Study design <p>Cross-sectional study.</p> Objective <p>To identify the relationship of prescription opioid use, self-reported misuse of opioids, and binge drinking days with suicidal ideation (SI) in a cohort of participants with spinal cord injury (SCI).</p> Setting <p>Medical university in the southeastern United States.</p> Methods <p>This was a cross-sectional analysis of self-report data from 1253 study participants with SCI, all of whom were enrolled in a longitudinal study of health outcomes. SI was assessed and dichotomized using item 9 on the Patient Health Questionnaire-9.</p> Results <p>Occasional use of 3 or more prescription opioids was associated with greater odds of SI (OR = 3.53, CI = 1.50–8.31), as was self-reported misuse of prescription opioids (OR = 3.51, CI = 1.83–6.72). Days of binge drinking was unrelated to SI. Odds of SI were higher for those with depression (OR = 5.98, CI = 3.60–9.92) and those who reported 15 or more painful days in a month (OR = 2.15, CI = 1.24–3.73). Compared with the most severe SCI (high cervical, non-ambulatory), participants who were ambulatory (OR = 0.36, CI = 0.15-0.86) or were non-cervical/non-ambulatory (OR = 0.32, CI = 0.14-0.75) reported lower odds of SI.</p> Conclusions <p>Prescription opioid use needs to be closely monitored by healthcare professionals for those who use multiple opioids and who self-report misusing opioids, as there is a relationship with SI, even when considering multiple covariates pain and depression.</p>