Emergency Medicine Forum

A 22 y/o female is admitted with the chief complaint of suicidal ideation.

HPI:  This 22 y/o female has a history of depression and heroin addiction arrives for evaluation on a Sunday morning.  She has been hospitalized several times for depression, and has taken an overdose of pills once in a suicide attempt (2 yrs ago). She had been trying to get off of heroin, so she is enrolled in a methadone clinic.  She had been going regularly, but this past week, she became depressed and did not go on Thursday, Friday or Saturday. Now she is having nausea, vomiting, diarrhea, and muscle aches. She told the triage nurse:   “I’m going through withdraw and I feel so bad I want to kill myself.”
She denies any pains, just states she feels miserable.  No homicidal ideation. 
PMH:  hospitalizations for depression/suicide attempt.  ED visits related to heroin abuse.  No other medical problems. 
PE: HR 101, RR=20, BP=130/80, afebrile, Sat 98% on room air
WDWN in NAD
Exam completely unremarkable.

1. What drugs (besides methadone) are available to treat heroin addiction?

a. Methadone is a synthetic opiate medication that binds to the same receptor as heroin, but when taken orally, it has a gradual onset of action, and the effects are sustained. This reduces the desire for other opioids (like heroin) but also prevents withdrawal symptoms. (1) 

Methadone is only available through a specialized opiate treatment program.

b. Buprenorphine is also taken orally (like methadone) but is has less risk of overdose and withdrawal effects.  Also, this medication can be prescribed in the privacy of a doctor’s office.  It is commonly combined with Naltrexone so that the effects when given IV are negated. (1)

c. Naltrexone:  This is an opioid receptor blocker which negates the effects of heroin if taken.  This essentially takes away the ‘high’ of using heroin.  It can only be given to those already detoxified as it would precipitate withdrawal symptoms if the patient was still addicted to heroin. (1)

2. Does heroin addiction increase or decrease the suicide risk?

Heroin users are 14 times more likely than peers to die from suicide. (2).  It’s no surprise that drugs as a method of suicide play a larger role in suicide among heroin users compared to the general population.

3. Besides heroin addiction, what other condition can be treated with Naltrexone?

Naltrexone has been approved as an adjunct to psychosocial treatment for alcoholism.  (3)

4. What is the most common method used in suicides in the US?

Firearms are the method used in more than half of suicides in the US. (4).  Males commit suicide with firearms 57% of the time, whereas females use firearms 32% of the time. Females are more likely to use poisoning (38%) as the method of suicide.  (Data from 2004 (4).  There are also age differences in the methods to commit suicide. For example, in 2004, in 10-14 yr old girls, hanging / suffocation was the most common method (79%). (5)

Outcome:  This patient was given catapress and  bentyl to offset some of the symptoms of withdrawal.  After a period of observation, and lengthily discussion with our social worker (in conjunction with a psychiatrist) the patient revealed she simply wanted her dose of methadone, and ultimately denied any suicidal ideation.  She agreed to follow up with the methadone clinic on Monday, and was given her dose of Methadone and discharged. 

References:

1. National Institute of Drug Abuse.  NIDA Info Facts:  Heroin.  Accessed at:  “http://www.nida.nih.gov/infofacts/heroin.html”
2. Darke S, Ross J.  Suicide among Heroin Users:  Rates, Risk Factors and Methods.  Addiction 2002 Nov; 97(11):1383-94.  Accessed at:  “http://www.ncbi.nlm.nih.gov/pubmed/12410779”
3. US Department of Health and Human Services and SAMHSA’s National Clearing House for Alcohol and Drug Information.  Naltrexone and Alcoholism Treatment. Executive Summary and Recommendations.  Accessed at: http://ncadi.samhsa.gov/govpubs/bkd268/28c.aspx
4. National Institute of Mental Health. Suicide in the US:  Statistics and Prevention.  Accessed at:  “http://www.nimh.nih.gov/health/publications/suicide-in-the-us-statistics-and-prevention/index.shtml#factors”
5. Medical News Today. Youth Suicide Rate Rises 8% IN USA, Biggest Climb in 15 yrs. 2007 Sept 7.  Accessed at: ”http://www.medicalnewstoday.com/articles/81868.php“