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Suicidality

Recovery plans for recurrence of use often emphasize overdose prevention for patients receiving medications for OUD, but suicide risk is frequently overlooked.1 People with OUD are more likely to die by suicide.2 OUD and injection drug use are associated with a 13-fold increased risk of suicide relative to the general population.3 In 2022, more than 81,000 people died from opioid-involved overdoses, and an estimated 20-30% may have been suicides.1 Yet, most opioid-overdose prevention strategies fail to include suicide screening or targeted interventions.1

Nearly half of those who die by suicide saw a primary care provider in the month before their death.4 As a primary care provider, you are in a key position to identify and respond to suicide risk. Assess suicide risk just as you would evaluate chest pain—determine who needs immediate intervention and distinguish them from those whose risk is low. While universal suicide screening in primary care is not yet the standard care, targeted screening for patients receiving medications for OUD can save lives.

All staff should know how to proceed if a person is at imminent risk of suicide.

Practices seek to identify all patients with OUD who are at risk of suicide by implementing routine, targeted screening at initial and designated follow-up visits. For patients whose suicide risk assessment indicates moderate to high risk, providers deliver brief interventions for safety planning and connect patients with additional care, as appropriate.

Ensure all staff can recognize the warning signs of suicidality. Key warning signs requiring immediate action include:

  • Threats of self-harm;
  • Attempts to access dangerous materials like firearms and pills;
  • Expressions of hopelessness or worthlessnesss;5 and
  • Agitation, anxiety, and poor impulse control, as these can make a person more likely to move from suicidal thoughts to making a suicide plan or suicide attempt.6

Your office staff are often in a good position to notice and alert you to concerning behavior changes. For patients at risk for suicide, educate them and their loved ones about suicide warning signs and how to respond.

For more warning signs, see the Suicide Prevention Resource Center.

If warning signs are present and self-harm is likely imminent, contact the following resources in collaboration with your patient, or have your patient or their loved ones contact any of the following:

  • 24-hour 988 Suicide & Crisis Lifeline Text or call 988 or go to https://988lifeline.org/
  • The National Suicide Prevention Lifeline at 1-800-273-TALK (8255);
  • Mental health Crisis services for assessment and support either locally or via telehealth;7 or
  • Emergency care (911 or the nearest emergency department) in acute crises.

Alternatively, consider working with your patient and their loved ones to arrange psychiatric hospitalization if there is imminent risk, such as the patient expressing a desire to die, having a specific and feasible plan they intend to carry out, and the patient being unwilling to consider alternatives. Be aware that not all psychiatric hospitals use evidence-based strategies to reduce suicide risk. For more information see Emerging Best Practices for Addressing Suicidality in Primary Care.

If your practice has the resources, consider developing more extensive suicide protocols and procedures.

Screening: Screen patients at intake and regular intervals, ideally in the context of screening for depression, anxiety, and trauma. Treat or refer patients who screen positive.

Suicide Risk Assessment: If a patient is at a significantly elevated risk for suicide, conduct a suicide risk assessment. Tools such as the SAFE-T Suicide Assessment can be helpful. During the assessment,

  • Ask the patient about suicidal thoughts, plans, prior intent, and attempts; and
  • Make a clinical judgement of suicide risk.

Safety Planning: If a patient is at significant risk for suicide (e.g., expressing intent or making viable plans), conduct a brief safety planning intervention with them. Use lethal means safety counseling to collaborate with them to restrict access to firearms, medications, and other things that could be used to carry out a suicide attempt. (See Lethal Means Safety Counseling: Recommendations for Providers.) A collaboratively developed safety plan can reduce the likelihood of a suicide attempt.8 See the Resources section for more information.

Related approaches—such as Crisis Response Planning,9 the Collaborative Assessment and Management of Suicidality (CAMS),10 and motivational interviewing—can enhance prevention efforts. These methods support patient autonomy, foster engagement in care, and promote collaborative management of suicide risk.

Referral to Treatment: When appropriate, connect patients with mental health care—ideally professionals experienced in suicide care. Establish partnerships with mental health providers to ensure continuity of care.6 Since some patients may hesitate to engage in care, follow-up with the mental health provider within 48 hours and continue to check in weekly, to ensure that your patient continues to receive recommended services. See the Counseling and Other Psychosocial Supports section.

Documentation and Follow-up: Throughout the plan of care for suicidal patients, document all risk assessments, safety plans, referrals, and follow-ups to support continuity of care.5,11 Regular contact with patients and families can help ensure adherence to treatment and patients ongoing safety.5 For example, one promising strategy is the Caring Contacts intervention,12 which involves sending brief, non-demanding messages expressing care and support. This low-cost approach can be a meaningful way to maintain connection between visits.

  • Don't think there is nothing you can do for patients at risk of suicide if you are not trained as a mental health practitioner. Screening tools and effective interventions are available that can be implemented in primary care or other health care settings.
  • Don't think that suicide risk is fixed. Risk of suicide may fluctuate depending on life stressors, so it is important to frequently rescreen or assess patients.
  • Don't screen for suicidality without a plan for how to respond if the results indicate a patient is at risk for suicide.
  • Don't assume that screening is the only way to identify patients at risk for suicide. Be alert to other warning signs or cues you may encounter.

1. Oquendo MA, Volkow ND. Suicide: A Silent Contributor to Opioid-Overdose Deaths. N Engl J Med. 2018;378(17):1567-1569. doi:10.1056/NEJMp1801417

2. Rizk MM, Herzog S, Dugad S, Stanley B. Suicide Risk and Addiction: The Impact of Alcohol and Opioid Use Disorders. Curr Addict Rep. 2021;8(2):194-207. doi:10.1007/s40429-021-00361-z

3. Wilcox HC, Conner KR, Caine ED. Association of alcohol and drug use disorders and completed suicide: an empirical review of cohort studies. Drug Alcohol Depend. 2004;76 Suppl:S11-19. doi:10.1016/j.drugalcdep.2004.08.003

4. National Institute of Mental Health. Primary Care Can Play Key Role in Suicide Prevention. NIMH. 2024. Accessed April 29, 2025. https://www.nimh.nih.gov/news/science-updates/2024/primary-care-can-play-key-role-in-suicide-prevention

5. Tupa E, Hendrickson A, Cole K, Koch H. Western Interstate Commission for Higher Education Mental Health Program. Western Interstate Commission for Higher Education Mental Health Program (WICHE MHP); 2017. Accessed April 28, 2025. https://sprc.org/wp-content/uploads/2023/03/Suicide_Prevention_Toolkit_US_April_2018.pdf

6. McDowell AK, Lineberry TW, Bostwick JM. Practical Suicide-Risk Management for the Busy Primary Care Physician. Mayo Clin Proc. 2011;86(8):792-800. doi:10.4065/mcp.2011.0076

7. Shoib S, Shaheen N, Anwar A, et al. The effectiveness of telehealth interventions in suicide prevention: A systematic review and meta-analysis. Int J Soc Psychiatry. 2024;70(3):415-423. doi:10.1177/00207640231206059

8. Radin AK, Shaw J, Brown SP, et al. Comparative effectiveness of safety planning intervention with instrumental support calls (ISC) versus safety planning intervention with two-way text message caring contacts (CC) in adolescents and adults screening positive for suicide risk in emergency departments and primary care clinics: Protocol for a pragmatic randomized controlled trial. Contemporary Clinical Trials. 2023;131:107268. doi:10.1016/j.cct.2023.107268

9. Bryan C. Suicide Prevention Therapy. Suicide Prevention Therapy. Accessed June 5, 2025. https://suicidepreventiontherapy.com/crisis-response-planning-1

10. Swift JK, Trusty WT, Penix EA. The effectiveness of the Collaborative Assessment and Management of Suicidality (CAMS) compared to alternative treatment conditions: A meta-analysis. Suicide and Life-Threatening Behavior. 2021;51(5). doi:10.1111/sltb.12765

11. Arnon S, Shahar G, Brunstein Klomek A. Continuity of care in suicide prevention: current status and future directions. Front Public Health. 2024;11. doi:10.3389/fpubh.2023.1266717

12. Tu L. How Caring Contacts Addresses the Connection Between Loneliness and Suicide. Healthline. October 3, 2022. Accessed June 5, 2025. https://www.healthline.com/health/send-a-letter-save-a-life-suicide-prevention-through-caring-contacts