Opioid dose and risk of suicide

Risk of Suicide After Cancer Diagnosis in England

IMPORTANCE

A diagnosis of cancer carries a substantial risk of psychological distress. There has not yet been a national population-based study in England of the risk of suicide after cancer diagnosis.

OBJECTIVES

To quantify suicide risk in patients with cancers in England and identify risk factors that may assist in needs-based psychological assessment.

DESIGN, SETTING, AND PARTICIPANTS

Population-based study using data from the National Cancer Registration and Analysis Service in England linked to death certification data of 4 722 099 individuals (22 million person-years at risk). Patients (aged 18-99 years) with cancer diagnosed from January 1, 1995, to December 31, 2015, with follow-up until August 31, 2017, were included.

EXPOSURES

Diagnosis of malignant tumors, excluding nonmelanoma skin cancer.

MAIN OUTCOMES AND MEASURES

All deaths in patients that received a verdict of suicide or an open verdict at the inquest. Standardized mortality ratios (SMRs) and absolute excess risks (AERs) were calculated.

RESULTS

Of the 4 722 099 patients with cancer, 50.3% were men and 49.7% were women. A total of 3 509 392 patients in the cohort (74.3%) were aged 60 years or older when the diagnosis was made. A total of 2491 patients (1719 men and 772 women) with cancer died by suicide, representing 0.08% of all deaths during the follow-up period. The overall SMR for suicide was 1.20 (95% CI, 1.16-1.25) and the AER per 10 000 person-years was 0.19 (95% CI, 0.15-0.23). The risk was highest among patients with mesothelioma, with a 4.51-fold risk corresponding to 4.20 extra deaths per 10 000 person-years. This risk was followed by pancreatic (3.89-fold), esophageal (2.65-fold), lung (2.57-fold), and stomach (2.20-fold) cancer. Suicide risk was highest in the first 6 months following cancer diagnosis (SMR, 2.74; 95% CI, 2.52-2.98).

CONCLUSIONS AND RELEVANCE

Despite low absolute numbers, the elevated risk of suicide in patients with certain cancers is a concern, representing potentially preventable deaths. The increased risk in the first 6 months after diagnosis may indicate an unmet need for psychological support. The findings of this study suggest a need for improved psychological support for all patients with cancer, and attention to modifiable risk factors, such as pain, particularly in specific cancer groups.

Characteristics of self-inflicted drug overdose deaths in North Carolina

BACKGROUND

Drug overdose mortality is a major public health concern in the United States, with prescription opioids contributing substantially to recent increases in drug overdose deaths. Compared to unintentional drug overdose deaths, relatively little data describes intentional self-inflicted drug overdose deaths (i.e., suicide by drug overdose). The aim of this study was to examine the characteristics of self-inflicted drug overdose deaths, overall and in comparison to unintentional drug overdose deaths.

METHODS

We linked vital statistics, prescription drug monitoring program, and toxicology data for self-inflicted and unintentional drug overdose deaths among North Carolina residents in 2012.

RESULTS

Most self-inflicted (79.2%) and unintentional (75.6%) drug overdose decedents had a prescription for a controlled substance within one year of death. Toxicology results revealed that antidepressants contributed to a significantly higher percent of self-inflicted compared to unintentional drug overdose deaths (45.0% vs. 8.1%). Among deaths in which commonly prescribed opioids (oxycodone, hydrocodone) or benzodiazepines (alprazolam, clonazepam) contributed to death, a significantly higher percent of self-inflicted drug overdose decedents had a prescription for the substance within 30days of death compared to unintentional drug overdose decedents.

CONCLUSIONS

The results highlight the use of prescription opioids, benzodiazepines, and antidepressants among self-inflicted drug overdose decedents. Importantly, the results indicate that self-inflicted drug overdose decedents were more likely than unintentional drug overdose decedents to have potential contact with the health care system in the weeks preceding death, offering an opportunity for professionals to identify and intervene on risk factors or signs of distress and potential for self-harm.

Frequency of prescription opioid misuse and suicidal ideation, planning, and attempts

The goal of this study was to examine the relationship between past-year frequency of prescription opioid misuse and past-year suicidal ideation, suicide planning, and suicide attempts. Secondary data analyses were conducted using data from 41,053 participants of the 2014 National Survey of Drug Use and Health. Past-year frequency of prescription opioid misuse was grouped into 4 categories: none, less than monthly (1-11 times), monthly to weekly (12-51 times), and weekly or more (52 times or more). Binomial logistic regression analyses adjusted for demographics, overall health rating, depression, anxiety, and substance use disorders to test the associations between frequency of prescription opioid misuse and suicide-related variables. Compared to those who did not endorse prescription opioid misuse in the past year, prescription opioid misuse was significantly associated with suicidal ideation, suicide planning, and suicide attempts for each frequency of use category in unadjusted models (p < 0.05). In adjusted models, frequency of prescription opioid misuse remained significantly associated with suicidal ideation (p < 0.05 for each frequency category); however, only the group reporting weekly or more use on average was associated with suicide planning and attempts (p < 0.05). The findings provide novel specificity regarding prescription opioid use in relation to suicide-related outcomes further supporting enhanced access to suicide prevention and nonpharmacological approaches to pain management across various settings.

Suicidal ideation and suicidal self-directed violence following clinician-initiated prescription opioid discontinuation among long-term opioid users

OBJECTIVE

Little is known about patient outcomes following discontinuation of opioid therapy, which may include suicidal ideation (SI) and suicidal self-directed violence (SSV). The purpose of this study was to examine correlates of SI and non-fatal SSV in a sample of patients discontinued from long-term opioid therapy (LTOT).

METHOD

Five hundred-nine Veterans Health Administration (VHA) patients whose clinicians discontinued them from LTOT were selected from a national cohort of VHA patients who discontinued opioids in 2012. The sample comprised patients with a substance use disorder and matched controls. Patient electronic health records were manually reviewed to identify discontinuation reasons and the presence of SI or SSV in the 12months following discontinuation.

RESULTS

Forty-seven patients (9.2%) had SI only, while 12 patients (2.4%) had SSV. In covariate-adjusted logistic regression models, mental health diagnoses associated with having SI/SSV included post-traumatic stress disorder (aOR=2.56, 95% CI=1.23-5.32) and psychotic disorders (aOR=3.19, 95% CI=1.14-8.89). Other medical comorbidities, substance use disorder and pain diagnoses, opioid dose, and benzodiazepine prescriptions were unrelated to SI/SSV.

CONCLUSIONS

Among patients with a substance use disorder and matched controls, there are high rates of SI/SSV following opioid discontinuation, suggesting that these "high risk" patients may require close monitoring and risk prevention.

Suicide Deaths With Opioid Poisoning in the United States: 1999-2014

OBJECTIVES

To describe trends in suicides with opioid poisoning noted as a contributing cause of death.

METHODS

Using National Vital Statistics data (1999-2014), we calculated age-adjusted rates of suicide with opioid poisoning (International Classification of Diseases, Tenth Revision codes T40.0-T40.4) per 100 000 population per year and annual percentage change (APC) in rates. We used Joinpoint regression to examine trends in suicide rates and proportion of suicides involving opioids.

RESULTS

The annual age-adjusted death rate from suicide with opioid poisoning as a contributing cause of death increased from 0.3 per 100 000 in 1999 to 0.7 per 100 000 in 2009 (APC = 8.1%; P < .001), and remained at 0.6 to 0.7 per 100 000 through 2014. The percentage of all suicides with opioid poisoning listed as a contributing cause of death increased from 2.2% in 1999 to 4.4% in 2010 (P < .001). Rates were similar for men and women, higher among Whites than non-Whites, higher in the West, and highest for individuals aged 45 to 64 years.

CONCLUSIONS

Opioid involvement in suicides has doubled since 1999. These analyses underscore the need for health care providers to assess suicidal risk in patients receiving opioids.

Not so patchy story of attempted suicide…leading to 24 hours of deep sleep and survival!

Here, we present a somewhat unusual suicide attempt where, despite an unbelievable overdose with transdermal fentanyl patches, the patient survived. The patient-a woman aged 70 years, who has suffered from chronic back pain despite starting transdermal fentanyl patches in 2007. The unconventional method of attempted suicide was based on online research into deaths from fentanyl patch toxicity. She had gradually accumulated 100 µg fentanyl patches from repeat prescriptions, applying 14 patches with fatal intent, alongside 2 45 mg mirtazapine tablets, and concurrent therapeutic doses of tramadol and morphine sulfate oral solution. However, after 24 hours, she awoke from a deep sleep to the sound of the telephone ringing, somewhat amazed her drastic efforts had failed. During admission to Great Western hospital, she was seen by liaison psychiatry and subsequently transferred to the care of the pain management team, to which she had already been referred.

A feasibility study to determine the benefits of upper extremity virtual rehabilitation therapy for coping with chronic pain post-cancer surgery

BACKGROUND

Persistent pain in shoulder and arm following post-surgical breast cancer treatment can lead to cognitive and physical deficits. Depression is also common in breast cancer survivors. Virtual reality therapy with integrative cognitive and physical rehabilitation has not been clinically trialed for this population. The novel BrightArm Duo technology improved cognition and upper extremity (UE) function for other diagnoses and has great potential to benefit individuals coping with post-surgical breast cancer pain.

OBJECTIVES

The aim of this study was to explore the feasibility of BrightArm Duo therapy for coping with post-surgical chronic pain and associated disability in breast cancer survivors with depression.

METHODS

BrightArm Duo is a robotic rehabilitation table modulating gravity loading on supported forearms. It tracks arm position and grasping strength while patients play three-dimensional (3D) custom integrative rehabilitation games. Community-dwelling women (N = 6) with post-surgical breast cancer pain in the upper arm trained on the system twice a week for 8 weeks. Training difficulty increased progressively in game complexity, table tilt and session length (20-50 minutes). Standardized assessments were performed before and after therapy for pain, cognition, emotion, UE function and activities of daily living.

RESULTS

Subjects averaged upwards of 1300 arm repetitions and 850 hand grasps per session. Pain intensity showed a 20% downward trend (p = 0.1) that was corroborated by therapist observations and participant feedback. A total of 10 out of 11 cognitive metrics improved post-training (p = 0.01) with a significant 8.3-point reduction in depression severity (p = 0.04). A total of 17 of 18 range of motion metrics increased (p < 0.01), with five affected-side shoulder improvements above the Minimal Clinically Important Difference (8°). In all, 13 out of 15 strength and function metrics improved (p = 0.02) with lateral deltoid strength increasing 7.4 N on the affected side (p = 0.05).

CONCLUSION

This pilot study demonstrated feasibility of using the BrightArm Duo Rehabilitation System to treat cancer survivors coping with upper body chronic pain. Outcomes indicate improvement in cognition, shoulder range, strength, function and depression.

Pharmacokinetic and pharmacodynamic evaluation of oxycodone and naltrexone for the treatment of chronic lower back pain

INTRODUCTION

Chronic low back pain (CLBP) is a common and difficult illness to manage. Some individuals with CLBP have pain processing disorders and are also at risk for opioid abuse, misuse; addiction and diversion. Guidelines have been published to guide management; neuromodulation, exercise, mindfulness-based stress reduction and cognitive behavior therapies among other non-pharmacological reduce the pain of CLBP with minimal toxicity. Pharmacological management includes acetaminophen, NSAIDs and antidepressants, mainly duloxetine. Abuse-deterrent opioids have been developed which have been shown to reduce pain and opioid abuse risk. ALO-02 is a tamper-resistant sustained release opioid consisting of extended release oxycodone and sequestered naltrexone. Pivotal studies of ALO-02 have centered on patients with CLBP.

AREAS COVERED

This manuscript will review CLBP, the pivotal analgesic and clinical abuse potential studies of ALO-02. The opinion will cover whether opioids should be used for CLBP, when they should be used and opioid choices.

EXPERT OPINION

ALO-02 is one of several opioids which can be considered in the management of CLBP. The outcome to a trial of opioids should be function rather than analgesia. Most analgesic trials for CLBP have had analgesia as the primary outcome and function has not been vigorously studied as an outcome. Opioids should be considered as a trial only when other non-opioid analgesics have failed to improve analgesia and function. Universal precautions should be routinely part of phase III analgesic trial particularly for chronic non-malignant pain.