Opioid dose and risk of suicide

Postmortem screening of opioids, benzodiazepines, and alcohol among rural and urban suicide decedents

PURPOSE

Fatal suicides involving opioids are increasingly common, particularly in rural areas. As co-use of opioids with other substances contributes significantly to mortality risk, we examined whether positive screens for opioids with other substances is more prevalent among rural versus urban suicide deaths, as this could have implications for public health strategies to reduce overdose suicides.

METHODS

Data from all states reporting opioid-related overdose suicides in the National Violent Death Reporting System from 2012 to 2015 were used. Relative risk ratios were obtained using multinomial logistic regression, comparing opioid-only to (1) opioid and alcohol, (2) opioid and benzodiazepines, and (3) opioid, alcohol, and benzodiazepines suicides across rurality. Models were fit using robust standard errors and fixed effects for year of death, adjusting for individual, county, and state-level covariates.

FINDINGS

There were 3,781 opioid-overdose suicide decedents (42% female) tested for all 3 substances during the study period. Unadjusted prevalence of positive screens in decedents varied across rurality (P = .022). Urban decedents were more likely to test positive for opioids alone, while rural decedents were more to likely test positive for opioids and benzodiazepines.

CONCLUSIONS

Rural suicides are associated with increased opioid and benzodiazepine positive screens. These findings suggest the need for rural-focused interventions to support appropriate co-prescribing, better health education for providers about risks associated with drug mixing, and more linkages with mental health services.

Characteristics of Suicides and Toxicology in a Cohort of Individuals With Opioid Use Disorder

Suicide in patients with opioid use disorder (OUD) is a complex issue. In addition to accidental intoxications, a higher prevalence of fatal suicides in patients with OUD can be found compared to the general population. In this study, suicides with a diagnosis of OUD documented in the project "Suicides, A National Survey" were extracted from our data bank. Individuals with a diagnosis of OUD in their medical history were compared to other suicides. The analyses included clinical and demographic factors as well as an investigation of suicide methods and toxicology of psychotropic drugs. For the statistical analyses, we applied chi-square tests and calculated odds ratios. Out of 6,495 suicide cases in Switzerland between 2000 and 2010, 215 individuals with a medical history of OUD could be identified. Persons in OUD cases were significantly younger than in other suicide cases (p < .001) and had more frequently a positive history for suicide attempts (p = .02). In addition, persons in OUD cases were more often female (p = .076). Intentional self-poisoning with medication was applied more often in individuals with OUD compared to other suicide methods (p < .001). When self-poisoning with drugs was compared to violent suicide methods, a combination of benzodiazepines with antidepressants was predominantly found. Our study yielded significant characteristics and risk factors for suicides in individuals with OUD. The predominant method of suicide in individuals with OUD was intended self-poisoning by medication. This knowledge is of clinical importance for the monitoring of at-risk individuals with OUD as well as for suicide prevention in this patient group.

The role of social isolation in opioid addiction

Humans are social animals: social isolation hurts people both psychologically and physically. Strong, positive social bonds help people to live longer and healthier lives compared with their more isolated peers. Opioid use disorder is associated with feelings of social isolation, an increased risk of suicide and, at the community level, lower social capital. I propose a psychobiological mechanistic explanation that contributes to the association between opioid use and social isolation. The endogenous opioid system plays a central role in the formation and maintenance of social bonds across the life span and has been investigated primarily through the framework of the brain opioid theory of social attachment. In primates, maternal-infant bonding and social play are both impaired by the administration of naltrexone (an opioid antagonist), and in humans, the chronic use of opioids appears to be particularly (relative to other drugs) corrosive to close relationships. Social isolation may play a role in the development and exacerbation of opioid use disorder. Taken together, work on the brain’s opioid system suggests a possible mechanistic basis for bidirectional causal links between social isolation and opioid use disorder. Evaluation of this hypothesis would benefit from longitudinal psychosocial and neuropsychopharmacological investigations.

Heightened healthcare utilization & risk of mental disorders among Veterans with comorbid opioid use disorder & posttraumatic stress disorder

Although Veterans with posttraumatic stress disorder (PTSD) are vulnerable to opioid misuse, there is limited research evaluating the psychosocial and medical sequalae experienced by Veterans with comorbid PTSD and opioid use disorder (OUD). Using data from a nationwide, longitudinal registry of Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) Veterans oversampled for PTSD with a 1:1 ratio of men to women, we identified Veterans with lifetime diagnoses of comorbid PTSD and OUD (n = 40), PTSD and non-opioid substance use disorder (SUD; n = 386), PTSD only (n = 901), and non-opioid SUD only (n = 52) using medical record data. We then compared these groups on Veterans Affairs emergency, urgent care, and inpatient healthcare utilization, suicide risk, functional impairment, and the presence of comorbid mental conditions in the following 1-2 years. Relative to all other groups, Veterans with comorbid OUD and PTSD had increased likelihood of emergency room and inpatient care, probable somatoform and major depressive disorders, and greater functional impairment. Both the PTSD/OUD group and PTSD/non-opioid SUD group demonstrated increased suicidality, urgent care utilization, and probable generalized anxiety disorder relative to Veterans with PTSD only or non-opioid SUD only. Results suggest that comorbid OUD and PTSD are associated with greater likelihood of negative psychiatric and healthcare related outcomes, even relative to PTSD comorbid with other types of SUDs. Findings support the importance of concentrated and sustained efforts to improve prevention and intervention strategies for Veterans struggling with PTSD symptoms and opioid misuse.

Shared correlates of prescription drug misuse and severe suicide ideation among clinical patients at risk for suicide

OBJECTIVE

Unintentional drug overdose and suicide have emerged as public health problems. Prescription drug misuse can elevate risk of overdose. Severe suicidal ideation increases risk of suicide. We identified shared correlates of both risk factors to inform cross-cutting prevention efforts.

METHODS

We conducted a cross-sectional study using the Military Suicide Research Consortium's Common Data Elements survey; 2012-2017 baseline data collected from 10 research sites were analyzed. The sample included 3962 clinical patients at risk of suicide. Factors examined in relation to the outcomes, prescription drug misuse and severe suicidal ideation, included demographic characteristics and symptoms of: hopelessness; anxiety; post-traumatic stress disorder; alcohol use; other substance use; prior head/neck injury; insomnia; and belongingness. Poisson regression models with robust estimates provided adjusted prevalence ratios (aPRs) and 97.5% confidence intervals (CIs).

RESULTS

Medium and high (vs. low) levels of insomnia were positively associated with prescription drug misuse (aPRs p < 0.025). Medium (vs. low) level of insomnia was positively associated with severe suicidal ideation (aPR: 1.09; CI: 1.01-1.18). Medium and high (vs. low) levels of perceived belongingness were inversely associated with both outcomes (aPRs p < 0.025).

CONCLUSIONS

Research should evaluate whether addressing sleep problems and improving belongingness can reduce prescription drug misuse and suicidal ideation simultaneously.

Efficacy of a Psychosocial Pain Management Intervention for Men and Women With Substance Use Disorders and Chronic Pain: A Randomized Clinical Trial

IMPORTANCE

Chronic pain is common in those with substance use disorders (SUDs) and predicts poorer addiction treatment outcomes. A critical challenge for addiction treatment is to develop effective methods to improve pain-related and substance use-related outcomes for those in treatment for SUDs.

OBJECTIVE

To examine the efficacy of an integrated behavioral pain management intervention (Improving Pain During Addiction Treatment [ImPAT]) for men and women with SUDs to treat pain, functioning, and substance use.

DESIGN, SETTING, AND PARTICIPANTS

In this randomized clinical trial, 8 sessions of ImPAT were compared with 8 sessions of a supportive psychoeducational control (SPC) condition for adults with pain treated at a large residential SUD treatment program. Follow-up occurred at 3, 6, and 12 months postbaseline. A total of 1372 adults were screened, including 960 men and 412 women, and 510 adults were randomized, including 264 men and 246 women. The goal was to recruit approximately equal numbers of men and women to examine results separately in men and women. A total of 470 of 510 participants (92.2%) completed at least 1 follow-up assessment. Data were collected from October 3, 2011, to January 14, 2016. Data were analyzed from February 1, 2016, to May 1, 2020.

INTERVENTIONS

ImPAT focused on how a psychosocial model of pain was associated with functioning and relapse prevention and provides skills to manage pain. SPC served as the active control condition and involved discussions of topics like nutrition and the course of addiction, which were intended to be relevant to the patient population and to have face validity but be distinct from the content of ImPAT.

MAIN OUTCOMES AND MEASUREMENTS

The primary outcomes were pain intensity, pain-related functioning, and behavioral pain tolerance at 12 months. Secondary outcomes were frequency of alcohol and drug use over 12 months.

RESULTS

Of the 510 included participants, the mean (SD) age was 34.8 (10.3) years. A total of 133 men and 122 women were assigned to ImPAT, and a total of 131 men and 124 women were assigned to the SPC condition. Over 12 months of follow-up, randomization to the ImPAT intervention was associated with higher tolerance of pain among men, higher by a mean score of 0.11 (95% CI, 0.03 to 0.18; P = .004; Cohen d = 0.40) at 3 months and by 0.07 (95% CI, -0.01 to 0.19; P = .11; Cohen d = 0.25) at 12 months. Women receiving the ImPAT intervention experienced a reduction in pain intensity from 3 to 12 months, while women receiving the SPC condition experienced an increase in pain intensity, resulting in lower pain in the ImPAT condition by a mean score of 0.58 (95% CI, -0.07 to 1.22; P = .08; Cohen d = -0.22) at 12 months. No differences were found between the ImPAT and SPC conditions on alcohol or drug use.

CONCLUSIONS AND RELEVANCE

Behavioral pain management is not typically included in addiction treatment, but the present results indicate that this type of intervention was associated with better pain-related outcomes, including pain tolerance in men and pain intensity in women. Improvements in substance use-related outcomes beyond that achieved by treatment as usual were not observed. Treatment programs should consider providing psychosocial pain management services to augment standard addiction treatment.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01372267.

Suicide attempts and death among heroin-involved women seeking methadone treatment in Taiwan

BACKGROUND

The present study aims to profile the hazard fluctuation of suicide attempts and deaths among heroin-involved women seeking methadone maintenance treatment (MMT) and to investigate sociodemographic and clinical factors predicting the time to have suicidal behaviors.

METHODS

We identified a retrospective cohort comprising 2780 women receiving methadone treatment in the period of 2012-2016. Healthcare records were obtained from Taiwan's National Health Insurance Research Database, and suicide deaths were ascertained from the national death register. Competing risk survival analyses were used to estimate the risk of suicide attempts and deaths within one year and three years of MMT enrollment.

RESULTS

A total of 1.2 % of MMT-treated women ever visited hospital for suicide attempt, and 0.5 % died by confirmed suicide. The risk of treated suicide attempt reached its peak at the end of the 8th month after methadone initiation, whereas the risk of confirmed suicide death was relatively stable during the first one and a half years. A history of treated depressive disorders appears to be the strongest risk predictor for treated suicide attempts (Adjusted Hazard Ratio [aHR] = 3.45; 95 % CI = 1.66-7.19) and confirmed suicide death (aHR = 3.47; 95 % CI = 1.20-10.0). Retaining in methadone treatment may significantly lower the hazard of probable suicide death by 52 %.

CONCLUSIONS

Women with heroin use disorders should receive careful attention for suicide risk at intake assessment and over the course of treatment and recovery. Preventive strategies should target unmet clinical and social needs and evaluate gender-specific barriers for treatment engagement.

Drug Overdose and Suicide Among Veteran Enrollees in the VHA: Comparison Among Local, Regional, and National Data

Background

Suicide is the 10th leading cause of death in the US, primarily from drug overdose. In 2017, 67.8% of drug overdoses were with prescription opioids. The rate of opioid use disorder among patients in the Veterans Health Administration (VHA) is 7 times higher than that of non-VHA enrollees. This study compares the incidence of overdose and suicide across facility, regional, and national levels in the VHA system in the context of a multispecialty opioid risk reduction program at the North Florida/South Georgia Veteran Health System (NF/SGVHS).

Methods

This retrospective study used fiscal years 2012 to 2016 overdose and suicide aggregate data from the US Department of Veterans Affairs (VA) Support Service Center medical diagnosis cube and VA Suicide Prevention Program. Overdose data were aggregated by facility and fiscal year, and overdose rates (per 1,000 individuals) were calculated.

Results

The average annual rate of overdose diagnosis at NF/SGVHS during the study period was slightly higher (16.8 per 1,000) compared with its region (16.0 per 1,000), and VHA national (15.3 per 1,000) rates. The NF/SGVHS had the lowest average annual rate of suicide (9.1 per 100,000) during the study period, which was one-quarter of the VHA national rate.

Conclusions

NF/SGVHS developed and implemented a biopsychosocial model of pain treatment that includes primary care integrated with mental health and addiction services. The presence of this program during a period when the facility was tapering opioid prescriptions could explain the relative reduced suicide rate.

Relationships Between Opioid Dosing, Pain Severity, and Disability in a Community-Based Chronic Pain Population: An Exploratory Retrospective Analysis

OBJECTIVE

To determine the relationship between opioid dose change, pain severity, and function in patients with chronic pain.

DESIGN

Retrospective cohort study.

SETTING

Community interdisciplinary pain management practice.

SUBJECTS

A total of 778 patients with chronic pain prescribed opioids for three or more consecutive months between April 1, 2013, and March 1, 2015.

METHODS

Changes in opioid dose, pain severity rating, modified Roland Morris Disability Questionnaire score, and opioid risk data were extracted from medical records and analyzed for associations.

RESULTS

Two hundred forty-three subjects (31.2%) had an overall dose decrease, 223 (28.7%) had a dose increase, and 312 (40.1%) had no significant change in dose (<20% change). There was a weak negative correlation between change in opioid dose and change in pain severity (r = -0.08, P = 0.04) but no association between change in disability scores and dose change (N = 526, P = 0.13). There was a weak positive correlation between change in pain severity rating and change in disability scores (r = 0.16, P < 0.001).

CONCLUSIONS

The results suggest that escalating opioid doses may not necessarily result in clinically significant improvement of pain or disability. Similarly, significant opioid dose reductions may not necessarily result in worsened pain or disability. This exploratory investigation raised questions of possible subgroups of patients who might demonstrate improvement of pain and disability with opioid dose adjustments, and further research should prospectively explore this potential, given the limitations inherent in retrospective analyses. Prescribers should still consider reduction of opioid doses as recommended by current guidelines, in an effort to mitigate the potential risks associated with high-dose treatment.

Trust, conversations and the 'middle space': A qualitative exploration of the experiences of physiotherapists with clients with suicidal thoughts and behaviours

In Australia, physiotherapists are registered healthcare practitioners who possess the knowledge and skills to care for clients with poor physical health as a result of musculoskeletal, neurological, and respiratory conditions. Although physiotherapists are not considered a primary profession in the Australian mental health workforce, the association between suicide and poor physical health suggests that they may encounter clients with suicidal thoughts and behaviours. We used a qualitative approach inspired by phenomenology to explore the experiences of nine physiotherapists who encountered clients with suicidal thoughts and behaviours. We used a combination of focus groups and in-depth interviews to collect this data. The data were analysed inductively using framework analysis. The main themes identified in the data were: i) the importance of trust, ii) the mechanism of conversation, and iii) the 'middle space'. The middle space refers to the experience of working with clients at risk of low or medium risk of suicide. A trusting practitioner-client relationship was reported to be essential in facilitating the disclosure of suicidal thoughts and behaviours. Physiotherapists also reported that less structured subjective assessments encourage clients to talk more openly, which in turn facilitates the disclosure of suicidal thoughts and behaviours. Once the disclosure of suicidal thoughts and behaviours occurred, physiotherapists reported a lack of confidence regarding role clarity and issues associated with this. Difficulties were most evident during encounters with clients with low to medium suicide risk due to a lack of confidence in the accuracy of assessment of these clients. The findings suggest that physiotherapists are well placed to detect and/or receive disclosure of suicidal thoughts and behaviours, as well as the need for physiotherapists to be trained in how to support clients who disclose suicidal thoughts and behaviours.

Complementary, Integrative, and Nondrug Therapy Use for Pain Among US Military Veterans on Long-term Opioids

BACKGROUND

Long-term opioid therapy for chronic pain arose amid limited availability and awareness of other pain therapies. Although many complementary and integrative health (CIH) and nondrug therapies are effective for chronic pain, little is known about CIH/nondrug therapy use patterns among people prescribed opioid analgesics.

OBJECTIVE

The objective of this study was to estimate patterns and predictors of self-reported CIH/nondrug therapy use for chronic pain within a representative national sample of US military veterans prescribed long-term opioids for chronic pain.

RESEARCH DESIGN

National two-stage stratified random sample survey combined with electronic medical record data. Data were analyzed using logistic regressions and latent class analysis.

SUBJECTS

US military veterans in Veterans Affairs (VA) primary care who received ≥6 months of opioid analgesics.

MEASURES

Self-reported use of each of 10 CIH/nondrug therapies to treat or cope with chronic pain in the past year: meditation/mindfulness, relaxation, psychotherapy, yoga, t'ai chi, aerobic exercise, stretching/strengthening, acupuncture, chiropractic, massage; Brief Pain Inventory-Interference (BPI-I) scale as a measure of pain-related function.

RESULTS

In total, 8891 (65%) of 13,660 invitees completed the questionnaire. Eighty percent of veterans reported past-year use of at least 1 nondrug therapy for pain. Younger age and female sex were associated with the use of most nondrug therapies. Higher pain interference was associated with lower use of exercise/movement therapies. Nondrug therapy use patterns reflected functional categories (psychological/behavioral, exercise/movement, manual).

CONCLUSIONS

Use of CIH/nondrug therapies for pain was common among patients receiving long-term opioids. Future analyses will examine nondrug therapy use in relation to pain and quality of life outcomes over time.

Race and Gender Are Associated with Opioid Dose Reduction Among Patients on Chronic Opioid Therapy

OBJECTIVE

Among patients with chronic pain, risk of opioid use is elevated with high opioid dose or concurrent benzodiazepine use. This study examined whether these clinical factors, or sociodemographic factors of race and gender, are associated with opioid dose reduction.

DESIGN AND SETTING

A retrospective cohort study of outpatients prescribed chronic opioid therapy between 2007 and 2012 within a large, academic health care system in Bronx, New York, using electronic medical record data. Included patients were prescribed a stable dose of chronic opioid therapy over a one-year "baseline period" and did not have cancer.

METHODS

The primary outcome was opioid dose reduction (≥30% reduction from baseline) within two years. Multivariable logistic regression tested the associations of two clinical variables (baseline daily opioid dose and concurrent benzodiazepine prescription) and two sociodemographic variables (race/ethnicity and gender) with opioid dose reduction.

RESULTS

Of 1,097 patients, 463 (42.2%) had opioid dose reduction. High opioid dose (≥100 morphine-milligram equivalents [MME]) was associated with lower odds of opioid dose reduction compared with an opioid dose <100 MME (adjusted odds ratio [AOR] = 0.69, 95% confidence interval [CI] = 0.54-0.89). Concurrent benzodiazepine prescription was not associated with opioid dose reduction. Black (vs white) race and female (vs male) gender were associated with greater odds of opioid dose reduction (AOR = 1.82, 95% CI = 1.22-2.70; and AOR = 1.43, 95% CI = 1.11-1.83, respectively).

CONCLUSIONS

Black race and female gender were associated with greater odds of opioid dose reduction, whereas clinical factors of high opioid dose and concurrent benzodiazepine prescription were not. Efforts to reduce opioid dose should target patients based on clinical factors and address potential biases in clinical decision-making.

Prevalence and Characteristics Associated with Chronic Noncancer Pain in Suicide Decedents: A National Study

OBJECTIVE

The aims were to estimate the prevalence of CNCP in suicide decedents, and compare sociodemographic and clinical characteristics of people who die by suicide (i) with and without a history of CNCP and (ii) among decedents with CNCP who are younger (<65 years) and older (65 + years).

METHOD

We examined all closed cases of intentional deaths in Australia in 2014, utilizing the National Coronial Information System.

RESULTS

We identified 2,590 closed cases of intentional deaths in Australia in 2014 in decedents over 18 years of age. CNCP was identified in 14.6% of cases. Decedents with CNCP were more likely to be older, have more mental health and physical health problems, and fewer relationship problems, and were more likely to die by poisoning from drugs, compared with decedents without CNCP. Comparisons of older and younger decedents with CNCP found that compared to younger (<65 years) decedents with CNCP, older decedents (65 + years) were less likely to have mental health problems.

CONCLUSIONS

This is the first national study to examine the characteristics of suicide deaths with a focus on people with CNCP. Primary care physicians should be aware of the increased risk for suicide in people living with CNCP, and it may be useful for clinicians to screen for CNCP among those presenting with suicidal behaviors.

The first 24 h: opioid administration in people with spinal cord injury and neurologic recovery

STUDY DESIGN

Retrospective chart review.

OBJECTIVES

The objective of this study was to characterize opioid administration in people with acute SCI and examine the association between opioid dose and (1) changes in motor/functional scores from hospital to rehabilitation discharge, and (2) pain, depression, and quality of life (QOL) scores 1-year post injury.

SETTING

Spinal Cord Injury Model System (SCIMS) inpatient acute rehabilitation facility.

METHODS

Patients included in the SCIMS from 2008 to 2011 were linked to the National Trauma Registry and the electronic medical record. Three opioid dose groups (low, medium, and high) were defined based on the total morphine equivalence in milligrams at 24 h. The associations between opioid dose groups and functional/motor outcomes were assessed, as well as 1-year follow-up pain and QOL surveys.

RESULTS

In all, 85/180 patients had complete medication records. By 24 h, all patients had received opioids. Patients receiving higher amounts of opioids had higher pain scores 1 year later compared with medium- and low-dose groups (pain levels 5.5 vs. 4 vs. 1, respectively, p = 0.018). There was also an 8× greater risk of depression 1 year later in the high-dose group compared with the low-dose group (OR: 8.1, 95% CI: 1.2-53.7). In analyses of motor scores, we did not find a significant interaction between opioid dose and duration of injury.

CONCLUSIONS

These preliminary findings suggest that higher doses of opioids administered within 24 h of injury are associated with increased pain in the chronic phase of people with SCI.

Oxycodone, Hydromorphone, and the Risk of Suicide: A Retrospective Population-Based Case-Control Study

INTRODUCTION

Opioids have been increasingly associated with suicide, but whether they are independent contributors is unclear. Oxycodone and hydromorphone are commonly prescribed high-potency opioids that can differentially affect mood.

OBJECTIVE

The objective of this study was to explore whether oxycodone and hydromorphone are differentially associated with suicide.

METHODS

We conducted a retrospective population-based case-control study in Ontario, Canada, from 1992 to 2014. Using coronial data, we defined case subjects as individuals who died by suicide involving an opioid overdose. Each of these was matched with up to four controls who died of accidental opioid overdose. We ascertained exposure to oxycodone, hydromorphone, and other opioids from postmortem toxicology testing. We used odds ratios and 95% confidence intervals to examine whether opioid-related suicide was disproportionately associated with oxycodone relative to hydromorphone.

RESULTS

We identified 438 suicides and 1212 accidental deaths, each of which involved either oxycodone or hydromorphone but not both. The median age at death was 49 years and 51% were men. After adjusting for a history of self-harm, psychiatric illness, and exposure to other opioids, we found that oxycodone was more strongly associated with suicide than hydromorphone (adjusted odds ratio 1.59; 95% confidence interval 1.20-2.11). In a secondary analysis, we observed a trend of similar magnitude in which combined exposure to oxycodone and hydromorphone was more strongly associated with suicide than hydromorphone alone (adjusted odds ratio 1.68; 95% confidence interval 0.92-3.09).

CONCLUSIONS

While preliminary, these findings support the possibility that some high-potency opioids might independently influence the risk of suicide in susceptible individuals.

Pain as a risk factor for suicidal ideation. A population-based longitudinal cohort study

OBJECTIVE

To examine the longitudinal association between pain and suicidal ideation in the general adult population.

METHOD

Data were used from two waves (baseline and three-year follow-up) of the Netherlands Mental Health Survey and Incidence Study-2. Persons without prior 12-month suicidal ideation at baseline were included in this study (N = 5242). Pain severity and interference due to pain in the past month were measured using the 36-item Short Form Health Survey. Suicidal ideation and DSM-IV mental disorders were assessed using the Composite International Diagnostic Interview. Logistic regression analyses were performed.

RESULTS

Moderate to very severe pain (OR 3.39, p < .001) and moderate to very severe interference due to pain (OR 2.35, p .01) were associated with a higher risk for incident suicidal ideation at follow-up after adjustment for baseline sociodemographic variables and mental disorders. No interaction effects were found between pain severity or interference due to pain and mental disorders.

CONCLUSION

Moderate to severe pain and interference due to pain are risk factors for suicidal ideation independently of concomitant mental disorders. We suggest taking assessment and management of suicidal ideation in patients with pain into account both in clinical treatment as well as in suicide prevention action plans.

Acute stressors and clinical characteristics differentiate death by suicide, accident, or natural causes among illicit and prescription opiate users

BACKGROUND

Opiate misuse has reached epidemic levels. Prevention efforts depend on distinguishing opiate users from abusers. The current study compared opioid users who died by natural cases, accidents, and suicide using psychological autopsy methods. Groups were compared on substance use characteristics, treatment history, experiences of negative life events, and circumstances at the time of death.

METHODS

Substance use and suicide risk were evaluated using psychological autopsy methods in 63 decedents with positive toxicology for opiates at death divided into three groups: adults dying by suicide (n = 19), accident (n = 19), and natural causes (n = 25). Groups were compared on several dependent measures, using chi-square analyses to examine categorical variables and one-way analyses of variance (ANOVA) to examine continuous variables.

RESULTS

Individuals who died by suicide were similar in many ways to adults who died by an accidental overdose. However, suicide completers were more likely to have struggled with severe depression, and previously attempted suicide, whereas the accidental overdose sample was more likely to display a chronic pattern of severe drug abuse.

CONCLUSIONS

The current study helps to distinguish between opiate users who are at risk for death by an accidental or intentional overdose. In the ongoing opiate crisis, clinicians must understand the risk of overdose and the nuances of accidental behaviors compared to purposeful ones. Signs of suicidal planning, relevant psychopathology, and ongoing life stress may be useful points of intervention for stopping the increasing number of deaths among opiate users.

Suicide among people treated for drug use disorders: a Danish national record-linkage study

Background

Substance use disorders are a major risk factor for suicide. However, less is known about specific risk factors for suicide in people with substance use disorders.

Methods

This population cohort study assessed suicide among people treated for drug use disorders in Denmark 2000–2010, and described risk factors for completed suicide. Data from 27,942 individuals enrolled in treatment were linked to national registers and matched with controls without drug use disorder and with (n = 138,136) or without psychiatric history (n = 1574). Competing risk regression was used to identify risk factors of completed suicide.

Results

There were 163 suicides among patients with a history of drug treatment (0.6% of patients). Increased risk was associated with younger age at enrolment (hazard ratio [HR] = 0.97, 95% confidence interval (CI): 0.95, 0.98), history of psychiatric care (HR = 1.96, CI 95%: 1.39, 2.77), opioid use (HR = 1.81, 95% CI: 1.23, 2.68), and alcohol use (HR = 1.56, 95% CI: 1.09, 2.23). Lower risk was associated with cannabis use (HR = 0.69, 95% CI: 0.50, 0.96). Compared with age- and gender-matched controls without a history of treatment for substance use disorders or recent psychiatric care, the standardized mortality ratio due to suicide was 7.13 for people with drug use disorder without a history of psychiatric care (95% CI: 5.81, 8.44), 13.48 for people with drug use disorder and psychiatric history (95% CI: 9.75, 17.22), and 13.61 for people with psychiatric history only (95% CI: 6.72, 20.50).

Conclusions

Risk of suicide is increased among people with drug use disorders. Access to treatment for co-morbid mental health problems for people with drug use disorders could potentially reduce risk of suicide.

Why Are Suicide Rates Increasing in the United States? Towards a Multilevel Reimagination of Suicide Prevention

Suicide, a major public health concern, takes around 800,000 lives globally every year and is the second leading cause of death among adolescents and young adults. Despite substantial prevention efforts, between 1999 and 2017, suicide and nonfatal self-injury rates have experienced unprecedented increases across the United States - as well as in many other countries in the world. This chapter reviews the existing evidence on the causes behind increased suicide rates and critically evaluates the impact of a range of innovative approaches to suicide prevention. First, we briefly describe current trends in suicide and suicidal behaviors and relate them to recent time trends in relevant suicide risk markers. Then, we review the existing evidence in suicide prevention at the individual and the population levels, including new approaches that are currently under development. Finally, we advocate for a new generation of suicide research that examines causal factors beyond the proximal and clinical and fosters a socially conscious reimagining of suicidal prevention. To this end, we emphasize the need for the conceptualization of suicide and suicidal behaviors as complex phenomena with causes at several levels of organization. Future interdisciplinary research and interventions should be developed within a multilevel causal framework that can better capture the social, economic, and political settings where suicide, as a process, unfolds across the life course.

The Role of Opiates in Social Pain and Suicidal Behavior

With more than 800,000 deaths by suicide each year and 20 to 30 times more suicide attempts worldwide, suicide is a major public health problem. Current treatments of SB are mainly based on pharmacological treatments that are not specific of SB (e.g. antidepressants), and new therapeutic targets are urgently needed. Recent data strengthen the ancient conception pain (social, psychic, physical) that is at the core of the suicidal process and should be incorporated in the clinical assessment of suicide risk. Then, the mechanisms involved in the regulation of pain may open new avenues regarding therapeutic perspectives. Opiates appear to be a promising candidate in treatment of SB. Indeed, since the last two decades, growing evidences suggest an implication of the opioid system in the pathophysiology of SB, this conduct to the elaboration of randomized controlled trials (RCTs) using opiates in patients with SB. Results suggesting an anti-suicidal effect of buprenorphine and the potential opioidergic-related anti-suicidal effect of ketamine both contribute to the growing interest in opiates use in SB. In this review, we will summarize a large part of the evidence that leads researchers and clinicians to be interested in the use of opiates for SB treatment and discuss on new opioid pharmacological options for suicidal patients.

Opioid Taper Is Associated with Subsequent Termination of Care: a Retrospective Cohort Study

BACKGROUND

Opioid tapering is increasingly utilized by providers to decrease risks of chronic opioid therapy, but it is unknown whether tapering is associated with termination of care.

OBJECTIVE

To determine whether patients taking chronic opioid therapy who experienced opioid tapers were at greater risk of subsequently terminating their care compared with those who were continued on their doses.

DESIGN

Retrospective cohort study of patients in a large, urban health system between 2008 and 2012 with 2 years of follow-up.

PARTICIPANTS

Adult patients prescribed a stable baseline dose of chronic opioid therapy of at least 25 morphine milligram equivalents per day during a baseline year.

MAIN MEASURES

An opioid taper during an exposure year, defined as a reduction in the average daily dose of at least 30% from the baseline dose in both of the two 6-month periods in the year following the baseline year. Opioid dose continuation was defined as any increase in dose, no change in dose, or any decrease up to 30% compared with baseline dose in the exposure year. The primary outcome was termination of care, defined as no outpatient encounters in the health system, in the year following the exposure year.

KEY RESULTS

Of 1624 patients on chronic opioid therapy, 207 (15.5%) experienced an opioid taper and 78 (4.8%) experienced termination of care. Compared with opioid dose continuation, opioid taper was significantly associated with termination of care (AOR 4.3 [95% CI 2.2-8.5]).

CONCLUSIONS

Opioid taper is associated with subsequent termination of care. These findings invite caution and demonstrate the need to fully understand the risks and benefits of opioid tapers.

A national case fatality study of drugs taken in intentional overdose

BACKGROUND

Intentional drug overdose (IDO) has been linked with marked increases in premature mortality risk due to suicide, accidents and other causes, yet little is known about how case fatality risk varies according to the type of drug/s taken. This study aimed to examine the incidence of IDO, to identify the predictors of fatal IDO and to establish which drugs are linked with greater risk of a fatal outcome.

METHODS

Data from the National Self-Harm Registry, and the National Drug-Related Deaths Index, 2007-2014, were used to calculate incidence, examine overdose characteristics and estimate case fatality risk ratios.

RESULTS

We examined 63,831 non-fatal and 364 fatal IDOs (incidence: 148.8 and 1.01 per 100,000 respectively). Compared to non-fatal IDOs, fatal cases were more often male (55.2% vs. 42.0%), older in age (median 44 vs. 35 years), and more frequently involved multiple drugs (78.3% vs. 48.5%). Tricyclic antidepressants were associated with a 15-fold increased risk of death and opioids a 12-fold increased risk, relative to the reference category (non-opioid analgesics). While the risk of fatal outcome was higher for males than females, the elevation in risk was greater in females when tricyclic antidepressants or opioids were taken.

CONCLUSION

Male gender, increasing age and multiple drug use were associated with fatal IDO outcome. Tricyclic antidepressants and opioids were associated with a significantly increased risk of death following intentional overdose. Clinicians need to consider the case fatality risk of drugs when determining treatment for patients at risk of or those who have previously harmed themselves.

Suicide Has Many Faces, So Does Ketamine: a Narrative Review on Ketamine's Antisuicidal Actions

PURPOSE OF REVIEW

Suicidal behaviours are a challenge for a medical system and public health, partly due to the current lack of evidence-based, effective, rapid tools for suicidal crisis management. Ketamine and its enantiomer esketamine have raised hopes regarding this issue in the recent years. However, their efficacy in suicidal behaviours and mechanisms for it remain a topic of debate.

RECENT FINDINGS

Subanesthetic ketamine doses rapidly, albeit transiently decrease suicidal ideation, with effects emerging within an hour and persisting up to a week. Current evidence points to various and not necessarily exclusive mechanisms for ketamine's antisuicidal action, including effects on neuroplasticity, inflammation, reward system and pain processing. Ketamine rapidly decreases suicidal ideation, but whether it leads to meaningful clinical outcomes past 1 week is unclear. Multiple putative mechanisms drive ketamine's antisuicidal action. Future studies will have to show long-term ketamine treatment outcomes and further elucidate its mechanisms of action.

A randomized trial comparing the Tennant Biomodulator to transcutaneous electrical nerve stimulation and traditional Chinese acupuncture for the treatment of chronic pain in military service members

BACKGROUND

The present investigation tested the efficacy of the Tennant Biomodulator, a novel pain management intervention that uses biofeedback-modulated electrical stimulation, to reduce chronic pain and its psychosocial sequelae in a sample of current and former military service members. The Tennant Biomodulator used on its most basic setting was compared to two commonly used, non-pharmacological pain treatments-traditional Chinese acupuncture and transcutaneous electrical nerve stimulation (TENS)-in a comparative efficacy, randomized, open-label trial.

METHODS

Participants included 100 active duty and retired service men and women with chronic pain undergoing treatment at the Brooke Army Medical Center in Texas, USA, randomly assigned to receive six, weekly sessions of either Tennant Biomodulator treatment, traditional Chinese acupuncture, or TENS, in addition to usual care. Recruitment was conducted between May 2010 to September 2013. Outcome measures were collected at intake, before and after each treatment session, and at a 1-month follow-up. Intent-to-treat analyses were used throughout, with mixed models used to investigate main effects of group, time, and group × time interactions with consideration given to quadratic effects. Outcomes measured included ratings of chronic pain, pain-related functional disability, and symptoms of post-traumatic stress disorder (PTSD) and depression.

RESULTS

On average, regardless of their treatment group, participants exhibited a 16% reduction in pain measured by the Brooke Army Medical Center's Clinic Pain Log [F(1, 335) = 55.7, P <  0.0001] and an 11% reduction in pain-related disability measured by the Million Visual Analog Scale [MVAS: F(1, 84) = 28.3, P <  0.0001] from baseline to the end of treatment, but no one treatment performed better than the other, and the reductions in pain and pain-related disability were largely lost by 1-month follow-up. Symptoms of PTSD and depression did not change significantly as a function of time or group.

CONCLUSIONS

Findings build on previous work suggesting that traditional Chinese acupuncture and TENS can reduce pain and its functional sequelae without risks associated with pharmacological pain management. The Tennant Biomodulator used on its most basic setting performs as well as these other interventions. Based on the present findings, large, randomized controlled trials on the Tennant Biomodulator are indicated. Future work should test this device using its full range of settings for pain-related psychological health.

TRIAL REGISTRATION

Clincialtrials.gov (NCT01752010); registered December 14, 2012.

Attenuation of antidepressant and antisuicidal effects of ketamine by opioid receptor antagonism

We recently reported that naltrexone blocks antidepressant effects of ketamine in humans, indicating that antidepressant effects of ketamine require opioid receptor activation. However, it is unknown if opioid receptors are also involved in ketamine's antisuicidality effects. Here, in a secondary analysis of our recent clinical trial, we test whether naltrexone attenuates antisuicidality effects of ketamine. Participants were pretreated with naltrexone or placebo prior to intravenous ketamine in a double-blinded crossover design. Suicidality was measured with the Hamilton Depression Rating Scale item 3, Montgomery-Åsberg Depression Rating Scale item 10, and Columbia Suicide Severity Rating Scale. In the 12 participants who completed naltrexone and placebo conditions, naltrexone attenuated the antisuicidality effects of ketamine on all three suicidality scales/subscales (linear mixed model, fixed pretreatment effect, p < 0.01). Results indicate that opioid receptor activation plays a significant role in the antisuicidality effects of ketamine.

Concurrent use of benzodiazepines, antidepressants, and opioid analgesics with zolpidem and risk for suicide: a case-control and case-crossover study

PURPOSE

To evaluate whether the concurrent use of benzodiazepines, antidepressants, and opioid analgesics with zolpidem increases the risk of suicide or triggers suicide compared with the use of zolpidem alone.

METHODS

We conducted a case-control and case-crossover study using the Korean National Health Insurance Service-National Sample Cohort database. Cases were older than 20 years with a suicide record (International Codes of Disease 10th Revision codes: X-60-X84 and Y87.0 intentional self-harm) between January 1, 2004, and December 31, 2013. For case-control design, ten controls were matched to each case by age, sex, index year, region, income, and health insurance type. For case-crossover analysis, we set hazard period to 60 days and assigned five corresponding sets of control periods of equal length. Exposure was assessed during 60 days before suicide for combinations of benzodiazepines, antidepressants, opioid analgesics with zolpidem against zolpidem alone. We conducted a conditional logistic regression to estimate odds ratios (ORs) and their 95% confidence intervals (CIs).

RESULTS

In the case-control study, the risk of suicide was 2.80-fold higher in cases taking benzodiazepines and antidepressants with zolpidem than in those taking zolpidem alone (adjusted OR [aOR], 2.80; 95% CI, 1.38-5.70). However, in the case-crossover study, suicide risk showed no significant difference (crude OR [cOR], 0.92; 95% CI, 0.55-1.52) and was underpowered.

CONCLUSIONS

The results of the traditional case-control study confirmed that the concurrent use of benzodiazepines and antidepressants with zolpidem was associated with an increased risk of suicide compared with the use of zolpidem alone. However, there was no significant difference in the magnitude of risk in the within-person comparison design.

Past-year opioid misuse and suicide attempt are positively associated in high suicide risk veterans who endorse past- year substance use

The main purpose of this study was to test the relationship between past-year suicide attempt (SA) and past-year opioid misuse among Veterans at high risk of suicide who reported using at least one illicit substance or alcohol in the past year. Baseline data from 130 high suicide-risk Veterans (n = 39 past-year opioid misusers; n = 91 past-year users of other substances) who enrolled in a randomized controlled trial testing adjunctive Mindfulness-Based Cognitive Therapy to Prevent Suicidal Behavior were used. Information was collected on a semi-structured interview that included the Columbia-Suicide Severity Rating Scale to collect suicide attempt history. Past-year opioid misusers, compared to those who used at least one other illicit substance or alcohol in the past year, were more likely to have made a past-year SA. Past-year opioid misuse remained associated with past-year SA in multivariate analysis that included other known risk factors for SA. Our findings show a robust link between near-term SA and opioid misuse in Veterans.

The Role of Opioid Use in Distinguishing between Suicidal Ideation and Attempts

OBJECTIVE

Opioid use disorders are associated with heightened suicidal ideation, suicide attempts, and suicide death. This study aimed to examine the extent to which opioid differentiates between those with suicide attempts from those with lifetime suicidal ideation but no history of attempt.

METHODS

Participants were drawn from the US National Guard and a residential substance use treatment facility. Multinomial logistic regression was utilized to determine the extent to which a lifetime history of nonmedical opioid use differentiated between (1) individuals with no lifetime history of suicidal ideation or attempt, (2) individuals with a history of suicidal ideation but no attempt, and (3) individuals with a history of at least one suicide attempt.

RESULTS

History of opioid use among National Guard personnel and opioid use disorders among substance-dependent patients were associated with an increased likelihood of having at least one suicide attempt relative to both a history of suicidal ideation but no attempts and no history of ideation or attempts. Findings held when accounting for lifetime nonmedical use of other substances and the presence of other lifetime substance use disorders.

CONCLUSIONS

Results highlight the importance of assessing for suicide risk among opioid users.

Barriers to Utilization of Prescription Drug Monitoring Programs Among Prescribing Physicians and Advanced Practice Registered Nurses at Veterans Health Administration Facilities in Oregon

Objective

To identify barriers to using state prescription drug monitoring programs (PDMPs) among prescribing physicians and advanced practice registered nurses across a variety of Veterans Health Administration (VA) settings in Oregon.

Design

In-person and telephone-based qualitative interviews and user experience assessments conducted with 25 VA prescribers in 2018 probed barriers to use of state PDMPs.

Setting

VA health care facilities in Oregon.

Subjects

Physicians (N = 11) and advanced practice registered nurses (N = 14) who prescribed scheduled medications, provided care to patients receiving opioids, and used PDMPs in their clinical practice. Prescribers were stationed at VA medical centers (N = 10) and community-based outpatient clinics (N = 15); medical specialties included primary care (N = 10), mental health (N = 9), and emergency medicine (N = 6).

Methods

User experience was analyzed using descriptive statistics. Qualitative interviews were analyzed using conventional content analysis methodology.

Results

The majority of physicians (64%) and advanced practice registered nurses (79%) rated PDMPs as “useful.” However, participants identified both organizational and software design issues as barriers to their efficient use of PDMPs. Organizational barriers included time constraints, clinical team members without access, and lack of clarity regarding the priority of querying PDMPs relative to other pressing clinical tasks. Design barriers included difficulties entering or remembering passwords, unreadable data formats, time-consuming program navigation, and inability to access patient information across state lines.

Conclusions

Physicians and advanced practice registered nurses across diverse VA settings reported that PDMPs are an important tool and contribute to patient safety. However, issues regarding organizational processes and software design impede optimal use of these resources.

Research on the pathophysiology, treatment, and prevention of suicide: practical and ethical issues

BACKGROUND

Despite decades of research, the rate of death from suicide is rising in the United States. Suicide is a complex and multifactorial phenomenon and, to date, no validated biomarkers that predict suicidal behavior have been identified. Only one FDA-approved drug to prevent suicide exists, and it is approved only for patients with schizophrenia. Although anti-suicide psychotherapeutic techniques exist, treatment takes time, and only preliminary data exist for rapid-acting therapies.

DISCUSSION

While more research into suicidal ideation and acute suicidal behavior is clearly needed, this research is fraught with both practical and ethical concerns. As a result, many investigators and bioethicists have called for restrictions on the types of research that individuals with suicidal behavior can participate in, despite the fact that the available empirical evidence suggests that this research can be done safely. This manuscript presents background information on the phenomenology of suicide, discusses the current state of treatment and prevention strategies, and reviews the practical and ethical issues surrounding suicide research in the context of available empirical data. Currently, the causes of suicide are poorly understood, in part due to the fact that very few studies have investigated the acute suicidal crisis. Although some biomarkers for predicting risk have been developed, none have been sufficiently validated. The most successful current interventions involve means restriction. However, while numerous hurdles face researchers, these are not insurmountable. The available evidence suggests that research into suicide can be conducted both safely and ethically.

Prevalence and correlates of suicide attempt among Chinese individuals receiving methadone maintenance treatment for heroin dependence

To date, there have been very limited studies regarding the clinical epidemiology of attempted suicide in Chinese individuals with heroin-dependence. The objective of this study was to examine the prevalence and correlates of suicide attempt in Chinese individuals receiving methadone maintenance treatment for heroin dependence. Demographic, clinical, and psychosocial data of 603 methadone-maintained patients with heroin dependence were collected with a standardized self-administered questionnaire. The presence of suicide attempt and antisocial personality disorder was assessed by using a single question and the Mini-International Neuropsychiatric Interview 5.0. The one-month and lifetime prevalence rates of suicide attempt were 9.5% and 34.2%, respectively. In multivariable logistic regression, lifetime suicide attempt was significantly associated with female gender (OR = 2.81), being 20–39 years old (OR = 2.73), an education level of primary school or lower (OR = 2.07), poor economic status (OR = 3.06), injecting heroin before methadone maintenance treatment (OR = 2.92), depressive symptoms (OR = 3.46), anxiety symptoms (OR = 1.88), and antisocial personality disorder (OR = 2.85). Suicide attempt is very prevalent among Chinese individuals receiving methadone maintenance treatment for heroin dependence. Services for patients with heroin dependence in methadone maintenance treatment clinics in China should include psychosocial supports, periodic screening for suicide attempt and other suicidal behaviors and, when needed, psychiatric treatment and crisis intervention.

Access to means of lethal overdose among psychiatric patients with co-morbid physical health problems: Analysis of national suicide case series data from the United Kingdom

BACKGROUND

Many physical health problems are associated with elevated suicide risk whilst also providing access to means of overdose. We aimed to investigate whether psychiatric patients with physical co-morbidities who die by suicide were more likely than those without co-morbidities to self-poison with non-psychotropic medications.

METHODS

We analysed data on 14,648 psychiatric patients who died by suicide in England & Wales during 2004-2015, as recorded by the National Confidential Inquiry into Suicide and Safety in Mental Health. Using logistic regression models adjusted for age, gender, ethnicity, and primary drug dependence/misuse we compared patients diagnosed with physical co-morbidities versus those without to assess whether a greater proportion of the former had died by overdose, and medication prescribed to treat such disorders (e.g. opioids, insulin).

RESULTS

24% (n = 3525) were recorded as having physical co-morbidity. A greater proportion of these individuals died by self-poisoning than those without physical co-morbidity (37% vs. 20%, p < .001; adjusted OR 2.47; 95% CI 2.26-2.70), and they were more likely to have used medications for a physical health disorder in overdose (50% vs. 34%; adjusted OR 2.10; 95% CI 1.80-2.46), particularly opioids (30% vs. 22%; p < .001), paracetamol/opioid compounds (11% vs. 7%, p < .001) and insulin (4% vs. 1%, p < .001).

LIMITATIONS

Use of survey data may have resulted in under-reporting of physical health problems and/or overdose medications.

CONCLUSIONS

Overdose, rather than hanging, is the leading cause of suicide among psychiatric patients with physical co-morbidities, particularly using non-psychotropic medications. There is potential for means restriction in preventing suicide among these patients.

Fatal and Non-fatal Self-Injury in the USA: Critical Review of Current Trends and Innovations in Prevention

PURPOSE OF REVIEW

To examine current trends in suicide and self-injury in the USA, as well as potential contributors to their change over time, and to reflect on innovations in prevention and intervention that can guide policies and programs to reduce the burden of suicide and self-injury in the USA.

RECENT FINDINGS

Suicide and non-fatal self-injury are on the rise in the USA. Reasons for such trends over time remain speculative, although they seem linked to coincident increases in mood disorders and drug use and overdose. Promising innovative prevention and intervention programs that engage new technologies, such as machine learning-derived prediction tools and computerized ecologic momentary assessments, are currently in development and require additional evidence. Recent increases in fatal and non-fatal self-harm in the USA raise questions about the causes, interventions, and preventive measures that should be taken. Most innovative prevention efforts target individuals seeking to improve risk prediction and access to evidence-based care. However, as Durkheim pointed out over 100 years ago, suicide rates vary enormously between societal groups, suggesting that certain causal factors of suicide act and, hence, should be targeted at an ecological level. In the next generation of suicide research, it is critical to examine factors beyond the proximal and clinical to allow for a reimagining of prevention that is life course and socially focused.

Assessment and Management of Patients at Risk for Suicide: Synopsis of the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines

DESCRIPTION

In May 2019, the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) approved an update to the 2013 joint clinical practice guideline for assessing and managing patients who are at risk for suicide. This guideline provides health care providers with a framework by which to screen for, evaluate, treat, and manage the individual needs and preferences of VA and DoD patients who may be at risk for suicide.

METHODS

In January 2018, the VA/DoD Evidence-Based Practice Work Group convened to develop a joint VA/DoD guideline including clinical stakeholders and conforming to the National Academy of Medicine's tenets for trustworthy clinical practice guidelines. The guideline panel drafted key questions, systematically searched and evaluated the literature through April 2018, created algorithms, and advanced 22 recommendations in accordance with the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system.

RECOMMENDATIONS

This synopsis, which includes 3 clinical practice algorithms, summarizes the key recommendations of the guideline related to screening and evaluation, risk management and treatment, and other management methods. Risk management and treatment recommendations address both pharmacologic and nonpharmacologic approaches for patients with suicidal ideation and behavior. Other management methods address lethal means safety (such as restricting access to firearms, poisons, and medications and installing barriers to prevent jumping from lethal heights) and population health strategies.

Sexual minority disparities in opioid misuse, perceived heroin risk and heroin access among a national sample of US adults

BACKGROUND

Lesbian, gay and bisexual (LGB) adults have elevated use of many substances compared to heterosexual adults, yet LGB disparities in specific types of opioid misuse and perceived opioid risk have not been fully characterized.

METHODS

Data on 126,463 adults (including 8241 LGB adults) were from the 2015-2017 National Survey of Drug Use and Health. Logistic regression was used to estimate lesbian/gay (L/G) and bisexual disparities (relative to same-gender heterosexuals) for: lifetime prescription pain reliever misuse, heroin use and injection heroin use; past-year opioid misuse and opioid use disorder (OUD); and perceived risk of and access to heroin.

RESULTS

All LGB subgroups had elevated lifetime pain reliever misuse rates relative to same-gender heterosexuals. Lifetime heroin use was elevated among LGB women and bisexual men; bisexual women had 4 times the odds of injection heroin use. LGB women and gay men had 1.4-2.4 times the odds of past-year opioid misuse; bisexual women had 2.5 times the odds of OUD. LGB women reported both lower perceived risk of trying heroin and greater perceived heroin access.

CONCLUSIONS

Lifetime and past-year opioid misuse is elevated among LGB adults. Bisexual women are particularly at-risk, uniquely exhibiting disparities on high-risk injection use and OUD. Lower perceived risk of and greater access to heroin among LGB women may play a role in the onset or continuation of opioid misuse. Opioid misuse disparities among LGB adults are of substantial concern given the resultant elevated risk for fatal and non-fatal opioid overdose.

Association between nonmedical use of opioids or sedatives and suicidal behavior among Chinese adolescents: An analysis of sex differences

OBJECTIVE

The rising rate of suicidal behavior among adolescents is a growing concern, and sex differences may induce differential exposure to prescription drug misuse or suicidal behavior. We estimated, among Chinese adolescents, (1) the prevalence of nonmedical use of prescription drugs, suicidal ideation and suicide attempts; (2) whether nonmedical use of prescription drugs was independently associated with suicidal ideation and suicide attempts; and (3) whether there were sex differences in the associations.

METHODS

This was a secondary analysis of the data drawn from the 2015 National School-based Chinese Adolescents Health Survey. A total of 94,911 students completed questionnaires and qualified for our survey (response rate: 93.7%). All analyses were conducted separately for boys and girls.

RESULTS

There were significant sex differences in the prevalence of opioid or sedative misuse, and the sources and reasons for nonmedical use of prescription drugs ( p < 0.05). The prevalence of suicidal ideation or suicide attempts was significantly higher in girls than in boys (suicidal ideation: 17.9% among girls vs 14.1% among boys; suicide attempts: 3.5% among girls vs 2.7% among boys). Among girls, frequent use of opioids was associated with an increased risk of suicidal ideation (adjusted odds ratio = 1.84, 95% confidence interval = [1.57, 2.17]) and suicide attempts (adjusted odds ratio = 2.96, 95% confidence interval = [2.34, 3.74]), and frequent use of sedatives was also positively associated with suicidal ideation (adjusted odds ratio = 2.23, 95% confidence interval = [1.91, 2.60]) and suicide attempts (adjusted odds ratio = 4.02, 95% confidence interval = [3.25, 4.99]). These associations were also statistically significant in boys, but the magnitudes of adjusted odds ratios for the associations between frequent use of opioids and sedatives and suicidal behavior were greater in girls than boys.

CONCLUSION

There exist significant sex differences in the prevalence rates of nonmedical use of prescription drugs and suicidal behavior, and the child's sex plays a role in the association between nonmedical use of prescription drugs and suicidal behavior. The significant sex differences found above may provide a basis for early identification of adolescents at high risk of suicidal behavior.

Opioid Therapy for Chronic Pain: Overview of the 2017 US Department of Veterans Affairs and US Department of Defense Clinical Practice Guideline

Description

The US Department of Veterans Affairs (VA) and US Department of Defense (DoD) revised the 2010 clinical practice guideline (CPG) for the management of opioid therapy for chronic pain, considering the specific needs of the VA and DoD and new evidence regarding prescribing opioid medication for non-end-of-life-related chronic pain. This paper summarizes the major recommendations and compares them with the US Centers for Disease Control and Prevention (CDC) guideline for prescribing opioids.

Patient Population

This Opioid Therapy CPG was developed for VA-DoD service members, veterans, and their families.

Methods

The VA/DoD Evidence-Based Practice Work Group convened a VA/DoD guideline renewal development effort and conformed to the guidelines established by the VA/DoD Joint Executive Council (JEC) and VA/DoD Health Executive Council (HEC). The panel developed questions, searched and evaluated the literature, developed recommendations using GRADE methodology, and developed algorithms. Passage of the CARA Act by Congress compelled consideration and comparison with the CDC opioid therapy guideline mid-development.

Results

There were 18 recommendations made. This article focuses on guideline development and key recommendations with CDC comparisons taken from four major areas, including: initiation and continuation of opioids;type, dose, follow-up, and taper of opioids;risk mitigation;acute pain.

Conclusions

Guideline development and recommendations are presented. There was substantial overlap with the CDC opioid guideline. Additionally, there were items particularly relevant to the VA-DoD, including risk mitigation, suicide prevention, and preventing opioid use disorder in young patients. Our guideline highlights avoiding opioid therapy longer than 90 days as a critical juncture.

The relationship between past 12-month suicidality and reasons for prescription opioid misuse

BACKGROUND

Understanding reasons for prescription opioid misuse can help elucidate suicide prevention efforts. The goal of the current study is to assess associations of reasons for prescription opioid misuse subtypes and suicide-related variables. We also assessed whether prescription opioid misuse differentiates ideators from those who attempt suicide.

METHODS

Using data from the 2015-2017 National Survey of Drug Use and Health (N = 45,074), prescription opioid misuse subtypes were grouped as follows: (a) Pain only, (b) Other reasons, and (c) Mixed reasons (i.e., pain and at least one other reason). Logistic regressions examined associations of misuse subtypes and past 12-month suicide-related variables (ideation, planning, attempts) relative to non-misusers. Logistic regression analyses were also conducted among the subset reporting ideation to assess whether prescription opioid misuse differentiated ideators with no attempt from ideators with an attempt.

RESULTS

In adjusted models, the Pain only and the Other reasons subtypes were associated with ideation and planning, but not attempts. The Mixed reasons subtype had higher odds of suicide ideation and planning compared to those not misusing prescription opioids and the Pain only misuse subtype. The Mixed reasons subtype had higher odds of a suicide attempt only when compared to those not misusing prescription opioids. Prescription opioid misuse was also associated with suicide attempts among the subset of ideators.

CONCLUSIONS

Findings indicate that people misuse prescription opioids for various reasons, and misuse subtypes are associated with past 12-month suicidality. Addressing pain and other reasons for misuse together through use of evidence-based treatments may help mitigate suicide risk.

Impact of delisting high-strength opioid formulations from a public drug benefit formulary on opioid utilization in Ontario, Canada

PURPOSE

High-strength opioid formulations were delisted (removed) from Ontario's public drug formulary in January 2017, except for palliative patients. We evaluated the impact of this policy on opioid utilization and dosing.

METHODS

We conducted a longitudinal study among patients receiving publicly funded, high-strength opioids from August 2016 to July 2017. The primary outcome measure was weekly median daily opioid dose (in milligrams of morphine or equivalent; MME) of (1) publicly funded and (2) all opioid prescriptions irrespective of funding source, evaluated using interrupted time series analyses and stratified by palliative care status.

RESULTS

Following policy implementation, the weekly median daily dose of publicly funded opioids decreased immediately among non-palliative patients by 10 MME (95% confidence limit [CL], -16.8 to -3.1) from a pre-intervention dose of 424.5 MME (95% CL, 417.8-431.2) and fell gradually among palliative patients by 3.9 MME per week (95% CL, -5.5 to -2.3) from a pre-intervention dose of 450.1 MME (95% CL, 432.5-467.7). In contrast, among all opioid prescriptions, gradual reductions in weekly median daily doses were observed only for non-palliative patients, which decreased by 0.7 MME per week (95% CL, -1.3 to -0.2) from a pre-intervention dose of 426.2 MME (95% CL, 420.9-431.5).

CONCLUSION

The delisting of publicly-funded, high-strength opioids was accompanied by changes in funding source and small reductions in the weekly median daily doses dispensed. Although observed dose reductions of less than 1 MME weekly are likely not clinically relevant, safety implications of these changes require further monitoring.

From Substance Use Disorders in Life to Autopsy Findings: A Combined Case-Record and Medico-Legal Study

Objectives: Several studies have shown mortality and suicide risk in substance use disorders, and autopsy findings with respect to the used substances. However, there seems to be a gap in the knowledge about substances misused in life and at death at the within-person level. Methods: All consecutive, autopsied patients during 1993 to 1997, who had been in contact with the Addiction Centre in Malmö from 1968, were investigated (365 subjects). Drug misuse in the long-term course noted in case records was related to autopsy findings. Self-inflicted death (suicide/undetermined suicide/accidental overdose) was compared with natural death. Results: Benzodiazepine misuse was associated with a high risk of autopsy findings of the substance in suicide and death of undetermined intent. It was also associated among non-misusers, but less so. An alcohol level above 1‰ was found more often in self-inflicted death. Prescription opioids at autopsy were mainly found in self-inflicted death among non-misusers. Heroin misuse was related to overdose. Central nervous system stimulants (CNS-S) and cannabis were rarely found in self-inflicted death among previous misusers. The overlap between depression in life and antidepressants at death was low. Conclusions: Benzodiazepines and alcohol seem to disinhibit suicidal tendencies. Suicide risk among users of cannabis and CNS-S may be related to other risk factors than acute use. Implications for suicide prevention are discussed.

Polymorphism A118G of opioid receptor mu 1 (OPRM1) is associated with emergence of suicidal ideation at antidepressant onset in a large naturalistic cohort of depressed outpatients

Antidepressants have been the object of an international controversy for about thirty years. Some patients are inclined to develop suicidal ideation (SI) at antidepressant onset; this phenomenon is known as Treatment Emergent Suicidal Ideation (TESI), and it has conducted regulatory bodies to prompt warnings on antidepressants. Since, few studies have explored the pharmacogenomics of TESI. Given the growing body of evidence connecting the opioidergic system with suicidal behavior (particularly mu opioid receptor (MOR)), we decided to examine the relationship between two genetic polymorphisms (SNPs) in the opioidergic system and TESI in a sample of 3566 adult depressed outpatients. General practitioners and psychiatrists throughout France followed participants for 6 weeks after an initial prescription of tianeptine, an antidepressant treatment with mu agonism. Suicidal ideation was assessed with the item 10 of the Montgomery-Asberg Depression Rating Scale (item dedicated to SI) at baseline, and after 2 weeks, 4 weeks and 6 weeks. We analysed rs1799971 from the OPRM1 gene and rs105660 from the OPRK1 gene. Within the sample, 112 patients reported TESI while 384 did not. We found a significant association between AA genotype of rs1799971 and TESI even after adjustment for potential cofounders (OR = 1.93, 95% CI = [1.07; 3.49]; p-value = 0.03). On the other hand there were no significant association between rs1799971 and rs105560 with worsening of suicidal ideation or lifetime suicide attempts. Nevertheless, our results suggest a possible involvement of opioidergic system in TESI.