America is undercounting the number of suicide deaths, despite the rise in suicide rates in the 21st century, experts caution in a commentary published in the journal Injury Prevention .
In 2024, the national suicide rate was 37.5% higher than in 2000. During that same period, the death rate from opioid and other drug poisoning increased more than threefold. Yet the recorded suicide rate from drug poisoning only increased from 1.3 to 1.8 per 100,000 people.
Injury epidemiologist Ian Rockett, PhD, adjunct professor of Psychiatry at University of Rochester Medicine who authored a lead essay in the commentary, believes that as many as 30% of overdose deaths recorded as “accidental” or of “undetermined” intent may in truth be suicides.
Why are most overdose deaths classified as accidents?
While the ongoing opioid epidemic has led to increases in suicides by drug poisoning, these deaths are highly susceptible to misclassification, says Rockett, who has studied the undercounting of injury and mortality for over three decades. For medical examiners and coroners, suicides by drug poisoning are not as clear cut as suicides by more overt methods like hanging or firearm. With limited investigative resources and inconsistent levels of training, medical examiners and coroners often turn to “accident” as the default determination, as they are unable to determine a person’s intent given a lack of supporting evidence.
“Most drug overdoses are the result of motivated behaviors and are not ‘accidents’ in the strict sense. They aren’t completely random events like a tree branch falling on someone’s head,” explained Eric Caine, MD, professor emeritus of Psychiatry and co-founder and past director of the Center for the Study and Prevention of Suicide at University of Rochester Medicine. “Recurrent illicit drug use, especially with drugs from unknown sources, is really self‑injury in a public health sense, often leading to death but not accidental death.”
A New Measure: Self-Injury Mortality
Rockett proposes using a reporting concept called self-injury mortality or SIM—a hybrid measure that combines registered suicides with most drug-self-intoxication deaths. SIM shifts the focus away from inferring intent after death (something that is very difficult to do without a suicide note, documented psychiatric history, or a record of prior attempts) to accounting for the behaviors of the individual prior to death.
A SIM checkbox on death certificates could help to distinguish true accidents from volitional acts, like deliberately using illicit drugs. Caine, who contributed to the commentary, believes this would provide “a clearer understanding of the behavior without getting caught up in intentionality questions.”
Commentary authors Steven Stack and Kurt Nolte, from Wayne State University and University of New Mexico School of Medicine respectively, agree that SIM is a well-conceived, more inclusive measure that can help to reveal hidden suicide death data.
A Call to Action: Understand the Size of the Problem
Suicide has long been prone to underreporting, due in large part to stigma and scarcity of expertise and resources in medical examiner and coroner offices. But Rockett believes that accounting and reporting has deteriorated substantially as the opioid and suicide epidemics, and more recently, the COVID-19 pandemic, overwhelmed already-stressed medical examiners and coroners.
Commentary authors believe the use of SIM could reduce the biases and other factors that distort suicide statistics, providing a more accurate picture of the problem in the U.S.
“In public health, the first step is to know the size of a problem. Then you can develop interventions and measure outcomes accurately,” added Caine. “Misclassification and undercounting break this chain. Without an accurate measure of burden, it is impossible to gauge how big the problem is or to evaluate interventions.”
Injury Prevention
People
Deterioration of American suicide accounting as rates rise during the 21st century and responses by suicidologists with respective expertise in psychiatry, sociology and forensic pathology
14-Jul-2026