US jails, like the communities they serve, are in the throes of a drug addiction epidemic; specifically a rise in opiate addiction. Predictably, death rates are on the rise. However, it is not just accidental overdoses that are behind the steep increase in deaths attributed to such drugs as heroin. In jails, the increased mortality among this population is occurring as a result of suicide.
Although jails have shown a greater understanding that drug withdrawal, such as from alcohol or benzodiazepines, can be dangerous and even life-threatening, the risks from withdrawal off of opiates are often downplayed. There is the commonly held misperception that heroin withdrawal, although physically miserable in the short-term, is not life-threatening. Certainly, the physical symptoms of opiate withdrawal generally won’t cause death; however, the suicidal thoughts and consequent behaviors very well might. Along with the physical symptoms, feelings of hopelessness and depression can manifest quickly. A heroin user can feel he or she has no way out. Gripped by an overwhelming and constant flood of negative emotions, excruciating physical suffering, and mental clarity, he or she may see suicide as the only option for relief.
“I was so sick (from heroin withdrawal) …sick of living like this …I felt depressed and hopeless. I wanted it to all stop.” ~Anonymous
Studies are fairly consistent in showing that heroin users, for example, have a 14 times higher risk of suicide than the non-drug using public. They also show that as many as 35% of heroin user deaths are a result of suicide.
The early stages of opiate withdrawal often include powerful cravings, anxiety, depression, irritability, sleeplessness, restlessness, physical discomfort/pain, feelings of desperation, and suicidal thoughts. To be clear, self-destructive thoughts are not unique to opiate withdrawal and has been found in relation to other substances, such as alcohol and benzodiazepines.
In order to better serve our population of patients, we recommend the use of a suicide screening tool created by the National Institute for Mental Health (NIMH): ASQ (Ask Suicide-Screening Questions).
This single-paged screening is to be used by custody and nursing staff to assist in determining when immediate referrals to the physician and/or mental health professionals are necessary, as well as when suicide watch protocols should be initiated.
This screening tool is not a mental health assessment or evaluation and is intended to help the lay person identify those people who may not be obviously suicidal. ASQ has easy to follow recommendations outlining how to handle patients with increased risk of self-harm.
The ASQ tool should routinely be used by custody or nursing staff when a person is booked into the facility and states he or she has a history of suicide, when the person states they have a history of substance abuse, and at least once daily for each day (7 days minimally) a patient is on a withdrawal protocol of any kind (opiate, alcohol, benzodiazepine). The repeated inquiry enables staff to identify if suicidal ideation emerges in the withdrawing patient.
Jail medical staff have been trained and directed to use the ASQ tool. Compliance in use is critical for patient safety and risk management. Asking about suicide is “half the battle.” It ensures that at-risk patients, such as those going through active withdrawal, have access to healthcare while improving identification and management of suicidal ideation and behavior. Doing so with appropriate documentation, as is afforded in part by the ASQ, prevents against allegations of “deliberate indifference” (i.e., failing to act on a foreseeable risk to detainee safety). At the end of the day, jails should be a safe environment for staff and detainees alike. Preventing suicide furthers this important mission.
If you have any questions about the ASQ tool or suicide prevention techniques, please contact Dr. Melissa Caldwell, CCHP-MH – Director of Mental Health Services.