six self-report questions from the Washington Group Measure of Disability which captured 1) visual disability, 2) hearing disability, 3) cognitive disability, 4) self-care disability, 5) independent living disability, and 6) ambulatory disability. Respondents answered “yes” or “no” to the six questions in the measure. This standard set of questions have been commonly used in population health surveys (Palmer and Harley, 2011; United Nations Statistics Division, 2017), and has been found to be effective in identifying the prevalence of disability in populations, especially in domains most closely associated with social exclusion (CDC, 2012; Washington Group on Disability Statistics, 2017). A response of “yes” was coded ‘1,’ and a response of “no” was coded ‘0.’ Respondents were identified as having a disability if they answered “yes” to any one of the six questions.

Non-medical prescription opioid use (NMPOU)

NMPOU was defined as any past year use of prescription pain relievers which was not directed by a doctor. Respondents were first told, “When you answer these questions, please think only about your drug use in any way a doctor did not direct you to use it, including: (1) using it without a prescription of your own, (2) using it in greater amounts, more often, or longer than you were told to take it, and (3) using it in any other way a doctor did not direct you to use it.” They were then asked, “Have you ever, even once, used prescription pain relievers in any way a doctor did not direct you to use it?” A follow-up question was asked for those who responded yes, “How long has it been since you last used prescription pain relievers?” A value of ‘1’ was coded for respondents who reported any prescription pain reliever use in the past year which was not directed by a doctor, and ‘0’ for use more than a year ago or never used.

Covariates

Covariates in this study included socio-demographic variables such as age (18–25, 26–34, 35–49, 50 and older), race/ethnicity, gender, marital status, poverty, education, full-time employment, only adult in the household, urban/small metro/rural region of residence, social security, and health insurance status. We included other substance use variables which were available in the NSDUH dataset, such as binge drinking alcohol in the last 30 days, and the use of the following substances in the past year: marijuana/hashish, heroin, cocaine, crack cocaine, methamphetamine, inhalant, hallucinogen, and non-medical prescription fentanyl, stimulant, tranquilizer and sedative. Illicitly manufactured fentanyl was not available and could not be included in the analysis. Health and mental health variables included: poor health as measure by self-rated health, past-year major depressive episode, psychological distress measured by the Kessler Psychological Distress Scale (K6; Kessler et al., 2002), and mental health impairment measured by a modified World Health Organization Disability Assessment Schedule (Center for Behavioral Health Statistics and Quality, 2020).

Statistical Analyses

Initial univariate analyses were conducted to examine the prevalence of suicidality measured as 1) having serious thoughts of suicide, 2) making a plan for suicide, and 3) making a suicide attempt, all within the past year for those who engage in NMPOU and those who did not. In addition, univariate analyses included subgroup differences in prevalence of disability and sociodemographic variables among those with and without NMPOU. Weighted logistic regression analyses were first conducted to examine the main effects of NMPOU and disability status with the three separate suicidality outcomes (having serious thoughts of suicide, making a plan for suicide, and making a suicide attempt). Control variables included demographics, other substance use, and health and mental health. Interaction analyses were conducted for NMPOU and disability status. All analyses were conducted using Stata 15.0.

Results

The independent variables of interest in this study were NMPOU and disability status as measured by the six questions from the Washington Group Measure of Disability. The study sample included 1,621 adults 18 and older who engaged in NMPOU and 36,467 who reported no use.

Prevalence of NMPOU & Suicidality Stratified by Disability Status

Weighted results indicated that 3.6% of the study sample reported past-year NMPOU. Comparing disability status, 5.9% of people with disabilities reported NMPOU compared to 3.0% of people without disabilities. Among those who use NMPO, a higher percentage reported having a disability (33.2%) compared to those without NMPOU (20.0%). Consistent with past research, suicidality was more prevalent for those reporting NMPOU compared to those without NMPOU (Serious Thoughts of Suicide: 16.0% compared to 5.5%, Having a Plan for Suicide: 7.7% compared to 2.0%, Suicide Attempts: 5.3% compared to 1.3%). Among those who reported having a disability, suicidality also was more prevalent compared to those without a disability (Serious Thoughts of Suicide: 12.6% compared to 4.2%, Having a Plan for Suicide: 5.5% compared to 1.3%, Suicide Attempts: 3.9% compared to 0.8%). As shown in Table 1, over three times the percentage of those who use reported suicidality (thoughts, plan, attempt) compared to those without NMPOU. Similarly, over three times the percentage of people with disabilities reported suicidality, compared to people without disabilities (see Table 3).

Table 1.

Descriptive Variables Characteristic of Those With and Without Non-medical Prescription Opioid Use (n=38,088)

Variables Those With Non-Medical Prescription Opioid Use (n=1,621) Those Without Non-Medical Prescription Opioid Use (n=36,467) Effect Size †
Suicidality
 Serious Thoughts of Suicide 16.0% 5.5% 0.08***
 Having a Plan for Suicide 7.7% 2.0% 0.07***
 Suicide Attempts 5.3% 1.3% 0.06***
Have 1 or More Disabilities 33.2% 20.0% 0.06
No Disability 66.8% 80.0%
Socio-demographics
 Age
  18–25 18.4% 12.5% 0.08***
  26–34 24.3% 15.8%
  35–49 29.8% 24.3%
  50–64 18.8% 25.7%
  65+ 8.7% 21.8%
 Race
  White 68.4% 65.4% 0.03*
  Black 11.2% 12.1%
  Asian 2.9% 5.9%
  Hispanic 17.6% 16.6%
 Gender 54.2% 48.0%
  Male 54.2% 48.0% 0.02***
  Female 45.8% 52.0%
 Married 36.7% 52.5% 0.06***
 2x poverty 41.5% 30.6% 0.04***
 College graduate 25.6% 34.5% 0.03***
 Employed Full-Time 53.0% 50.3% 0.01
 Only adult in household 22.8% 20.0% 0.01
 Region 0.02
  Large metro 54.8% 56.1%
  Small metro 33.6% 30.1%
  Non-metro 11.6% 13.8%
Open in a new tab
*

p-value <0.05

**

p-value <0.01

***

p-value <0.001

†

For effect sizes, Cohen’s D was calculated for the t-test comparing the K6 score between users and non-users. Cramer’s V was calculated for Chi-square tests of categorical variables with users and non-users.

Table 3.

Main Effect and Interaction Effect of Non-Medical Prescription Opioid Use (NMPOU) and Race on Suicidality (n=38,088)†

Serious Thoughts of Suicide Have a Plan for Suicide Suicide Attempts
Those With NMPOU Those Without NMPOU OR (95% CI) Those With NMPOU Those Without NMPOU OR (95% CI) Those With NMPOU Those Without NMPOU OR (95% CI)
Non-Medical Prescription Opioid Use b 16.0% 5.5% 1.00 (0.77; 1.30) 7.7% 2.0% 1.24 (0.86; 1.79) 3.9% 0.8% 1.41 (0.84; 2.37)
Have 1 or More Disability b 12.6% 4.2% 1.13 (0.94; 1.37) 5.5% 1.3% 1.28 (1.03; 1.58)* 3.9% 1.3% 1.72 (1.30; 2.29)***
No Disability (Ref) 9.8% 4.1% -- 3.9% 1.3% -- 2.5% 0.7% --
Non-Medical Prescription Opioid Use x Disabled 1.47 (1.01; 2.12)* 1.89 (1.23; 2.92)** 2.57 (1.30; 5.09)**
Pseudo R2 0.34a 0.29a 0.25a
Wald Statistic F Statistic (df) 68.81*** (43, 8) 50.41*** (43, 8) 59.04*** (43, 8)
Open in a new tab
*

p-value <0.05

**

p-value <0.01

***

p-value <0.001

†

All analyses controlled for socio-demographics, other substance use (binge drinking, cannabis, heroin, fentanyl, cocaine, crack cocaine, inhalants, hallucinogens, methamphetamine, stimulants, tranquilizers, sedatives), self-rated health, and mental health (past-year major depressive episode, psychological distress, mental health impairment). Estimates from these variables can be furnished upon request.

a

Pseudo R2 was not estimated with survey design weights due to issues of heteroskedasticity. The Pseudo R2 value presented here is unweighted.

b

The main effects reported here in Table 3 are controlling for the interaction effects between NMPOU and disability status. The interaction term (Non-Medical Prescription Opioid Use x Disabled) was statistically significant for all three measures of suicidality, even when controlling for the main effects in this interaction analysis.

In terms of socio-demographic variables, those with NMPOU tended to be younger compared to those without NMPOU. Percentages for those with and without NMPOU were similar for non-Hispanic White, Black, and non-White Hispanic adults. Rates of NMPOU were higher for males compared to females (Male: 54.2%, Female: 45.8%), and lower percentages of those with (36.7%) compared to those without NMPOU (52.5%) were married. Higher rates of poverty (41.5%) were found for those with compared to those without NMPOU (30.6%). A higher percentage of those without NMPOU were college graduates (34.5%) compared to those with NMPOU (25.6%). Statistically similar percentages of those with (53.0%) and those without NMPOU (50.3%) reported being employed full time. No statistically significant differences were observed with only adult in the household or regionality (Large metro, Small metro, and Non-metro) among those with and without NMPOU (see Table 1).

Multivariate Logistic Regression Results for Those With & Without NMPOU

We hypothesized that (H1) NMPOU will be associated with higher risk of suicidality as measured by (H1a) serious thoughts of suicide, (H1b) making a suicide plan and (H1c) making a suicide attempt in the past year, even when controlling for socio-demographic, mental health and other substance use variables. As shown in Table 2, results indicated that H1b was supported, and that past-year NMPOU was associated with 37% higher odds for having a plan for suicide (OR = 1.37, SE = 0.21, 95% CI: [1.01, 1.87], p < 0.05), even when controlling for all other variables in the analysis. Having one or more disabilities was associated with 30% higher odds for having a plan for suicide (OR = 1.30, SE = 0.13, 95% CI: [1.06, 1.60], p < 0.05) and 73% higher odds for suicide attempt (OR = 1.73, SE = 0.25, 95% CI: [1.30, 2.31], p < 0.001).

Table 2.

Aggregate Multivariate Logistic Regression of Non-Medical Prescription Opioid Use with Suicidality (n=38,088)

Serious Thoughts of Suicide Have a Plan for Suicide Suicide Attempts
Variables OR (SE) 95% CI OR (SE) 95% CI OR (SE) 95% CI
Non-Medical Prescription Opioid Use 1.13 (0.14) 0.88; 1.45 1.37 (0.21)* 1.01; 1.87 1.46 (0.36) 0.90; 2.38
Have 1 or More Disabilities 1.16 (0.10) 0.97; 1.38 1.30 (0.13)* 1.06; 1.60 1.73 (0.25)*** 1.30; 2.31
Socio-demographics
Age
 18–25 (Ref) -- -- --
 26–34 0.85 (0.06)* 0.73; 0.98 0.77 (0.08)* 0.62; 0.95 0.86 (0.11) 0.69; 1.12
 35–49 0.71 (0.07)** 0.59; 0.86 0.50 (0.07)*** 0.37; 0.67 0.51 (0.09)*** 0.36; 0.73
 50–64 0.63 (0.08)** 0.49; 0.82 0.45 (0.09)*** 0.31; 0.66 0.56 (0.13)* 0.36; 0.88
 65+ 0.50 (0.09)*** 0.36; 0.71 0.56 (0.20) 0.30; 1.07 0.29 (0.12)** 0.13; 0.66
Race
 White (Ref) -- -- --
 Black 0.43 (0.05)*** 0.35; 0.53 0.40 (0.06)*** 0.30; 0.55 0.64 (0.12)* 0.44; 0.94
 Asian 0.58 (0.09)** 0.42; 0.79 0.68 (0.14) 0.44; 1.04 0.59 (0.14)* 0.37; 0.96
 Hispanic 0.76 (0.09)* 0.60; 0.95 0.85 (0.15) 0.60; 1.21 0.83 (0.14) 0.60; 1.16
Gender
 Male (Ref) -- -- --
 Female 0.93 (0.06) 0.82; 1.06 1.08 (0.09) 0.91; 1.28 1.30 (0.19) 0.97; 1.75
Married 0.84 (0.09) 0.67; 1.04 0.98 (0.13) 0.75; 1.30 1.01 (0.19) 0.70; 1.48
2x poverty 0.92 (0.07) 0.78; 1.08 0.96 (0.11) 0.76; 1.21 1.07 (0.16) 0.79; 1.44
College graduate 1.28 (0.09)** 1.11; 1.47 1.10 (0.11) 0.89; 1.35 0.84 (0.12) 0.63; 1.13
Employed Full-Time 1.06 (0.07) 0.92; 1.23 1.13 (0.10) 0.95; 1.34 1.13 (0.16) 0.86; 1.49
Only adult in household 0.91 (0.09) 0.74; 1.12 0.97 (0.13) 0.73; 1.28 1.04 (0.18) 0.73; 1.48
Region
 Large metro (Ref) -- -- --
 Small metro 1.18 (0.10) 0.99; 1.39 1.20 (0.11) 0.99; 1.44 1.16 (0.19) 0.83; 1.60
 Non-metro 1.13 (0.12) 0.90; 1.40 1.26 (0.18) 0.95; 1.68 1.01 (0.17) 0.73; 1.42
Alcohol & Substance Use
 Binge drinking alcohol 1.12 (0.08) 0.98; 1.29 1.16 (0.12) 0.95; 1.43 0.98 (0.13) 0.75; 1.27
 Marijuana/hashish 1.15 (0.08)* 1.00; 1.33 1.03 (0.11) 0.83; 1.28 1.08 (0.15) 0.82; 1.43
 Heroin 0.42 (0.20) 0.16; 1.10 0.61 (0.30) 0.23; 1.65 0.49 (0.31) 0.14; 1.72
 Fentanyl 1.70 (0.54) 0.89; 3.25 2.10 (0.83) 0.95; 4.63 1.39 (0.82) 0.43; 4.54
 Cocaine 0.77 (0.12) 0.56; 1.06 1.10 (0.22) 0.73; 1.65 0.92 (0.23) 0.56; 1.51
 Crack cocaine 2.04 (1.04) 0.73; 5.70 0.86 (0.46) 0.29; 2.53 1.23 (0.67) 0.41; 3.68
 Inhalant 1.49 (0.33) 0.95; 2.33 1.21 (0.52) 0.51; 2.86 1.57 (0.82) 0.55; 4.50
 Hallucinogen 1.45 (0.20)* 1.10; 1.91 1.08 (0.23) 0.70; 1.67 1.26 (0.35) 0.72; 2.19
 Methamphetamine 0.70 (0.20) 0.39; 1.25 0.51 (0.13) 0.30; 1.00 0.93 (0.29) 0.50; 1.72
 Stimulant 1.00 (0.13) 0.77; 1.30 0.99 (0.18) 0.69; 1.41 1.07 (0.26) 0.66; 1.75
 Tranquilizer 1.14 (0.016) 0.86; 1.51 1.50 (0.24)* 1.09; 2.07 1.33 (0.26) 0.89; 1.99
 Sedative 0.99 (0.29) 0.56; 1.78 0.84 (0.32) 0.39; 1.81 0.93 (0.39) 0.40; 2.18
Health & Mental Health
 Poor health 0.89 (0.09) 0.72; 1.10 0.99 (0.14) 0.75; 1.30 1.09 (0.21) 0.74; 1.60
 Past-year depressive episode 6.03 (0.62)*** 4.92; 7.41 1.04 (0.01)*** 1.02; 1.06 3.37 (0.70)*** 2.22; 5.12
 Psychological distress (K6) 1.07 (0.01)*** 1.05; 1.08 1.04 (0.01)*** 1.02; 1.06 1.02 (0.02) 0.99; 1.06
 Mental health impairment 1.08 (0.01)*** 1.06; 1.09 1.09 (0.01)*** 1.07; 1.12 1.06 (0.01)*** 1.03; 1.09
Pseudo R2 0.34a 0.29a 0.25a
Wald Statistic (42, 9) 58.55*** 55.11*** 45.08***
Open in a new tab
*

p-value <0.05

**

p-value <0.01

***

p-value <0.001

a.

Pseudo R2 was not estimated with survey design weights due to issues of heteroskedasticity. The Pseudo R2 value presented here is unweighted.

With regard to socio-demographic variables, older age cohorts had lower overall odds for suicidality (thoughts of suicide, have a plan for suicide, and suicide attempts) compared to the 18 to 25 year old group (see Table 2). Among race groups, Black (OR = 0.43, SE = 0.05, 95% CI: [0.35, 0.53], p < 0.001), Asian (OR = 0.58, SE = 0.09, 95% CI: [0.42, 0.79], p < 0.01), and Hispanic (OR = 0.76, SE = 0.09, 95% CI: [0.60, 0.95], p < 0.05) respondents had lower odds for serious thoughts of suicide compared to non-Hispanic Whites. Black respondents had lower odds for having a plan for suicide compared to non-Hispanic Whites (OR = 0.40, SE = 0.06, 95% CI: [0.30, 0.55], p < 0.001). Black (OR = 0.64, SE = 0.12, 95% CI: [0.44, 0.94], p < 0.05) and Asian (OR = 0.59, SE = 0.14, 95% CI: [0.37, 0.96], p < 0.05) respondents had lower odds for making a suicide attempt compared to non-Hispanic Whites. No other statistical differences in race and suicidality were observed. Having a college degree was associated with 28% higher odds for having serious thoughts of suicide (OR = 1.28, SE = 0.09, 95% CI: [1.11, 1.47], p < 0.01). Gender, marital status, employment, being the only adult in the household, and regionality were not statistically significant in the full analysis.

We hypothesized that (H2) differences will be found for people with disabilties compared to those without disabilities in the association of NMPOU and suicide, as measured by (H2a) thoughts of suicide, (H2b) having a suicide plan, and (H2c) having a suicide attempt, and disability status will have a moderating effect on this relationship. From Table 3, findings from interaction analyses indicated that H2b and H2c were supported; people with disabilities compared to those without a disability had over 28% higher odds for having a suicide plan (OR = 1.28, SE = 0.14, 95% CI: [1.03, 1.58], p < 0.05) and 72% higher odds for making a suicide attempt in the past year (OR = 1.72, SE = 0.24, 95% CI: [1.30, 2.29], p < 0.001). The interaction of NMPOU and disability was statistically significant for (H2b) having a plan for suicide (OR = 1.89, SE = 0.41, 95% CI: [1.23, 2.92], p < 0.01) and (H2c) suicide attempt (OR = 2.57, SE = 0.88, 95% CI: [1.30, 5.09], p < 0.01). These significant interaction effect results indicated that the association of NMPOU is stronger for people with disabilities in having a plan for suicide and making a suicide attempt during the past year. Although the interaction effect for the association of NMPOU and disability status on having serious thoughts of suicide (H2a) analysis was statistically significant (OR = 1.47, SE = 0.27, 95% CI: [1.01, 2.12], p < 0.05), this result should be interpreted with caution. As previously indicated on Table 2, both opioid misuse and disability status in the analysis without the interaction term were non-significant with suicidal ideation (H1a). The presence of the significant interaction term in this instance may be a result of an endogenous effect due to multicollinearity in this analysis.

Discussion

The current study examined differences in the relationship of opioid misuse with suicidality among people with and without disabilities. Consistent with past research, findings from the current study indicated that NMPOU was associated with higher odds for having a suicide plan in the past year, even when controlling for socio-demographic, other substance use, self-rated health, mental health, health access and inpatient and outpatient mental health utilization variables. The prevalence of disability was higher among those with and without NMPOU, and the odds for suicidality were higher for people with disabilities compared to those without a disability. In addition, the moderating effects of NMPOU on the relationship of disability with having a suicide plan and making a suicide attempt were statistically significant. These findings suggest that opioid misuse may have a more deleterious effect on suicidality for people with disabilities, who are already at higher risk for suicide compared to people without disabilities. In addition, the findings align with both the disability framework and Lazarus and Folkman’s stress and coping theory, in understanding the gap in the person and environment for people with disabilities as they manage their pain and health conditions. Furthermore, NMPOU can be understood as a maladaptive coping mechanism leading to increased risk for suicidality among people with disabilities.

Disability, NMPOU & Suicide

Results from this study are consistent with past research which highlighted the link in opioid misuse with deleterious mental health sequelae (Edlund et al., 2015; Fischer et al., 2012; Mojtabai et al., 2016; Salas et al., 2017; Scherrer et al., 2016; Sheridan et al., 2016; Yarborough et al., 2016), in particular the increased risk of suicide for vulnerable populations (Chan et al., 2020; Han et al., 2017; Han et al., 2020). We hypothesized that the association between NMPOU and suicidality would be stronger for people with disabilities. Our findings indicated that this was supported. Among those who reported opioid misuse, more had one or more disabilities (33.2%) compared to those without NMPOU (20.0%). Those with one or more disabilities also reported substantially higher rates in serious thoughts of suicide, having a plan for suicide and making a suicide attempt in the past year compared to people without disabilities (Serious Thoughts of Suicide: 12.6% compared to 4.2%, Having a Plan for Suicide: 5.5% compared to 1.3%, Suicide Attempts: 3.9% compared to 0.8%). People with disabilities who engaged in opioid misuse had higher prevalence and odds for having a suicide plan and making a suicide attempt in the past year compared to those without a disability. Our findings support that NMPOU has a moderating effect on the relationship of disability and suicide, indicating increased risk of suicide for people with disabilities.

Past research has highlighted vulnerabilities specific to people with disabilities regarding substance use and suicide (Khazem eg al., 2017; Lewis et al., 2017; Meltzer et al., 2012; Russel et al., 2009). People with disabilities experience diverse challenges and barriers that impact their overall physical and mental health (Centers for Disease Control and Prevention, 2021; Cree et al., 2020; NIDILRR, 2018). Consistent with past research, our findings suggest that this population is prescribed opioids at a higher rate than those without disabilities (Hong et al., 2019; Lauer et al., 2019). Findings from this study suggest that the harmful effects from prescription opioid misuse may disproportionately impact people with disabilities, and the link between opioid misuse and suicide may be stronger for this population compared to people without disabilities. Our findings indicate that the effects of the opioid epidemic may have exacerbated the risk for suicide in this population.

Findings from the present study align with previous research which identified disability status and opioid misuse as correlates of mental health problems and suicidality. People with disabilities have a heightened risk for suicide (Meltzer et al., 2012; Russel et al., 2009) and opioid use and misuse (Lauer et al., 2019). Many people with disabilities have pre-existing unmet mental health concerns, necessitating an urgent need for prevention programs that can be disability-specific and effectively engage with this underserved population.

Although older age was associated with lower odds for suicidality, it is important to highlight that the reference group for comparison are those aged 18 to 25, and past research has indicated that younger adults had the highest risks for both substance use and suicidality (Chan et al., 2020; Sheridan et al., 2016; Mojtabai & Olfson, 2020). More research is needed to further examine the impact of disability status and opioid misuse for age-specific cohorts.

Recommendations

Suicide is one of the leading causes of death in the United States (Ahmad & Anderson, 2021), and findings from this study contribute to the body of research indicating a link between prescription opioids and heightened risk of suicide among people with disabilities. People with disabilities who misuse prescription opioids have higher prevalence of thoughts of suicide, having a plan for suicide, and making a suicide attempt. After accounting for other variables such as sociodemographics and mental health, opioid misuse was associated with higher odds for having a suicide plan, while disability status was associated with higher odds for both suicide plan and attempts. Opioid misuse and disability status were not associated with higher odds for having serious thoughts of suicide. When examining each suicidality outcome for the full sample, the prevalence of having serious thoughts of suicide was the highest at 5.9%, having a plan for suicide at 2.2%, and suicide attempts at 1.4%. With the rise in suicide rates and mental health concerns even before the pandemic, having serious thoughts of suicide may be motivated by many different factors and stressors that are outside the scope of this study. However, our findings indicated that opioid misuse and disability were associated with more severe manifestations of suicidality such as having a suicide plan and previously making an attempt, which highlights the vulnerabilities specific to this population.

Among people who have a disability in this study, the percentages of those reporting serious thoughts of suicide, having a suicide plan, and making any suicide attempts were three times higher than people without disabilities. Similarly, those who misused opioids had three times the percentage of suicidality compared to those who did not misuse opioids. Given these areas of concern, it is recommended that healthcare professionals who work with people with disabilities take into account the risks of suicide for those with a history of prescription opioid misuse. There is a need for effective mental health services tailored for people with disabilities to address the impact of the opioid epidemic. A disability-oriented framework that is inclusive of the specific needs of all populations regardless of disability status can be an important part of policy and practice interventions.

Findings from this study suggest that the harmful effects of prescription opioids on suicide were more deleterious for people with disabilities compared to those without disabilities. People with disabilities are underserved in substance prevention and mental health services. This may be attributable to barriers related to the lack of accessibility and inadequacies in health insurance coverage. In the case of prescription opioids, the dearth of chronic pain management options further complicate the realities and challenges of managing a disability (NIDILRR, 2018). Much greater exploration is needed in pain management strategies in conjunction with prescription drug treatment and mental health counseling. Many people with disabilities have real and ongoing needs to manage pain, and more research is needed to identify alternatives that can be effective while addressing mental health for this population. Health promotion efforts can be directed to increasing mental health, substance use and suicide awareness for individuals, family members and health professionals in the disability community.

Suicide can be understood as a severe expression of psychological distress, and persons with disabilities are likely underidentified and undertreated for mental health issues which may result in increased risks for suicidality, especially in the context of the opioid epidemic. Psychosocial treatments that align with disability frameworks can be highly beneficial to engage and provide support to persons with disabilities, but must also take into account the very real needs of individuals with disabilities who are experiencing pain which may exacerbate their mental health challenges. Treatments that emphasize adaptive coping strategies can be particularly helpful, and can potentially increase awareness of both providers and treatment recipients in the need for mental health support in the context of opioid use and misuse.

Strengths and Limitations

The present study fills a gap in the literature on the relationship of NMPOU and suicidality among people with and without disabilities. Findings from this study used the 2019 NSDUH data which comprised a nationally representative, population-based sample of respondents. Despite the strengths of this study due to its generalizability and focus on individuals with disabilities, some limitations should be acknowledged. First, data collection was cross-sectional and did not use a longitudinal approach. As respondents were interviewed at one time rather than on multiple occasions, it is not possible to definitively determine if opioid use was causally prior to suicidality. However, other substance use, self-rated health, mental health, health access and mental health utilization were included in the analysis as proxies to control for pre-existing health and mental health conditions. These methodological considerations provide further evidence on the statistically significant association of NMPOU with suicide for people with disabilities in this study.

Next, data collected through the NSDUH relied on self-report. As such, respondents may have been reticent to share personal and sensitive information regarding substance use and mental health conditions for a number of reasons (e.g., fear of judgment, stigma, etc.). Despite the use of data collection techniques designed to mitigate these concerns, it is possible that some underreporting may have occurred which can contribute to a Type II error. Nevertheless, significant findings from this study were observed which highlight the link between opioid misuse and suicide for people with disabilities, contributing to the understanding of the needs of this population.

Despite the aforementioned limitations, the present study provided novel and important findings indicating that opioid misuse was associated with higher odds for having a suicide plan in the past year. Additionally, this association was stronger for individuals with disabilities who reported higher odds for having a suicide plan and a suicide attempt. Findings from the present study highlighted that opioid misuse was associated with higher odds for having a suicide plan for those with disabilities compared to those without disabilities.

Conclusion

Policies have sought to reduce the impact of the opioid epidemic by limiting the frequency and duration of prescriptions through legislation. Research has found that this approach had some effect in addressing outcomes related to the overprescribing of opioids (Cramer et al., 2021). Findings from the current study highlight that critical investments in mental health infrastructure may be what is necessary to address the impact of the opioid epidemic for vulnerable populations such as people with disabilities. Analysis from the data in this study suggest that the consequences of opioid misuse have important implications for underserved populations. Future research can expand on this analysis by examining trends across years and for different age cohorts, with emphasis on disaggregating disability types and access to treatment services.

Acknowledgements

This study used the 2019 public-use National Survey on Drug Use and Health data, which was made available by the U.S. Substance Abuse and Mental Health Services Administration.

Footnotes

The authors reported no other conflict of interest.

Declaration of competing interest

The authors of this study report no competing interests.

Disclosures: The PI of this study was supported through funding from the Rutgers University Asian Resource Centers for Minority Aging Research Center under NIH/NIA Grant P30-AG0059304 and the Health and Aging Policy Fellowship. The second author received support for this project from Eastern Michigan University’s Faculty Research Fellowship.

References

  1. Ahmad FB, Anderson RN (2021). The leading causes of death in the US for 2020. JAMA, 325(18), 1829–1830. 10.1001/jama.2021.5469 [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.). Washington, DC: Author. [Google Scholar]
  3. Baiden P, Graaf G, Zaami M, Acolatse CK, & Adeku Y (2019). Examining the association between prescription opioid misuse and suicidal behaviors among adolescent high school students in the United States. Journal of Psychiatric Research, 112, 44–51. 10.1016/j.jpsychires.2019.02.018 [DOI] [PubMed] [Google Scholar]
  4. Baumgartner JC, & Radley DC (2022). Overdose deaths surged in the first half of 2021, underscoring the need for action. To the Point. Commonwealth Fund. 10.26099/tmae-je82 [DOI] [Google Scholar]
  5. Becker WC, Fiellin DA, & Desai RA (2007). Non-medical use, abuse and dependence on sedatives and tranquilizers among U.S. adults: Psychiatric and socio-demographic correlates. Drug and Alcohol Dependence, 90(2–3), 280–287. 10.1016/j.drugalcdep.2007.04.009 [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Bellos S, Skapinakis P, Rai D, Zitko P, Araya R, Lewis G, Lionis C, & Mavreas V (2013). Cross-cultural patterns of the association between varying levels of alcohol consumption and the common mental disorders of depression and anxiety: Secondary analysis of the WHO collaborative study on psychological problems in general health care. Drug and Alcohol Dependence, 133(3), 825–831. 10.1016/j.drugalcdep.2013.08.030 [DOI] [PubMed] [Google Scholar]
  7. Bewley TH, Ben-Arie O, & James IP (1968). Morbidity and mortality from heroin dependence: Survey of heroin addicts known to home office. British Medical Journal, 1, 725–726. 10.1136/bmj.1.5594.725 [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Bohnert AS, & Ilgen MA (2019). Understanding links among opioid use, overdose, and suicide. New England Journal of Medicine, 380(1), 71–79. 10.1056/NEJMra1802148 [DOI] [PubMed] [Google Scholar]
  9. Carew AM, & Comiskey C (2018). Treatment for opioid use and outcomes in older adults: A systematic literature review. Drug and Alcohol Dependence, 182, 48–57. 10.1016/j.drugalcdep.2017.10.007 [DOI] [PubMed] [Google Scholar]
  10. Center for Behavioral Health Statistics and Quality. (2020). 2019 National Survey on Drug Use and Health: Public use file codebook. Substance Abuse and Mental Health Services Administration, Rockville, MD [Google Scholar]
  11. Centers for Disease Control and Prevention. (2015). Disability Overview. Washington, DC. http://www.cdc.gov/ncbddd/disabilityandhealth/disability.html
  12. Centers for Disease Control and Prevention. (2018). Leading Causes of Death by Age Group. Washington, DC. https://www.cdc.gov/injury/images/lc-charts/leading_causes_of_death_by_age_group_2018_1100w850h.jpg
  13. Centers for Disease Control and Prevention. (2017). Opioid Overdose. Washington, DC.https://www.cdc.gov/drugoverdose/data/heroin.html
  14. Centers for Disease Control and Prevention. (2020). The Mental Health of People with Disabilities. Washington, DC. https://www.cdc.gov/ncbddd/disabilityandhealth/features/mental-health-for-all.html
  15. Centers for Disease Control and Prevention. (2020). Web-based Injury Statistics Query and Reporting System. Washington, DC. https://webappa.cdc.gov/sasweb/ncipc/leadcause.html
  16. Center for Behavioral Health Statistics and Quality. (2018). 2017 National Survey on Drug Use and Health: Detailed Tables. Substance Abuse and Mental Health Services Administration, Rockville, MD. https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHDetailedTabs2017/NSDUHDetailedTabs2017.pdf [Google Scholar]
  17. Chan K, Zhou S*, Marsack-Topolewski C (2020). Race differences in adolescent opioid misuse and suicidality. Child and Adolescent Social Work Journal. 10.1007/s10560-020-00721-0 [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Chan KT, Winston P, Jennings R, Trant JA, & Moller M (2019). Age differences in the association of non-medical prescription opioid use and suicidality. Journal of Opioid Management, 15(1), 5–10. 10.5055/jom.2019.0480 [DOI] [PubMed] [Google Scholar]
  19. Clayton HB, Bohm MK, Lowry R, Ashley C, & Ethier KA (2019). Prescription opioid misuse associated with risk behaviors among adolescents. American Journal of Preventive Medicine, 57(4), 533–539. 10.1016/j.amepre.2019.05.017 [DOI] [PubMed] [Google Scholar]
  20. Cramer JD, Gunaseelan V, Hu HM, Bicket MC, Waljee JF, Brenner MJ (2021). Association of state opioid prescription duration limits with changes in opioid prescribing for Medicare beneficiaries. JAMA Internal Medicine. 10.1001/jamainternmed.2021.4281 [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Cree RA, Okoro CA, Zack MM, Carbone E (2020). Frequent mental distress among adults by disability status, disability type, and selected characteristics – United States 2018. Morbidity and Mortality Weekly Report (MMWR). https://www.cdc.gov/mmwr/volumes/69/wr/mm6936a2.htm [DOI] [PMC free article] [PubMed]
  22. Edlund MJ, Booth BM, & Han X (2012). Who seeks care where? Utilization of mental health and substance use disorder treatment in two national samples of individuals with alcohol use disorders. Journal of Studies on Alcohol and Drugs, 73(4), 635–646. 10.15288/jsad.2012.73.635 [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Fischer B, Lusted A, Roerecke M, Taylor B, & Rehm J (2012). The prevalence of mental health and pain symptoms in general population samples reporting nonmedical use of prescription opioids: A systematic review and meta-analysis. Journal of Pain, 13(11), 1029–1044. 10.1016/j.jpain.2012.07.013 [DOI] [PubMed] [Google Scholar]
  24. Folkman S, Lazarus RS, Gruen RJ, & DeLongis A (1986). Appraisal, coping, health status, and psychological symptoms. Journal of Personality and Social Psychology, 50(3), 571. 10.1037/0022-3514.50.3.571 [DOI] [PubMed] [Google Scholar]
  25. Ford JA, Hinojosa MS, & Nicholson HL (2018). Disability status and prescription drug misuse among US adults. Addictive Behaviors, 85, 64–69. 10.1016/j.addbeh.2018.05.019 [DOI] [PubMed] [Google Scholar]
  26. Grella CE, & Lovinger K (2012). Gender differences in physical and mental health outcomes among an aging cohort of individuals with a history of heroin dependence. Addictive Behaviors, 37(3), 306–312. 10.1016/j.addbeh.2011.11.028 [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Guo L, Xu Y, Deng J, Huang J, Huang G, Gao X, Wu H, Pan S, Zhang WH, & Lu C (2016). Association between nonmedical use of prescription drugs and suicidal behavior among adolescents. JAMA Pediatrics, 170(10), 971–978. 10.1001/jamapediatrics.2016.1802 [DOI] [PubMed] [Google Scholar]
  28. Hadland SE, Wharam JF, Schuster MA, Zhang F, Samet JH, & Larochelle MR (2017). Trends in receipt of buprenorphine and naltrexone for opioid use disorder among adolescents and young adults, 2001–2014. JAMA Pediatrics, 171(8), 747–755. 10.1001/jamapediatrics.2017.0745 [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Han B, Compton WM, Blanco C, Crane E, Lee J, & Jones CM (2017). Prescription opioid use, misuse, and use disorders in US adults: 2015 National Survey on Drug Use and Health. Annals of internal medicine, 167(5), 293–301. [DOI] [PubMed] [Google Scholar]
  30. Han B, Volkow ND, Compton WM, McCance-Katz EF (2020). Reported heroin use, use disorder, and injection among adults in the United States, 2002–2018. JAMA, 323(6), 568–571. 10.1001/jama.2019.20844 [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Hedegaard H, Curtin SC, & Warner M (2018). Suicide Mortality in the United States, 1999–2017. NCHS Data Brief, no 330. Hyattsville, MD: National Center for Health Statistics. Retrieved from https://www.cdc.gov/nchs/data/databriefs/db330-h.pdf [Google Scholar]
  32. Hong Y, Geraci M, Turk MA, Love BL, & McDermott SW (2019). Opioid prescription patterns for adults with longstanding disability and inflammatory conditions compared to other users, using a nationally representative sample. Archives of Physical Medicine and Rehabilitation, 100(1), 86–94. 10.1016/j.apmr.2018.06.034 [DOI] [PubMed] [Google Scholar]
  33. Husain-Krautter S (2019). Determining Prevalence of Substance Use Disorder in the Geriatric Population during Consult Services. American Journal of Geriatric Psychiatry, 27, S134–S135. 10.1016/j.jagp.2019.01.087 [DOI] [Google Scholar]
  34. Ilgen MA, Bohnert AS, Ganoczy D, Bair MJ, McCarthy JF, & Blow FC (2016). Opioid dose and risk of suicide. Pain, 157(5), 1079–1084. 10.1097/j.pain.0000000000000484 [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Kennedy J, Burley M, & Roll J (2018). The prevalence and treatment of opioid misuse among working-age adults with disabilities, 2016. Accessed at the website from a NIDILRR project containing information on opioid misuse. [Google Scholar]
  36. Kessler RC, Andrews G, Colpe LJ, Hiripi E, Mroczek DK, Normand SL, ... Zaslavsky AM (2002). Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychological Medicine, 32, 959–976. 10.1017/S0033291702006074 [DOI] [PubMed] [Google Scholar]
  37. Khazem LR, Jahn DR, Cukrowicz KC, & Anestis MD (2017). Health conditions, physical disabilities, perceived burdensomeness, and depressive symptoms influence suicidal ideation. Death Studies, 41(4), 220–225. 10.1080/07481187.2016.1251509 [DOI] [PubMed] [Google Scholar]
  38. Kuo YF, Raji MA, & Goodwin JS (2019). Association of disability with mortality from opioid overdose among US Medicare adults. JAMA Network Open, 2(11), e1915638–e1915638. 10.1001/jamanetworkopen.2019.15638 [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Lauer EA, Henly M, & Brucker DL (2019). Prescription opioid behaviors among adults with and without disabilities–United States, 2015–2016. Disability and Health Journal, 12(3), 519–522. 10.1016/j.dhjo.2018.12.001 [DOI] [PubMed] [Google Scholar]
  40. Lazarus RS (1993). Coping theory and research: Past, present, and future. Fifty years of the Research and Theory of RS Lazarus: An Analysis of Historical and Perennial Issues(1st ed., pp. 366–388). Psychology Press. [Google Scholar]
  41. Lazarus R, & Folkman S (1984). Stress, Appraisal, and Coping. New York: Springer Publishing Company. [Google Scholar]
  42. Lewis VM, Williams K, Koko C, Woolmore J, Jones C, & Powell T (2017). Disability, depression and suicide ideation in people with multiple sclerosis. Journal of Affective Disorders, 208, 662–669. 10.1016/j.jad.2016.08.038 [DOI] [PubMed] [Google Scholar]
  43. Lévesque A, Roy E, Jutras-Aswad D, Zang G, Artenie AA, & Bruneau J (2016). Examining the link between psychological distress, mental health disorders and sharing behaviors among cocaine users. Addictive Behaviors, 62, 54–59. 10.1016/j.addbeh.2016.06.004 [DOI] [PubMed] [Google Scholar]
  44. Mattson CL, Tanz LJ, Quinn K, Kariisa M, Patel P, Davis NL (2021). Trends and geographic patterns in drug and synthetic opioid overdose deaths — United States, 2013–2019. MMWR, 70, 202–207. 10.15585/mmwr.mm7006a4 [DOI] [PMC free article] [PubMed] [Google Scholar]
  45. Mazereeuw G, Sullivan MD, & Juurlink DN (2018). Depression in chronic pain: might opioids be responsible?. Pain, 159(11), 2142–2145. 10.1097/j.pain.0000000000001305 [DOI] [PubMed] [Google Scholar]
  46. McCabe SE, West BT, Veliz P, McCabe VV, Stoddard SA, & Boyd CJ (2017). Trends in medical and nonmedical use of prescription opioids among US adolescents: 1976–2015. Pediatrics, 139(4), 1–9. 10.1542/peds.2016-2387 [DOI] [PMC free article] [PubMed] [Google Scholar]
  47. Meltzer H, Brugha T, Dennis MS, Hassiotis A, Jenkins R, McManus S, Rai D, & Bebbington P (2012). The influence of disability on suicidal behaviour. Alter, 6(1), 1–12. 10.1016/j.alter.2011.11.004 [DOI] [Google Scholar]
  48. Mojtabai R, & Olfson M (2020). National Trends in Mental Health Care for US Adolescents. JAMA Psychiatry, 77(7), 703–714. 10.1001/jamapsychiatry.2020.0279 [DOI] [PMC free article] [PubMed] [Google Scholar]
  49. Mojtabai R, Olfson M, & Han B (2016). National trends in the prevalence and treatment of depression in adolescents and young adults. Pediatrics, 138(6), 1–1-. 10.1542/peds.2016-1878 [DOI] [PMC free article] [PubMed] [Google Scholar]
  50. Morden NE, Munson JC, Colla CH, Skinner JS, Bynum JP, Zhou W, & Meara ER (2014). Prescription opioid use among disabled Medicare beneficiaries: Intensity, trends and regional variation. Medical Care, 52(9), 852. 10.1097/MLR.0000000000000183 [DOI] [PMC free article] [PubMed] [Google Scholar]
  51. National Institute on Disability, Independent Living, and Rehabilitation Research. (2018). Summary of response from a request for information: People with disabilities and opioid use disorder.
  52. Palmer M, & Harley D (2011). Models and measurement in disability: An international review. Health Policy and Planning, 27(5), 357–364. 10.1093/heapol/czr047 [DOI] [PubMed] [Google Scholar]
  53. Reif S, Lauer EA, Adams RS, Brucker DL, Ritter GA, & Mitra M (2021). Examining differences in prescription opioid use behaviors among US adults with and without disabilities. Preventive Medicine, 153, 106754. 10.1016/j.ypmed.2021.106754 [DOI] [PubMed] [Google Scholar]
  54. Russell D, Turner RJ, & Joiner TE (2009). Physical disability and suicidal ideation: A community-based study of risk/protective factors for suicidal thoughts. Suicide and Life-Threatening Behavior, 39(4), 440–451. [DOI] [PubMed] [Google Scholar]
  55. Salas J, Scherrer JF, Schneider FD, Burroughs T, Sullivan MD, Bucholz KK, ... Ahmedani BK (2017). New-onset depression following stable, slow, and rapid rate of prescription opioid dose escalation. Pain, 158(2), 306–312. 10.1097/j.pain.0000000000000763 [DOI] [PMC free article] [PubMed] [Google Scholar]
  56. Scherrer JF, Salas J, Copeland LA, Stock EM, Ahmedani BK, Sullivan MD, … Lustman PJ (2016). Prescription opioid duration, dose, and increased risk of depression in 3 large patient populations. Annals of Family Medicine, 14(1), 54–62. 10.1370/afm.1885 [DOI] [PMC free article] [PubMed] [Google Scholar]
  57. Sheridan DC, Laurie A, Hendrickson RG, Fu R, Kea B, & Horowitz BZ (2016). Association of overall opioid prescriptions on adolescent opioid abuse. The Journal of Emergency Medicine, 51(5), 485–490. 10.1016/j.jemermed.2016.06.049 [DOI] [PMC free article] [PubMed] [Google Scholar]
  58. Song Z (2017). Mortality quadrupled among opioid-driven hospitalizations, notably within lower-income and disabled white populations. Health Affairs, 36(12), 2054–2061. 10.1377/hlthaff.2017.0689 [DOI] [PMC free article] [PubMed] [Google Scholar]
  59. Streck JM, Parker MA, Bearnot B, Kalagher K, Sigmon SC, Goodwin RD, & Weinberger AH (2022). National trends in suicide thoughts and behavior among US adults with opioid use disorder from 2015 to 2020. Substance Use & Misuse, 1–10. 10.1080/10826084.2022.2046102 [DOI] [PMC free article] [PubMed] [Google Scholar]
  60. Substance Abuse and Mental Health Services Administration. (2018). Reports and detailed tables from the 2017 National Survey on Drug Use and Health. Retrieved from https://www.samhsa.gov/data/nsduh/reports-detailed-tables-2017-NSDUH
  61. Sullivan MD (2018). Depression effects on long-term prescription opioid use, abuse, and addiction. The Clinical Journal of Pain, 34(9), 878–884. 10.1097/AJP.0000000000000603 [DOI] [PubMed] [Google Scholar]
  62. United Nations Statistics Division. 2017. Washington Group on Disability Statistics homepage. https://unstats.un.org/unsd/methods/citygroup/washington.htm.
  63. Vadivelu N, Kai AM, Kodumudi V, Sramcik J, & Kaye AD (2018). The opioid crisis: a comprehensive overview. Current Pain and Headache Reports, 22(3), 16. 10.1007/s11916-018-0670-z [DOI] [PubMed] [Google Scholar]
  64. Volkow ND, & McLellan AT (2016). Opioid abuse in chronic pain—misconceptions and mitigation strategies. New England Journal of Medicine, 374(13), 1253–1263. doi: 10.1056/NEJMra1507771 [DOI] [PubMed] [Google Scholar]
  65. Washington Group on Disability Statistics. (2017). WG conceptual framework. Retrieved from http://www.washingtongroup-disability.com/methodology-and-research/conceptual-framework/
  66. West NA, & Dart RC (2016). Prescription opioid exposures and adverse outcomes among older adults. Pharmacoepidemiology and Drug Safety, 25(5), 539–544. 10.1002/pds.3934 [DOI] [PubMed] [Google Scholar]
  67. Yarborough BH, Stumbo SP, Janoff SL, Yarborough MT, McCarty D, Chilcoat HD, Coplan PM, & Green CA (2016). Understanding opioid overdose characteristics involving prescription and illicit opioids: A mixed methods analysis. Drug and Alcohol Dependence, 167, 49–56. 10.1016/j.drugalcdep.2016.07.024 [DOI] [PubMed] [Google Scholar]

RESOURCES