Psychiatry Research 329 (2023) 115519 Contents lists available at ScienceDirect Psychiatry Research journal homepage: www.elsevier.com/locate/psychres Investigating the co-occurrence of marijuana use and prescription opioid misuse with multiple suicide attempts among adolescents with a history of suicidal ideation Philip Baiden a,*, Bethany Wood a, Catherine A. LaBrenz a, Henry K. Onyeaka b,c,d, Aaron Hagedorn a, Christian E. Vazquez a, Chioma Muoghalu e, Edinam C. Gobodzo f, John F. Baiden g, Yvonne Adeku h, Vera E. Mets i, Fawn A. Brown j a The University of Texas at Arlington, School of Social Work, 501 W. Mitchell Street, Box 19129, Arlington, TX, 76019, USA b Harvard Medical School, Department of Psychiatry, Boston, MA, 02115, USA c Massachusetts General Hospital, Department of Psychiatry, Boston, MA, 02115, USA d McLean Hospital, Department of Psychiatry, Boston, MA, 02478, USA e Plains Regional Medical Center, Clovis, New Mexico, NM, 88101, USA f Eastern Regional Hospital, P. O. Box 201, Koforidua, Ghana g East Airport International School, P. O. Box KAPM 57, KIA, Accra, Ghana h Western University, Department of Sociology, Social Science Centre, Room 5306, London, Ontario, N6A 5C2, Canada i University of Ghana, Legon, Department of Social Work, P. O. Box LG 419, Legon, Accra, Ghana j The University of Texas at Arlington, Department of Psychology, 501 Nedderman Dr, Box 19528, Arlington, TX, 76019, USA A R T I C L E I N F O A B S T R A C T Keywords: This study investigated the co-occurrent association of marijuana use and prescription opioid misuse with Multiple suicide attempts multiple suicide attempts among adolescents with a history of suicidal ideation. Data came from the 2019 Youth Suicidal ideation Risk Behavior Survey. The sample was comprised of adolescents ages 14–18 who reported suicidal ideation Prescription opioid misuse during the past year (n = 2,562). Multinomial logistic regression was used to examine the co-occurring asso- Marijuana use Adolescents ciation of marijuana use and prescription opioid misuse with multiple suicide attempts. Of the 2,562 adolescents who experienced suicidal ideation, 19.2 % also attempted suicide multiple times during the past year and 19.0 % reported ever using marijuana and misusing prescription opioids, 8.8 % misused prescription opioids only, and 33.3 % used marijuana only. In the multivariate model, for adolescents who used marijuana and misused pre- scription opioid, the risk of attempting suicide once was 1.77 times higher (RRR = 1.77, 95 % CI = 1.22–2.59) and the risk of multiple suicide attempts was 3.23 times higher (RRR = 3.23, 95 % CI = 1.95–5.33) when compared to adolescents who had never used marijuana nor misused prescription opioid. The risk of multiple suicide attempts was greater for bisexual and racial/ethnic minority adolescents and adolescents who felt sad or hopeless. Interventions that prevent prescription opioid misuse among adolescents may be effective in mitigating suicide attempts. 1. Introduction suicide among adolescents in the U.S. peaked in 2018 before declining in 2019 and 2020 (Ehlman, 2022), suicidal thoughts and behaviors (i.e., Globally, suicide has been identified as one of the leading causes of suicidal ideation, suicide planning, and suicide attempts) (Nock et al., death, responsible for 8.5 % of all-cause mortality among adolescents 2009) among adolescents remain a significant public health concern and young adults (Cha et al., 2018). In the United States (U.S.), suicide (Bridge et al., 2018; Hill et al., 2021; Lindsey et al., 2019). Suicidal ranks as the second leading cause of death among children and adoles- ideation refers to the presence of thoughts and ideas of engaging in a cents aged 10–24 years (Centers for Disease Control and Prevention behavior with the purpose of killing oneself. Suicidal ideation is (CDC, 2022)). Data from the CDC indicates that although the rate of different from the persistent preoccupation of one’s mind with thoughts * Corresponding author at: School of Social Work, The University of Texas at Arlington, 211 S. Cooper St., Box 19129, Arlington, TX, 76019. E-mail address: philip.baiden@uta.edu (P. Baiden). https://doi.org/10.1016/j.psychres.2023.115519 Received 23 May 2023; Received in revised form 28 September 2023; Accepted 29 September 2023 Available online 4 October 2023 0165-1781/© 2023 Elsevier B.V. All rights reserved. P. Baiden et al. P s y c h i a t r y R e s e a r c h 329 (2023) 115519 of death or dying. A suicide plan refers to taking the extra step of report experiencing suicidal ideation (Hong et al., 2023) or attempt formulating a plan of action through which one expects to carry out the suicide (Lee et al., 2022), and are also more likely to use marijuana to attempt (Nock and Favazza, 2009). Suicide attempt refers to a non-fatal cope with distress (Bujarski et al., 2012). Respiratory depression, altered directed potentially injurious behavior with the intent to die. A suicide memory, increased heartbeat, drowsiness, ataxia, and hypotonia are attempt may or may not result in injury (Crosby et al., 2011). some of the most frequently reported signs and symptoms of marijuana Ivey-Stephenson et al. (2020) examined data from the 2019 Youth use (Kaczor et al., 2021; Thomas and Mazor, 2017). Risk Behavior Survey (YRBS) and found that 18.8 % of adolescents in Previous studies have examined the associations between marijuana grades 9 through 12 seriously considered attempting suicide in the past use and suicide attempts (Esposito-Smythers et al., 2011; Gobbi et al., year, 15.7 % made a suicide plan, and 8.9 % attempted suicide. One of 2019; Kahn and Wilcox, 2022; Schmidt et al., 2020; Sellers et al., 2019) the strongest predictors of suicide attempts and death by suicide is or prescription-opioid-misuse and suicide attempts (Baiden et al., suicidal ideation (Klonsky et al., 2018; Nock et al., 2018). For instance, 2019a; Chan et al., 2022; Sampasa-Kanyinga et al., 2021; Zullig et al., Jacobson et al. (2013) examined reasons for attempting suicide among a 2015) among adolescents separately. Sellers et al. (2019) examined ef- community sample of 99 adolescents from New York State and found fects of alcohol use and marijuana use on suicidal ideation and attempts that more than half of the adolescents reporting thinking about suicide among a sample of 50 adolescents (mean age, 15.8) from an inpatient before they made their suicide attempt. They also found that those who psychiatric hospital in the northeastern U.S. and found that controlling had premeditations about suicide were 15 times more likely to endorse for all other variables, the odds of endorsing suicidal ideation increased wanting to die as the reason for attempting suicide than those who had by 48 % and the odds of attempting suicide increased by 94 % on a day not been thinking about suicide before the attempt. Franklin et al. when they used marijuana. Kahn and Wilcox (2022) also examined (2017) conducted a meta-analysis that included 365 studies to identify pooled data from the 2011–2017 YRBS and found that marijuana use risk factors associated with suicidal thoughts and behaviors and found was more strongly associated with suicide attempts than suicidal idea- that prior non-suicidal self-injury and suicidal ideation were the stron- tion. With respect to the association between prescription opioid misuse gest predictors of suicide attempts, outperforming prior suicide and suicide attempt, Zullig et al. (2015) examined the link between attempts. nonmedical use of prescription opioids and suicidality among a sample That notwithstanding, not all individuals who experience suicidal of 4148 adolescents in grades 9–12 enrolled in five public high schools in ideation go on to attempt suicide (Klonsky et al., 2018; Klonsky and May the U.S. and found that nonmedical use of prescription opioids was 2014). Mortier et al. (2018) examined data from 13,984 first-year stu- associated with 1.61 times higher odds of suicide attempts among males dents (mean age = 19.3, SD = 0.59) across 19 colleges in 8 countries and 2.06 times higher odds of suicide attempts among females. (Australia, Belgium, Germany, Mexico, Northern Ireland, South Africa, Furthermore, Sampasa-Kanyinga et al. (2021) examined data on 5582 Spain, and the U.S.) and found that only 24.4 % of lifetime ideators adolescents (mean age: 15.3 years) from Ontario, Canada and found that transitioned to an attempt during the past 12 months. Stewart et al. controlling for demographic and other correlates of suicidal thoughts (2019) in their study on life stressors and suicidal thoughts and behav- and behaviors, the odds of making suicide attempts during the past year iors noted that most of the correlates and predictors of suicidal thoughts were threefold higher among adolescents who had ever misused pre- and behaviors among adolescents were strongly associated with suicidal scription opioid when compared to their counterparts who have never ideation, and only weakly associated with suicide attempts. Another misused prescription opioid. meta-analysis on what distinguishes suicide ideators from suicide However, there is a dearth of research examining the co-occurrence attempters found that feelings of hopelessness and symptoms of of marijuana use and prescription-opioid-misuse either concurrently or depression were strongly associated with suicidal ideation, but were sequentially with suicide attempts among adolescents. Examining the poorly associated with suicide attempts among those with a history of co-occurrence association of marijuana use and prescription-opioid- suicidal ideation (May and Klonsky, 2016). As a result, Klonsky et al. misuse with suicide attempts among adolescents with a history of sui- (2021) bemoaned the fact that “currently, not even a single strong cidal ideation is important for several reasons. First, marijuana is the predictor of suicide attempts among ideators has been identified” (439). most prevalent illicit substance among adolescents in the U.S. (Ham- Although firearm remains one of the most common methods of death mond et al., 2020; Johnston et al., 2022; Substance Abuse and Mental by suicide in the U.S. (Kivisto et al., 2021; Osborne et al., 2021; Stanley Health Services Administration, 2019). Second, available research has et al., 2017), intentional overdose and prescription opioid misuse have shown that the use of marijuana often co-occurs with other substances been found to account for a greater number of suicide attempts and including prescription opioids which can have additive effects on death by suicide among adolescents each year (Bortz, 2019; Caupp et al., adolescent mental health and suicidal behaviors (McCabe et al., 2012; 2018; Gaither et al., 2016; Roehler et al., 2021). For instance, Gaither Olfson et al., 2018; Sellers et al., 2019). Indeed, analyzing data from the et al. (2018) found that the mortality rate attributed to opioid misuse Monitoring the Future study, McCabe et al. (2015) found that among among children and adolescents in the U.S. increased from 0.22 in 1999 adolescents who misused prescription opioids in the past year, 51 % to 0.81 per 100,000 lives in 2016, representing an increase of 268.2 %, co-ingested prescription opioids with marijuana. Third, recent advances with the highest annual rates occurring among adolescents aged 15 to 19 in developmental neurobiology have enhanced our understanding that years. The recent unprecedented increase in opioid-related overdose the prefrontal cortex of the adolescent brain is not fully developed until deaths among adolescents presents a major public health concern about about age 25 (Giedd, 2015; Spear, 2013). As a result, the co-occurrence the harmful effects of prescription opioid misuse on suicidal behaviors of marijuana use with prescription-opioid-misuse could have long-term (Baiden et al., 2019a). One study found that most drug-related hospital adverse consequences on brain functioning and overall mental emergency department (ER) visits by adolescents relating to suicide well-being (Cancilliere et al., 2018; deShazo et al., 2019). Fourth, un- attempts involve on average 1.8 drugs (Substance Abuse and Mental derstanding the co-occurrence of marijuana use and prescription opioid Health Services Administration, 2013). misuse with suicide attempts among adolescents with a history of sui- Moreover, studies have described the effects of marijuana overdose cidal ideation could help inform future suicide prevention strategies among adolescents (Hughes et al., 2023; Richards et al., 2017; Thomas among adolescents. et al., 2021). Other studies show that marijuana is one of the most Moreover, few studies on suicide attempts have focused on differ- common illicit substances among adolescents (Johnston et al., 2022; entiating multiple suicide attempters from other suicidal adolescents. Substance Abuse and Mental Health Services Administration, 2019) and The existing few studies have found that younger in age, female sex, has the potential to increase the risk of suicide attempts among ado- suicidal ideation, family suicide history, symptoms of depression and lescents (Esposito-Smythers et al., 2011; Kahn and Wilcox, 2022; Sellers anxiety, loneliness, hopelessness, and substance use predicted multiple et al., 2019). Adolescents with high levels of distress are more likely to suicide attempts among adolescents (Guo et al., 2019; Merchant et al., 2 P. Baiden et al. P s y c h i a t r y R e s e a r c h 329 (2023) 115519 2009; Pengpid and Peltzer, 2021; Smith et al., 2021). Merchant et al. “4 or 5 times,” and “6 or more times.” Adolescents who attempted sui- (2009) found that feelings of hopelessness were more prevalent among cide multiple times during the past 12 months were coded as 2, ado- adolescent multiple attempters than first-time attempters. Smith et al. lescents who attempted suicide once during the past 12 months were (2021) examined correlates of multiple suicide attempts among ado- coded as 1, whereas adolescents who did not attempt suicide during the lescents from 61 countries in Africa, Asia, and the Americas and found past 12 months were coded as 0. that loneliness, substance use, and sleep problems were the strongest correlates of multiple suicide attempts. Adolescents suffering from 2.2.2. Explanatory variable mental health problems who feel hopeless may self-mediate themselves The main explanatory variable examined in this study was marijuana with marijuana, prescription opioids, or illicit substances (Baiden and use and prescription-opioid-misuse. Marijuana use was measured based Tadeo, 2019). Moreover, consumption of substance use may increase the on responses to the question, “During your life, how many times have risk for multiple suicide attempts as they have been found to be asso- you used marijuana?” Adolescents who used marijuana one or more ciated with memory and judgment impairment (Mizoguchi and times during their lifetime were recoded as 1, otherwise, they were Yamada, 2019; Volkow et al., 2014). Therefore, it is important to un- recoded as 0. Prescription-opioid-misuse was measured as a binary derstand factors associated with multiple suicide attempts among ado- variable based on responses to the question, “During your life, how lescents with a history of suicidal ideation and develop suicide many times have you taken prescription pain medicine without a doc- prevention strategies focusing on this vulnerable population. tor’s prescription or differently than how a doctor told you to use it? (Count drugs such as Codeine, Vicodin, OxyContin, Hydrocodone, and 1.1. Current study Percocet)” Adolescents who took prescription pain medicine without a doctor’s prescription at least once were recoded as 1, otherwise, they Notwithstanding the fact that single substance use among adoles- were coded as 0. Based on these two variables, a nominal variable with cents is less common than polysubstance use (Goodwin et al., 2022; four categories was created: “0 = never used marijuana and never McCabe et al., 2015; Tomczyk et al., 2016), previous research that have misused prescription opioid,” “1 = marijuana use only,” “2 = prescrip- examined the association between marijuana use and suicide attempts tion-opioid-misuse only,” and “3 = marijuana use and prescription- (Esposito-Smythers et al., 2011; Gobbi et al., 2019; Kahn and Wilcox, opioid-misuse.” 2022; Schmidt et al., 2020; Sellers et al., 2019) or prescription-opioid-misuse and suicide attempts (Baiden et al., 2019a; 2.2.3. Demographic characteristics and covariates Chan et al., 2022; Sampasa-Kanyinga et al., 2021; Zullig et al., 2015) Age, sex, sexual identity, and race/ethnicity were included as de- among adolescents have done so separately. Drawing on a large na- mographic characteristics, and feeling sad or hopeless as a covariate. tionally representative sample of adolescents, this study seeks to add to Age was measured in years, whereas sex was coded as “0 = male” versus the literature on substance use and suicide attempts by examining the “1 = female.” Sexual identity was measured as a nominal variable into co-occurring association of marijuana use and “Straight,” “Gay/lesbian,” “Bisexual,” and “Not sure/Questioning.” prescription-opioid-misuse with multiple suicide attempts among ado- Race/ethnicity was coded as a nominal variable into the following cat- lescents with a history of suicidal ideation. Based on the extant litera- egories: “non-Hispanic White,” “non-Hispanic Black,” “Hispanic,” and ture, we hypothesized that the co-occurrence of marijuana use and “Other.” Lastly, feeling sad or hopeless was measured as a binary vari- prescription-opioid-misuse would be associated with multiple suicide able based on the question, “During the past 12 months, did you ever feel attempts, net the effects of demographic characteristics and feelings of so sad or hopeless almost every day for two weeks or more in a row that sadness or hopelessness. you stopped doing some usual activities?” Adolescents who answered “yes” were coded as 1, whereas those who answered “no” were coded as 2. Methods 0. 2.1. Data source and sample 2.3. Data analyses Data were obtained from the 2019 Youth Risk Behavior Survey Data were analyzed using descriptive and multivariable analytic (YRBS). The YRBS is a cross-sectional school-based national survey techniques. First, missing data analyses were conducted to assess conducted by the Centers for Disease Control and Prevention (CDC) whether adolescents with observed data on one variable were signifi- every two years to examine health-risk behaviors that contribute to the cantly different from adolescents with missing data on another variable. leading causes of death and disability among adolescents in the U.S. The The percentage of missing data ranged from less than 1 % (feelings of objectives, methodology, and sampling procedure for the YRBS have sadness or hopelessness) to 20 % (multiple suicide attempt). We found been described elsewhere (Brener et al., 2013; Kann et al., 2018; Un- that data were missing completely at random (MCAR), that is, the derwood et al., 2020) and in other publications by the authors (Baiden probability of missingness on one variable is not dependent on any et al., 2020, 2021, 2022, 2023). The YRBS was approved by the CDC’s observed data (Van Ginkel et al., 2020). Given that data were MCAR, Institutional Review Board (IRB), and the de-identified data are publicly Multiple Imputation using Chained Equations (MICE) was chosen as the available. The initial sample size for the 2019 national YRBS was 13,677 most appropriate technique to impute complete data (Van Buuren, adolescents aged 12–18 years. Adolescents aged 12 and 13 were 2018). Multiple imputation is a simulation-based approach for analyzing excluded from the analysis due to small sample size (unweighted n = missing data that replaces missing values with multiple sets of simulated 159). Of the 13,677 adolescents, 2562 were between the ages of 14 and values to complete the dataset and adjust for missing data uncertainty 18 years and reported experiencing in suicidal ideation during the past (Rubin, 1996). A similar approach has been used by the authors in year and constituted the analytic sample for this study. handling mising data in previous studies (Baiden et al., 2020, 2021, 2022, 2023). The results indicates that 39.1 % of the total sampling 2.2. Variables variance is attributable to missing data. The general distribution of all the variables included in the analysis 2.2.1. Outcome variable was then examined using percentages. First, we conducted ordinal lo- The outcome variable investigated in this study was multiple suicide gistic regression to examine the association between the co-occurrence attempts and was measured based on response to the question, “During of marijuana use and prescription-opioid-misuse with multiple suicide the past 12 months, how many times did you actually attempt suicide?” attempts given that our outcome variable (i.e., multiple suicide at- with the following response options “0 times,” “1 time,” “2 or 3 times,” tempts) was measured as an ordinal variable into categories of “no 3 P. Baiden et al. P s y c h i a t r y R e s e a r c h 329 (2023) 115519 attempt,” “one attempt,” and “multiple attempts.” However, we found 3.2. The co-occurrence association of marijuana use and prescription- that the proportional odds assumption was violated when we conducted opioid-misuse with multiple suicide attempts ordinal logistic regression. Therefore, we elected to conduct multino- mial logistic regression. Relative risk ratios (RRRs) were reported Table 2 shows the multivariable multinomial logistic regression re- together with their 95 % Confidence Intervals (CI). Variables were sults examining the co-occurring association of marijuana use and considered significant if the p-value was less than 0.05, or if the 95 % CI prescription-opioid-misuse with multiple suicide attempts among ado- did not contain 1.00. Stata’s “svyset” command was used to account for lescents with a history of suicidal ideation while controlling for the ef- the weighting and complexity of the cluster sampling design employed fects of demographic characteristics and feelings of sadness or by the YRBS. All analyses were performed using STATA 17 MP (Stata hopelessness. The global F statistic of the model was significant indi- Corp., College Station, Texas, USA). cating that the overall model was fit F(24, 48.5) = 8.02, p < .001. Controlling for the effects of demographic characteristics and feeling sad 3. Results or hopeless, for adolescents who use marijuana and misuse prescription opioid, the risk of attempting suicide once was 1.77 times higher (RRR 3.1. Sample characteristics = 1.77, p = .004, 95 % CI = 1.22–2.59) and the risk of multiple suicide attempts was 3.23 times higher (RRR = 3.23, p < .001, 95 % CI = Table 1 shows the general distribution of the study variables. Of the 1.95–5.33) when compared to adolescents who have never used mari- 2562 adolescents who experienced in suicidal ideation during the past juana nor misuse prescription opioid. Use of marijuana only was not year, about one in five (19.2 %) also made multiple suicide attempts associated with single or multiple suicide attempts. However, misuse of during the past year, 21.9 % attempted suicide once during the past prescription opioid only was significantly associated with multiple sui- year, and 58.9 % did not attempt suicide during the past year. About one cide attempts (RRR = 2.48, p = .005, 95 % CI = 1.34–4.59) but not with in five (19.0 %) adolescents with a history of suicidal ideation reported single suicide attempt. ever using marijuana and misusing prescription opioids, 8.8 % misused Age and sex were not significantly associated with multiple suicide prescription opioids only, 33.3 % used marijuana only, and 38.9 % have attempts. The risk of multiple suicide attempts was higher among ado- never used marijuana or misused prescription opioids. About two in lescents who self-identified as bisexual when compared to their coun- three (65.5 %) adolescents with a history of suicidal ideation were fe- terparts who self-identified as straight (RRR = 1.64, p = .011, 95 % CI = males. About five out of six adolescents with a history of suicidal idea- 1.13–2.38). Controlling for the effects of other factors, the risk of mul- tion (83.6 %) reported feeling sad or hopeless almost every day for two tiple suicide attempts was 2.64 times higher for adolescents who self- weeks or more in a row that they stopped doing some usual activities. identified as non-Hispanic Black (RRR = 2.64, p < .001, 95 % CI = Table 2 Co-occurring association of marijuana use and prescription opioid misuse with multiple suicide attempts among adolescents with a history of suicidal ideation (N = 2562). Table 1 Variables One attempt Multiple attempts Sample characteristics (N = 2562). RRR (95 % C. p-value RRR (95 % C. p-value Variables Frequency (weighted I.) I.) %) Marijuana use and Outcome variable prescription opioid Suicide attempt misuse (Neither) None 1509 (58.9) Marijuana use only 1.37 .080 1.14 .594 One attempt 562 (21.9) (0.96–1.94) (0.70–1.84) Multiple attempts 491 (19.2) Prescription opioid 1.57 .118 2.48 .005 Main explanatory variable misuse only (0.89–2.78) (1.34–4.59) Marijuana use and prescription opioid misuse Both marijuana use and 1.77 .004 3.23 <0.001 Neither marijuana use nor prescription opioid misuse 997 (38.9) prescription opioid (1.22–2.59) (1.95–5.33) Marijuana use only 854 (33.3) misuse Prescription opioid misuse only 225 (8.8) Age in years 0.90 .085 0.95 .441 Both marijuana use and prescription opioid misuse 486 (19.0) (0.80–1.01) (0.84–1.08) Control variables Sex (Male) Age Female 0.92 .627 0.87 .451 14 years 325 (12.7) (0.67–1.28) (0.60–1.26) 15 years 654 (25.5) Sexual identity (Straight) 16 years 713 (27.8) Gay/lesbian 0.77 .479 1.47 .229 17 years 584 (22.8) (0.37–1.61) (0.78–2.78) 18 years 286 (11.2) Bisexual 1.14 .489 1.64 .011 Sex (0.78–1.66) (1.13–2.38) Male 884 (34.5) Other/questioning 0.91 .776 1.24 .504 Female 1678 (65.5) (0.48–1.74) (0.65–2.37) Sexual identity Race/ethnicity (Non- Straight 1676 (65.4) Hispanic White) Gay/lesbian 149 (5.8) Non-Hispanic Black 1.13 .625 2.64 <0.001 Bisexual 564 (22.0) (0.68–1.89) (1.67–4.18) Other/questioning 173 (6.8) Hispanic 1.06 .738 1.63 .012 Race/ethnicity (0.74–1.53) (1.12–2.38) Non-Hispanic White 1290 (50.4) Other 0.97 .850 1.92 .006 Non-Hispanic Black 357 (13.9) (0.67–1.39) (1.22–3.02) Hispanic 551 (21.5) Felt sad or hopeless (No) Other 364 (14.2) Yes 2.52 <0.001 1.96 .014 Felt sad or hopeless (1.57–4.03) (1.15–3.34) No 421 (16.4) F(24, 48.5)=8.02, p < .001. Yes 2141 (83.6) NB: Reference category is indicated in parenthesis. 4 P. Baiden et al. P s y c h i a t r y R e s e a r c h 329 (2023) 115519 1.67–4.18), 1.63 times higher for Hispanic (RRR = 1.63, p = .012, 95 % non-Hispanic Black, Hispanics, and “Other” were more likely to report CI = 1.12–2.38), and 1.92 times higher for adolescents who self-identify making multiple suicide attempts extends past studies (Baiden et al., as “Other” (RRR = 1.92, p = .006, 95 % CI = 1.15–3.02) when compared 2019b; Ivey-Stephenson et al., 2020). Whereas suicidal ideation is more to adolescents who self-identified as non-Hispanic Whites. Race/ prevalent among non-Hispanic White adolescents than non-Hispanic ethnicity was not significantly associated with attempting suicide once. Black adolescents (Kann et al., 2018; Lorenzo-Luaces and Phillips, Lastly, for adolescents who felt sad or hopeless, the risk of attempting 2014), this pattern is reversed when looking at suicide attempts with suicide once was 2.52 times higher (RRR = 2.52, p < .001, 95 % CI = non-Hispanic Black and Native American adolescents having the highest 1.57–4.03), and the risk of multiple suicide attempts was 1.96 times risk of suicide attempts (Bridge et al., 2018; Lindsey et al., 2019). Some higher (RRR = 1.96, p = .014, 95 % CI = 1.15–3.34) when compared to scholars have attributed this racial paradox in suicidal behaviors to adolescents who do not feel sad or hopeless. perceived racial discrimination (Walker et al., 2014). Exposure to everyday racial discrimination, neighborhood and community violence 4. Discussion are associated with marijuana use (Ahuja et al., 2022; Steele, 2016) and opioid misuse among Black adolescents (Nicholson et al., 2022), which Drawing on a large nationally representative sample of adolescents may contribute to suicide attempts as found in this study. Additionally, from the U.S., this is one of the first studies to investigate the co- the finding that bisexual adolescents had higher odds of multiple suicide occurring association of marijuana use and prescription-opioid-misuse attempts compared to their straight counterparts corroborate and extend with multiple suicide attempts among adolescents with a history of previous literature, which has attributed this disparity to forms of suicidal ideation. We found that among adolescents with a history of marginalization including bi-erasure or bi-invisibility (Salway et al., suicidal ideation, about one in five made multiple suicide attempts, 21.9 2019). % attempted suicide once during the past 12 months, and about one in five reported ever using marijuana and misusing prescription opioid. 4.1. Implications Given the increasing rates of suicide attempts among adolescents in the U.S. (CDC, 2021; Lindsey et al., 2019), and the dearth of research on the Findings from this study highlight the importance of screening for transition from suicidal ideation to suicide attempts (Klonsky et al., multiple types of substance misuse and implementing preventive pro- 2018), it is important to understand factors associated with multiple gramming for adolescents. Furthermore, it is important to integrate suicide attempts among adolescents with a history of suicidal ideation mental health and substance use prevention and intervention pro- and develop suicide prevention strategies that focus on this vulnerable gramming for adolescents. This could include coordinated, interdisci- population. It is important to note that the 2019 YRBS was conducted in plinary community-level systems (Beardslee et al., 2011) such as the spring of 2019 before the official start of the COVID-19 pandemic. partnerships between school systems, mental health providers, and However, it is important to bear this in mind when interpreting the other healthcare providers. In parallel, given that the YRBS is adminis- findings of the present study. tered at schools, it could also be beneficial to have school-based Controlling for the effects of demographic characteristics and feeling screening, and then target prevention and early intervention for ado- sad or hopeless, adolescents with suicidal ideation who only misused lescents who report mental health issues and/or substance use. Indeed, a prescription opioids, and those who used marijuana and misused pre- prior review of mental health interventions for youth found an increased scription opioids, had higher odds of making multiple suicide attempts. uptick in service utilization when services were provided within the The findings of this study extend past research that have found an as- school setting (Dunne et al., 2017). Finally, our findings have implica- sociation between marijuana use separately (Esposito-Smythers et al., tions for future research and policy as marijuana continues to be legal- 2011; Kahn and Wilcox, 2022; Sellers et al., 2019) and ized. While marijuana use itself was not associated with suicide attempt prescription-opioid-misuse (Baiden et al., 2019a; Zullig et al., 2015) among adolescents in our sample, its co-occurrence with prescription with suicide attempts among adolescents. Some reasons have been opioid misuse did increase the likelihood of multiple suicide attempts. offered that may help explain the association between marijuana use Therefore, as legalization of marijuana continues to be rolled out in and prescription-opioid-misuse with suicide attempt. First, Case and different counties and states, it is important to continue to examine the Deaton (2017) posited that rising incidents of opioid use in the U.S. impact of changing policy on its use and co-use with other substances. could be attributed to cumulative disadvantage that makes some in- This is important among adolescents and young adults as the brain dividuals use opioids to cope with feelings of hopelessness. Opioid use continues to develop and be particularly susceptible through age 25 then exacerbates the onset and maintenance of depressive symptoms (Giedd, 2015; Spear, 2013). which can then lead to suicide attempts and overdose death (Case and Deaton, 2017). Second, marijuana use and misuse of prescription opioid 4.2. Limitations could adversely impact social relations (Oviedo-Joekes et al., 2011) leading to alienation and rejection from family, friends, and other This study has some limitations. First, this is a cross-sectional study valued social groups. Such feelings of alienation and rejection with no hence, no casual inferences could be made. Only association can be one to turn to particularly in times of crises may make some adolescents inferred. It is possible that some adolescents may have attempted suicide feel that they are a burden unto others thereby triggering a suicide prior to using marijuana or misusing prescription opioids. Also, we were attempt. unable to ascertain the temporal sequencing between use of marijuana Notably, findings from our study did not find a significant association and prescription opioid misuse. An adolescent could be using marijuana between marijuana use by itself and suicide attempts among adolescents daily, and misused prescription once two years ago, then attempted with a history of suicidal ideation. However, the co-occurrence of suicide in the past year while completely sober. In addition, there were marijuana use and prescription opioid misuse increased the odds of no measures of lifetime suicidal ideation or suicide attempts to enable us suicide attempt over three-fold. This finding builds upon research that to ascertain whether the suicide attempt within the past year occurred has found co-occurring marijuana use and other illicit substance use to after a history of lifetime suicidal ideation. Longitudinal studies are have negative effects on adolescent mental health, including suicidal needed to address these limitations and establish the temporal order behaviors (McCabe et al., 2012; Sellers et al., 2019). This is also con- between the co-occurrence of marijuana use and prescription-opioid- cerning as one recent study found that over half of adolescents who misuse with multiple suicide attempts. Second, the use of a single item misused prescription opioids in the past year had co-ingested opioids in measuring suicidal ideation and suicide attempts is subject to with marijuana (McCabe et al., 2015), which could further exacerbate misclassification since adolescents have to draw on their own definition mental health issues. The finding that adolescents who self-identified as of what constitutes ideation or attempt (Hom et al., 2016). Third, the use 5 P. Baiden et al. P s y c h i a t r y R e s e a r c h 329 (2023) 115519 of secondary data limits our ability to examine other theoretically outcomes among Black adolescents: findings from a population-based study. relevant factors that might be associated with multiple suicide attempts J. Affect. Disord. Rep. 12, 100511. Baiden, P., Tadeo, S.K., 2019. Examining the association between bullying victimization (e.g., history of family suicide attempts and self-harm). Moreover, the and prescription drug misuse among adolescents in the United States. J. Affect. 2019 YBRS made no specific mention of the type of opioid that was Disord. 259, 317–324. misused. Future studies should examine the misuse of opiates (i.e., Co- Baiden, P., Tadeo, S.K., Graaf, G., Respress, B.N., 2019b. Examining the association between weapon carrying on school property and suicide attempt among adolescents deine, Vicodin, OxyContin, Hydrocodone, Percocet) that are commonly in the United States. Soc. Work Public Health 34 (7), 570–582. linked to overdose deaths as many adolescents use these drugs to cope Baiden, P., Xiao, Y., Asiedua-Baiden, G., LaBrenz, C.A., Boateng, G.O., Graaf, G., with mental and emotional problems (Baiden et al., 2019a). Muehlenkamp, J.J., 2020. Sex differences in the association between sexual violence victimization and suicidal behaviors among adolescents. J. Affect. Disord. Rep. 1, 100011. 5. Conclusion Beardslee, W.R., Chien, P.L., Bell, C.C., 2011. 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