Suicide and Life‐Threatening Behavior 1

© 2020 The American Association of Suicidology

DOI: 10.1111/sltb.12627

Prevalence and Characteristics Associated with

Chronic Noncancer Pain in Suicide Decedents:
A National Study
GABRIELLE CAMPBELL , SHANE DARKE, LOUISA DEGENHARDT, HARRIET TOWNSEND,
GREGORY CARTER, BRIAN DRAPER, MICHAEL FARRELL, JOHAN DUFLOU AND JULIA LAPPIN

Abstract
Objective: The aims were to estimate the prevalence of CNCP in suicide decedents,
and compare sociodemographic and clinical characteristics of people who die by
suicide (i) with and without a history of CNCP and (ii) among decedents with
CNCP who are younger (<65 years) and older (65 + years).
Method: We examined all closed cases of intentional deaths in Australia in 2014,
utilizing the National Coronial Information System.
Results: We identified 2,590 closed cases of intentional deaths in Australia in 2014
in decedents over 18 years of age. CNCP was identified in 14.6% of cases.
Decedents with CNCP were more likely to be older, have more mental health and
physical health problems, and fewer relationship problems, and were more likely to
die by poisoning from drugs, compared with decedents without CNCP.
Comparisons of older and younger decedents with CNCP found that compared to
younger (<65 years) decedents with CNCP, older decedents (65 + years) were less
likely to have mental health problems.
Conclusions: This is the first national study to examine the characteristics of suicide
deaths with a focus on people with CNCP. Primary care physicians should be aware of
the increased risk for suicide in people living with CNCP, and it may be useful for
clinicians to screen for CNCP among those presenting with suicidal behaviors.

GABRIELLE CAMPBELL, National Drug and University of Newcastle, Newcastle, NSW,

Alcohol Research Centre, UNSW, Sydney, NSW,
Australia and School of Health and Sport Sciences,
University of the Sunshine Coast, Sunshine Coast,
QLD, Australia; SHANE DARKE, HARRIET
TOWNSEND, AND MICHAEL FARRELL, National
Drug and Alcohol Research Centre, UNSW,
Sydney, NSW, Australia; LOUISA DEGENHARDT,
National Drug and Alcohol Research Centre,
UNSW, Sydney, NSW, Australia, School of
Population and Global Health, University of
Melbourne, Melbourne, VIC, Australia, Murdoch
Children’s Research Institute, Parkville, VIC,
Australia and Department of Global Health,
School of Public Health, University of
Washington, Seattle, WA, USA; GREGORY
CARTER, Centre for Brain and Mental Health
Research, Faculty of Health and Medicine,
Australia and Calvary Mater Newcastle, Edith St
Waratah, NSW, Australia; BRIAN DRAPER, Centre
for Healthy Brain Ageing, School of Psychiatry,
University of New South Wales, Sydney, NSW,
Australia and Dementia Centre for Research
Collaboration, University of New South Wales,
Sydney, NSW, Australia; JOHAN DUFLOU, Sydney
Medical School, University of Sydney, Sydney,
NSW, Australia; JULIA LAPPIN, National Drug and
Alcohol Research Centre, UNSW, Sydney, NSW,
Australia and School of Psychiatry, University of
New South Wales, Sydney, NSW, Australia.
Address correspondence to G. Campbell,
School of Health and Sport Sciences, University of
the Sunshine Coast, Sunshine Coast, USCLocked
Bag 4 Maroochydore, QLD 4558, Australia;
E‐mail: gcampbell@usc.edu.au
2 PREVALENCE AND CHARACTERISTICS
INTRODUCTION
Suicide remains a significant cause of pre-
ventable mortality worldwide and is ranked in
the top ten leading causes, by age‐standard-
ized mortality rates, in several regions glob-
ally (Naghavi, 2019). In the United States,
nearly 45,000 lives were lost to suicide in
2016 and several States have observed a 30%
increase in suicide rates since 1999 (CDC,
2018). In Australia, from 2016 to 2017, the
number of suicide deaths increased by 9.1%
(Australian Bureau of Statistics, 2018). Pre-
liminary Australian 2017 data suggest that
suicide rates were among the highest
recorded in a decade (Australian Bureau of
Statistics, 2018). Importantly, people who die
by suicide are not a homogenous group
(Clapperton et al., 2018). Rather, patterns,
trends, and key risk factors for suicide change
over time. It is crucial that emerging risk fac-
tors are investigated and identified in order to
optimize effective prevention strategies.
One such risk factor is chronic non-
cancer pain (CNCP), that is, pain that persists
for longer than three months (Merskey &
Bogduk, 1994). CNCP is estimated to affect
approximately one‐fifth to one‐third of the
world’s population (Campbell et al., 2015a;
Cimas et al., 2018; Dahlhamer et al., 2018;
Jackson et al., 2016). Prevalence is expected
to increase in the coming decades, reflecting
the increasing number of older adults living
with chronic health problems in these popula-
tions (Blyth et al., 2001; Johannes et al.,
2010). People living with CNCP often expe-
rience complex comorbidities including mul-
tiple pain conditions and other physical
health and mental health issues. Emerging
research has linked CNCP as a risk factor for
suicide‐related behaviors, that is, ideations,
planning, and attempts (Calati et al., 2015;
Campbell et al., 2015a; Ilgen et al., 2013).
People living with CNCP are 2–3 times more
likely to engage in suicide‐related behaviors
than the general population (Tang & Crane,
2006). Up to 60% of those who report life-
time and past 12‐month suicide‐related
behaviors have a history of chronic pain
(Campbell et al., 2016).
Joiner’s interpersonal theory (IPT) of
suicide (Joiner, 2007) provides some explana-
tions of the association between suicide and
chronic pain. The impact of chronic pain on
an individual’s employment, physical and
mental functioning and quality of life, and the
reliance on for assistance with everyday tasks
is prevalent in this population. These are con-
sistent with the perceived burdensomeness
and thwarted belongingness in Joiner’s theory
(Joiner, 2007). The integrated motivational–
volitional model of suicidal behavior
(O’Connor & Kirtley, 2018) provides further
evidence, proposing that increased physical
pain tolerance, as experienced by people with
chronic pain, can lead to acquired capability
to act on suicidal thoughts.
Although there have been some recent
advances in knowledge of suicide‐related
behaviors and CNCP, much less is known
about the prevalence and associations of
CNCP with suicide mortality (Cochran et al.,
2014; Ilgen et al., 2016; Petrosky et al., 2018).
To date, no studies have specifically examined
the prevalence of CNCP among deaths by
suicide at the population level. Only a minor-
ity of people who engage in suicide‐related
behaviors, such as ideation and attempts, will
die by suicide (Carroll et al., 2014). By exam-
ining suicide deaths, we can obtain a greater
understanding of the prevalence of the prob-
lem and understand the factors that may
interact with CNCP to increase the likeli-
hood of suicide. This has the potential to
uncover possible opportunities to intervene
and target suicide prevention in the CNCP
population. The current study examined all
suicide deaths in Australia in 2014 in order to:
(1) determine the proportion of com-
pleted suicide cases where there is a
history of CNCP;
(2) compare the sociodemographic and
clinical characteristics of people
who die by suicide with and without
a history of CNCP; and
(3) compare sociodemographic and
clinical characteristics and circum-
stances of death between younger
and older people (below and of/
CAMPBELL ET AL.
above 65 years) with a history of
CNCP.
METHOD
The National Coronial Information
System (NCIS) is an electronic database of
information containing case details from coro-
nial files of all Australian states and territories
from July 1, 2000 (with the exception of
Queensland where files date from January 1,
2001). The NCIS is managed by the Victorian
Department of Justice and has been found to
have more detailed information recorded than
other information systems, such as the Aus-
tralian Bureau of Statistics National Deaths
Index data (Bugeja et al., 2016).
The coronial files consist of documenta-
tion including coroners’ findings, autopsy and
toxicology reports, and police narratives. Cause
of death is ascertained by a forensic pathologist
and noted in the autopsy and coroner’s report.
In Australia, the criteria for reporting a death
vary between jurisdictions. In general, a death
is reportable to the coroner where the person
dies unexpectedly and the cause of death is
unknown; the person died in a violent and
unnatural manner; the person died during, or
as a result of anesthetic; the person was “held in
care” or in custody immediately before death; a
medical practitioner has been unable to issue a
death certificate stating the cause of death; or
the identity of the decedent is unknown.
Ethics
This study was funded through a Soci-
ety for Mental Health Research early career
researcher grant, and ethical approval was
obtained through UNSW ethics (HC17024),
NCIS (MO388), Department of Justice and
Regulation Human Research Ethics Com-
mittee (CF/17/4103), and the Coroners
Court of Western Australia (EC12‐2017).
Case Identification
All closed cases where suicide (inten-
tional self‐harm) was determined to be the
3
manner of death, in people aged 18 years and
over, from the January 1, 2014, until the
December 31, 2014, were examined. The year
2014 was selected as it was the most recent
year that would have the greatest number of
closed cases to be investigated. Data extrac-
tion occurred from August 2017 to February
2018. During this time, the proportion of
closed (and therefore eligible) cases was 88%.
A sample of 2708 suicide cases was identified
from the NCIS database. Cases where the
decedent was under the age of 18 years
(n = 81) were excluded. Cases were also
excluded if they were still under investigation
at the time of data extraction (n = 37) result-
ing in a final sample of 2590.
Outcome Variables
Coronial files were examined to deter-
mine mentions of chronic pain. The presence
of chronic pain was coded if there were men-
tions of chronic pain in any of the coronial
files, such as police narratives, findings, or
autopsy reports. Related terms such as arthri-
tis, fibromyalgia, back or neck pain, and
migraines were included. Coronial files,
including police narratives, and autopsy,
coronial, and toxicology reports, were manu-
ally reviewed by research assistants. Weekly
discussion by the team assisted with coding
ambiguous cases. Cases that included men-
tions of cancer (n = 124) were excluded from
the CNCP group and included in the non‐
CNCP group, because the focus for this study
was CNCP.
Independent Variables
Routinely collected data in the NCIS
include age, sex, country of birth, employ-
ment status, usual occupation, marital status,
location and activity at the time of incident,
mechanism and object or substance involve-
ment at the time of death, and medical cause
of death and intent. The most frequent mode
of suicide was categorized into seven groups
based on ICD 10 codes from the underlying
cause of death. These included hanging (ICD
10 code X70), poisoning by drugs (ICD 10
4 PREVALENCE AND CHARACTERISTICS
codes X60‐X65), carbon monoxide poisoning
(ICD 10 code X67), firearms (ICD 10 codes
X72‐X74), jumping (ICD 10 code X80), and
sharp object (ICD 10 code X78). All other
underlying causes of death were coded into an
“other” category. This included drowning
(X71), smoke/fire or explosives (X75‐X76),
moving object (X81), motor vehicle crash
(X82), and unspecified means (X83‐X84). The
decedent’s postcode was used to determine
whether the decedent resided in a major city,
regional or remote center. These were based
on the Australian Bureau of Statistics remote-
ness classifications. Years of potential life lost
(YLL) was calculated by multiplying the num-
ber of deaths by the remaining life expectancy
for each decedent.
Data on mental health mentions and
other physical health conditions were recorded
into a free text field and were later recoded into
the following categories: Physical health free
text was recoded into musculoskeletal, cardio-
vascular, respiratory, diabetes, cancer, and
liver disease. Mental health free text was
recoded into depression, anxiety, schizophre-
nia/psychosis, bipolar affective disorder, per-
sonality disorders, and posttraumatic stress
disorder. These were classified based on speci-
fic mentions of the conditions in the coronial
reports. Mentions of illicit drug and alcohol
use were also coded. The total numbers of
mental and physical health problems were cal-
culated, and a binary variable was created to
identify three or more mental and physical
health conditions documented for each case.
Coronial files were also searched for
information pertaining to common risk fac-
tors for suicide. These included mentions of
recent job loss, relationship problems (part-
ner, friends, or family), recent loss of children
(due to death, custody arrangements, or
divorce), grief, and recent financial difficul-
ties. These data were collected to compare
whether there were any differences in known
risk factors for people living with CNCP,
compared to people without CNCP. Data
were also extracted for whether the decedent
had left a note or a message and whether a
previous suicide attempt was mentioned in
the coronial files.
Toxicology reports were inspected to
identify substances that were present in the
blood at the time of death: alcohol, cannabis,
amphetamines, opioids, nonopioid anal-
gesics, benzodiazepines, antidepressants,
antipsychotics, and pentobarbitone.
Data Analysis
All analyses were conducted using
STATA version 15. Frequencies and propor-
tions and 95% confidence intervals (CI) are
presented for sociodemographic and clinical
characteristics. For age at death, mean and
standard deviations are reported as the data
were normally distributed. Comparisons were
made using logistic regression and reported
as odds ratios and 95% CI are presented. Due
to multiple comparisons, we used a p‐value
significance cutoff of .001.
Secondary Analysis
Additional analyses were conducted to
examine sociodemographic, clinical, and cir-
cumstantial differences, on a reduced set of
the most common variables, between younger
people (<65 years) with and without chronic
pain and older people (65 years and older)
with and without chronic pain to examine
whether there were any potential informative
associations (see Appendices 1 and 2).
RESULTS
Characteristics of Suicide Deaths in
Australia in 2014
A number of 2,590 closed cases of inten-
tional self‐harm were identified. The mean age
of decedents was in the mid‐forties
(46.4 years), and three‐quarters were male
(76.2%). Over one‐third were married or de
facto (36.9%), employed (38.4%), and living in
rural or remote areas (35.0%) (Table 1). The
mean YPLL due to suicide was 36.5 (SD 16.1).
Mentions of mental health problems
were common (65.3%) with depression the
most prevalent, mentioned in over half of
CAMPBELL ET AL. 5

cases. One in ten decedents had mentions of
three or more mental health problems. Physi-
cal health problems were identified in over
one‐fifth of cases (22.4%), the most common
being cardiovascular disease (9.8%). CNCP
was identified in 14.6% (95% CI 13.3–16.0,
n = 379) of cases and contributed a mean of
27.5 (SD 15.4) YPLL. Less than 3% of cases
reported three or more physical health prob-
lems (Table 1).
Among all suicide deaths, the most
common risk factors identified were

TABLE 1
Characteristics of People Who Died Via Suicide According to History of Chronic Noncancer Pain,
Australia, 2014
People without a People with a Bivariate comparisons
recorded history recorded history
Total of CNCP of CNCP
n = 2590 n = 2,211 n = 379
% (95% CI) % (95% CI) % (95% CI) OR (95% CI) p value

Mean age (SD) 46.4 (17.49) 44.7 (16.9) 56.6 (17.6) 11.9 (10.02–13.72) <.0001
Male 76.2 (74.5–77.8) 77.0 (75.2–78.7) 71.2(66.5–75.6) 1.35 (1.06–1.72) .015
Married/de facto 36.9 (35.1–38.8) 36.5 (34.5–38.5) 39.8 (35.0–44.9) 1.15 (0.92–1.44) .207
Employed 38.4 (26.5–40.3) 40.1 (38.0–42.1) 28.5 (24.2–33.3) 0.60 (0.47–0.76) <.0001
Rural/remote 35.0 (33.7–37.7) 35.3 (33.4–37.4) 36.4 (31.7–41.4) 1.05 (0.84–1.32) .681
Mental health
Any mental health 65.3 (63.4–67.1) 63.6 (61.6–65.6) 74.9 (70.3–79.1) 1.71 (1.34–2.19) <.0001
illness
Depression 56.0 (54.1–57.9) 54.0 (52.0–56.1) 67.3 (62.4–71.8) 1.75 (1.39–2.20) <.0001
Anxiety 15.2 (13.9–16.6) 14.7 (13.3–16.2) 18.5 (14.9–22.7) 1.31 (1.00–1.75) .057
Schizophrenia/ 8.2 (7.2–9.3) 8.3 (7.2–9.5) 7.7 (5.4–10.8) 0.92 (0.61–1.38) .682
psychosis
Bipolar 4.9 (4.1 5.8) 4.8 (4.0–5.8) 5.0 (3.2–7.7) 1.04 (0.63–1.71) .884
Personality 3.7 (3.0–4.5) 3.7 (3.0–4.6) 3.4 (2.0–5.8) 0.92 (0.51–1.67) .790
disorder
PTSD 2.6 (2.0–3.3) 2.4 (1.8–3.1) 4.0 (2.4–6.5) 1.71 (0.95–3.07) .072
Alcohol use 9.2 (8.1–10.3) 9.0 (7.9–10.3) 10.0 (7.4–13.5) 1.13 (0.78–1.62) .522
problems
Substance use 7.7 (6.7–8.8) 7.6 (6.6–8.8) 7.9 (5.6–11.1) 1.04 (0.69–1.56) .854
problems
3 or more MH 10.0 (8.9–11.3) 9.8 (8.6–11.1) 11.6 (8.7–15.3) 1.21 (0.86–1.71) .271
problems
Physical health
Any physical 22.4 (20.9–24.1) 17.8 (16.3–19.5) 49.3 (44.3–54.4) 4.49 (3.57–5.65) <.0001
health illness
Musculoskeletal 8.7 (7.7–9.9) 2.9 (2.3–3.7) 42.5 (37.6–47.5) 24.4 (17.7–33.6) <.0001
Cardiovascular 9.8 (8.8–11.1) 7.4 (6.4–8.6) 24.3 (20.2–28.9) 4.00 (3.01–5.31) <.0001
disease
Respiratory 4.0 (3.3–4.8) 2.9 (2.3–3.7) 10.0 (7.4–13.5) 3.68 (2.43–5.58) <.0001
disease
Diabetes 3.9 (3.2–4.7) 3.3 (2.6–4.1) 7.6 (5.4–10.8) 2.46 (1.58–3.84) <.0001
Liver disease 2.6 (2.0–3.3) 2.2 (1.7–2.9) 4.7 (3.0–7.4) 2.20 (1.28–3.82) .005
3 or more physical 2.6 (2.1–3.3) 1.6 (1.1–2.2) 8.7 (6.2–12.0) 5.9 (3.6–9.7) <.0001
health problems

Bold is significant at p < .001

6 PREVALENCE AND CHARACTERISTICS
relationship problems (24.5%) followed by
financial difficulties (14.9%) (Table 2). One‐
quarter of decedents had made a previous sui-
cide attempt (26.0%) and more than half left a
note (58.6%). The most common method
used was hanging (55.2%), followed by over-
dose from poisoning (14.5%). The most com-
monly detected drug present was alcohol,
identified in over one‐third of cases (37.0%),
followed by benzodiazepines (24.9%) and
antidepressants (24.1%).
Characteristics Associated with Chronic
Pain in Suicide Deaths
Compared with decedents without
CNCP, decedents with CNCP were older
and less likely to be employed. Decedents
with CNCP were also more likely to have
mental health problems, particularly depres-
sion (67.3% vs 54.0%) and more likely to have
physical health problems than those without
CNCP (Table 1).
Compared with decedents without
CNCP, decedents with CNCP were less
likely to be recorded as having relation-
ship problems. CNCP decedents were less
likely to die by hanging and had more
than three times the odds of dying by
drug poisoning (OR 3.48, 95% CI 2.70–
4.48). With the exception of alcohol, there
were marked differences in the toxicology
profiles of decedents with and without
CNCP. Decedents with CNCP were sig-
nificantly more likely to have opioids (OR
3.42, 95% CI 2.69–4.35) and nonopioid
analgesics present (OR 3.02. 95% CI
2.36–3.87). Although overall use was rare
(n = 50, 1.9%), decedents with CNCP had
over four times the odds of having pento-
barbitone present in the toxicology (OR
4.05, 95% CI 2.28–7.21) than those
without.
Sociodemographic, Clinical Characteristics
and Circumstances: Comparisons between
Younger and Older Decedents with CNCP
Among decedents with CNCP, two‐
thirds (67.8% n = 257) were under 65 years
and one‐third (32.2%, n = 122) 65 years or
over. Compared with those younger than 65,
older decedents were less likely to have identi-
fied mental health problems, more likely to
have physical health problems, and more
likely pentobarbitone present, though this
was not significant at the conserva-
tive < 0.001 level (Table 3).
Comparisons between Younger (<65
Years) and Older (65 Years and Over)
Decedents With and Without CNCP
Additional analyses were performed
comparing decedents younger and older with
and without chronic pain. Among younger
people (<65 years), decedents with CNCP
were significantly more likely to have any
mental health or physical health problems
(see Appendix 1). Younger people with
CNCP were also less likely to die by hanging
and more likely to die by poisoning and have
more pharmaceuticals present in their toxi-
cology.
Among older decedents (65 years and
greater) with and without CNCP, there were
very few significant (see Appendix 2). Dece-
dents with CNCP were more likely to have
physical health problems recorded, more
likely to die by poisoning, and more likely to
have nonopioid analgesics present in their
toxicology, compared to decedents without
CNCP.
DISCUSSION
To our knowledge, this is the first
study to examine the characteristics of suicide
deaths with a focus on people with CNCP in
a national population. Overall, we identified
2,590 closed cases of suicide deaths in people
over 18 years of age in Australia, among
whom approximately one in seven decedents
had a documented history of CNCP. Unem-
ployment, mental health, and physical health
problems were common in both but were
more common among decedents with CNCP
than those without. CNCP suicide deaths
were proportionally more likely to occur by
CAMPBELL ET AL. 7

TABLE 2
Risk Factors, Suicide Method, and Toxicology among People Who Died Via Suicide According to History
of Chronic Noncancer Pain, Australia, 2014
People without a People with a Comparisons
recorded history recorded history
Total of CNCP of CNCP
n = 2590 n = 2,211 n = 379
Recent risk factors % (95% CI) % (95% CI) % (95% CI) OR (95% CI) p value

Job loss 6.1 (5.2–7.1) 5.9 (5.0–6.9) 7.4 (5.1–10.5) 1.27 (0.84–1.95) .258
Relationship 24.5 (22.9–26.2) 26.0 (24.2–27.8) 16.1 (12.7–20.2) 0.55 (0.41–0.73) <.0001
problems
Loss of children 7.6 (6.6–8.7) 7.9 (6.9–9.2) 5.3 (3.4–8.1) 0.64 (0.40–1.04) .070
Financial difficulties 14.9 (13.6–16.4) 14.6 (13.2–16.1) 16.9 (13.4–21.0) 1.19 (0.89–1.59) .251
Previous attempt 26.0 (24.4–27.7) 25.3 (23.6–27.2) 29.8 (25.4–34.6) 1.25 (0.98–1.59) .069
Left note 58.6 (56.7–60.5) 57.6 (55.5–59.7) 64.6 (59.7–69.3) 1.34 (1.07–1.69) .010
Method
Hanging 55.2 (53.3–57.1) 57.7 (55.6–59.8) 40.6 (35.8–45.7) 0.50 (0.40–0.63) <.0001
Poisoning—drugs 14.6 (13.2–16.0) 11.6 (10.4–13.0) 31.7 (27.2–36.5) 3.52 (2.73–4.53) <.0001
Carbon monoxide 6.3 (5.4–7.3) 6.2 (5.2–7.2) 6.8 (4.7–9.9) 1.12 (0.73–1.74) .599
Firearm 6.0 (5.1–7.0) 5.9 (5.0–6.9) 6.6 (4.5–9.6) 1.13 (0.73–1.76) .587
Jumping 4.2 (3.5–5.0) 4.5 (3.7–5.4) 2.3 (1.2–4.5) 0.52 (0.26–1.04) .063
Sharp object 2.7 (2.2–3.4) 2.7 (2.1–3.5) 2.9 (1.6–5.2) 1.07 (0.56–2.06) .835
Othera 14.4 (13.1–15.8) 14.6 (13.2–16.2) 12.9 (9.9–16.7) 0.86 (0.63–1.19) .377
Toxicology—drugs detected
Alcohol 37.0 (35.1–38.9) 37.1 (35.2–39.2) 35.9 (31.2–40.9) 0.95 (0.75–1.19) .630
Cannabis 10.7 (9.5–11.9) 11.2 (10.0–12.6) 7.4 (5.1–10.5) 0.63 (0.42–0.95) .027
Amphetamines 6.6 (5.7–7.7) 7.3 (6.2–8.4) 2.9 (1.6–5.2) 0.38 (0.20–0.71) .002
Opioids 17.3 (15.9–18.8) 14.1 (12.7–15.6) 35.9 (31.2–40.9) 3.42 (2.69–4.35) <.0001
Nonopioid analgesic 16.1 (14.8–17.6) 13.4 (12.1–14.9) 31.9 (27.4–36.8) 3.02 (2.36–3.87) <.0001
Benzodiazepines 24.9 (23.2–26.6) 22.4 (20.7–24.2) 39.1 (34.2–44.1) 2.22 (1.76–2.79) <.0001
Pentobarbitone 1.9 (1.5–2.5) 1.4 (1.0–1.9) 5.3 (3.4–8.1) 4.05 (2.28–7.21) <.0001
Antidepressant 24.1 (22.5–25.8) 22.5 (20.8–24.3) 33.2 (28.7–38.2) 1.71 (1.35–2.17) <.0001
Antipsychotics 9.3 (8.3–10.5) 8.8 (7.7–10.0) 12.7 (9.7–16.4) 1.51 (1.07–2.11) .017
a
Other includes drowning, vehicles, pesticides, moving object, not specified, fire, and explosives.
(ICD 10 codes X66, X68, X69, X71, X75 X79, X81–X84)
Bold is significant at p < .001

intentional overdose with opioids, benzodi-
azepines, antidepressants, and nonopioid
analgesics.
CNCP is a prevalent problem, and sui-
cidality is common among people living with
CNCP (Campbell et al., 2015a). This study
demonstrates that CNCP is also importantly
associated with suicide deaths. We identified
that 14.6% of all adult deaths by suicide have
a documented history of CNCP. This figure
is higher than those reported elsewhere: A
recent study from the United States identified
chronic pain in 8.8% of cases (Petrosky et al.,
2018). Our study, like that of Petrosky et al.,
(2018), relied on coronial data and therefore
police narratives and coronial findings to
identify CNCP in suicide. It is likely that our
estimates of CNCP are therefore less than
true prevalence.
CNCP has a major impact on the indi-
vidual in terms of quality of life, mental health
and physical health status, relationships, and
employment (Blyth et al., 2001; Breivik et al.,
2013; Campbell et al., 2015b). We found that,
compared with people who died by suicide
without CNCP, people with CNCP were less
8 PREVALENCE AND CHARACTERISTICS

TABLE 3
Characteristics, circumstances, and toxicology comparisons of people less than 65 years and 65 and over
with CNCP
A. People with a B. People with B vs A (ref) Comparisons
recorded history a recorded history
of CNCP younger of CNCP 65 years
than 65 years and older
n = 257 n = 122
% (95% CI) % (95% CI) OR (95% CI) p value

Male 72.8 (70.0–77.9) 68.0 (59.1–75.8) 0.79 (0.50–1.27) .342

Rural/remote 38.4 (32.6–44.6) 32.2 (24.4–41.2) 0.76 (0.48–1.20) .244
Any mental health illness 83.3 (78.2–87.4) 57.4 (48.3–66.0) 0.27 (0.17–0.44) <.0001
Three or more mental 15.6 (11.6–20.6) 3.3 (1.2–8.5) 0.18 (0.06–0.53) .002
health illnesses
Depression 73.5 (67.8–78.6) 54.0 (45.1–62.8) 0.42 (0.27–0.66) <.0001
Anxiety 21.8 (17.1–27.3) 11.5 (6.9–18.6) 0.28 (0.21–0.37) .017
Substance use 11.3 (7.9–15.8) 0.8 (0.1–0.6) 0.06 (0.09–0.48) .008
Alcohol use 13.2 (9.6–18.0) 3.3 (1.2–8.5) 0.22 (0.08–0.64) .005
Any previous attempt 35.4 (29.8–41.5) 18.0 (12.1–26.0) 0.40 (0.24–0.68) .001
Intention reported 61.9 (55.7–67.6) 70.5 (61.7–78.0) 1.47 (0.93–2.34) .102
Physical health
Three or more physical 5.1 (2.9–8.5) 16.4 (10.7–24.2) 3.68 (1.76–7.68) .001
health illnesses
Musculoskeletal 34.2 (28.7–40.3) 59.8 (50.8–68.2) 2.86 (1.83–4.46) <.0001
Cardiovascular 11.3 (7.9–15.8) 51.6 (42.7–60.5) 8.40 (4.97–14.19) <.0001
Respiratory 7.0 (4.4–10.9) 16.4 (10.8–24.2) 2.60 (1.32–5.13) .006
Method
Hanging 43.9 (37.9–50.1) 33.6 (25.7–42.6) 0.64 (0.41–1.01) .056
Poisoning—drugs 31.1 (25.7–37.1) 32.8 (25.0–41.7) 1.08 (0.68–1.71) .746
Carbon monoxide 6.2 (3.8–9.9) 8.2 (4.4–14.7) 1.34 (0.59–3.06) .479
Firearm 5.4 (3.2–9.0) 9.0 (5.0–15.7) 1.72 (0.76–3.90) .195
Jumping 3.5 (1.8–6.6) 0 – –
Sharp object 0.8 (0.2–3.1) 7.4 (3.8–13.7) 10.2 (2.16–47.8) .003
Other* 11.7 (8.2–16.2) 15.6 (10.1–23.3) 1.39 (0.75–2.59) .292
Toxicology—drugs detected
Alcohol 40.9 (35.0–47.1) 25.4 (18.4–34.0) 0.49 (0.31–0.79) .004
Cannabis 10.9 (7.6–15.4) 0 – –
Opioids 37.4 (31.6–43.4) 32.8 (25.0–41.7) 0.82 (0.52–1.29) .387
Nonopioid analgesic 27.6 (22.5–33.5) 41.0 (32.6–50.0) 1.81 (1.16–2.86) .010
Benzodiazepines 37.3 (31.6–43.5) 42.6 (34.0–51.7) 1.25 (0.80–1.93) .326
Pentobarbitone 3.1 (1.6–6.1) 9.8 (5.6–16.6) 3.40 (1.35–8.54) .009
Antidepressant 35.8 (30.1–41.9) 27.9 (20.5–36.6) 0.69 (0.43–1.11) .127
Antipsychotics 15.6 (11.6–20.6) 6.6 (3.3–12.7) 0.38 (0.17–0.84) .017
a
Other includes drowning, vehicles, pesticides, moving object, not specified, fire, and explosives.
(ICD 10 codes X66, X68, X69, X71, X75 X79, X81–X84).
Bold is significant at p < .001

likely to be employed, more likely to have may be understood by the fact that the
mentions of any mental health problems par- deceased with CNCP were more likely to be
ticularly depression, and more likely to have older and therefore more likely to have physi-
other physical health comorbidities. This cal health problems and be retired.
CAMPBELL ET AL.
Nonetheless, one in three decedents
with CNCP was less than 65 years old. Pre-
vious research has found that younger people
living with CNCP have more complex clini-
cal profiles than older people with CNCP
(Campbell et al., 2015b). This was supported
in the current study. Deceased with CNCP
who were under 65 years were significantly
more likely to have mental health problems
identified compared with those 65 years or
older. As identification of mental health
problems in older people is often a challenge
in primary care and for families, it is unclear
whether these findings are an accurate repre-
sentation of what happens (Andreas et al.,
2017). Considering that CNCP can be a life-
time condition, it is important that the men-
tal health of people living with CNCP is
assessed and treated and that access to suit-
able care is made available and affordable.
Additionally, we identified that both
younger and older decedents with CNCP
were more likely to have physical health
problems recorded, over and above their
CNCP. The importance of physical health
as risk factor for suicide should be investi-
gated further.
In the overall sample, relationship
problems were a common risk factor for sui-
cide, reported in approximately one‐quarter
of cases. Consistent with previous US
research (Petrosky et al., 2018), relationship
problems were less likely to be reported
among Australian cases of suicide with
CNCP. This finding supports the conclu-
sions of the US study (Petrosky et al., 2018),
that other stressors (including CNCP) may
be more important in this group.
Approximately one in three of all
decedents had made a previous attempt.
While a previous attempt was not signifi-
cantly more common among those with
CNCP, this finding suggests that there
may be opportunities for intervention
among people with CNCP and suicidal
behaviors. Screening for CNCP should be
conducted among those presenting to care
with suicidal behaviors. Similarly, enquiry
about suicidal behaviors should be made in
those with CNCP.
9
Increasing our knowledge of the char-
acteristics of people with CNCP who die by
suicide is essential to create opportunities for
intervention. Reducing access to means has
been found to be one of the most effective
measures to reduce suicide deaths. In the cur-
rent study, we found that decedents with
CNCP were proportionally more likely to die
by intentional overdose than by hanging.
Hanging is traditionally the most common
method for suicide in Australia (Australian
Bureau of Statistics, 2018). As we identified,
people with CNCP were also more likely to
have other physical health problems and were
more likely to have medicines, including opi-
oids, nonopioid analgesics, and benzodi-
azepines, present in their toxicology reports.
With multiple physical health problems
comes exposure to multiple medicines. The
potential for dependence and misuse of these
drugs is well known (Darke et al., 2019;
Lader, 2011). Furthermore, there is increas-
ing potential for people to gain access to
potentially lethal medications through online
markets including the Dark Web (Oberhaus,
2018). Concerningly, we found that people
with CNCP had four times the odds of having
pentobarbitone present in their toxicology at
the time of death. Pentobarbitone is a short‐
acting barbiturate central nervous system
depressant. Internationally, it has garnered
attention due to advocacy through euthanasia
groups, (Solbeck et al., 2019) and currently, it
is classified as a highly restricted and con-
trolled Schedule 8 drug in Australia.
Although restriction of access to poten-
tially lethal means has been found to be an
effective measure in reducing suicide behav-
iors (Hawton et al., 2013; Mann et al., 2005)
among people living with CNCP with multi-
ple physical and mental health problems,
there is a need to balance the need for effec-
tive pain management and the ease of access
to other available effective treatments.
Although increased screening of suicidal
behaviors in primary care has been recom-
mended (O’Connor et al. 2013), it is impor-
tant to acknowledge that only a minority of
people with suicidal ideation will make a sui-
cide attempt and even fewer will die by suicide
10
(Carroll et al., 2014). Importantly, the predic-
tive value of suicidal ideation for subsequent
suicide is significantly lower in nonpsychiatric
cohorts such as primary health care or general
population samples than among people who
receive psychiatric care (McHugh et al.,
2019). Increasing access to other treatment
options, especially pain management pro-
grams, would be preferable to simply restrict-
ing access to necessary medications in people
with suicidal ideation. Indeed, it has been sug-
gested that the restriction of medication, with
no alternative effective pain management,
might actually lead to increased suicide rates
in people living with CNCP (Ilgen, 2018).
With an aging population and
increases in CNCP, where there is no simple
effective treatment, it is important to increase
access to specialist supportive services such as
multidisciplinary pain treatment programs
that may assist patients in managing their
CNCP. Pain management programs com-
prising a multidisciplinary team of health pro-
fessionals, including psychologists,
physiotherapists, and pain specialists, are the
best approach for managing CNCP (Kamper
et al., 2015). One of the challenges in provid-
ing effective treatment is accessibility to these
multidisciplinary pain management programs
which, unlike opioid medication, are largely
not subsidized by the health system. Access
and affordability of these programs are essen-
tial in order to address the multitude of prob-
lems experienced by this population. In
addition, suicide rates are 1.7 higher in rural/
remote areas (AIHW, 2019). We found that
just under 40% of younger people who die by
suicide with CNCP lived in rural or remote
areas. Access to multidisciplinary pain ser-
vices for people in rural and remote areas in
Australia remains limited and is a crucial tar-
get for services improvement (Hogg et al.,
2012).
Limitations
One of the major strengths of the cur-
rent study was that it included all closed sui-
cide cases in people over the age of 18 years
in Australia in 2014. Although the use of
PREVALENCE AND CHARACTERISTICS
NCIS has been recognized as a unique data
source that provides reliable and high‐quality
detailed information (Bugeja et al., 2016), sev-
eral limitations should be acknowledged. The
current study was based on coronial files and
not on clinical diagnoses. Reliance on inves-
tigative reports means that the results pre-
sented here are likely to underrepresent the
true numbers of people experiencing CNCP.
We are limited to details that are provided by
police, family, and friends. We do not know
any specific pain factors such as pain duration,
cause of pain, pain severity, and impact of
pain on everyday life. Additionally, it is diffi-
cult to ascertain from coronial files the exact
risk factors that were directly related to an
individual’s suicide. Cases were also restricted
to those coded as having deliberate intention.
Cases of undetermined intent were thus not
included.
CONCLUSION
The current study was the first national
study to examine CNCP among suicide
deaths in Australia. Acknowledgment and
understanding of CNCP as a risk factor for
suicide are crucial. Primary care physicians
should be aware of the increased risk for sui-
cide in people living with CNCP, and clini-
cians should screen for CNCP among those
presenting with suicidal behaviors. Although
restriction of access to means is an effective
suicide prevention strategy, it is important
that patients with suicidal ideation receive
targeted and tailored support, rather than
simply having access to their medicines
restricted. In order to address CNCP and sui-
cide, it is important that both affordability
and access to pain management programs
become a priority.
This study was funded by the Society
for Mental Health Research Early Career
Research Fellow grant. GC is supported by
National Health and Medical Research
Council fellowships (#1119992). The
National Drug and Alcohol Research Centre
at University of New South Wales, Australia,
is supported by funding from the Australian
CAMPBELL ET AL.
Government, under the Substance Misuse
Prevention and Service Improvements Grant
Fund. GC has received an investigator‐initi-
ated untied educational grants from Reckitt
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CAMPBELL ET AL. 13

APPENDIX 1

Comparison of younger people (<65 years) with and without history of chronic non-
cancer, Australia, 2014

Bivariate comparisons
Younger people
(< 65 years old) Younger people
without a with a recorded
recorded history of
history of CNCP CNCP
n = 1,928 n = 257
% (95% CI) % (95% CI) OR (95% CI) p value

Mean age (SD) 40.2 (12.5) 46.6 (10.7) 6.48 (4.87–8.08) <.0001
Male 76.7 (74.8–78.5) 72.8 (67.0–77.9) 1.23 (0.92–1.65) .163
Married/de facto 34.8 (32.7–36.9). 38.5 (32.7–44.6) 1.18 (0.89–1.53) .235
Employed 44.6 (42.4–46.8) 39.7 (33.7–45.8) 0.82 (0.63–1.07) .136
Rural/remote 34.7 (32.6–36.8) 38.4 (32.6–44.6) 1.18 (0.90–1.54) .236
Mental health
Any mental health 65.4 (63.2–67.4) 83.3 (78.2–87.4) 2.64 (1.88–3.71) <.001
illness
Depression 55.3 (53.1–57.5) 73.5 (67.8–78.6) 2.25 (1.68–3.00) <.0001
Anxiety 15.4 (13.9–17.1) 21.8 (17.1–27.3) 1.53 (1.11–2.11) .009
3 or more MH 10.6 (9.3–12.0) 15.6 (11.6–20.6) 1.56 (1.08–2.25) .018
problems
Physical health
Any physical health 12.9 (11.5–14.5) 38.9 (33.1–45.0) 4.29 (3.23–5.70) <.0001
illness
3 or more physical 0.5 (0.3–0.9) 5.1 (3.0–8.5) 10.2 (4.43–25.55) <.0001
health problems
Method of suicide
Hanging 61.0 (58.8–63.2) 44.0 (38.0–50.1) 0.50 (0.39–0.65) <.0001
Poisoning—drugs 11.0 (9.6–12.5) 30.7 (25.4–36.7) 3.59 (2.66–4.85) <.0001
Toxicology—drugs detected
Alcohol 39.5 (37.4 (41.7) 40.9 (35.0–47.0) 1.06 (0.81–1.38) .682
Opioids 13.5 (12.1–15.1) 37.4 (31.6–43.5) 3.81 (2.87–5.06) <.0001
Nonopioid analgesic 12.0 (10.7–13.6) 27.6 (22.5–33.4) 2.79 (2.06–3.79) <.0001
Benzodiazepines 21.3 (19.5–23.2) 37.4 (31.6–43.5) 2.21 (1.68–2.91) <.0001
Antidepressant 22.0 (20.2–23.9) 35.8 (30.1–41.9) 1.98 (1.50–2.61) <.0001
Antipsychotics 9.0 (7.8–10.3) 15.6 (11.6–20.6) 1.87 (1.29–2.71) .001

Bold is significant at p < .001

14 PREVALENCE AND CHARACTERISTICS

APPENDIX 2

Comparison of older people (65 years and over) with and without history of chronic non-
cancer, Australia, 2014

Bivariate comparisons
Older people
Older people (65+) with a
(65 + years old) recorded
without a recorded history of
history of CNCP CNCP
n = 283 n = 122
% (95% CI) % (95% CI) OR (95% CI) p value

Mean age (SD) 75.6 (8.0) 77.5 (8.5) 1.88 (0.15–3.62) .034
Male 79.2 (74.0–83.5) 68.0 (59.2–75.8) 1.78 (1.11–2.87) .017
Married/de facto 48.1 (42.3–53.9) 42.6 (34.1–51.6) 0.80 (0.52–1.23) .315
Employed 9.2 (6.3–13.2) 4.9 (2.2–10.6) 0.51 (0.20–1.28) .150
Rural/remote 39.9 (34.4–45.8) 32.2 (24.4–41.1) 0.72 (0.46–1.21) .144
Mental health
Any mental health 51.6 (45.7–57.4) 57.4 (48.4–65.9) 1.26 (0.82–1.94) .285
illness
Depression 45.6 (39.8–51.4) 54.1 (45.1–62.8) 1.41 (0.92–2.15) .116
Anxiety 9.5 (6.6–13.6) 11.5 (6.9–18.5) 1.23 (0.62–2.43) .554
3 or more MH 4.2 (2.4–7.3) 3.3 (1.2–8.5) 0.77 (0.24–2.42) .649
problems
Physical health
Any physical health 51.2 (45.4–57.0) 71.3 (62.6–78.7) 2.36 (1.50–3.73) <.0001
illness
3 or more physical 8.8 (6.0–12.8) 16.4 (10.8–24.1) 2.02 (1.08–3.80) .029
health problems
Method
Hanging 35.3 (30.0–41.1) 33.6 (25.7–42.5) 0.93 (0.59–1.45) .738
Poisoning—drugs 15.9 (12.1–20.7) 32.8 (25.0–41.7) 2.58 (1.57–4.23) <.0001
Toxicology—drugs detected
Alcohol 21.2 (16.8–26.4) 25.4 (18.4–34.0) 1.27 (0.77–2.08) .352
Opioids 17.7 (13.6–22.6) 32.8 (25.0–41.7) 2.273 (1.40–3.70) .001
Nonopioid analgesic 23.0 (18.4–28.3) 41.0 (32.5–50.0) 2.33 (1.45–3.67) <.0001
Benzodiazepines 30.4 (25.3–36.0) 42.6 (34.1–51.6) 1.70 (1.10–2.64) .018
Antidepressant 26.1 (21.3–31.6) 27.9 (20.6–36.6) 1.09 (0.68–1.76) .719
Antipsychotics 7.4 (4.9–11.1) 6.6 (3.3–12.6) 0.88 (0.38–2.04) .757

Bold is significant at p < .001