Opioid use disorders, psychiatric comorbidities, and risk for suicide attempts among veterans seeking pain care

Analysis of nonfatal suicide attempts and demographic characteristics of US military veterans with opioid use disorder: A descriptive VA medical center study

BACKGROUND AND OBJECTIVES

Suicide and opioid use disorder (OUD) frequently co-occur, and veterans are at a high risk for both conditions. This study aims to determine the characteristics of a cohort of veterans with co-occurring OUD and suicide attempts.

METHOD

Three hundred fifty-three (n = 353) veterans registered at a VA medical center with OUD and at least one suicide attempt between January 2010 and December 2021 were analyzed.

RESULTS

9.4% of OUD veterans had lifetime suicide attempts, with 7.1% attempting postdiagnosis. High rates of unemployment (88.1%) and housing instability (73.1%) were observed, along with a 98% prevalence of comorbid psychiatric conditions.

DISCUSSION AND CONCLUSIONS

Gaining a deeper understanding of this patient population can help improve strategies for preventing suicide and treating OUD more effectively.

SCIENTIFIC SIGNIFIANCE

This study is unique in the current literature for investigating and comparing nonfatal lifetime suicide attempt rates in veterans before and after an OUD diagnosis.

The Impact of Cognitive Behavioral Therapy for Substance Use Disorders on Veterans' Interpersonal Difficulties

Background: Substance use disorders (SUDs) negatively impact veterans and their relationships with others. Although there are several evidence-based treatments for SUD symptoms, there is less research on whether reduction in SUD symptoms coincides with reduction in interpersonal difficulties. Methods: In this study we examined the relationship between SUD and relationships in a national sample of 458 veterans who received approximately 12 sessions of Cognitive Behavioral Therapy for Substance Use Disorders (CBT-SUD) through the Veterans Health Administration (VHA). Results: Parallel latent growth curve modeling (LGCM) indicated that self-reported alcohol use, drug use, and interpersonal difficulties decreased over the course of treatment. Alcohol and drug use were positively associated with each other and with interpersonal difficulties at each time point, and baseline alcohol and drug use were negatively associated with the reduction of use over time. However, there was little evidence that reductions in substance use led to a reduction in interpersonal difficulties (or vice-versa). Conclusions: Findings highlight promising strategies to further understand how CBT-SUD may enhance reductions in substance use as well as improve relationships with family and friends.

Suicidal behavior across a broad range of psychiatric disorders

Suicide is a leading cause of death worldwide. In 2020, some 12.2 million Americans seriously contemplated suicide, 3.2 million planned suicide attempts, and 1.2 million attempted suicide. Traditionally, the approach to treating suicidal behavior (SB) has been to treat the "underlying" psychiatric disorder. However, the number of diagnoses associated with SB is considerable. We could find no studies describing the range of disorders reported to be comorbid with SB. This narrative review summarizes literature documenting the occurrence of SB across the lifespan and the full range of psychiatric diagnoses, not only BPD and those that comprise MDE, It also describes the relevance of these observations to clinical practice, research, and nosology. The literature searches contained the terms "suicid*" and each individual psychiatric diagnosis and identified 587 studies. We did not include case reports, case series, studies only addressing suicidal ideation or non-suicidal self-injury (NSSI), studies on self-harm, not distinguishing between SB and NSSI and studies that did not include any individuals that met criteria for a specific DSM-5 diagnosis (n = 366). We found that SB (suicide and/or suicide attempt) was reported to be associated with 72 out of 145 diagnoses, although data quality varied. Thus, SB is not exclusively germane to Major Depressive Episode (MDE) and Borderline Personality Disorder (BPD), the only conditions for which it is a diagnostic criterion. That SB co-occurs with so many diagnoses reinforces the need to assess current and past SB regardless of diagnosis, and supports the addition of charting codes to the DSM-5 to indicate current or past SB. It also comports with new data that specific genes are associated with SB independent of psychiatric diagnoses, and suggests that SB should be managed with specific suicide prevention interventions in addition to treatments indicated for co-occurring diagnoses. SB diagnostic codes would help researchers and clinicians document and measure SB's trajectory and response to treatment over time, and, ultimately, help develop secondary and tertiary prevention strategies. As a separate diagnosis, SB would preclude situations in which a potentially life-threatening behavior is not accounted for by a diagnosis, a problem that is particularly salient when no mental disorder is present, as is sometimes the case.

Perspectives Regarding Medications for Opioid Use Disorder Among Individuals with Mental Illness

Most people with co-occurring opioid use disorder (OUD) and mental illness do not receive effective medications for treating OUD. To investigate perspectives of adults in a publicly-funded mental health system regarding medications for OUD (MOUD), we conducted semi-structured telephone interviews with 13 adults with OUD (current or previous diagnosis) receiving mental health treatment. Themes that emerged included: perceiving or using MOUDs as a substitute for opioids or a temporary solution to prevent withdrawal symptoms; negative perceptions about methadone/methadone clinics; and viewing MOUD use as "cheating". Readiness to quit was important for patients to consider MOUDs. All participants were receptive to discussing MOUDs with their mental health providers and welcomed the convenience of receiving care for their mental health and OUD at the same location. In conclusion, clients at publicly-funded mental health clinics support MOUD treatment, signaling a need to expand access and build awareness of MOUDs in these settings.

Profiles of Patients with Opioid Use Disorders Presenting a History of Suicidal Ideations and Attempts

Suicide rates are higher for people with an opioid use disorder, compared to the general population. This study aims to characterize opioid agonist treatment entrants who present a history of suicidal ideations or suicide attempts, according to concurrent comorbidity profiles, in an opioid use disorder treatment facility. A chart review design was used. Data was collected from 202 patient files. Bivariate and multivariate analyses were conducted. In multivariate analysis, patients with a diagnosis or symptoms of a mood disorder were 2.48 [1.01 - 6.11] times more likely to report suicidal ideations and 2.64 [1.05 - 6.62] times more likely to report suicide attempts. Those with a diagnosis or symptoms of an anxiety disorder were 2.41 [1.01 - 5.81] times more likely to report suicidal ideations. Patients who report chronic pain were 2.59 [1.06 - 6.35] times more likely to report suicidal ideations as well. The probability to report suicide attempts was 5.09 [1.16 - 22.4] times higher for those with a confirmed or suspected personality disorder. Clinicians should bear in mind the high suicide rates in people with opioid use disorder, as well as the importance of addressing suicidal risk and providing easy access to mental health and chronic pain treatment as part of the service offer in opioid agonist treatment. Future research should focus on evaluating the effectiveness of treatments aimed at addressing the needs of opioid agonist treatment patients with interrelated mental health and pain comorbidity profiles to reduce risks associated with suicide.

Motivations for Prescription Drug Misuse Related to Mental Health Problems in Adults

BACKGROUND

Prescription drug misuse (PDM) is a significant public health problem associated with mental health symptoms.

OBJECTIVES

This project investigates the connections between PDM motivations and mental health to inform intervention efforts.

METHODS

Using nationally representative adult data from the 2016-2018 National Survey on Drug Use and Health (N = 128,205; 53% female) this project investigated which motivations for misuse are related to past-year mental health problems including any mental illness, serious mental illness, major depressive episode, and suicidal thoughts. Complex samples logistic regression models of the main motivation of PDM for each mental health problem were conducted separately for each prescription drug class (i.e., opioids, tranquilizers, sedatives, and stimulants) while controlling for demographic characteristics.

RESULTS

Adults that reported PDM were more likely than those with no PDM to endorse past year mental health problems. Compared to those that reported PDM of other medications, those misusing prescription opioids and tranquilizers to help with emotions and misusing sedatives to "relax or relieve tension" were more likely to have all categories of mental health problems. Those that misused prescription stimulants to "help study" had lower odds of all mental health problems.

CONCLUSIONS

While there were differences based on prescription drug class, a range of motivations increased adults' likelihood to have mental health problems and common themes were found across drug classes. While causality is still undetermined, prevention and intervention efforts that are multifaceted and individualized, while broadly providing adults with other ways to cope with negative emotions are likely to help reduce PDM.

Number of opioid overdoses and depression as a predictor of suicidal thoughts

BACKGROUND

Opioid use disorders are associated with increased risk of suicide thoughts, attempts, and death. We explored key variables from two theories of the development of suicidal thoughts and attempts (the interpersonal and three-step theories of suicide) to understand possible mechanisms underlying the association between opioid use and suicide risk. We hypothesized that interpersonal connections, variables reflecting psychological and physical pain, and variables that reduce fear of death (prior overdoses and risk-taking behaviors) would be associated with increased risk of thoughts of suicide.

METHODS

Participants (N = 141) were opioid users recruited from an epicenter of the opioid crisis in Philadelphia using a mobile research center and completed an interview to assess substance use, depression, medical comorbidities, and suicidal thoughts among other variables.

RESULTS

Univariate analyses showed that prior history of overdose, diagnosis of depression, older age, homelessness, and interpersonal connection were each associated with increased likelihood of endorsing thoughts of death/suicide. Multivariable analyses revealed prior history of overdose and depression were the variables most strongly associated with risk for thoughts of suicide.

CONCLUSIONS

Consistent with two theories of the development of suicidal thoughts and attempts, exposure to variables that reduce fear of death (e.g., overdoses) were associated with suicidal thoughts. In contrast, other risk-taking behaviors, medical comorbidities, and substance use were not key predictors of suicidal thoughts in this sample. Implications for targeted risk assessment among clinicians are discussed.

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.

Effect of Ego Depletion on Interpersonal Trust among Individuals with Substance Use Disorders

Individuals with substance use disorders (SUD) undergo treatment to recover from addiction. However, exerting self-control, which is essential for successful abstinence from drug addiction, can cause ego depletion. This study experimentally investigated the effect of ego depletion on interpersonal trust and examined possible changes in the ego depletion effect across different abstinence periods. This study employed a 2 (ego depletion: high vs. low) × 2 (partners: non-SUD vs. SUD) mixed factorial design. The participants were 273 male individuals with SUD and with periods of drug abstinence ranging from several days to 2 years, who resided in a compulsory drug rehabilitation center. The participants were first asked to complete an ego depletion task, followed by a decision-making task in a trust game, first with a non-SUD stranger, and then with a SUD stranger. Ego depletion was not related to trust in non-SUD strangers. However, ego depleted participants were more likely to trust SUD strangers than non-ego depleted participants. Moreover, this ego depletion effect fluctuated near the end of SUD treatment. This study highlights the importance to ensure follow-up outpatient care and offer social support services for individuals with SUD after compulsory SUD treatment.