This article is from Kaiser Health News, a nonprofit news service covering health issues. The story is part of a partnership that includes nonprofit WBUR-FM of Boston, NPR and KHN.Mady Ohlman was 22 on the evening some years ago when she stood in a friend\u2019s bathroom looking down at the sink.\u201cI had set up a bunch of needles filled with heroin because I wanted to just do them back-to-back-to-back,\u201d Ohlman recalled. She doesn\u2019t remember how many she injected before collapsing, or how long she lay drugged-out on the floor.\u201cBut I remember being pissed because I could still get up, you know?\u201dShe 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\u2019d been addicted to opioids \u2014 controlled by the drugs \u2014 for more than three years.\u201cAnd doing all these things you don\u2019t want to do that are horrible \u2014 you know, selling my body, stealing from my mom, sleeping in my car,\u201d Ohlman said. \u201cHow could I not be suicidal?\u201dFor 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.\u201cYou realize getting clean would be a lot of work,\u201d Ohlman said, her voice rising. \u201cAnd you realize dying would be a lot less painful. You also feel like you\u2019ll be doing everyone else a favor if you die.\u201dOhlman, 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 opioidsMassachusetts, 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\u2019s difficult to determine a person\u2019s true intent.\u201cFor one thing, medical examiners use different criteria for whether suicide was involved or not,\u201d Bharel said, and the \u201ctremendous amount of stigma surrounding both overdose deaths and suicide sometimes makes it extremely challenging to piece everything together and figure out unintentional and intentional.\u201dResearch on drug addiction and suicide suggests much higher numbers.\u201c, it looks like it\u2019s anywhere between 25 and 45 percent of deaths by overdose that may be actual suicides,\u201d said Dr. Maria Oquendo, immediate past president of the American Psychiatric Association.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.\u201cThey are not monitoring it,\u201d said Oquendo, who chairs the department of psychiatry at the University of Pennsylvania. \u201cThey are probably not assessing it in the kinds of depths they would need to prevent some of the deaths.\u201dThat\u2019s 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\u2019ve considered hurting themselves.\u201cNo one has answered the chicken and egg ,\u201d said Dr. Kiame Mahaniah, a family physician who runs the Lynn Community Health Center in Lynn, Mass. Is it that patients \u201chave mental health issues that lead to addiction, or did a life of addiction then trigger mental health problems?\u201dWith so little data to go on, \u201cit\u2019s so important to provide treatment that covers all those bases,\u201d Mahaniah said.\u2018Deaths of Despair\u2019When doctors do look deeper into the reasons patients addicted to opioids become suicidal, some economists predict they\u2019ll 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 \u201cdeaths of despair.\u201d\u201cWe think of opioids as something that\u2019s thrown petrol on the flames and made things infinitely worse,\u201d Deaton said, \u201cbut the underlying deep malaise would be there even without the opioids.\u201dMany 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.\u201cAnd also thinking about a sense of purpose in life,\u201d Cutler said. \u201cThat is, even if one is doing well financially, is there a sense that one is contributing in a meaningful way?\u201dTackling despair iIn the addiction community\u201cI know firsthand the sense of hopelessness that people can feel in the throes of addiction,\u201d 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.\u201cThe vast majority of people I know who are in recovery often talk about this profound sense of re-establishing \u2014 and sometimes establishing for the first time \u2014 a connection to a much larger community,\u201d Botticelli said.Ohlman said she isn\u2019t sure why her attempted suicide, with multiple injections of heroin, didn\u2019t work.\u201cI just got really lucky,\u201d Ohlman said. \u201cI don\u2019t know how.\u201dA big part of her recovery strategy involves building a supportive community, she said.\u201cMeetings; 12-step; sponsorship and networking; being involved with people doing what I\u2019m doing,\u201d said Ohlman, ticking through a list of her priorities.There\u2019s a fatal overdose at least once a week within her Cape Cod community, she said. Some are accidental, others not. Ohlman said she\u2019s 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.