Substances and Suicide Loss: When Pain Looks for Relief

The toxicology report came back from the medical examiner, or maybe you already knew before it did. Alcohol in the system. A medication they were not supposed to be taking, or one they had quietly stopped weeks before. A pattern of substance use you had watched for years, or one you never saw coming at all. And now a single set of relentless questions sits in the middle of your grief.

Did the drugs kill them? The alcohol? The medication?

In fifteen plus years of co-facilitating our suicide loss support group at SOS Madison with my wife Teri, I have sat across from more survivors carrying some version of these questions than I can count. The question of substances and suicide loss is one of the most loaded pieces of grief a person can carry, because it feels like it should have a clean answer, and it almost never does.

What I have learned, from facilitation and from our own loss, is that a substance is rarely the whole story. It is usually a piece of a much older and much harder story, one about pain that had gone on too long and finally found something that promised to make it quieter. Understanding that difference does not undo what happened. It can change what you are carrying, and how heavy it feels to carry it.

If you are in crisis right now, please call or text 988 for the 988 Suicide and Crisis Lifeline. They are available around the clock, and survivors of suicide loss carry a real, elevated risk of their own.

In This Post

• What the Toxicology Report Actually Tells You
• Why Does a Positive Result Still Leave You With More Questions?
• The Medication Question and the Black Box Warning
• What Supplements and Other Medications Can Hide
• When the Cause of Death Itself Is Not Clear
• Self-Medication and What They Were Actually Reaching For
• Are You Looking for Someone to Blame
• When Two Griefs Carry Two Stigmas
• What the Research Shows About Substances and Suicide Risk
• Carrying the Questions That Do Not Resolve

What the Toxicology Report Actually Tells You

A toxicology report tells you what was in a body at the time of death. That is all of what it does. It does not tell you whether the alcohol, the drugs, or the medication caused the death, whether it was the final push, or whether the death would not have happened without it.

Television has trained a lot of us to expect something different. On CSI, on the old Quincy reruns, the toxicology result is the magic moment, the single test that cracks the case and hands everyone a clean answer before the credits roll. Real forensic toxicology does not work that way. It offers one piece of a much more complicated picture, not a verdict.

For many families, the wait comes first. National data from toxicology laboratories puts the average turnaround at just over a month, and postmortem cases specifically, along with anything in a backlogged jurisdiction, often run considerably longer. That stretch of not knowing, planning a service, answering the same question from relatives, going back to work, all while a lab somewhere is still doing its work, is its own specific kind of grief. It is real before any report ever arrives, and it does not require an answer to be valid. In our case it took 12 weeks to arrive, and we had to pay for a copy of the report.

The most recent CDC data on suicide deaths, drawn from the National Violent Death Reporting System, gives a clearer picture than the numbers people assume.

Among people who died by suicide that were actually tested:

• Roughly 4 in 10 had a positive result for alcohol.
• Roughly 1 in 5 tested positive for opioids.
• Cannabis and benzodiazepines each showed up in a smaller but still real share of tested cases.

Those numbers matter, but so does something easy to miss inside them. Blood alcohol testing was only conducted for less than half of suicide deaths nationally, and most other substance categories were tested even less often. How thoroughly a death gets tested also depends heavily on where it happened. An earlier CDC review of state-level data found toxicology testing rates ranging from roughly one in four suicide deaths in Oregon to nearly all of them in Virginia, a gap that has far more to do with local medical examiner policy than with anything about the deaths themselves.

A negative or missing result does not mean a substance was absent. A positive result does not mean it was the reason.

What gets tested for matters as much as whether testing happened at all. Standard postmortem tests are often built around drugs of abuse, opioids, stimulants, and similar substances, frequently using a first-pass screening method designed specifically for that category.

Forensic toxicology guidance explicitly allows labs to skip confirming a nonimpairing prescription medication even when it shows up on an initial screen, and some therapeutic drugs are not part of the standard panel at all unless someone specifically requests them. A report that does not mention the antidepressant, the mood stabilizer, or the blood pressure medication your person took every day does not necessarily mean it was not there. It often means the panel was never looking for it.

That distinction matters for another reason too. A substance showing up on a report is not the same as the person having a substance use disorder. It might reflect a single occasion, a last attempt to feel less afraid, a dose taken specifically because the person knew what was coming and wanted to be less present for it. The report cannot tell you the difference. It was never meant to.

Suicide, in nearly every documented case, comes from an accumulation of pressures rather than one final cause. The glass slowly filling with water is the image I return to most often in our support group meetings when someone is looking for the one thing that tipped everything over. A substance is sometimes one of the last drops in a glass that had been filling for a long time. It is very rarely the whole glass.

Why Does a Positive Result Still Leave You With More Questions?

A positive result records presence, not intent. It cannot tell you whether your person leaned on that substance for years or reached for it only once, that day. It cannot tell you what they were thinking, or whether they were even fully aware of what they had taken. Toxicology explains the chemistry of a single moment. It was never meant to explain a person’s actions.

The Medication Question and the Black Box Warning

If you are wondering whether a medication played a role, you are not alone in that question, and you are not wrong to ask it.

Non-adherence to psychiatric medication is common. Research on people diagnosed with depression estimates that somewhere between 28 and 52 percent do not take medication exactly as prescribed, for reasons ranging from side effects and cost to the belief that they no longer need it once they start to feel better. Medication reduces suicide risk. It does not eliminate it, and it does not work the same way for every person, which is part of why genetic research into how people metabolize psychiatric medications has become an active area of study rather than a settled science.

There is a specific version of this concern that deserves to be discussed. Since 2004, the FDA has required a boxed warning on antidepressants describing an increased risk of suicidal thinking in children and adolescents, a warning the FDA expanded in 2007 to cover young adults up to age 24. My wife Teri reached for that exact warning in the early months after we lost our son John. Every commercial for an antidepressant seemed to list suicidal thoughts among its risks, and for a while, that warning was the only explanation she could hold onto. I wrote more about where that particular search for a target led us in the post on blame after suicide loss, if you want the fuller account.

What the warning itself actually says is more complicated than the thirty seconds of a television disclaimer. In the FDA’s own original analysis, the increase in suicidal thinking during the trials that led to the warning was small, roughly 4 percent on medication compared to 2 percent on placebo, and no suicides occurred in those trials at all. The FDA’s language accompanying the warning states plainly that depression and other psychiatric disorders are themselves the most significant cause of suicide risk, not the treatment for them.

If you are a parent sitting with this specific fear right now, you are carrying something I have carried myself, and something I have watched other parents in our support group carry. It does not make the concern irrational. It does mean the warning was never designed to say what grief sometimes needs it to say.

What Supplements and Other Medications Can Hide

There is an issue that very few people ask about, and it deserves more attention than it gets.

Supplements, over-the-counter products, and herbal remedies such as St. John’s Wort, 5-HTP, or SAMe are widely used by people trying to manage anxiety or depression outside the formal treatment system, sometimes without ever telling a doctor. Some of these interact with prescription psychiatric medications in ways that genuinely matter, and a standard toxicology screen may not test for them at all, which means they can be part of the picture without ever appearing in the report you were handed.

If you found supplements or unfamiliar bottles among the person’s things and have been quietly wondering whether they mattered, that wondering is not unreasonable. A clinical pharmacist can sometimes speak to a specific combination if you bring them the names of what was found. It will not always give you a definitive answer. It is still a real and legitimate question to bring somewhere.

When the Cause of Death Itself Is Not Clear

For some survivors, the substance question carries an added weight that goes beyond blame. It goes to whether the death was suicide at all.

The illicit drug supply in the United States has become heavily contaminated with fentanyl. According to the National Institute on Drug Abuse, law enforcement seized more than 115 million fentanyl-containing pills in 2023 alone, a number 2,300 times higher than in 2017. NIDA’s director has said plainly that any pill not obtained directly from a pharmacy carries real risk of contamination, even from a single use. Someone who purchased what they believed to be one drug may have taken something far more lethal without knowing it.

Fentanyl contamination is not the only reason a death becomes harder to identify. Many drug-related suicide deaths involve more than one substance at once, not because someone set out to combine them, but because each one alone might not have been enough. A Norwegian study of overdose suicides found more than one drug present in 96 percent of cases, most often an opioid alongside a benzodiazepine. Individually, either might have been survivable. Together, they were not. That combination is chemistry, not something anyone standing outside the moment could have known or stopped.

This is where you may be sitting with something few people talk about openly. Maybe your person didn’t want to die that day. Maybe they wanted the pain to stop for a few hours, and what they took to do that turned out to be something else entirely.

Medical examiners determine manner of death based on the evidence available about intent, and a note, if one exists, is often central to that evidence. Most people who die by suicide do not leave a suicide note, so the lack of a suicide note is common, not unusual. When that evidence is genuinely mixed, a death can be ruled undetermined rather than suicide. That single word can feel like relief to one survivor and like an erasure of the truth to another, and both reactions make complete sense. It can also carry practical consequences, including how life insurance policies with suicide exclusions are handled and how the death is recorded on official documents going forward.

If you received an undetermined ruling, or if you are sitting with real uncertainty about whether this was suicide or an accidental overdose, you are not required to resolve that uncertainty to grieve well. Some questions do not close. Peer support with other survivors who understand exactly this kind of not knowing can matter more here than continuing to search for a verdict the evidence itself cannot give you.

Self-Medication and What They Were Actually Reaching For

Here is the discussion that has mattered to many of the survivors I have sat with, and the one this whole post is really about.

Many people in real psychological pain turn to drugs or alcohol to manage what they have no other tools to handle. Alcohol quiets anxiety for a while. Opioids can quiet a kind of internal pain that is difficult to describe to anyone, including yourself. Marijuana blunts an emotional intensity that has become unbearable to sit inside.

Dr. Edwin Shneidman, widely considered the father of suicidology, spent more than forty years studying why people die by suicide. Near the end of that career, he distilled everything he had learned into what he called a five word summary of his life’s work. What that summary points to is psychache, the unbearable psychological pain that builds until a person cannot find another way through it. Suicide is very rarely about a desire to die. It is about wanting pain to stop.

Seen through that lens, the substances take on a different shape. They were not reached for because the person wanted to die. They were reached for because the person was in pain they could not carry any other way, using whatever was available, whatever seemed to help even for an hour.

Understanding that changes the perspective of the grief you carry. It moves the drugs or the drinking from cause to symptom, from verdict to evidence of how much pain someone was in and how hard they were fighting to survive it, even in a way that ultimately did not work.

This does not make their pain any less dangerous, only more understandable. Alcohol specifically lowers the barrier between suicidal thinking and suicidal action, and it remains one of the most consistently documented risk factors in the research. Discussing that risk honestly and understanding what someone was reaching for are not in conflict with each other. Both are part of seeing the whole person, not just the moment that ended their life.

If you are still in the middle of learning this yourself, that is not a failure of understanding. It took me years to get here, and some days I still have to find my way back to it.

Are You Looking for Someone to Blame

Drugs and alcohol become a focus for survivors because they are concrete. You can point to them. A pill bottle. A receipt. A conversation about drinking that you wish you had pushed harder in. In a loss that resists explanation, something concrete feels like relief, even when pointing to it does not actually explain anything.

I wrote at length about this pattern, and the many other places blame tends to land, in the post on blame after suicide loss, which is worth reading in full if any of this feels familiar.

Many survivors do not settle on one target and stay there. Blame moves. This week it might focus on the drinking. Next week it moves to a doctor, or a friend who was there that night, or back inward onto yourself. That movement is common, and it does not mean you are doing your grief wrong. It usually means the underlying pain has not found anywhere else to land yet.

If you are in the middle of that cycle right now, you do not have to force yourself out of it today. You are allowed to notice it happening without demanding that you resolve it on the spot. It is something that you should discuss with your grief counselor.

When Two Griefs Carry Two Stigmas

Suicide loss carries its own stigma. Substance use carries a separate one. When both are part of the same death, many survivors end up managing a kind of silence that is heavier than either loss would be alone.

You may find yourself hesitant to say how the person died, worried that saying drugs or drinking were involved will let people reduce the whole of who they were down to that one fact. Researchers who study grief after suicide and after drug-related death side by side have found that families carry blame differently depending on which one it was, and that a death involving both carries a weight of its own. That combination is often what grief researchers call disenfranchised grief, meaning it is not consistently recognized or openly mourned the way other losses are.

If this is part of what you are carrying, know that the person you lost was never only the drugs or the drinking. That pain deserves to be understood before any of the rest of the story gets told.

What the Research Shows About Substances and Suicide Risk

The clinical picture matters here, even though it does not answer the personal question you actually have.

Substance use disorders do raise suicide risk. Research from the Pew Charitable Trusts found the risk of death by suicide increases nearly 6 times for people with alcohol use disorder alone. That risk climbs further, to roughly 11 times, for people with co-occurring alcohol, drug, and tobacco use disorders.

The American Foundation for Suicide Prevention notes that the large majority of people who die by suicide had a diagnosable mental health condition at the time of death, and substance use disorders are often one of the conditions layered underneath everything else.

Here is the other side of that picture, the side that keeps elevated risk from quietly becoming certainty. Tens of millions of Americans live with a substance use disorder in any given year. The overwhelming majority of them do not die by suicide. And most suicide deaths, including many where a substance was present, do not involve a diagnosed substance use disorder at all.

Elevated risk describes a population, not a prediction about any one person, and it was never a prediction about your person specifically.

Elevated risk is also not the same as cause. It means substance use and suicidal pain frequently share the same roots, the same untreated struggles, the same isolation, the same exhaustion from carrying something alone for too long. They are often two expressions of one underlying suffering rather than one thing causing the other in a straight line.

Carrying the Questions That Do Not Resolve

If you are still turning this over months or years after the loss, that is not unusual, and it does not mean you are stuck.

Watch for hindsight bias, the quiet certainty that you should have known, should have searched harder, should have asked more directly about what you now know was there. The substance question amplifies that particular ache, because it feels like there was something specific and visible that could have been caught in time.

Many survivors in our group describe researching toxicology results or medication interactions late at night, long after everyone else has gone to bed. If that is where you find yourself, write the questions down instead of carrying them silently. They will still be there in the morning, and you will likely be steadier when you sit with them again.

There is one more thing worth mentioning, because this post has spent a lot of time on the substances your person reached for: If it is your own drinking or your own substance use that has changed since the loss, that reaching makes just as much sense as anything described here. Grief is its own kind of unbearable pain, and looking for something to make it quieter for a while is human, not a failure, and not a sign that history is repeating itself. The SAMHSA National Helpline at 1-800-662-4357 offers free, confidential support and treatment referrals around the clock, and it exists for exactly this kind of reaching too.

If the weight of any of this becomes too much to hold, the 988 Suicide and Crisis Lifeline is available by call or text, day or night, and it was built for exactly this kind of moment. Working through guilt that has attached itself to the drugs, the alcohol, a medication, or an action you wish had gone differently is some of the most important work suicide loss survivors do, and there is no deadline on when to start it.

Suicide is often preventable, and it is not always preventable, and both of those things can be true without canceling each other out. That complexity is at the center of what the research actually shows about prevention, and it is worth reading if the word preventable has been sitting heavily on you.

Whatever the toxicology report says, whatever you knew or did not know at the time, you did not cause this. The drugs, the alcohol, the medication may have been part of a much larger picture, but they were never all of it, and they were never something you alone could have controlled. The person you lost was in more pain than anyone standing outside it could fully reach. That is the truth underneath the toxicology report, underneath the medication, underneath every question you are still asking. It was never really about the drugs. The alcohol. The medication. It was about pain looking for somewhere to go.

Posts You May Also Like

• Blame After Suicide Loss: Why the Grieving Mind Needs a Target – Goes deeper into every place blame tends to land after a suicide loss, including the family history behind why this topic matters so much to me personally.
• Suicide Is Not About a Desire to Die: Understanding Psychache – The full story of Shneidman’s research and what it means for survivors trying to understand why their person’s pain became unbearable.
• Is Suicide Preventable? Not Always, and Never Your Fault – A longer look at the real limits of prevention, for anyone whose grief keeps circling back to what could have stopped this.
• Genetics and Suicide: What Family History Means for Survivors – Covers how genetics shapes both suicide risk and how a person responds to psychiatric medication, useful if the medication questions in this post feel unresolved.
• 988 for Suicide Loss Survivors: What It Is and When to Call – A practical guide to a resource survivors themselves are allowed to use, not just something for the person who died.

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