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Mady Ohlman was 22 on the evening some years ago when she stood in a friend’s bathroom looking down at the sink.

“I had set up a bunch of needles filled with heroin because I wanted to just do them back-to-back-to-back,” Ohlman recalled. She doesn’t remember how many she injected before collapsing, or how long she lay drugged-out on the floor.

“But I remember being pissed because I could still get up, you know?”

She wanted to be dead, she said, glancing down, a wisp of straight brown hair slipping from behind an ear across her thin face.

At that point, said Ohlman, she’d been addicted to opioids — controlled by the drugs — for more than three years.

“And doing all these things you don’t want to do that are horrible — you know, selling my body, stealing from my mom, sleeping in my car,” Ohlman said. “How could I not be suicidal?”

For this young woman, whose weight had dropped to about 90 pounds, who was shooting heroin just to avoid feeling violently ill, suicide seemed a painless way out.

“You realize getting clean would be a lot of work,” Ohlman said, her voice rising. “And you realize dying would be a lot less painful. You also feel like you’ll be doing everyone else a favor if you die.”

Ohlman, who has now been sober for more than four years, said many drug users hit the same point, when the disease and the pursuit of illegal drugs crushes their will to live. Ohlman is among at least 40 percent of active drug users who wrestle with depression, anxiety or another mental health issue that increases the risk of suicide.

Measuring Suicide Among Patients Addicted To Opioids

Massachusetts, where Ohlman lives, began formally recognizing in May 2017 that some opioid overdose deaths are suicides. The state confirmed only about 2 percent of all overdose deaths as suicides, but Dr. Monica Bharel, head of the Massachusetts Department of Public Health, said it’s difficult to determine a person’s true intent.

“For one thing, medical examiners use different criteria for whether suicide was involved or not,” Bharel said, and the “tremendous amount of stigma surrounding both overdose deaths and suicide sometimes makes it extremely challenging to piece everything together and figure out unintentional and intentional.”

Research on drug addiction and suicide suggests much higher numbers.

“[Based on the literature that’s available], it looks like it’s anywhere between 25 and 45 percent of deaths by overdose that may be actual suicides,” said Dr. Maria Oquendo, immediate past president of the American Psychiatric Association.

“But I remember being pissed because I could still get up, you know?”

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Oquendo pointed to one study of overdoses from prescription opioids that found nearly 54 percent were unintentional. The rest were either suicide attempts or undetermined.

Several large studies show an increased risk of suicide among drug users addicted to opioids, especially women. In a study of about 5 million veterans, women were eight times as likely as others to be at risk for suicide, while men faced a twofold risk.

The opioid epidemic is occurring at the same time suicides have hit a 30-year high, but Oquendo said few doctors look for a connection.

“They are not monitoring it,” said Oquendo, who chairs the department of psychiatry at the University of Pennsylvania. “They are probably not assessing it in the kinds of depths they would need to prevent some of the deaths.”

That’s starting to change. A few hospitals in Boston, for example, aim to ask every patient admitted about substance use, as well as about whether they’ve considered hurting themselves.

“No one has answered the chicken and egg [problem],” said Dr. Kiame Mahaniah, a family physician who runs the Lynn Community Health Center in Lynn, Mass. Is it that patients “have mental health issues that lead to addiction, or did a life of addiction then trigger mental health problems?”

With so little data to go on, “it’s so important to provide treatment that covers all those bases,” Mahaniah said.

‘Deaths Of Despair’

When doctors do look deeper into the reasons patients addicted to opioids become suicidal, some economists predict they’ll find deep reservoirs of depression and pain.

In a seminal paper published in 2015, Princeton economists Angus Deaton and Anne Case tracked falling marriage rates, the loss of stable middle-class jobs and rising rates of self-reported pain. The authors say opioid overdoses, suicides and diseases related to alcoholism are all often “deaths of despair.”

“We think of opioids as something that’s thrown petrol on the flames and made things infinitely worse,” Deaton said, “but the underlying deep malaise would be there even without the opioids.”

Many economists agree on remedies for that deep malaise. Harvard economics professor David Cutler said solutions include a good education, a steady job that pays a decent wage, secure housing, food and health care.

“And also thinking about a sense of purpose in life,” Cutler said. “That is, even if one is doing well financially, is there a sense that one is contributing in a meaningful way?”

Tackling Despair In The Addiction Community

“I know firsthand the sense of hopelessness that people can feel in the throes of addiction,” said Michael Botticelli, executive director of the Grayken Center for Addiction at Boston Medical Center; he is in recovery for an addiction to alcohol.

Botticelli said recovery programs must help patients come out of isolation and create or recreate bonds with family and friends.

“The vast majority of people I know who are in recovery often talk about this profound sense of re-establishing — and sometimes establishing for the first time — a connection to a much larger community,” Botticelli said.

“We think of opioids as something that’s thrown petrol on the flames and made things infinitely worse, but the underlying deep malaise would be there even without the opioids.”

Ohlman said she isn’t sure why her attempted suicide, with multiple injections of heroin, didn’t work.

“I just got really lucky,” Ohlman said. “I don’t know how.”

A big part of her recovery strategy involves building a supportive community, she said.

“Meetings; 12-step; sponsorship and networking; being involved with people doing what I’m doing,” said Ohlman, ticking through a list of her priorities.

There’s a fatal overdose at least once a week within her Cape Cod community, she said. Some are accidental, others not. Ohlman said she’s convinced that telling her story, of losing and then finding hope, will help bring those numbers down.

The National Suicide Prevention Lifeline is 800-273-8255.

This story is part of a partnership that includes WBUR, NPR and Kaiser Health News.

This story was written by Martha Berbinger and contributed by Kaiser Health News, a national health policy news service that is an editorially independent part of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.