BJA Education, 23(8): 320e326 (2023)
doi: 10.1016/j.bjae.2023.05.005
Matrix codes: 1D01,
2E03, 3E00
Suicidality in chronic pain: assessment and
management
M. Chincholkar* and S. Blackshaw
Manchester and Salford Pain Centre, Salford, UK
*Corresponding author: Mahindra.Chincholkar@nca.nhs.uk
Keywords: chronic pain; pain; suicide; suicidal ideation
Learning objectives
By reading this article you should be able to:

Describe the epidemiology, risk factors and pro-
tective factors for suicidality.

Explain the need for individualised assessment of
risk.

Discuss the management strategies based on this
assessment.
Suicide is a serious global public health issue. It accounted for
1.3% of all deaths in 2019, which is higher than deaths from
malaria, HIV/AIDS, breast cancer, or war and homicide.1 It has
been estimated that for every one adult who has died by sui-
cide, there are >20 individuals who may have attempted sui-
cide. The risk of death from suicide in individuals with chronic
pain is at least twice that of individuals without chronic pain.2
Despite the high risk, there is little formal training in the
assessment and management of the risk of suicide. The article
describes the epidemiology, risk factors and protective factors
for suicidality. It also provides a practical guide to help assess
and manage this risk.
Mahindra Chincholkar MD FRCA FFPMRCA is the Clinical director
of the Manchester and Salford Pain Centre. He is an associate editor
of BJA Education and council member of the British Pain Society. His
major clinical interests are neuromodulation for chronic pain and
neuropathic pain.
Sarah Blackshaw ClinPsyD is a principal clinical psychologist
within the health psychology team at Salford Royal Hospital. Her
main clinical interest is the use of cognitive behavioural therapy in
different health conditions including chronic pain, chronic fatigue/
ME, diabetes, cancer, heart conditions, HIV and sexual health.
Accepted: 16 May 2023
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Advance Access Publication Date: 27 June 2023
Key points

The risk of death from suicide increases two-fold
in individuals with chronic pain.

Not all patients at risk of suicide present with
suicidal ideation.

Risk factors for suicidality do not always predict
suicide.

Risk assessment tools to predict suicide should
not be used in isolation.

Individualised assessment of intent, risk factors
and protective factors can inform appropriate
strategies to mitigate risk.
Terminology
Suicide is the act of intentionally causing one’s own death.
Although death from suicide is uncommon, thoughts about
engaging in suicide-related behaviours (suicidal ideation) are
very common in individuals with chronic pain.2 There are
several terms related to suicide (Table 1).3 Self-harm is a
broader term that includes suicide attempts and deliberate
injury to self without intention to cause death. The term sui-
cidality includes suicidal ideation, suicide plans and suicide
attempts.
Epidemiology
The risk of suicidality is high in individuals with chronic pain,
as pain provokes an aversive emotional response. This
increased risk can partly be explained by the association with
comorbid psychiatric conditions such as depression. However,
aspects of chronic pain are uniquely associated with increased
risk even after controlling for psychiatric conditions.4
Estimates of the prevalence of suicidal ideation vary
considerably. In a questionnaire-based survey conducted in a
pain management centre, up to 32% of patients reported some
320
 Suicidality in chronic pain

Table 1 Common terms related to suicide.3

Suicide Death caused by self-directed injurious behaviour with any intent to die as a result of the
behaviour.
Suicide attempt A non-fatal self-directed potentially injurious behaviour with any intent to die as a result of the
behaviour. A suicide attempt may or may not result in injury.
Suicidal self-directed violence Behaviour that is self-directed and deliberately results in injury or the potential for injury to
oneself. There is evidence, whether implicit or explicit, of suicidal intent. This encompasses
suicide deaths and suicide attempts.
Other suicidal behaviour and Acts or preparation toward making a suicide attempt, but before potential for harm has begun.
preparatory acts
Suicidal ideation Passive thoughts about wanting to be dead or active thoughts about killing oneself, not
accompanied by preparatory behaviour.
Self-harm An act with non-fatal outcome, in which an individual deliberately initiates a non-habitual behaviour
that, without intervention from others, will cause self-harm, or deliberately ingests a substance in
excess of the prescribed or generally recognised therapeutic dosage, and which is aimed at realising
changes which the subject desired via the actual or expected physical consequences.
Suicidal behaviour Includes suicide, suicide attempts, other suicidal behaviour and preparatory acts.

form of recent suicidal ideation.4 It has been estimated that
5e14% of individuals with chronic pain attempt suicide over
their lifetime, and this risk could be four times higher in pa-
tients referred to a pain clinic.2,5 A retrospective analysis of
the National Violent Death reporting system in the United
States from 2003 to 2014 showed that chronic pain was pre-
sent in 9% of the 123,000 individuals who died by suicide.6 This
figure is likely to be an underestimate because of the nature of
the data and the limitations of data collection. Therefore, it is
unlikely that we will be able to determine the true prevalence
of suicide attempts and completed suicides.
Risk factors
Risk factors are characteristics that increase the risk of sui-
cidality. As most patients who attempt or complete suicide
have prior suicidal ideation, studies on risk factors for suici-
dality focus on suicidal ideation. These studies are limited by
the fact that risk factors for suicidal ideation may not neces-
sarily predict suicide attempts and suicide completion.7 It is
difficult to conduct studies of suicide attempts and suicide
completion as they are statistically much rarer events. How-
ever, most studies have found a strong association between
chronic persistent pain and suicidal ideation, attempts and
completion in different populations.8,9
Another confounding factor is that it is difficult to differ-
entiate between a true suicide attempt and a suicide gesture
or self-harm without intent to commit suicide.8 Almost half of
adults with a lifetime history of suicide attempts reported that
it was an act of desperation to gain help or support and that
they did not want to die.10
Pain-related risk factors
Few studies have suggested that there is an association be-
tween specific pain characteristics and an increased risk of
suicidality. Counterintuitively, some studies indicate that
although chronic pain is independently associated with
increased risk, this is not related to the pain characteristics.11
Pain intensity
There is some evidence to support the intuitive view that the
risk of suicidal ideation and suicide attempts increases with
the intensity of pain. The risk of suicidal ideation increased
with moderate to very severe pain (odds ratio 3.39) and pain
interference (odds ratio 2.3) even after adjustment for baseline
sociodemographic variables and mental disorders.12 A large
database study of 221,817 patients found that even after
adjusting for covariates, the presence of moderate to severe
pain in the year before accessing pain services was signifi-
cantly associated with suicide attempts with hazard ratios of
1.41 and 1.29, respectively.13
Type of pain
Few studies have attempted to determine the extent to which
suicide is associated with specific pain conditions. In the
largest database study so far (n¼4,863,086) that explored the
risk of suicidality with non-cancer pain conditions, an
increased risk was present with every chronic pain condition
except arthritis and neuropathy.14 However, after controlling
for covariates including comorbid psychiatric conditions,
significant associations were only found for back pain,
migraine and ‘psychogenic pain’. Psychogenic pain is an
outdated term that refers to pain that can be attributed to
psychological conditions. The authors of this study speculate
that the risk of suicidality was increased in patients given this
flawed diagnosis as they are likely to have received less active
treatment because clinicians did not perceive the pain to be
real. Back pain and pain from arthritis were the most common
medical conditions in suicide decedents from the National
Violent Death Reporting System.6 Although the evidence is
unclear and sometimes contradictory, it is possible that there
are important differences in the risk of suicidality between
different pain conditions and that the risk is increased even in
patients without comorbid psychiatric conditions. This high-
lights the need to assess risk even when psychiatric comor-
bidity is not apparent.
Pain-related sleep disturbances
Sleep disturbances are common in patients with chronic pain
with a prevalence of 50e80%.15 The bidirectional relationship
between chronic pain and insomnia is well establisheddsleep
deprivation resulting from insomnia increases pain intensity
which in turn causes sleep disturbances.15 Suicidal ideation is
more prevalent in patients with chronic pain who report se-
vere insomnia resulting in daytime dysfunction and high pain

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Suicidality in chronic pain

intensity.16 This effect is independent of the effects of

depression, which is often associated with insomnia. Not all Table 2 Risk factors and protective factors for suicidality in
patients who experience sleep disturbances describe suicidal chronic pain.23,24
ideation. The process by which sleep deprivation may lead to
suicidal ideation and behaviours is poorly understood. Risk factors

Pain-related risk factors

Pain-related catastrophising
Catastrophising is a maladaptive coping strategy that has
Pain characteristicsdintensity and type of pain
been associated with pain-related disability. It is charac-
Sleep disturbances

Pain catastrophising
terised by the tendency to amplify the threat value of pain,

Opioid use
helplessness and the persistence of pain-related thoughts.17
The magnitude of catastrophising is a consistent predictor
General risk factors
of the risk of suicidal ideation and behaviours, the effect of
which is partly mediated by depression.4,18 Pain-related cat- Sociodemographic
astrophising results in insomnia caused by intrusive pain-
Stressful life events (e.g. job loss, relationship instability)
related thoughts that in turn can impact pain intensity.19
Males, LGBT, ethnic minority

Lack of social support
Personal background
Opioid use
Substance misuse
Opioids are often used for the management of chronic pain,
Feeling close to someone who died by suicide or exposure to
but their use, especially at higher doses is associated with a suicidal behaviour of key others, use of suicide-promoting
higher risk of suicidal behaviours. A large retrospective data- website/social media

Access to lethal means
base study (n¼123,946) showed that higher prescribed opioid
Psychological factors
doses were associated with increased suicide risk even after
Previous self-harm or suicide attempts
controlling for demographic and clinical features.20 The risk
Mental illness, especially recent relapse or discharge from
was least for patients receiving <20 mg morphine equivalent inpatient care

Impulsivity or diagnosis of personality disorder
per day. The relationship between opioid use and suicide is

Disengagement from mental health services
likely to be multifaceted and linked to biological, medical and
High degree of emotional pain and negative thoughts
social factors.21 Pain-related changes to reward neuro- (hopelessness, helplessness, guilt)
circuitry, concomitant mental health disorder and increased
Sense of entrapment, sense of shame, or both
opioid prescribing increase the risk of overdose and suicide
Psychotic phenomenon

with opioids. Conversely, another retrospective database

study showed that patients are at a greater risk of death from Protective factors
overdose or suicide after stopping opioid treatment, with the
Individual-level factors
risk increasing with treatment duration before stopping.22
Problem solving
The authors recommend intensive risk mitigation for at
Self-control of thoughts, behaviour and emotions
least the first 3 months after starting and after stopping
Hopefulness, reasons for living and optimism
opioids. Psychosocial factors

Connectedness to family, community and social institutions

Religious faith and spirituality
General risk factors Employment

Easy access to effective clinical and psychological care
Several risk factors are known to increase the risk of suicide
in the general population. Patients should be evaluated for
the presence of general risk factors in addition to pain-
specific risk factors. However, it is uncertain if these fac-
to care are other major protective factors.24 Few studies have
tors differ in individuals with chronic pain. Comorbid psy-
assessed the factors associated with recovery from suicidality.
chiatric conditions such as depression and substance abuse
A secondary analysis of a national survey in Canada found
are associated with an increased risk of suicide. The high
that remission from suicidal ideation was more likely in pa-
risk associated with substance abuse has implications for
tients who were older, female, white, better educated, had a
misuse of analgesics, particularly opioids and gabapenti-
confidant and used spirituality as a coping mechanism. They
noids. The concomitant use of these two classes of drugs
were less likely to have a history of depression and anxiety,
has been associated with an increased risk of sudden death.
and less likely to have low household incomes and therefore
Table 2 provides a summary of the general risk factors for
difficulty in meeting basic expenses.25
suicidality.23,24
The complex interplay between risk and protective factors
must be considered when attempting to assess an individual’s
Protective factors vulnerability to suicidality. Not all factors have an equal
impact, but the highest risk is seen in those with multiple risk
Protective factors are characteristics that reduce the risk of
factors. The significance of factors can vary between in-
suicidality (Table 2). The role of protective factors in the
dividuals and communities.
context of chronic pain has not been extensively studied.
General protective factors that protect an individual against
suicidality include problem-solving skills, coping skills that
allow individuals to control their thoughts and emotions and
Screening tools
positive future thinking.24 Positive family relationships, social Screening tools for evaluation of the risk of suicide are often
support, religious participation, employment and easy access used in clinic practice but have a poor predictive value for

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 Suicidality in chronic pain

suicide.26 A national mixed methods study on risk assessment
Have you thought about how you may act on these
tools identified 156 risk assessment tools in all 85 NHS mental thoughts?
health trusts. In the UK, the Patient Health Questionnaire-9
The clinician’s response to these questions will also form
(PHQ-9) is used extensively in primary care to assist in the
part of the intervention. Calm, compassionate responses are
diagnosis of depression and quantify its severity and response
more likely to contain distress than dismissive or anxious
to treatment. Item 9 specifically screens for the presence of
responses. It is also important to establish barriers that pre-
suicidal ideation. A positive response is a moderate predictor
vent patients from acting on any disclosed plans and to
of subsequent death resulting from suicide. In a retrospective
ascertain any protective factors (Fig. 1). It is necessary to
database study of 84,418 outpatients, the cumulative risk of
highlight the difference between thinking about suicide and
death attributable to suicide at 1 yr increased from 0.03%
acting on such thoughts to fully ascertain the next steps. The
among those reporting no thoughts of death or self-harm
clinician’s instinct is important, because patients can deny
ideation to 0.3% among those reporting such thoughts
suicidal thoughts. A mismatch between words and behaviour
‘nearly every day’.27
should warn clinicians of attempts to downplay the psycho-
Using depression screening tools such as PHQ-9 might not
logical impact of pain.
be sufficient to detect the risk of suicide and are not a
replacement for a comprehensive assessment of suicidality
and protective factors. Although a positive response to item 9 Warning signs
is associated with increased risk, a negative response does not
imply a reduced risk. In a study of veterans, 71.6% of veterans Risk factors are characteristics that increase the risk of sui-
who completed suicide responded ‘not at all’ to item 9 in the cidality but do not indicate the immediate risk of suicide.33
PHQ-9 completed within 30 days.28 The National Institute for Risk factors apply to populations rather than at an individ-
Health and Care Excellence (NICE) in the UK has published ual level. It is important to differentiate between the two as
guidelines on the management of self-harm that specifically this determines any actions required. It is important to
recommend that risk assessment tools should not be used to remember that the absence of risk factors does not mean that
predict future suicide or repetition of self-harm.29 The limi- the patient is not at risk of suicide. Not all ‘high-risk’ patients
tations of the tools are well recognised but most clinicians are vulnerable to suicide. An understanding of risk factors
support their use as a tool to guide assessment, but not for allows individuals and communities to implement strategies
predictive purposes.30 A comprehensive psychosocial to decrease risk over time. However, assessment for warning
assessment taking into account individual needs and risks signs is essential to help recognise behaviours that indicate an
should inform a management plan instead. immediate risk of suicide that necessitates appropriate steps
to mitigate this risk. An individual may be at a high risk of
suicide if they state that they want to hurt or kill themselves,
actively look for ways to kill themselves such as stockpiling
Assessment of risk tablets or talk or write about death, dying or suicide. Table 3
lists some behaviours that are warning signs of immediate
A collaborative and compassionate assessment of risks risk of suicide.34
including questioning about suicidal plans is an essential
component of the pain consultation. The absence of risk
should not be assumed in patients who do not report any Management of risk
suicidal ideation. Some 60% of patients who later die by sui-
The management of acute suicide risk is different from that of
cide deny having suicidal thoughts when questioned and only
patients who are at a high but not imminent risk. Figure 1
1.7% of patients with suicidal ideation die as a result of sui-
gives an overview of the management of risk in the pain clinic.
cide.31 A compassionate consultation with assessment after
establishing a rapport is more likely to enable patients to ex-
press their feelings and help identify those at risk. Imminent risk
When assessing risk, questions should be unambiguous. It
In individuals at imminent risk (that is, suicidal ideation has
can feel uncomfortable to ask about suicidal intent but every
been identified and the person has a plan to act on these
patient must be asked about suicidal ideation and intent at the
thoughts or has a lack of barriers to acting on these thoughts
initial assessment, regardless of presentation. A risk assess-
and is unsure as to how they may keep themselves safe), ur-
ment should be conducted at every visit, regardless of an
gent referral to local crisis teams is essential to provide a
apparent absence of suicidal ideation at the initial assessment
thorough risk assessment and appropriate support. The Na-
(Fig. 1). Some clinicians are concerned that asking about sui-
tional Confidential Enquiry into suicide and homicide in pa-
cide risk increases the chances that someone will act on their
tients with mental illness found that patient safety was
ideation, or that they are somehow ‘putting ideas into the
improved with access to 24-h crisis care.35 The patient must
patient’s head’. On the contrary, asking about suicide can
be escorted to the emergency department if the patient is seen
decrease suicide risk,32 (Supplementary Fig. S1).
in hospital. If the patient leaves the clinic and you are con-
Questions that might help elicit information about the risk
cerned for their safety, contact the police for a welfare check.
of suicide include:
A robust safety plan, adequate support and removal of access

Do you feel life is not worth living? (If yes, unambiguously to means are required.
asking about suicide is important)

Have you had thoughts about ending your life? (If yes, it is
Risk not imminent
important to establish intent)

Have you felt like acting on these thoughts? (If yes, it is When the risk of suicide is not imminent, the overall strategy
then important to establish means) includes collaborative and compassionate assessment and

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Suicidality in chronic pain

Assess for intent

Do you feel life is not worth living?
Have you had thoughts about ending your life?
Have you felt like acting on these thoughts?
Imminent risk
Refer to the local crisis team for an urgent
assessment. Escort to ED if in hospital. If the
patient leaves the clinic, contact police for a
welfare check.

Are there evidence of plans and reduced
barriers?
Assess if the patient intends to act on their plan
or is at risk of impulsively acting on their plan.
Have you thought about how you may act on
these thoughts? Have you made any current or
future plans? Do you have access to means?
Have you made preparations? E.g. wills, notes,
goodbyes.
Establish barriers to acting on feelings. Is there
anything that keeps you from harming yourself?
What would stop you?
Highlight difference between thinking about
suicide and acting on thoughts. How likely is it
you will act on these thoughts in the next
month? Can you keep yourself safe?
Not at imminent risk but limited barriers
Limit access to means and review
medications that can be potentially lethal in
an overdose.
Establish safety plan if feelings increase.
What would you do if you had an increase in
thoughts?
Continue to monitor risk at subsequent
attendances. Contact primary care clinician
urgently and agree on collaborative
approach to review and monitoring.
Not at imminent risk and barriers present
Establish safety plan if feelings increase.
Contact primary care clinician to establish
monitoring of risk.

Safety plan components

Individualised strategies (reminders of barriers, music)

Calming/distracting activities (calming thoughts, writing down feelings)
Restriction of access to common means of suicide (making medications less accessible)
Contacts for social and crisis support (friends, family, suicide prevention helplines or website,
local healthcare support, emergency contacts for out of hours support)

Fig 1 Assessment of suicide risk and management.

intervention, co-production of a safety plan, liaising with the

primary care clinicians and limiting access to means. Table 3 Warning signs of immediate risk of suicide.34

Means restriction Talking about:

In all individuals at risk of suicide, regardless of protective
Wanting to die
factors, limiting access to means is recommended. Means
Great guilt or shame

Being a burden to others
restriction has historically been a successful method of
limiting risk.36 The assumption that a person deprived of the Feeling:
means of harming themselves will simply choose different
Empty, hopeless, trapped, or having no reason to live

Extremely sad, more anxious, agitated, or full of rage
means is wrong. Suicidality in its acute phase is a state that

Unbearable emotional or physical pain
fluctuates, and if a person can be kept safe throughout the
peak of a suicidal crisis, the immediate risk is reduced. Drug Changing behaviour, such as:

Making a plan or researching ways to die
overdose with prescription medicines is a common method of
Withdrawing from friends, saying goodbye, giving away
suicide, with opioids having the highest risk of fatal outcomes important items, or making a will
followed by barbiturates and antidepressants.37 Means re-
Taking dangerous risks such as driving extremely fast
striction could therefore include strategies to reduce avail-
Displaying extreme mood swings

Eating or sleeping more or less
ability of potentially lethal drugs such as limiting the duration

Using drugs or alcohol more often
of prescriptions, regular assessment and monitoring for
dependence and withdrawal if necessary. NICE has published

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comprehensive guidance for safe prescribing of medicines
associated with dependence or withdrawal that can help
guide prescribing in this cohort of patients.38
Safety plan
A risk management plan (safety plan) is integral to mitigating
the risk of suicide. This is a mutually agreed set of strategies
including individualised strategies that can keep patients safe
such as activities to increase hope, calming or distracting ac-
tivities, means restriction and contacts for support in the
event of worsening suicidal thoughts and increased risk of
suicide. The Royal College of Psychiatrists report on self-harm
and suicide in adults (CR229) recommends the use of online
platforms to facilitate the development of safety plans such as
https://stayingsafe.net/.23
Psychological interventions
Psychological assessment can identify risk factors for suicidal
ideation such as sleep difficulties and catastrophising that
may be amenable to psychological interventions. Suicidal
ideation is not in itself a barrier to pain rehabilitation, but
acute suicidal intent needs to be managed outside of the
chronic pain clinic setting, which typically does not provide
the level of intensity needed, or the ability to provide out of
hours support
Managing pain-related distress
Pain not only affects the body but also how people feel
emotionally. Patients can experience many losses because of
pain such as their social life, job and financesdthis can lead to
low self-esteem and distress. Although some patients can
cope well, others are unable to manage their distress. The
psychological factors that determine the ability to cope are not
clear but there is evidence for the role of mental defeat. The
daily experience of living with debilitating pain that does not
respond to treatment can cause patients to view themselves
negatively as a failure. Mental defeat is associated with a high
risk of suicidal intent.39
Hopelessness is another driving factor for suicidal ideation.
Hope itself has been conceptualised as a cognitive process with
three parts: goal, pathway and agency.40 The hope that medical
interventions will cure chronic pain may lead to despair and an
increase in suicidality when this does not occur.
Clinicians can help by removing the focus from diagnosis
and cure where this is not possible to helping patients achieve
valued goals. Identification of clear pain management goals
and setting a realistic pathway for treatment and facilitating
patient belief in their ability to work towards their valued
goals is more helpful than setting up idealistic expectations of
cure.
Conclusions
Suicidal ideation is common in patients attending the pain
clinic and is associated with an increased risk of suicide.
However, the absence of ideation and risk factors of suicidality
does not indicate the absence of risk of suicide. Appropriate
pain management and an individualised assessment of intent
and protective factors could help to mitigate this risk.
Declaration of interests
MC is an editor and editorial board member of BJA Education.
SB declares that they have no conflicts of interest.
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Suicidality in chronic pain
MCQs
The associated MCQs (to support CME/CPD activity) will be
accessible at www.bjaed.org/cme/home by subscribers to BJA
Education.
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.bjae.2023.05.005.
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