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 recalls. 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 says, glancing down. A wisp of straight brown hair slips from behind an ear across her thin face.
At that point, says Ohlman, she'd been addicted to opioids — controlled by the drugs, she says — 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 says. "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 says, 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, says 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 says confirmed suicides are only about 2 percent of all overdose deaths, but Dr. Monica Bharel, head of Massachussett's department of public health, says it's very difficult to determine the person's true intent.
"For one thing, medical examiners use different criteria for whether suicide was involved or not," Bharel says, 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," says Dr. Maria Oquendo, immediate past president of the American Psychiatric Association.
Oquendo points to one study of overdoses from prescription opioids that found 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 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 says few doctors look for a connection.
"They are not monitoring it," says 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 [question]," says 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 says.
'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 marriages 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 says, "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 says 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 says. "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," says Michael Botticelli, director of the Grayken Center for Addiction at Boston Medical Center; he is in recovery for an addiction to alcohol.
Botticelli says 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 reestablishing — and sometimes establishing for the first time — a connection to a much larger community," Botticelli says.
Ohlman says she isn't sure why her attempted suicide, with multiple injections of heroin, didn't work.
"I just got really lucky," Ohlman says. "I don't know how."
A big part of her recovery strategy involves building a supportive community, she says.
"Meetings; 12-step; sponsorship and networking; being involved with people doing what I'm doing," says Ohlman, ticking through a list of her priorities.
There's a fatal overdose at least once a week within her Cape Cod community, she says. Some are accidental, others not. Ohlman is 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 NPR's reporting partnership with NPR, WBUR and Kaiser Health News .
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