Pain isn't always obvious - Know the signs - Suicide is preventable

Talking Points and Data Briefing on the Intersection of Substance Use and Suicide Prevention



National Recovery Month (Recovery Month) is a national observance held every September to educate Americans that substance use treatment and mental health services can enable those with a mental and/or substance use disorder to live a healthy and rewarding life. This year, in support of National Suicide Prevention Awareness Week and World Suicide Prevention day, also held in the month of September, we are encouraging a special focus on the intersection between alcohol and drug use and suicide prevention. The observances are closely related, as there’s a strong co-morbidity and substantial overlap among risk and protective factors.  


  • Alcohol and Drug Use Disorders have been found to be second only to Depression and other  Mood Disorders as the most frequent risk factors for suicidal behavior (1).  
  • Increased alcohol and drug use has often been reported as a warning sign for suicide (2).
  • Individuals with a diagnosable substance use disorder are almost 6 times more likely to report a lifetime suicide attempt than those without a substance use disorder (3). 
  • Numerous studies of individuals in drug and alcohol treatment programs show that past suicide attempts and current suicidal thoughts are common (4,5). 

Commonly Used Terms

Substance Use: the use of alcohol or drugs, and includes substances such as cigarettes, marijuana, illegal drugs, prescription drugs, inhalants and solvents. 

Substance Misuse: the harmful or hazardous use of substances including alcohol and drugs such as cigarettes, marijuana, illegal drugs, prescription drugs, inhalants and solvents. 

Substance Use Disorder: the Diagnostic and Statistical Manual of Mental Disorders term used for when the recurrent use of alcohol and/or drugs causes significant impairment, including health problems, disability, and failure to meet major responsibilities. 

Addiction: a chronic, relapsing disorder characterized by compulsive alcohol or drug seeking, continued use despite harmful consequences, and long-lasting changes in the brain. 

Risk Factors: characteristics of a person or his or her environment that put that am at disproportionately higher likelihood of suicide.  

Protective Factors: personal or environmental characteristics that help protect people from suicide.



Suicides and Suicide Attempts are Significantly Affected by Substance Use


Many individuals turn to drugs and alcohol as a solution for managing symptoms such as anxiety and depression, especially when no other coping mechanisms are sought or known. On the other hand, the use of substances can also trigger or worsen co-occurring symptoms such as anxiety or depression. In both cases, the risk of suicide may increase. For example, a level of disinhibition occurs when an individual is intoxicated, which may be one of the reasons alcohol and/or drug misuse is a significant risk factor for suicide (3). Further, it has been found that suicide is a leading cause of death among people who misuse alcohol and drugs (3). 

  • 22% of suicide deaths involved alcohol intoxication (3)
  • 30-40% of suicide attempts involved acute alcohol intoxication (3). 
  • 20% of suicide deaths involved opiates (3). 
  • From 2005 to 2011, drug related suicide attempts treated in the emergency department increased 51%, with almost all involving a prescription drug over-the-counter medication (3). 


Shared Risk & Protective Factors (3)


Individuals at risk for substance misuse and suicide share a number of risk factors, as well as protective factors. Individuals with a diagnosable substance use disorder are almost 6 times more likely to report a lifetime suicide attempt than those without a substance use disorder (4). When compared to the general population, individuals treated for alcohol use disorder are at a 10 times greater risk of suicide (11). The suicide rate among males with a substance use disorder is 2 to 3 times higher than among males who do not have a substance use disorder. Among women, a substance use disorder increases the risk of suicide by 6.5 times (7).  


Individuals who enter into treatment, after the cessation of all alcohol and drug use, and/or while in addiction recovery are often at higher risk of suicide for several reasons. They often feel overwhelmed by mental health symptoms that they have been medicating with substance use. They are often entering treatment when a number of co-occurring life crises may be occurring (e.g., the loss of a job, marital problems), when their substance use is out of control, increasing other risk factors; and lastly they enter treatment at peaks in depressive symptoms (9). 


If professionals and peers are aware of the overlap between risk and protective factors amongst those at risk of substance misuse and suicide they can implement prevention programming that reduces risk and enhances protective factors. The image below, from SAMHSA (3) summarizes the shared risk and protective factors amongst those abusing substances and those who may be suicidal. 

  Shared risk factors and shared protective factors

Alcohol and Drug (AOD) Treatment Providers – Partners in Suicide Prevention


Numerous studies of individuals in drug and alcohol treatment programs show that past suicide attempts and current suicidal thoughts are common (5,6). Because alcohol and other drug treatment providers are in regular contact with patients at risk for relapse and suicide, they are an important resource for early detection and prevention of suicidal behavior. Further, alcohol and other drug treatment providers and suicide prevention professionals have a unique opportunity to collaborate with one another to address common goals. The following graphic from SAMSHA (3) summarizes what alcohol and other drug treatment providers (substance misuse professionals) and suicide prevention professionals can do, together, to improve outcomes for the greater good. 




What Can You Do?

  • Invite AOD providers to participate in suicide prevention gatekeeper trainings, or if you are an AOD provider, request a suicide prevention presentation or training from your local county behavioral health agency.
  • Ask AOD providers to share information about suicide prevention in their publications and on social media.  Pre-written social media posts and drop-in articles can be found in the Suicide Prevention Week Activation Kits on the Each Mind Matters website:
  • Ask AOD providers to post one or more of the ‘Know the Signs’ posters in their building.  These can be downloaded for free at
  • Share the educational (and fun!) suicide prevention activities created by Each Mind Matters with AOD providers to host a game night.  Available activities include Bingo/Loteria and Trivia.  Both of these can be downloaded for free on the







Restaurant and Bar Industry – Partners in Suicide Prevention

A survey of over 2000 culinary workers conducted by the Heirloom Foundation found that 94% reported having current or past mental health issues, particularly depression, anxiety and substance use disorders (12). Three quarters of respondents reported multiple mental health conditions. Most respondents pointed to the stigma of mental health conditions and lack of access to behavioral health care as major barriers. In 2016 SAMHSA reported that food service and accommodation workers had the highest reported rates of a past year substance use disorder of any industry included in the study, and that rates of illicit drug use were rising in that industry (13).


The Centers for Disease Control’s Suicide Rates by Major Occupational Group reported that Food Preparation and Serving Related industry had the 11th highest rate of suicide of occupations, and that this rate had increased by 43% between 2012 and 2015 (14). 


Several common occupational-related factors might contribute to these statistics. Restaurant work is often characterized by irregular hours, high pressure and stress, fast pace and physical demands that can lead to injuries and chronic pain.  Alcohol is abundant and readily available. Many do not have health insurance, and access to behavioral health care is limited. There is a culture of valuing “toughness” in holding up under the strains of the work. Many workers blow off steam and manage physical and mental stress through alcohol and drug use. People working within the industry report that stigma around admitting mental health and substance use problems, as well as concerns about career jeopardy, close a vicious loop that keeps people who need help from seeking it.


These statistics were collected well before the COVID-19 crisis hit in March 2020. Since then most restaurants have had to significantly change the way they do business, and some have had to close their doors altogether. In addition to the heartbreak of losing a business built with hard work and a dream, the pandemic has led to loss of work for many employed in the restaurant industry, with no clear end in sight. The hardship and uncertainty of these times for those in the restaurant industry is leading to behavioral health challenges among those who may never have experienced them before and is likely to compound risk for those who were already vulnerable. 


A shining light in the restaurant industry is "I Got Your Back". This initiative was formed in 2019 not long after the death of Anthony Bourdain by a chef in Sacramento who had lost many colleagues to suicide and wanted to help. I Got Your Back is a collaborative effort across several restaurants in the Sacramento area that is working to change the culture around mental health. Components include training, confidential online screening tools, and encouraging help-seeking through training peer counselors and promoting local resources.


Fair Kitchens is a movement to inspire a culture of wellness within the restaurant industry. The organization has found that research by Unilever Food Solutions revealed a serious wellbeing issue within professional kitchens: 74% of chefs are sleep deprived to the point of exhaustion; 63% of chefs feel depressed, and more than half feels pushed to the breaking point. Overall, the organization believes that a positive kitchen culture will make for a healthier business overall. Fair Kitchen’s website includes solutions to achieve a culture of wellness, such as mental health trainings for chefs and mental health guides. In addition, chefs across the world are featured in personal video stories where they share about their own principles of wellness and mental health. 


A Balanced Glass, is a forum that offers insights, learnings and tips to support the physical and mental health and wellness of wine professionals around the world. Recognizing that managing long-term health while working with and around alcohol is not always easy. The forum provides a community, as well as weekly stories, to help bring guidance and access to others in the industry. Since its launch in March 2018, more than 500 wine professionals spanning nine countries have joined the community. 


The California Restaurant Association offers advocacy and guidelines for best practices in the restaurant industry, including staff wellness and health. It also shares the latest information about COVID-19-related policies, relief programs, and how to meet new requirements. The CRA has chapters around the state. Visit their web site at to find out about their work and to locate chapters around the state.  



What Can You Do?

  • Learn about restaurant initiatives that might be happening in your county or bring one to your county!
  • Offer to partner with restaurants to launch a campaign using Each Mind Matters and Know the Signs materials and toolkits to promote wellness, stigma reduction, and suicide prevention among restaurant staff.
  • Ask local restaurant associations to share suicide prevention information in their staff communication, post Know the Signs posters in their common areas, and share social media posts during September and throughout the year.  All of these can be found in the Suicide Prevention Week Activation Kits on the Each Mind Matters website:
  • Connect with the restaurant industry in your area to offer suicide prevention gatekeeper trainings for employees. Contact individual restaurants or reach out to the California Restaurant Association to ask about chapters in your area.
  • Share ‘Know the Signs’ coasters with local restaurants and bars.  
  • Partner with a local restaurant to host a Trivia night! An activity tip sheet and Trivia game cards can be downloaded on the 
  • Search the EMM Collection on Suicide Prevention in the Workplace to find out more about effective workplace strategies and tools such as educational presentations, drop-in articles, and outreach materials.



Each Mind Matters Resources: A wide range of resources can be viewed and downloaded on the Each Mind Matters Resource Center at




  1. Center for Disease Control: Suicide Rising Across US
  2. Center for Disease Control: Suicides Due to Alcohol and/or Drug Overdose (Accessed: 11/25/19)
  3. SAMSHA: Substance Use and Suicide (Accessed 11/25/19)
  4. Kessler RC, Borges G, Walters EE. Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Survey. Arch Gen Psychiatry. 1999;56:617-626. (Accessed 11/25/19)
  5. Ilgen MA, Burnette ML, Conner KR, et al. The association between violence and lifetime suicidal thoughts and behaviors in individuals treated for substance use disorders. Addict Behav. 2010;35:111-115. (Accessed 11/25/19)
  6. Roy A. Characteristics of cocaine dependent patients who attempt suicide. Arch Suicide Res. 2009;13:46-51. (Accessed 11/25/19)
  7. Ilgen MA, Bohnert AS, Ignacio RV, et al. Psychiatric diagnoses and risk of suicide in veterans. Arch Gen Psychiatry. 2010;67:1152-1158. (Accessed 11/25/19)
  8. SAMSHA: (Accessed 4/7/20)
  9. Ross, J., Teesson, M., Darke, S., Lynskey, M.,Ali, R., Ritter, A. et al. (2005). The characteristics of heroin users entering treatment:findings from the Australian treatment outcome study (ATOS). Drug and Alcohol Review, 24, 411­418 (Accessed 4/7/20). 
  10. Ilgen, M. A., Harris, A. H., Moos, R. H., & Tiet, Q. Q. (2007). Predictors of a suicide attempt one year after entry into substance use disorder treatment. Alcoholism: Clinical and Experimental Research, 31, 635–642. (Accessed 4/7/20).
  11. 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. (Accessed 4/7/20).