Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Effective • People Recover

IN BRIEF

2016

SUBSTANCE USE AND SUICIDE: 

A NEXUS REQUIRING A 

PUBLIC HEALTH APPROACH

Suicide is a serious and preventable public health problem in the United States. Collaboration among 

prevention professionals across behavioral health fields has the potential to reduce suicide rates. While 

multiple factors influence suicidal behaviors, substance use—especially alcohol use—is a significant 

factor that is linked to a substantial number of suicides and suicide attempts. This “nexus” between 

substance use and suicide provides an opportunity for behavioral health leaders to develop a cohesive 

strategy within a public health framework to reduce suicidal behaviors and suicide rates.

This In Brief summarizes the relationship between substance use and suicide and provides state and tribal 

prevention professionals with information on the scope of the problem, an understanding of traditional 

barriers to collaboration and current programming, and ways to work together on substance misuse and 

suicide prevention strategies. 

Scope of the Problem 
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IN BRIEF

How Prevalent Is Substance Misuse and Suicide? 

In 2013, there were more than 41,000 deaths as a result of suicide in the U.S. (CDC, 2015). Suicide is the 

tenth leading cause of death, claiming more lives each year than death due to motor vehicle crashes. It is 

the second leading cause of death for young people age 10 

to 24, as well as for those age 25 to 42 (CDC, 2015).

Additionally, almost four percent of adults—9.4 million 

people—age 18 or older had serious thoughts of suicide in 

the past 12 months, according to the National Survey on 

Drug Use and Health (NSDUH) (SAMHSA, 2014b). The 

prevalence of suicide ideation and suicide attempts varies 

based on demographic and individual factors, including age 

and substance use. Within the adult population, 2.7 million 

reported making a suicide plan, and 1.1 million reported a 

suicide attempt (SAMHSA, 2015) 

Suicide rates vary considerably within different population 

subgroups and are affected by factors such as 

socioeconomic status, employment, occupation, sexual 

orientation, and gender identity: 

• Americans age 45–54 were more likely to die by 

suicide than any other single age group, with 19.7 

deaths per 100,000, compared to 13.0 per 100,000 

within the general population (CDC, 2015a);

• Adolescents and young adults (age 15–24) had a 

suicide rate of 11.1 per 100,000, whereas suicide 

among children ages 5–14 was relatively rare—0.96 

per 100,000 in 2013 (CDC, 2015);

• The rates of suicide were almost four times higher for men than for women (20.6 per 100,000 vs. 5.7 

per 100,000) and were highest among Whites (14.9 per 100,000) (CDC, 2015); and

• In 2013, suicide rates were 11.7 per 100,000 for American Indians/Alaska Natives, 6.0 per 100,000 

for Asians/Pacific Islanders, 5.3 per 100,000 for Hispanics, and 5.4 per 100,000 for African

Americans (CDC, 2015).

Substance misuse is also prevalent in the U.S. among individuals age 12 and older in 2014: 

• Approximately 1 in 12 (21.5 million) had a substance use disorder in the past year;

• Almost one quarter engaged in binge drinking in the past month; and 

• Over 10 percent used illicit drugs in the past month (SAMHSA, 2015).

At-Risk Populations 

for Suicide 

The following populations are known 

to have an increased risk for suicidal 

behaviors (HHS, 2012):

• American Indians/Alaska Natives

• Individuals bereaved by suicide

• Individuals in justice and child 

welfare settings

• Individuals who engage in nonsuicidal self-injury

• Individuals who have attempted 

suicide

• Individuals with medical 

conditions

• Individuals with mental and/or 

substance use disorders

• LGBT individuals

• Members of the armed forces and 

veterans

• Men in midlife

• Older men
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Substance Use and Suicide: A Nexus Requiring a Public Health Approach

2016

3 

Suicides and Suicide Attempts Are Significantly Affected by 

Substance Use 

Individuals with substance use disorders 

(SUDs) are particularly susceptible to suicide 

and suicide attempts. Indeed, suicide is a 

leading cause of death among people who 

misuse alcohol and drugs (SAMHSA, 2008; 

HHS, 2012; Wilcox, Conner, & Caine, 2004; 

Pompili et al., 2010). Substance misuse

significantly increases the risk of suicide:

• Approximately 22 percent of deaths by 

suicide involved alcohol intoxication, with 

a blood-alcohol content at or above the 

legal limit (CDC, 2014b); 

• Opiates (including heroin and prescription painkillers) were present in 20 percent of suicide deaths, 

marijuana in 10.2 percent, cocaine in 4.6 percent, and amphetamines in 3.4 percent (CDC, 2014b). 

One of the reasons alcohol and/or drug misuse significantly affects suicide rates is the disinhibition that 

occurs when a person is intoxicated (HHS, 2012; Pompili et al., 2010). Although less is known about the 

relationship between suicide risk and other drug use, the number of substances used seems to be more

predictive of suicide than the types of substances used (HHS, 2012). However, the research on this 

subject is limited, and the relationship between drug misuse and suicide risk is even less developed. More 

research is needed on the association between different drugs, drug combinations, and self-medication on 

suicidal behavior (SAMHSA, 2008).

Surveillance data nevertheless reveal that a diagnosis of alcohol misuse or dependence is associated with 

a suicide risk that is 10 times greater than the suicide risk in the general population, and individuals who 

inject drugs are at about 14 times greater risk for suicide (Wilcox, Conner, & Caine, 2004; SAMHSA, 

2009).

Acute alcohol intoxication is present in about 30-40 percent of suicide attempts (Cherpitel, Borges, & 

Wilcox, 2004; SAMHSA, 2009). Many of these suicide attempts require medical attention, and every year 

about 650,000 people receive treatment in emergency rooms following a suicide attempt (Chang, Gitlin, 

& Patel, 2011). In 2011, approximately 230,000 emergency department visits resulted from drug-related 

suicide attempts, and almost all involved a prescription drug or over-the-counter medication. The number 

of emergency department visits for drug-related suicide attempts increased 51 percent overall from 2005 

to 2011, and more than doubled among people age 45–64 (SAMHSA, 2014a). The text box on page 4

provides some additional information regarding alcohol’s role in suicidal behavior. 
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4 

IN BRIEF

Alcohol’s Behavioral Mechanism as a Catalyst for Suicide 

Acute alcohol intoxication may substantially increase the risk of suicide by decreasing inhibitions and 

increasing depressed mood. The acute effects of alcohol intoxication act as important proximal risk factors 

for suicidal behavior among individuals with alcohol use disorders and those without. Mechanisms 

responsible for alcohol’s ability to increase the proximal risk for suicidal behavior include alcohol’s ability 

to (1) increase psychological distress, (2) increase aggressiveness, (3) propel suicidal ideation into action 

through suicide-specific alcohol expectancies (e.g., alcohol may supply the motivation to complete the 

action, the user may believe that alcohol will assist in completing suicide painlessly), and (4) constrict 

cognition, which impairs the generation and implementation of alternative coping strategies (Hufford, 2001).

Programs that Address the Substance Use/Suicide 

Nexus 

SAMHSA’s National Registry for Evidence-based Programs and Practices (NREPP) and the Suicide 

Prevention Resource Center’s (SPRC’s) Best Practices Registry include evidence-based programs that 

focus on substance misuse and suicide prevention in different settings (see Resources). The text box

below summarizes three programs that specifically target adolescents and their caregivers. 

Many of these programs contain replicable elements—e.g., life skills training—that support effective 

problem-solving and emotional regulation, the nurturing of positive connections with friends and family 

members, and strong ties to both school and community. Taken together, these social supports can protect 

individuals from both substance use and suicide. Other programs provide treatment and recovery support 

and help guide the individual toward recovery from SUDs and from preoccupations with suicidal 

thoughts. 

A Sampling of Evidence-Based Programs for Adolescents and 

Their Caregivers 

Model Adolescent Suicide Prevention Program (MASPP) uses a public health-oriented suicidal-behavior 

prevention and intervention program originally developed for a Native American tribe in New Mexico. The 

goals of the program are to reduce the incidence of suicides and suicide attempts by adolescents through 

community education about suicide and related behavioral issues that include alcohol and substance misuse.

Emergency Department Means Restriction Education is an intervention for adult caregivers of young adults 

or adolescents who are seen in the emergency department and determined through a mental health assessment to 

be at-risk for suicide. Parents and adult caregivers of these at-risk youth are taught to recognize the importance 

of taking immediate action to restrict access to alcohol, prescription drugs, and firearms in the home. Caregivers 

are given practical advice on how to restrict access to—or dispose of—alcohol and prescription drugs. 

Coping and Support Training (CAST) is a school-based small group counseling program for at-risk youth that 

has demonstrated decreased suicide risk factors in adolescents. The program, offered through 12 55-minute 

sessions, can be delivered by trained teachers, counselors, social workers, or others with similar experience. The 

program is available from Reconnecting Youth, Inc., for a fee.
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Substance Use and Suicide: A Nexus Requiring a Public Health Approach

2016

5 

Traditional Barriers to Collaboration among State 

and Tribal Agencies 

Organizational Barriers 

Prevention professionals who work on substance use and suicide issues are usually housed in different 

state agencies or tribal organizations according to their “specialty.” Within states, substance misuse

prevention specialists typically reside in the Single State Authority for substance misuse or behavioral 

health, whereas suicide prevention specialists are based within mental health, injury, or violence 

prevention offices, which may be located within larger public health, mental health, or public safety 

agencies. Other suicide prevention specialists may be based in combined behavioral health (i.e., mental 

health and substance misuse) agencies. Organizational barriers to collaborating may exist due to each 

agency’s unique and distinct mission and the structures in place for addressing its mission. Using an 

interagency approach to develop a comprehensive suicide prevention strategy, state and tribal 

governments can bridge organizational barriers, build connections among agencies, and facilitate 

collaboration. 

Funding Barriers 

Funding mechanisms are another potential barrier to collaboration. Federal funding, which includes Block 

Grants for both mental health and substance misuse and Partnerships for Success grants for substance 

misuse prevention (among others), is typically disbursed to a specific state agency or tribal government, 

which then provides sub-grants to community agencies or organizations, institutions of higher education, 

or tribal organizations. These funding streams may reinforce each agency’s unique way of operating and 

fulfilling its mission. Formation of suicide prevention councils, coalitions, or work groups that bring 

together stakeholders across agencies and organizations can help to coordinate funding from different 

sources and promote collaboration to tackle suicide prevention activities. Such collaboration is likely 

crucial for effective, sustained, and comprehensive efforts.

Philosophical Differences 

In the span of several decades, there has been a growing realization that substance misuse and suicide are 

both public health issues requiring comprehensive, population-based strategies. Such a public health 

approach includes prevention programs as well as clinical treatment for individuals who present with 

behavioral health issues. In Native American communities, suicide and substance misuse prevention 

strategies must also reflect cultural traditions and traditional views of health (HHS, 2010; IHS, 2007). 

Professionals working in the behavioral health field are moving away from a focus primarily on the 

individual (and individual factors) toward implementation of prevention and health promotion strategies 

for the whole community. Previously, substance misuse preventionists thought of suicide as a mental 

health issue that was best addressed through clinical interventions, especially for depression. Those 

working in the substance misuse field left suicide prevention mainly to mental health professionals. At the

same time, mental health professionals were not always trained to work with suicidal persons who had cooccurring mental and substance use problems. However, as research began to show the multiple social 

and environmental factors affecting suicide risk, it became apparent that population-based strategies 

aimed at reducing risk and increasing protective factors were critical. Additionally, risk and protective 

factors for both issues were found to overlap, and a risk factor for suicidal behavior included substance 

use and misuse. Working collaboratively across the mental health and substance misuse fields is therefore 

key to reducing suicide rates. 
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6 

IN BRIEF

Lack of Information 

Reluctance to work collaboratively across agencies, departments, organizations, and professions may also 

be due to lack of information about the link between substance use and suicidal behavior. Studies show 

that strategies to reduce alcohol use among young people ages 18 to 23—for example, minimum legal 

drinking age laws—affect suicide rates (Grucza et al., 2012; Birckmayer & Hemenway, 1999). One study 

concluded that the minimum legal drinking age of 21 may be preventing as many as 600 suicides annually 

in the U.S. (Grucza et al., 2012). Prevention professionals1

 should be informed about the connections 

between suicide and substance use--particularly underage alcohol use, binge drinking, and adult alcohol 

misuse-- and be encouraged to work together on prevention strategies. 

Working across state and tribal agencies, departments, and service providers may be challenging. Yet the 

rewards gained by substance misuse, mental health, and injury/violence prevention professionals 

combining their subject matter expertise far outweigh systemic challenges. The sections that follow 

provide recommendations to both state and tribal policymakers and prevention specialists for addressing 

the nexus between substance use and suicide, and thereby improving public health. SAMHSA’s Suicide 

Prevention Resource Center (SPRC) has developed a Collaboration Continuum to help states, tribes, 

campuses, and communities identify where they are on the continuum and find ways to strengthen their 

collaboration efforts (see below). 

 

1 Prevention professionals include clinicians, counselors, public health officials, and others who provide services 

aimed at preventing or reducing problems caused by alcohol, tobacco, and other drug use and abuse.

Contemplating

At this stage, 

agencies are 

thinking about 

collaborating. They 

have potential 

partners in mind, 

but have not 

approached them.

Cooperating

At this stage, 

agencies have 

decided 

partnering makes 

sense. They are 

engaging partners, 

but have no 

formal 

agreements.

Coordinating

At this stage, the 

partnership is 

growing stronger, 

and agencies are 

modifying their 

activities for 

mutual benefit. 

They are engaged 

in projects, 

initiatives, and 

work together.

Collaborating

At this stage, the 

partnership has 

formal 

agreements. 

Agencies are 

working together 

toward 

developing 

enhanced 

capacity to 

achieve a shared 

vision.
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Substance Use and Suicide: A Nexus Requiring a Public Health Approach

2016

7 

The Role of State and Tribal Policy Makers 

Why State and Tribal Officials Should Focus on the Substance 

Misuse/Suicide Nexus 

As discussed, the prevalence rates of suicide are greatly affected by substance use. These issues are not 

isolated to a single demographic; they affect everyone. State and tribal prevention professionals have the 

unique advantage of being in a position to promote a public health approach, supporting preventive 

interventions across the entire continuum from prevention to treatment to recovery supports. Focusing on 

alcohol consumption, population-based studies have begun to show that alcohol prevention is suicide 

prevention. For example, a study in Ontario, Canada, revealed that as alcohol consumption in a 

population rises, the suicide rate also rises by between 11 and 39 percent, suggesting that a population’s 

level of alcohol use may be correlated with the suicide rate (Mann et al., 2006). In the United States, the 

density of both on- and off-premise alcohol outlets in a county is associated positively with alcoholrelated suicide, especially among American Indians/Alaska Natives (Giesbrecht et al., 2014). Other 

studies have found that limiting alcohol availability may also reduce suicide mortality in a population 

(Pridemore & Snowden, 2009; Varnik et al., 2006; Markowitz, Chatterji, & Kaestner, 2003). For the 

research community, this underscores the importance of incorporating suicide-related outcomes into 

substance use prevention studies.

Actions for State and Tribal Policy Makers 

The suicide and substance misuse prevention fields need to align their efforts to promote healthy 

individuals and communities. The causes of suicide and substance misuse are complex, and coordination 

and collaboration among state and tribal policy makers are essential to identifying and implementing 

strategies to reduce the risks of suicidal behavior resulting from alcohol and other drug misuse. The 

public health approach to preventing suicide and substance misuse includes universal, selective, and 

indicated strategies. People who misuse substances and people who die by suicide share multiple risk 

factors and multiple protective factors. Thus, a multi-faceted, population-based approach should be 

adopted (SAMHSA, 2008; Caine, 2004; Knox et al., 2004; Goldston, 2004). State and tribal governments 

should follow a strategic planning process to develop a comprehensive suicide prevention strategy. What 

follows are some suggestions that state and tribal policymakers may implement to further promote this 

public health approach. 

Determine the extent of the problem. Estimating the incidence of substance misuse and suicidal 

behaviors within the state is a precursor to developing a strategy to reduce suicides linked to substance 

use. Data available from SAMHSA and CDC provide a starting place for analyzing the extent of the 

problem (see Resources). State epidemiological work groups may also have data to inform a prevention 

strategy. Further, review of the available data may reveal data gaps or inadequacies in the state’s or tribe’s 

surveillance systems and point to areas for improvement.
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IN BRIEF

Identify substance misuse and suicide prevention efforts already occurring within the state or tribe. 

An environmental scan for existing substance misuse and suicide prevention programs is the next step in 

developing a strategic plan to address the intersection between substance misuse and suicide. An 

environmental scan should include assessing programs in clinical and community settings, including 

hospitals, primary care clinics, behavioral health settings, crisis intervention programs, the criminal and 

juvenile justice systems, schools, college campuses, community-based organizations, workplaces, and 

faith-based organizations. The leaders for suicide and substance misuse prevention in states and tribes, 

working with other stakeholders, should oversee the task of conducting the environmental scan and 

developing a coordinated strategic plan. The leader for suicide prevention will often be the state’s 

designated lead(s) or contact person(s) for overseeing the state’s suicide prevention plan. These 

individuals may be designated by a state agency or governor’s office as the state suicide prevention 

coordinator, may be in an agency responsible for mental health or injury prevention, or may be associated 

with a state or community coalition or non-profit organization. In tribal communities, suicide prevention 

may be led by individuals in the tribal health department, the local Indian Health Service, or other 

agencies or organizations connected to suicide prevention efforts for the tribe, in partnership with 

traditional healers. Every state, U.S. territory, and the District of Columbia also has a National Prevention 

Network representative who administers substance misuse prevention initiatives.

Begin the dialogue with one another. Multi-disciplinary collaboration is a key attribute of public health. 

Therefore, a dialogue that emphasizes a public health approach and that engages all facets of the state, 

tribe, and community—the general public, elected officials, schools, parents, first responders, religious 

communities, health professionals, media, researchers, clinicians, counselors, and consumers (including 

suicide attempt survivors and loss survivors) and 

their families—should be launched and maintained. 

State agencies and tribal organizations may wish 

either to create a work group to explore the current 

needs of communities and identify existing service 

gaps or work with an existing state or tribal work 

group, council, or coalition on this issue. The group 

might be charged with creating an action plan for 

integrating suicide and substance misuse prevention

strategies. 

Translate the need for substance misuse/suicide 

prevention integration into distinct prevention funding initiatives. States and tribes provide funding to 

a wide range of community partners, including schools, workplaces, community-based organizations, 

tribal councils, and faith-based organizations for prevention programming and services. These partners 

collectively form a natural constituency for integrated funding initiatives. State and tribal policymakers 

can use the federal Garrett Lee Smith Memorial Act grants or the Partnerships for Success grants as 

models for partnership development and collaboration: the Garrett Lee Smith grants are designed to build 

infrastructure and enhance suicide prevention services within states, tribes, and on college campuses 

(among other objectives); Partnership for Success grants support diverse stakeholders to combine their 

efforts in reducing substance misuse. Additionally, the Substance Abuse Prevention and Treatment Block 

Grant and the Community Mental Health Services Block Grant provide funding for comprehensive 

prevention services. New funding streams might be created with these monies to leverage the resources 

and expertise of substance misuse, mental health, and injury prevention offices, and that target at-risk 

populations. 
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Substance Use and Suicide: A Nexus Requiring a Public Health Approach

2016

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Develop, disseminate, and implement policies supporting prevention of substance misuse and 

suicide. State and tribal policy development and implementation provide multiple opportunities for 

suicide and substance misuse prevention. For example, all states and some Native American/Alaska 

Native tribes and villages already have suicide and substance misuse prevention plans. These plans 

identify strategies to coordinate prevention activities across the state/tribe and to link substance misuse

and suicide prevention efforts. State agencies may want to encourage or require local entities (e.g., 

counties) to develop their own prevention plans to advance state goals and objectives. 

Another area of policy development is screening and assessment. States and tribal authorities can further 

their prevention goals by developing and promoting professional guidelines for assessing substance use 

disorders and suicide risk within primary care settings, emergency departments, specialty mental health 

and substance use disorder treatment centers, schools and institutions of higher education, and other 

settings. They may also decide to promote universal screening in some settings and select common 

screening and assessment tools.

States/tribes might also develop and require provider organizations to adopt policies on how to intervene 

with individuals found to have a substance use disorder or a risk for suicide. Additionally, policies might 

require all staff working in substance misuse and mental health programs to receive training on assessing 

substance use and suicide risk. A recent example is legislation passed in Washington State that requires 

mental health professionals to receive training in suicide assessment, treatment, and management (Wash. 

HB2315, 2014). Similar legislation was recently passed in Kentucky that includes alcohol and drug 

counselors, social workers, and psychologists (among others) (Ky. SB72, 2013). States may also wish to 

work with professional certification and licensing agencies to require competencies in assessing substance 

misuse, as well as continuing education on suicide prevention. 

Finally, some states and tribal governments may want to consider creating an office of suicide prevention 

within an agency that coordinates substance misuse and suicide prevention activities. As an example, 

Nevada has established an office within the Department of Health and Human Services’ Division of 

Public and Behavioral Health. 

Program development. Once information has been gathered about the prevalence of suicidal behaviors 

linked to substance use and available programs addressing these issues have been identified, states and

tribes should select and implement evidence-based programs that meet the specific cultural, community, 

and developmental norms of the targeted population. Programs selected or developed should fit the state’s 

or tribal community’s strategic plan. Community interventions must be able to deliver and, to some 

extent, integrate primary prevention, assessment, diagnostic, and treatment services (SAMHSA, 2008; 

SAMHSA, 2009). Screenings, brief interventions, and referrals to treatment (or other support services) 

should be components of these programs. The online registries offered by SAMHSA (NREPP, which 

includes evidence-based practices in behavioral health) and SPRC (Best Practices Registry, which 

includes best and evidence-based practices in suicide prevention) may be consulted for specific programs 

(see Resources on page 13).

Workforce development. The nexus between substance misuse and suicide must be emphasized in the 

training, including cross-training, of professionals who work in the mental health, injury prevention, and 

substance misuse prevention fields. While more treatment development is needed, evidence-based 

psychotherapies for individuals being treated after a suicide attempt (many of whom have substance use 

problems) have successfully prevented re-attempts (e.g., Brown et al., 2005), and have enhanced their 

engagement in both mental health and substance use disorder treatment (e.g., Stanley et al., 2015). As 
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10 

IN BRIEF

substance misuse interventions continue to improve and are better integrated in various care settings, 

training can be in the form of pre-service orientations, in-service development, materials development, as 

well as online and/or continuing education courses. 

What Should Prevention Professionals Do?

Be Aware of Shared Risk and Protective Factors 

Alcohol and drug misuse are second only to depression and other mood disorders as the most frequent 

risk factors for suicidal behavior (SAMHSA, 2008; IOM, 2002). Practitioners must be aware that

individuals who make a suicide attempt are at considerable risk for repeat attempts and eventual suicide 

and that this risk may last many years (Knesper, AAS, & SPRC, 2010). People at risk for suicide and 

substance misuse share a number of risk factors that include depression, impulsivity, and thrillseeking/life threatening behaviors (Goldston, 2004). Because risk and protective factors for the two can

overlap, prevention professionals need to be aware of them and to implement prevention programming 

that reduces risk and enhances protective factors within the population and in communities. 

Shared Risk Factors Shared Protective Factors

• Academic failure

• Aggressive tendencies or history of violent behavior

• Bullying, victimization

• Family conflict

• History of trauma or abuse 

• Hopelessness, impulsivity, low self-esteem

• Mental illness and/or substance use disorder

• Peer rejection

• Physical illness or chronic pain

• Previous suicide attempt(s)

• Relational, social, work, or financial losses

• Social withdrawal

• A trusting relationship with a counselor, physician, 

or other service provider

• An optimistic or positive outlook

• Childrearing responsibilities

• Coping and problem-solving skills

• Cultural and religious beliefs that discourage suicide

• Employment

• Involvement in community activities

• Perceiving that there are clear reasons to live

• Receiving effective mental and/or substance use 

disorder treatment/care 

• Resiliency, self-esteem, direction, perseverance

• Sobriety 

• Strong family bonds and social skills

Be Aware of Warning Signs 

Prevention professionals should be aware of and educate others about the warning signs for alcohol 

misuse or drug use, as well as suicidal behaviors. These signs may mean someone is at risk for suicide; 

the risk is greater if a behavior is new or has increased, and if it seems related to a painful event, loss, or 

change. For more information about these warning signs, 

refer to SAMHSA’s National Suicide Prevention Lifeline 

Wallet Card and “Signs and Symptoms” on the National 

Council on Alcoholism and Drug Dependence (NCADD) 

website.
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Substance Use and Suicide: A Nexus Requiring a Public Health Approach

2016

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Warning Signs of Substance Misuse

• Has smell of alcohol on breath or marijuana on

clothing

• Has burned fingers, burns on lips, or needle track

marks on arms

• Slurs speech or stutters, is incoherent

• Has difficulty maintaining eye contact

• Has dilated (enlarged) or constricted (pinpoint)

pupils

• Has tremors (shaking or twitching of hands and

eyelids)

• Is hyperactive and overly energetic

• Appears lethargic or falls asleep easily

• Exhibits impaired coordination or unsteady gait

(e.g., staggering, off balance)

• Speaks very rapidly or very slowly

• Experiences wide mood swings (highs and lows)

• Appears fearful or anxious; experiences panic

attacks

• Appears impatient, agitated, or irritable

• Is increasingly angry or defiant

• Talks about getting high, uses vocabulary typical

among drug users

• Behaves in an impulsive or inappropriate manner

• Denies, lies, or covers up

• Takes unnecessary risks or acts in a reckless manner

• Breaks or bends rules, cheats

• Misses interviews, appointments, or meetings or

arrives intoxicated

• Fails to comply with program requirements without

easily verifiable reasons (may be verbally

uncooperative to disguise the problem or divert

attention)

• Has difficulty concentrating, focusing, or attending

to a task

• Appears distracted or disoriented

• Makes inappropriate or unreasonable choices

• Has difficulty making decisions

• Experiences short-term memory loss

• Experiences blackout

• Needs directions repeated frequently

• Has difficulty recalling known details

• Needs repeated assistance completing ordinary

paperwork (e.g., application forms)

Warning Signs of Suicide

• Talking about wanting to die or to kill oneself

• Looking for a way to kill oneself, such as searching

online or buying a gun

• Talking about feeling hopeless or having no reason

to live

• Talking about feeling trapped or in unbearable pain

• Talking about being a burden to others

• Increasing the use of alcohol or drugs

• Acting anxious or agitated; behaving recklessly

• Sleeping too little or too much

• Withdrawing or feeling isolated

• Showing rage or talking about seeking revenge

• Displaying extreme mood swings

• Losing interest in things, or losing the ability to

experience pleasure

Actions for Prevention Professionals 

Substance misuse prevention and suicide prevention professionals each utilize a public health approach 

and, in so doing, have shared responsibilities and opportunities. Both should be informed about the many 

risks that affect the individuals and communities they work with. Both should also learn about suicide and 

substance use disorders and how misusing substances can affect suicidal thoughts and behaviors. Both

should identify opportunities to collaborate with the other to address their common goals, keeping in 

mind that substance misuse prevention is suicide prevention. The graphic on the next page summarizes 

what suicide and substance misuse prevention professionals can do to improve outcomes for individuals 

and communities. 
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12 

IN BRIEF

WHAT SHOULD SUBSTANCE MISUSE

PREVENTION PROFESSIONALS DO?

WHAT SHOULD SUICIDE PREVENTION 

PROFESSIONALS DO?

• Learn who is responsible for suicide 

prevention in your state or tribal 

organization 

Learn • Learn who is responsible for substance 

misuse prevention in your state or tribal 

organization 

• Become familiar with suicide 

prevention plans, strategies, and 

programs

Familiarize • Become familiar with substance misuse

prevention plans, strategies, and 

programs

• Identify public health goals that you 

have in common with agencies, 

organizations, and/or coalitions 

leading suicide prevention efforts

Identify • Identify public health goals that you 

have in common with agencies, 

organizations, and/or coalitions leading 

substance misuse prevention efforts

• Leverage each other’s strengths 

and ask to partner with suicide 

prevention agencies and coalitions

Leverage & Collaborate • Leverage each other’s strengths and ask 

to partner with substance misuse 

prevention agencies and coalitions

• Plan and implement cross-training 

on the link between substance 

misuse and suicidality and the risk 

factors and warning signs for 

substance misuse

Plan & Implement • Plan and implement cross-training on 

the link between suicidality and 

substance misuse, the different types of 

suicidal thoughts and behaviors, and the 

risk factors and warning signs for suicide

• Use process and outcome data to 

evaluate and make the case that 

prevention works—use data to 

show that reducing substance 

misuse lowers suicidal behavior and 

suicide attempts

Evaluate • Use process and outcome data from 

your substance misuse prevention 

colleagues to evaluate and make the 

case that substance misuse prevention 

is suicide prevention—suicide 

prevention programs that address 

substance misuse help to lower suicide 

rates

Collaboration among diverse stakeholders is necessary to meet the challenge of reducing suicidal 

behaviors. An example of one state’s comprehensive approach to suicide prevention is highlighted in the 

box below. 

Case Study: Massachusetts’ Comprehensive Approach

In Massachusetts, a strategic plan for suicide prevention was developed that received input from the 

departments of public health, violence/injury prevention, mental health, and substance misuse prevention. 

Recognizing that there may be poor linkages at the state and community levels among mental health, 

substance use and misuse, and community health services, the plan envisions a system in which 

individuals experiencing mental illness, SUDs, or feelings of suicide feel comfortable seeking help and 

have access to appropriate services in their communities.

The state’s suicide prevention strategic plan does not assume that a specific agency or organization has 

overall responsibility or capacity to address all of the plan’s goals. Rather, the plan creates opportunities 

for many individuals, organizations, and communities to make meaningful contributions toward 

achieving the plan’s goals (Commonwealth of Massachusetts, 2009).
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In summary, behavioral health leaders are encouraged to build and strengthen connections with their 

respective counterparts in suicide prevention, substance misuse prevention, and substance use disorder 

treatment. Through close coordination and collaboration, the nation will be able to advance a 

comprehensive public health strategy to reduce suicidal behaviors and suicide rates.
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IN BRIEF

Resources 

Data 

CDC’s National Electronic Injury Surveillance System—All Injury Program (NEISS-AIP) 

www.cdc.gov/injury/wisqars/index.html. 

CDC’s National Violent Death Reporting System (NVDRS) 

www.cdc.gov/violenceprevention/nvdrs/index.html. 

CDC’s Web-based Injury Statistics Query and Reporting System (WIQARS)—Fatal Injury Data 

http://www.cdc.gov/injury/wisqars/fatal.html. 

Department of Defense Suicide Event Report (DoDSER) 

www.t2.health.mil/programs/dodser. 

SAMHSA’s Behavioral Health Barometer, United States, 2014; SAMHSA’s Behavioral Health 

Barometer, United States, 2014, State Reports; both accessed at

http://store.samhsa.gov/product/Behavioral-Health-Barometer-2014/SMA15-4895 

http://archive.samhsa.gov/data/States_In_Brief_Reports.aspx.

Publications and Materials, Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment. 

Treatment Improvement Protocol (TIP) 50. SAMHSA, SMA 09-4381, 2009. Available at 

www.store.samhsa.gov. 

National Strategy for Suicide Prevention: Goals and Objectives for Action, U.S. Department of Health 

and Human Services, Office of the Surgeon General. Available at 

http://www.surgeongeneral.gov/library/reports/national-strategy-suicide-prevention/. 

Preventing Suicide: A Toolkit for High Schools. SAMHSA, SMA 12-4669, June 2012. Available at 

www.store.samhsa.gov. 

Promoting Emotional Health and Preventing Suicide: A Toolkit for Senior Living Communities. 

SAMHSA, SMA 10-4515, June 2010. Available at www.store.samhsa.gov. 

Suicide: Facts at a Glance. Centers for Disease Control and Prevention, 2012. Available at 

www.cdc.gov/violenceprevention/pdf/suicide_datasheet_2012-a.pdf.

Websites 

Website of the National Action Alliance for Suicide Prevention (a public/private partnership established 

in 2010 to advance the National Strategy for Suicide Prevention).

http://ActionAllianceForSuicidePrevention.org . 

SAMHSA’s National Registry for Evidence-Based Programs and Practices 

www.nrepp.samhsa.gov.

StopBullying.gov 

www.stopbullying.gov/. 

Suicide Prevention Resource Center Best Practices Registry

www.sprc.org/bpr. 
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Suicide Prevention Resource Center Substance Abuse and Suicide Prevention Collaboration Continuum 

http://www.sprc.org/states/collaborationcontinuum. 

Webinars 

Understanding the Connection Between Suicide and Substance Abuse: What the Research Tells Us 

http://captus.samhsa.gov/archived-webinar/understanding-connection-between-suicide-and-substanceabuse-what-research-tells-us. 

Understanding the Connection Between Suicide and Substance Abuse http://captus.samhsa.gov/archivedwebinar/understanding-connection-between-suicide-and-substance-abuse-what-research-tells-us. 

Suicide Prevention Hotlines 

National Suicide Prevention Lifeline

1-800-273-TALK (8255) 

www.SuicidePreventionLifeline.org.

Veterans Crisis Line

1-800-273-TALK (8255) PRESS 1

www.veteranscrisisline.net/ChatTermsOfService.aspx?account=Veterans%20Chat. 

Treatment Locators 

Behavioral Health Treatment Services Locator

http://findtreatment.samhsa.gov.
Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Effective • People Recover

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IN BRIEF

References 

An Act Concerning Suicide Prevention. Wash. HB2315, Chapter 71 (Wash. Stat. 2014). 

http://apps.leg.wa.gov/billinfo/summary.aspx?bill=2315&year=2013#history. 

An Act Related to Suicide Prevention Training. Ky. SB72, Chapter 210 (Ky. Stat. 2013). 

http://www.lrc.ky.gov/record/13rs/SB72.htm.

Birckmayer, J. & Hemenway, D. (1999). Minimum-age drinking laws and youth suicide, 1970–1990. 

American Journal of Public Health, 89(9): 1365–1368. 

Brown, G.K. et al. (2005). Cognitive therapy for the prevention of suicide attempts: a randomized trial. 

JAMA, 294(5): 563-570. 

Caine, E.D. (2004, February). Population-based approaches to suicide prevention in later life. 

Presentation at the annual meeting of the American Association of Geriatric Psychiatry, Baltimore, 

MD. 

Centers for Disease Control and Prevention. (2015). Web-Based Injury Statistics Query and Reporting 

System (WISQARS). Retrieved from http://www.cdc.gov/injury/wisqars/index.html. 

Centers for Disease Control and Prevention. (2015a). 2013 Mortality Multiple Cause Micro-data Files. 

National Vital Statistics Reports. Retrieved from 

http://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_02.pdf. 

Centers for Disease Control and Prevention. (2014b). Surveillance for Violent Deaths—National Violent 

Death Reporting System, 16 States, 2010. MMWR, 63(1). Retrieved from 

http://www.cdc.gov/mmwr/pdf/ss/ss6301.pdf. 

Chang, B., Gitlin, D., & Patel, R. (2011). The depressed patient and suicidal patient in the emergency 

department: Evidence-based management and treatment strategies. Emergency Medicine Practice,

13(9), 1–23. http://www.ncbi.nlm.nih.gov/pubmed/22164363. 

Cherpitel, C.J., Borges, G.L., & Wilcox, H.C. (2004). Acute alcohol use and suicidal behavior: A review 

of the literature. Alcoholism, Clinical and Experimental Research, 28, 18S–28S. 

http://www.ncbi.nlm.nih.gov/pubmed/15166633. 

Commonwealth of Massachusetts. (2009). Massachusetts Strategic Plan for Suicide Prevention Executive 

Summary. Retrieved from http://www.mass.gov/eohhs/docs/dph/com-health/injury/suicide-strategicplan-summary.doc. 

Giesbrecht, N., Huguet, N., Ogden, L., Kaplan, M. S., McFarland, B. H., Caetano, R., Conner, K. R. 

and Nolte, K. B. (2015), Acute alcohol use among suicide decedents in 14 US states: impacts of 

off-premise and on-premise alcohol outlet density. Addiction 110(2):300–7.

Goldston, D.B. (2004). Conceptual issues in understanding the relationship between suicidal behavior and 

substance use during adolescence. Drug and Alcohol Dependence, 76: S79–91. 

http://www.sciencedirect.com/science/article/pii/S0376871604002182. 
Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Effective • People Recover

Substance Use and Suicide: A Nexus Requiring a Public Health Approach

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17 

Grucza, R.A., Hipp, P.R., Norberg, K.E., Rundell, L., Evanoff, A., Cavazos-Rehg, P., & Bierut, L.J. 

(2012). Alcoholism: Clinical and Experimental Research, 36(2): 377–384. 

http://onlinelibrary.wiley.com/doi/10.1111/j.1530-0277.2011.01608.x/abstract. 

Heron, M. (2013). Deaths: Leading Causes for 2010. National Vital Statistics Reports, 62(6). Hyattsville, 

MD: National Center for Health Statistics. Retrieved from 

http://www.cdc.gov/nchs/data/nvsr/nvsr62/nvsr62_06.pdf.

Hufford, M.R. (2001). Alcohol and suicidal behavior. Clinical Psychology Review, 21(5): 797–811. 

http://www.ncbi.nlm.nih.gov/pubmed/11434231. 

Indian Health Service. (2007). Restoring Balance: Community Owned Wellness. Retrieved from 

http://www.sprc.org/sites/sprc.org/files/library/RestoringBalance.pdf.

Institute of Medicine. (2002). Reducing Suicide: A National Imperative. Washington, DC: National 

Academy Press.

Knesper, DJ, American Association of Suicidology, & Suicide Prevention Resource Center. (2010). 

Continuity of care for suicide prevention and research: Suicide attempts and suicide deaths 

subsequent to discharge from the emergency department or psychiatry inpatient unit. Retrieved from 

http://www.sprc.org/sites/sprc.org/files/library/continuityofcare.pdf. 

Knox, K.L., Conwell, Y., & Caine, E.D. (2004). If suicide is a public health problem, what are we doing 

to prevent it? American Journal of Public Health, 94(1): 37–45. 

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1449822/pdf/0940037.pdf.

Mann, R.E., Zalcman, R.F., Smart, R.G., Rush, B.R., & Suurvali, H. (2006). Alcohol consumption, 

Alcoholics Anonymous membership, and suicide mortality rates, Ontario, 1968-1991. Journal of 

Studies on Alcohol, 67(3): 445–453. 

Markowitz, S., Chatterji, P., & Kaestner, R. (2003). Estimating the impact of alcohol policies on youth 

suicides. The Journal of Mental Health Policy and Economics, 6: 37–46. 

http://www.icmpe.org/test1/docs/6-037_text.pdf.

Pompili, M., Serafini, G., Innamorati, M., Dominici, G., Ferracuti, S., Kotzalidis, G.D., & Lester, D. 

(2010). Suicidal behavior and alcohol abuse. International Journal of Environmental Research and 

Public Health, 7(4): 1392–1431. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2872355/pdf/ijerph07-01392.pdf. 

Pridemore, W.A., & Snowden, A.J. (2009). Reduction in suicide mortality following a new national 

alcohol policy in Slovenia: An interrupted time-series analysis. Journal of American Public Health, 

(99)5: 915–920. http://www.ncbi.nlm.nih.gov/pubmed/19299669. 

Stanley, B. (2015). Brief intervention and follow-up for suicidal patients with repeat emergency 

department visits enhances treatment engagement. American Journal of Public Health. 105(8): 1570-

1572. 

Substance Abuse and Mental Health Services Administration. (2008). Substance Abuse and Suicide 

Prevention: Evidence and Implications—A White Paper. (DHHS Publication No. SMA-08-4352). 

Rockville, MD: SAMHSA.
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IN BRIEF

Substance Abuse and Mental Health Services Administration. (2009). Addressing Suicidal Thoughts and 

Behaviors in Substance Abuse Treatment. Treatment Improvement Protocol (TIP) Series 50. (DHHS 

Publication No. (SMA) 09-4381). Rockville, MD: SAMHSA. 

Substance Abuse and Mental Health Services Administration. (2014). The DAWN Report: Emergency 

Department Visits for Drug-Related Suicide Attempts among Middle-Aged Adults Aged 45 to 64. 

Rockville, MD. Retrieved from http://www.samhsa.gov/data/sites/default/files/DAWN-SR154-

SuicideAttempts2014/DAWN-SR154-SuicideAttempts2014.htm. 

Substance Abuse and Mental Health Services Administration. (2015). NSDUH Data Review. Suicidal 

Thoughts and Behavior among Adults: Results from the 2014 National Survey on Drug Use and 

Health. Rockville, MD. Retrieved from http://www.samhsa.gov/data/sites/default/files/NSDUHFRR2-2014/NSDUH-DR-FRR2-2014.htm 

Substance Abuse and Mental Health Services Administration. (2015). Behavioral Health Trends in the 

United States: Results from the 2014 National Survey on Drug Use and Health. Rockville, MD. 

Retrieved from. http://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-

2014.htm#idtextanchor005 

U.S. Department of Health and Human Services Office of the Surgeon General and National Action 

Alliance for Suicide Prevention. (2012). 2012 National Strategy for Suicide Prevention: Goals and 

Objectives for Action. Washington, DC: HHS. Retrieved from 

http://www.surgeongeneral.gov/library/reports/national-strategy-suicide-prevention/full-report.pdf.

U.S. Department of Health and Human Services. (2010). To live to see the great day that dawns: 

Preventing suicide by American Indian and Alaska Native youth and young adults (DHHS 

Publication SMA (10)-4480, CMHS-NSPL-0196). Rockville, MD: Center for Mental Health 

Services, Substance Abuse and Mental Health Services Administration. Retrieved from 

http://www.sprc.org/sites/sprc.org/files/library/Suicide_Prevention_Guide.pdf. 

Värnik, A., Kõlves, K., Väli , M., Tooding, L.M., & Wasserman, D. (2006). Do alcohol restrictions 

reduce suicide mortality? Addiction, 102(2): 251–256. 

http://www.ncbi.nlm.nih.gov/pubmed/17222279. 

Wilcox, H.C., Conner, K.R., & Caine, E.D. (2004). Association of alcohol and drug use disorders and 

completed suicide: An empirical review of cohort studies. Drug and Alcohol Dependence, 76: S11–

S19. http://www.ncbi.nlm.nih.gov/pubmed/15555812.

In Brief

Acknowledgements

This In Brief was prepared for the Substance Abuse and Mental Health Services Administration 

(SAMHSA) by Abt Associates under contract number HHSS283200700008I/HHSS2834200IT with 

SAMHSA, U.S. Department of Health and Human Services (HHS). David Lamont Wilson served as 

the Government Project Officer.

Disclaimer

The views, opinions, and content of this publication are those of the author and do not necessarily 

reflect the views, opinions, or policies of SAMHSA or HHS.
Substance Use and Suicide: A Nexus Requiring a Public Health Approach

2016

Public Domain Notice

All material appearing in this document is in the public domain and may be reproduced or copied 

without permission from SAMHSA or the authors. Citation of the source is appreciated. The 

publication may not be reproduced or distributed for a fee without the specific, written authorization 

of the Office of Communications, SAMHSA, HHS. 

Recommended Citation

Substance Abuse and Mental Health Services Administration. (2015). Substance Use and Suicide: 

A Nexus Requiring a Public Health Approach. In Brief. 

Originating Office

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In Brief

Substance Use and Suicide: A Nexus Requiring 

A Public Health Approach 

HHS Publication No. SMA-16-4935 

Printed 2016