Opioid dose and risk of suicide

Self-injurious unnatural death among Veterans with HIV

OBJECTIVE

People with HIV (PWH) are at an increased risk of suicide and death from unintentional causes compared with people living without HIV. Broadening the categorization of death from suicide to self-injurious unnatural death (SIUD) may better identify a more complete set of modifiable risk factors that could be targeted for prevention efforts among PWH.

DESIGN

We conducted a nested case-control study using data from the Veterans Aging Cohort Study (VACS), a longitudinal, observational cohort of Veterans from 2006-2015. A total of 5036 Veterans with HIV, of whom 461 died by SIUD, were included in the sample.

METHODS

SIUD was defined using the International Classification of Disease 10 th revision cause of death codes. Cases ( n  = 461) included individuals who died by SIUD (intentional, unintentional, and undetermined causes of death). Controls ( n  = 4575) were selected using incidence density sampling, matching on date of birth ± 1 year, race, sex, and HIV status. SIUD and suicide was estimated using conditional logistic regression.

RESULTS

A previous suicide attempt, a diagnosis of an affective disorder, recent use of benzodiazepines, psychiatric hospitalization, and living in the western US significantly increased the risk of suicide and SIUD. Risk factors that appear more important for SIUD than for suicide included a drug use disorder, alcohol use disorder, Hepatitis C, VACS Index 2.0, current smoking, and high pain levels (7-10).

CONCLUSION

Limiting studies to known suicides obscures the larger public health burden of excess deaths from self-injurious behavior. Our findings demonstrate the benefit of expanding the focus to SIUD for the identification of modifiable risk factors that could be targeted for treatment.

Intersection of adverse childhood experiences, suicide and overdose prevention

Adverse childhood experiences (ACEs), suicide and overdose are linked across the life course and across generations and share common individual-, interpersonal-, community- and societal-level risk factors. The purpose of this review is to summarise the shared aetiology of these public health issues, synthesise evidence regarding potential community- and societal-level prevention strategies and discuss future research and practice directions.Growing evidence shows the potential for community- and societal-level programmes and policies, including higher minimum wage; expanded Medicaid eligibility; increased earned income tax credits, child tax credits and temporary assistance for needy families benefits; Paid Family Leave; greater availability of affordable housing and rental assistance; and increased participation in the Supplemental Nutrition Assistance Program (SNAP), to contribute to ACEs, suicide and overdose prevention. Considerations for future prevention efforts include (1) expanding the evidence base through rigorous research and evaluation; (2) assessing the implications of prevention strategies for equity; (3) incorporating a relational health perspective; (4) enhancing community capacity to implement, scale and sustain evidenced-informed prevention strategies; and (5) acknowledging that community- and societal-level prevention strategies are longer-term strategies.

Psychiatric diagnoses, somatic disorders, and emergency dispatches among individuals who used a national suicide crisis line

Crisis line responders initiate emergency dispatches by activating 911 or other local emergency services when individuals are determined to be at imminent risk for undesired outcomes. This study examined the association of characteristics, psychiatric diagnoses, and somatic symptoms with emergency dispatches in a national sample. Veterans Crisis Line data were used to identify contacts (i.e., calls, texts, chats, emails) that were linked with medical records and had a medical encounter in the year prior to contact. Hierarchical logistic regression clustered by responders was used to identify the association among demographics, psychiatric diagnoses, and somatic disorders, and emergency dispatches. Analyses examined 247,340 contacts from 2017 to 2020, with 27,005 (10.9%) emergency dispatches. Odds of an emergency dispatch increased with each diagnosis (three diagnoses Adjusted Odds Ratio [AOR] (95% CI) = 1.88 [1.81,1.95]). Odds were highest among individuals with substance use disorders (SUD) (alcohol AOR (95% CI) = 1.85 [1.80,1.91]; drugs AOR (95% CI) = 1.63 [1.58, 1.68]), which may be a result of intoxication or overdose during contact, requiring further research. Having more psychiatric and somatic conditions was associated with greater odds of an emergency dispatch, indicating that comorbidity contributed to the need for acute care.

Machine learning identifies risk factors associated with long-term opioid use in fibromyalgia patients newly initiated on an opioid

OBJECTIVES

Fibromyalgia is frequently treated with opioids due to limited therapeutic options. Long-term opioid use is associated with several adverse outcomes. Identifying factors associated with long-term opioid use is the first step in developing targeted interventions. The aim of this study was to evaluate risk factors in fibromyalgia patients newly initiated on opioids using machine learning.

METHODS

A retrospective cohort study was conducted using a nationally representative primary care dataset from the UK, from the Clinical Research Practice Datalink. Fibromyalgia patients without prior cancer who were new opioid users were included. Logistic regression, a random forest model and Boruta feature selection were used to identify risk factors related to long-term opioid use. Adjusted ORs (aORs) and feature importance scores were calculated to gauge the strength of these associations.

RESULTS

In this study, 28 552 fibromyalgia patients initiating opioids were identified of which 7369 patients (26%) had long-term opioid use. High initial opioid dose (aOR: 31.96, mean decrease accuracy (MDA) 135), history of self-harm (aOR: 2.01, MDA 44), obesity (aOR: 2.43, MDA 36), high deprivation (aOR: 2.00, MDA 31) and substance use disorder (aOR: 2.08, MDA 25) were the factors most strongly associated with long-term use.

CONCLUSIONS

High dose of initial opioid prescription, a history of self-harm, obesity, high deprivation, substance use disorder and age were associated with long-term opioid use. This study underscores the importance of recognising these individual risk factors in fibromyalgia patients to better navigate the complexities of opioid use and facilitate patient-centred care.

Prenatal opioid use as a predictor of postpartum suicide attempts among reproductive-age women enrolled in Oregon Medicaid

BACKGROUND

The rates of suicide and opioid use disorder (OUD) among pregnant and postpartum women continue to increase. This research characterized OUD and suicide attempts among Medicaid-enrolled perinatal women and examined prenatal OUD diagnosis as a marker for postpartum suicide attempts.

METHODS

Data from Oregon birth certificates, Medicaid eligibility and claims files, and hospital discharge records were linked and analyzed. The sample included Oregon Medicaid women aged 15-44 who became pregnant and gave live births between January 2008 and January 2016 (N = 61,481). Key measures included indicators of suicide attempts (separately for any means and opioid poisoning) and OUD diagnosis, separately assessed during pregnancy and the one-year postpartum period. Probit regression was used to examine the overall relationship between prenatal OUD diagnosis and postpartum suicide attempts. A simultaneous equations model was employed to explore the link between prenatal OUD diagnosis and postpartum suicide attempts, mediated by postpartum OUD diagnosis.

RESULTS

Thirty-three prenatal suicide attempts by any means were identified. Postpartum suicide attempts were more frequent with 58 attempts, corresponding to a rate of 94.3 attempts per 100,000. Of these attempts, 79% (46 attempts) involved opioid poisoning. A total of 1,799 unique women (4.6% of the sample) were diagnosed with OUD either during pregnancy or one-year postpartum with 53% receiving the diagnosis postpartum. Postpartum suicide attempts by opioid poisoning increased from 55.5 per 100,000 in 2009 to 105.1 per 100,000 in 2016. The rate of prenatal OUD also almost doubled over the same period. Prenatal OUD diagnosis was associated with a 0.15%-point increase in the probability of suicide attempts by opioid poisoning within the first year postpartum. This increase reflects a three-fold increase compared to the rate for women without a prenatal OUD diagnosis. A prenatal OUD diagnosis was significantly associated with an elevated risk of postpartum suicide attempts by opioid poisoning via a postpartum OUD diagnosis.

CONCLUSIONS

The risk of suicide attempt by opioid poisoning is elevated for Medicaid-enrolled reproductive-age women during pregnancy and postpartum. Women diagnosed with prenatal OUD may face an increased risk of postpartum suicides attempts involving opioid poisoning.

Suicidal ideation in female individuals with fibromyalgia and comorbid obesity: prevalence and association with clinical, pain-related, and psychological factors

OBJECTIVE

Individuals with fibromyalgia report alarming levels of suicidal ideation, and comorbidity with other chronic health conditions such as obesity-a risk factor for suicidal ideation per se-could further complicate the clinical picture. The aim of this study is to determine, in a sample of women with fibromyalgia and comorbid obesity, the prevalence of suicidal ideation and to evaluate clinical, pain-related and psychological factors associated with suicidal ideation.

METHODS

In total, 156 female individuals with fibromyalgia and obesity were recruited and completed a series of self-report measures that assessed (i) the level of pain intensity, (ii) depressive symptomatology, (iii) sleep quality, and (iv) pain catastrophizing. Suicidal ideation was evaluated by item #9 of the Beck Depression Inventory. In addition, information regarding previous suicide attempts and current opioid use was collected.

RESULTS

3n sum, 7.8% of participants reported presence of suicidal ideation. According to the results of the multiple logistic regression, depressive symptomatology, sleep quality, and pain catastrophizing were associated with the presence of suicidal ideation.

DISCUSSION

The presence of suicidal ideation in our sample was significantly associated with depressive symptomatology, sleep quality, and pain catastrophizing. Our findings are the first to suggest a unique (ie, independent of depressive symptomatology, and sleep quality) association between pain catastrophizing and suicidal ideation in the context of fibromyalgia and comorbid obesity. In order to prevent and reduce suicidal ideation, these factors should be assessed and targeted in interventions for pain management. Future research should investigate the extent to which addressing depressive symptoms, sleep quality, and pain catastrophizing reduces suicidal ideation.

Suicide within 1 year of non-fatal overdose: Risk factors and risk reduction with medications for opioid use disorder

OBJECTIVE

Individuals with substance use disorders and overdoses have high risk of suicide death, but evidence is limited on the relationship between interventions following the initial overdose and subsequent suicide death.

METHODS

National Medicare data were used to identify Medicare disability beneficiaries (MDBs) with inpatient or emergency care for non-fatal opioid overdoses from 2008 to 2016. Data were linked with National Death Index (NDI) to obtain dates and causes of death for the sample. Cox proportional hazards models estimated the associations between exposure to interventions (mechanical ventilation, MOUD) and suicide death.

RESULTS

The sample (n = 81,654) had a suicide rate in the year following a non-fatal overdose of 566 per 100,000 person-years. Post-overdose MOUD was associated with an adjusted hazard ratio of 0.20 (95%CI: 0.05,0.85). Risk of suicide was elevated for those whose initial overdoses required mechanical ventilation as part of the treatment (aHR: 1.86, 95%CI:[1.48,2.34]).

CONCLUSIONS

The year following a non-fatal opioid overdose is a very high-risk period for suicide among MDBs. Those receiving MOUD had an 80% reduction in the hazards of suicide, while those whose overdose treatment involved mechanical ventilation had 86% higher hazards of death by suicide. Our findings highlight the importance of psychiatric intervention in this high-risk population. Efforts are needed to initiate and retain more patients in MOUD.

Fatal drug overdoses in individuals treated pharmacologically for chronic pain: a nationwide register-based study

INTRODUCTION

Chronic pain patients may be at an increased risk for drug overdoses as a result of comorbid psychiatric disorders and treatment with risk-increasing prescription medications, such as opioids. We aimed to characterise fatal drug overdoses and investigate factors associated with the deaths among individuals who had been treated pharmacologically for chronic pain.

METHODS

We included all individuals who received analgesics reimbursed for chronic pain in Norway during 2010-9 (n=569 047). Among this population, we identified all individuals with drug overdoses as cause of death (cases). Extracting data from national registries on diagnoses, filled prescriptions, and socioeconomic variables, we used a nested case-control design to compare the cases with age- and sex-matched controls from the study population.

RESULTS

Overall, 623 (0.11%) individuals in the study population died of an overdose. Most, 66.8%, had overdosed accidentally, and 61.9% as a result of pharmaceutically available opioids. Compared with the controls (n=62 245), overdoses overall were associated strongly with substance use disorders (adjusted odds ratio 7.78 [95% confidence interval 6.20-9.77]), use of combinations of opioids, benzodiazepines and related drugs and gabapentinoids (4.60 [3.62-5.85]), previous poisoning with pharmaceuticals (2.78 [2.20-3.51]), and with living alone the last year of life (2.11 [1.75-2.54]). Intentional overdoses had a stronger association with previous poisonings with pharmaceuticals whereas accidental overdoses were strongly associated with substance use disorders.

CONCLUSIONS

This study shows the need for better identification of overdose and suicide risk in individuals treated for chronic pain. Extra caution is needed when treating complex comorbid disorders, especially with overdose risk-increasing medications.

Association of opioid or other substance use disorders with health care use among patients with suicidal symptoms

INTRODUCTION

Prior literature establishes noteworthy relationships between suicidal symptoms and substance use disorders (SUDs), particularly opioid use disorder (OUD). However, engagement with health care services among this vulnerable population remains underinvestigated. This study sought to examine patterns of health care use, identify risk factors in seeking treatment, and assess associations between outpatient service use and emergency department (ED) visits.

METHODS

Using electronic health records (EHRs) derived from five health systems across New York City, the study selected 7881 adults with suicidal symptoms (including suicidal ideation, suicide attempt, or self-harm) and SUDs between 2010 and 2019. To examine the association between SUDs (including OUD) and all-cause service use (outpatient, inpatient, and ED), we performed quasi-Poisson regressions adjusted for age, gender, and chronic disease burden, and we estimated the relative risks (RR) of associated factors. Next, the study evaluated cause-specific utilization within each resource category (SUD-related, suicide-related, and other-psychiatric) and compared them using Mann-Whitney U tests. Finally, we used adjusted quasi-Poisson regression models to analyze the association between outpatient and ED utilization among different risk groups.

RESULTS

Among patients with suicidal symptoms and SUD diagnoses, relative to other SUDs, a diagnosis of OUD was associated with higher all-cause outpatient visits (RR: 1.22), ED visits (RR: 1.54), and inpatient hospitalizations (RR: 1.67) (ps < 0.001). Men had a lower risk of having outpatient visits (RR: 0.80) and inpatient hospitalizations (RR: 0.90), and older age protected against ED visits (RR range: 0.59-0.69) (ps < 0.001). OUD was associated with increased SUD-related encounters across all settings, and increased suicide-related ED visits and inpatient hospitalizations (p < 0.001). Individuals with more mental health outpatient visits were less likely to have suicide-related ED visits (RR: 0.86, p < 0.01), however this association was not found among younger and male patients with OUD. Although few OUD patients received medications for OUD (MOUD) treatment (9.9 %), methadone composed the majority of MOUD prescriptions (77.7 %), of which over 70 % were prescribed during an ED encounter.

CONCLUSIONS

This study reinforces the importance of tailoring SUD and suicide risk interventions to different age groups and types of SUDs, and highlights missed opportunities for deploying screening and prevention resources among the male and OUD populations. Redressing underutilization of MOUD remains a priority to reduce acute health outcomes among younger patients with OUD.

Risk Factors for Self-Harm Ideation Among Persons Treated With Opioids for Chronic Low Back Pain

OBJECTIVES

Chronic pain is a significant health concern that adversely affects all aspects of life, including emotional well-being. Opioids are prescribed for the management of refractory, severe chronic pain, although they have been associated with adverse effects, including addiction and overdose. The aim of this study was to examine factors that predict thoughts of self-harm among adults with chronic pain who are prescribed opioids.

MATERIALS AND METHODS

Seven hundred sixty-five (N=765) persons with opioid-treated chronic lower back pain completed the Current Opioid Misuse Measure (COMM) and other validated questionnaires as part of a larger study. Response to 1 question from the COMM ("How often have you seriously thought about hurting yourself?") was used to assess suicide risk on a 5-point scale (0=never; 4=very often).

RESULTS

Participants were categorized into 3 groups according to their responses to the self-harm question: never (N=628; 82.1%), seldom or sometimes (N=74; 9.7%), and often or very often (N=63; 8.2%). Multivariate adjusted odds ratio (aOR) analyses indicated that reports of alcohol or drug overuse within the past month (aOR=1.41,[95% CI 1.11-1.78]), posttraumatic stress (PTSD; aOR=1.24,[1.07 to 1.44]), pain catastrophizing (aOR=1.03,[1.01 to 1.05]), not loving oneself (aOR=0.99,[.98-1.00]) and poor perceived mental health (aOR=0.94,[.92 to 97]) were most associated with thoughts of self-harm. Importantly, the ideation frequency of self-harm was highest among individuals treated with higher daily doses of opioids.

DISCUSSION

These results support the need for continued monitoring of adults treated with opioids for chronic pain, particularly among those on high-dose opioids who present with increased negative affect and concerns of substance misuse.

Predictors of fatal and nonfatal overdose after prescription of opioids for chronic pain: a systematic review and meta-analysis of observational studies

BACKGROUND

Higher doses of opioids, mental health comorbidities, co-prescription of sedatives, lower socioeconomic status and a history of opioid overdose have been reported as risk factors for opioid overdose; however, the magnitude of these associations and their credibility are unclear. We sought to identify predictors of fatal and nonfatal overdose from prescription opioids.

METHODS

We systematically searched MEDLINE, Embase, CINAHL, PsycINFO and Web of Science up to Oct. 30, 2022, for observational studies that explored predictors of opioid overdose after their prescription for chronic pain. We performed random-effects meta-analyses for all predictors reported by 2 or more studies using odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Twenty-eight studies (23 963 716 patients) reported the association of 103 predictors with fatal or nonfatal opioid overdose. Moderate- to high-certainty evidence supported large relative associations with history of overdose (OR 5.85, 95% CI 3.78-9.04), higher opioid dose (OR 2.57, 95% CI 2.08-3.18 per 90-mg increment), 3 or more prescribers (OR 4.68, 95% CI 3.57-6.12), 4 or more dispensing pharmacies (OR 4.92, 95% CI 4.35-5.57), prescription of fentanyl (OR 2.80, 95% CI 2.30-3.41), current substance use disorder (OR 2.62, 95% CI 2.09-3.27), any mental health diagnosis (OR 2.12, 95% CI 1.73-2.61), depression (OR 2.22, 95% CI 1.57-3.14), bipolar disorder (OR 2.07, 95% CI 1.77-2.41) or pancreatitis (OR 2.00, 95% CI 1.52-2.64), with absolute risks among patients with the predictor ranging from 2-6 per 1000 for fatal overdose and 4-12 per 1000 for nonfatal overdose.

INTERPRETATION

We identified 10 predictors that were strongly associated with opioid overdose. Awareness of these predictors may facilitate shared decision-making regarding prescribing opioids for chronic pain and inform harm-reduction strategies SYSTEMATIC REVIEW REGISTRATION: Open Science Framework (https://osf.io/vznxj/).

Drug Safety and Suicidality Risk of Chronic Pain Medications

Chronic pain is one of the main leading causes of disability in the world at present. A variety in the symptomatology, intensity and duration of this phenomenon has led to an ever-increasing demand of pharmacological treatment and relief. This demand for medication, ranging from well-known groups, such as antidepressants and benzodiazepines, to more novel drugs, was followed by a rise in safety concerns of such treatment options. The validity, frequency, and diversity of such concerns are discussed in this paper, as well as their possible effect on future prescription practices. A specific caution is provided towards the psychological safety and toll of these medications, regarding suicidality and suicidal ideation. Most significantly, this paper highlights the importance of pharmacovigilance and underscores the necessity of surveillance programs when considering chronic pain medication.

Dose Changes for Long-term Opioid Patients Following a State Opioid Prescribing Policy

BACKGROUND

In 2018, Nevada implemented opioid prescribing legislation (AB474) to support the uptake of CDC pain care guidelines. We studied the law's association with doses over threshold levels of morphine milligram equivalents (MMEs) and with time to dose increases and decreases, among long-term opioid patients.

METHODS

A difference-in-difference study examined dosing changes across opioid prescription episodes (ie, prescriptions within 30 day and within the same dosing threshold). Patients with at least 120 days supply over 6 months in Nevada and Colorado Medicaid pharmacy claims were included. Using a logistic regression model, we compare the predicted probabilities that opioid episodes exceeded 50 MME before and after implementation of the law, in both states. Adjusted hazard ratios (aHR) from a gap time survival model estimated time to escalate above 50 MME among low-dose episodes (<50 MME), and time to de-escalate below 50 MME among high-dose episodes (≥50 MME).

RESULTS

Among 453,577 episodes (74,292 patients), the Nevada law was associated with a 2.9% reduction in prescriptions over 50 MME (95% CI: -3.5, -2.3) compared with Colorado. While the law was also associated with slower escalation (Nevada: aHR = 0.75; 95% CI: 0.72, 0.77, Colorado: aHR = 1.04; 95% CI: 1.01, 1.06), it was also associated with slower de-escalation (Nevada: aHR = 0.87; 95% CI: 0.84, 0.89, Colorado: aHR = 0.97; 95% CI: 0.96, 0.99).

CONCLUSIONS

Slower dose escalations, rather than faster dose de-escalation, likely explain post-law reductions in doses over 50 MME. Slower dose de-escalations may be due to longer days supply post-policy.

Perspectives of homeless veterans living with substance use disorders (SUD) and mental illness

Upon returning home from the military, America's veterans face complex challenges such as homelessness and substance use disorders (SUD). Veterans who have experienced SUDs and homelessness are more likely to struggle with depression and suicidal behaviors. This study aims to understand homeless veterans' lived experiences of their everyday life and social interactions. We used semi-structured interviews to conduct a phenomenological study of 14 homeless veterans with known SUDs living in the Baltimore-Washington D.C. Metropolitan area. A Social-Ecological Model (SEM) was used to create themes, a priori, then used open coding analytic methods to identify emerging themes. Two-thirds of veterans used illicit drugs or abused alcohol, and nearly all reported a history of depression or anxiety. Suicidal behaviors were present in a third of all veterans. We found that veteran homelessness and substance use are strongly associated with emotional and physical trauma suffered while on active duty. Consequently, once homeless, a veteran's community may encourage and exacerbate SUDs, thus impeding a path toward sobriety. Homeless veterans who have struggled with SUDs and later experience a death in their family often relapse to substance use. Deeply exploring a veteran's relationships with family, friends, and their immediate community may reveal opportunities to address these issues using healthcare and community interventions.

DSM-5-TR diagnosis as a guide to suicide risk assessment

A specific mental disorder can itself constitute a risk factor for a completed suicide. Even more important, the disorder is typically a modifiable risk factor which informs its own treatment. Recent editions of the DSM have included "suicide subsections" for specific mental disorders and conditions in which the risks of suicidal thoughts and behaviors for the disorder are noted in the literature. The DSM-5-TR can therefore serve as a compendium to be referred to for initial guidance as to whether a specific disorder could contribute to the risk. Adding completed suicides and suicide attempts, also addressed in these subsections, the sections were examined individually for the four parameters of suicidality. Accordingly, the four parameters of suicidality examined here are: suicide, suicidal thoughts, suicidal behavior, and suicide attempts. After providing interpretive comments for each, the parameters for all disorders with a suicide subsection were tabulated for ease of reference. Because specific medical disorders are also associated with elevated rates of suicide, these disorders and the supporting research are tabulated and briefly acknowledged. Allowing for the limitations of the suicide subsections and their analysis, this exegesis is proposed to contribute to training in risk assessment for forensic psychiatry and psychology fellows and to highlight the potential referential value of the DSM-5-TR's suicide subsections for clinical practitioners and those who pursue research on suicide.

Evaluation of common prescription analgesics and adjuvant analgesics as markers of suicide risk: a longitudinal population-based study in England

Background

Analgesics prescriptions may provide a marker for identifying individuals at higher risk of suicide. In particular, awareness of which analgesics are implicated may help clinicians assess and modify risk.

Method

A case-control study in England using the Clinical Practice Research Datalink (for primary care records) linked with hospital and national mortality electronic registries. We included patients aged ≥15 who died by suicide between 2001 and 2019 (N = 14,515), to whom we individually matched 580,159 controls by suicide date and general practice (N = 594,674). Odds ratios (ORs) for suicide, controlled for age and sex, were assessed using conditional logistic regression.

Findings

Suicide risks were highest in those prescribed adjuvant analgesics (pregabalin, gabapentin and carbamazepine) (adjusted OR 4.07; 95% confidence intervals CI: 3.62-4.57), followed by those prescribed opioids (adjusted OR 2.01; 95% CI: 1.88-2.15) and those prescribed non-opioid analgesics (adjusted OR 1.48; 95% CI: 1.39-1.58) compared to those not prescribed these medications. By individual analgesic, the highest suicide risks were seen in patients prescribed oxycodone (adjusted OR 6.70; 95% CI: 4.49-9.37); pregabalin (adjusted OR 6.50; 95% CI: 5.41-7.81); morphine (adjusted OR 4.54; 95% CI: 3.73-5.52); and gabapentin (adjusted OR 3.12; 95% CI: 2.59-3.75). Suicide risk increased linearly with the number of analgesic prescriptions in the final year (p < 0.01 based on the likelihood ratio test), and the more different analgesics categories were prescribed in the final year (p < 0.01 based on the likelihood ratio test).

Interpretation

Analgesic prescribing was associated with higher suicide risk. This is a particular issue with regard to adjuvant non-opiate analgesics.

Funding

There was no funding for this study.

Prescription Opioid Misuse and Suicidal Behaviors Among US Veterans: A Cross-Sectional Study from the 2015-2019 National Survey on Drug Use and Health

Suicide continues to be a serious public health issue for the US veteran population as its prevalence has skyrocketed over the last 15 years. This cross-sectional study estimates the prevalence of suicidal behaviors and prescription opioid misuse among veterans and identifies associations between suicidal behaviors and misuse of prescription opioids using data from the National Survey on Drug Use and Health. The findings show that approximately 3.7% of all veterans in this sample experienced suicidal behaviors, while nearly 3.0% reported misusing prescription opioids. Veterans who misused prescription opioids had a much higher prevalence of suicidal behaviors (16.3%) than veterans who used prescription opioids without misuse (4.8%) and those who did not use prescription opioids at all (2.5%). Opioid misuse is strongly associated with suicidal behaviors among veterans. Immediate substance use and mental health screenings, upon first contact with a healthcare system, are imperative in preventing and reducing suicide rates within this vulnerable population.

Association between prescribed opioid dose and risk of motor vehicle crashes

ABSTRACT

Opioid-involved motor vehicle traffic fatalities have increased over the past 2 decades. However, the extent to which prescribed opioids increase the risk of motor vehicle crashes remains uncertain. This study used real-world healthcare claims data to examine the association between prescription opioid dose and motor vehicle crash risk. Using nationwide US commercial insurance claims data for 2010 to 2018, we identified 772,404 adults who received incident, noncancer opioid therapy. We examined associations between daily prescription opioid dose, calculated in morphine milligram equivalents (MME) from filled prescription claims, and risk of motor vehicle crashes, assessed as diagnoses of motor vehicle injuries in claims for emergency visits, inpatient hospitalizations, and ambulance transportation. We estimated associations using a within-individual design, which ruled out all time-stable confounding. We complemented the design with time-varying statistical adjustment for other pharmacotherapies and a negative control pain pharmacotherapy analysis (with incident cyclic antidepressant prescriptions). During 2,150,009 person-years of follow-up, there were 12,123 motor vehicle crashes (5.64 crashes per 1000 person-years). In within-individual comparisons, crash risk was greater during opioid prescription periods involving doses ≤60 MME/day (odds ratio [OR], 3.86; 95% confidence interval [CI], 3.54, 4.21), >60 to 120 MME/day (OR, 5.46; 95% CI, 4.44, 6.73), and >120 MME/day (OR, 3.45; 95% CI, 2.31, 5.15) than during off-treatment periods. The negative control analysis supported the specificity of the results to opioids rather than to other processes associated with pharmacologic pain management. These findings suggest that the receipt of prescription opioids, even at doses ≤60 MME/day, is associated with an increased risk of motor vehicle crashes.

The Use of Opioids in the Management of Chronic Pain: Synopsis of the 2022 Updated U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline

DESCRIPTION

In May 2022, leadership within the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) approved a joint clinical practice guideline for the use of opioids when managing chronic pain. This synopsis summarizes the recommendations that the authors believe are the most important to highlight.

METHODS

In December 2020, the VA/DoD Evidence-Based Practice Work Group assembled a team to update the 2017 VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain. The guideline development team included clinical stakeholders and conformed to the National Academy of Medicine's tenets for trustworthy clinical practice guidelines. The guideline team developed key questions to guide a systematic evidence review that was done by an independent third party and distilled 20 recommendations for care using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. The guideline team also created 3 one-page algorithms to help guide clinical decision making. This synopsis presents the recommendations and highlights selected recommendations on the basis of clinical relevance.

RECOMMENDATIONS

This guideline is intended for clinicians who may be considering opioid therapy to manage patients with chronic pain. This synopsis reviews updated recommendations for the initiation and continuation of opioid therapy; dose, duration, and taper of opioids; screening, assessment, and evaluation; and risk mitigation. New additions are highlighted, including recommendations about the use of buprenorphine instead of full agonist opioids; assessing for behavioral health conditions and factors associated with higher risk for harm, such as pain catastrophizing; and the use of pain and opioid education to reduce the risk for prolonged opioid use for postsurgical pain.

Chronic pain conditions and risk of suicidal behavior: a 10-year longitudinal co-twin control study

BACKGROUND

Understanding the relationship between chronic pain conditions and suicidal behavior-suicide attempt, other intentional self-harm, and death by suicide-is imperative for suicide prevention efforts. Although chronic pain conditions are associated with suicidal behaviors, these associations might be attributed to unmeasured confounding or mediated via pain comorbidity.

METHODS

We linked a population-based Swedish twin study (N=17,148 twins) with 10 years of longitudinal, nationwide records of suicidal behavior from health and mortality registers through 2016. To investigate whether pain comorbidity versus specific pain conditions were more important for later suicidal behavior, we modeled a general factor of pain and two independent specific pain factors (measuring pain-related somatic symptoms and neck-shoulder pain, respectively) based on 9 self-reported chronic pain conditions. To examine whether the pain-suicidal behavior associations were attributable to familial confounding, we applied a co-twin control model.

RESULTS

Individuals scoring one standard deviation above the mean on the general pain factor had a 51% higher risk of experiencing suicidal behavior (odds ratio (OR), 1.51; 95% confidence interval (CI), 1.34-1.72). The specific factor of somatic pain was also associated with increased risk for suicidal behavior (OR, 1.80; 95% CI, 1.45-2.22]). However, after adjustment for familial confounding, the associations were greatly attenuated and not statistically significant within monozygotic twin pairs (general pain factor OR, 0.89; 95% CI, 0.59-1.33; somatic pain factor OR, 1.02; 95% CI, 0.49-2.11) CONCLUSION: Clinicians might benefit from measuring not only specific types of pain, but also pain comorbidity; however, treating pain might not necessarily reduce future suicidal behavior, as the associations appeared attributable to familial confounding.

Pharmacological data science perspective on fatal incidents of morphine treatment

Morphine prescribed for analgesia has caused drug-related deaths at an estimated incidence of 0.3% to 4%. Morphine has pharmacological properties that make it particularly difficult to assess the causality of morphine administration with a patient's death, such as its slow transfer between plasma and central nervous sites of action and the existence of the active metabolite morphine-6-glucuronide with opioid agonistic effects, Furthermore, there is no well-defined toxic dose or plasma/blood concentration for morphine. Dosing is often adjusted for adequate pain relief. Here, we summarize reported deaths associated with morphine therapy, including associated morphine exposure and modulating patient factors such as pharmacogenetics, concomitant medications, or comorbidities. In addition, we systematically analyzed published numerical information on the stability of concentrations of morphine and its relevant metabolites in biological samples collected postmortem. A medicolegal case is presented in which the causality of morphine administration with death was in dispute and pharmacokinetic modeling was applied to infer the administered dose. The results of this analytical review suggest that (i) inference from postmortem blood concentrations to the morphine dose administered has low validity and (ii) causality between a patient's death and the morphine dose administered remains a highly context-dependent and collaborative assessment among experts from different medical specialties.

A National Retrospective Study of Antidepressants' Effects on Overdose and Self-Harm Among Adults Treated With Opioid Analgesics

OBJECTIVE

Because individuals with a history of depression who are receiving opioids are at higher risk for adverse events, the authors examined whether antidepressant treatment reduces risk for overdose and self-harm among individuals with a history of depression who receive opioids.

METHODS

Commercial insurance claims of individuals with a history of depression receiving opioids from 2007 to 2017 were used to quantify the association between antidepressant fills and adverse events among individuals after initiation of opioid treatment; the authors accounted for selection into treatment and used discrete-time, proportional hazards survival models.

RESULTS

Among 283,374 adults with a history of depression treatment, 8,203 experienced 47,486 adverse events from 2007 to 2017 in the 12 months after initiation of opioid treatment. Approximately half (N=144,052, 50.8%) filled an antidepressant prescription at least once in the 12 months after the opioid episode began. Individuals receiving antidepressants for at least 6 weeks had a reduced risk for any adverse event (adjusted odds ratio [AOR]=0.79, 95% confidence interval [CI]=0.65-0.97) as well as a reduced risk for opioid overdoses (AOR=0.78, 95% CI=0.64-0.96), overdoses from nonopioid controlled substances (AOR=0.76, 95% CI=0.62-0.94), overdoses from other substances (AOR=0.79, 95% CI=0.65-0.97), and other self-harm events (AOR=0.82, 95% CI=0.67-1.00).

CONCLUSIONS

Individuals with a history of depression who received opioid analgesics had a significantly lower risk for overdose and self-harm after they had been taking antidepressants for at least 6 weeks. Universal screening for mood disorders among individuals receiving opioids, and promptly providing evidence-based depression treatment when appropriate, may reduce adverse events.

Interprofessional Active Learning for Chronic Pain: Transforming Student Learning From Recall to Application

Chronic pain (CP) affects over 50 million Americans daily and represents a unique challenge for healthcare professionals due to its complexity. Across all health professions, only a small percentage of the curriculum is devoted to treating patients with CP. Unfortunately, much of the content is delivered passively via lecture without giving students an opportunity to practice the communication skills to effectively treat patients in the clinic. An interprofessional team of health educators identified 5 essential messages that students frequently struggle to convey to patients with CP. Those messages were based on interprofessional and profession-specific competencies to treat patients with CP from the International Association for the Study of Pain. The 5 messages highlighted the importance of (1) therapeutic alliance, (2) consistent interdisciplinary language, (3) patient prognosis, (4) evidence for pain medicine, surgery, and imaging, and (5) early referral to the interprofessional team. For each message, the team summarized relevant research supporting the importance of each individual message that could serve as a foundation for didactic content. The team then developed active learning educational activities that educators could use to have students practice the skills tied to each message. Each learning activity was designed to be delivered in an interprofessional manner.

The Association of Opioid Misuse and Suicidality among People with Disabilities

Background/Purpose: Past research has linked non-medical prescription opioid use (NMPOU) with suicide, though less focus has been placed among people with disabilities impacted by the opioid epidemic. This study examined the relationship of NMPOU and suicidality among people with and without disabilities while controlling for sociodemographic and other variables. Method: Using the 2019 National Survey on Drug Use and Health, weighted logistic regression analyses were conducted on a cross-sectional sample of 38,088 respondents 18 and older to examine the effect of opioid misuse and disability on serious thoughts of suicide, having a suicide plan, and making a suicide attempt. Results: Findings indicated opioid misuse was associated with 37% higher odds for having a suicide plan in the past year (OR = 1.37, p < .05). The main results indicated the people with disabilities had 30% higher odds for having a suicide plan (OR = 1.30, p < .05) and 73% higher odds for a suicide attempt in the past year (OR = 1.73, p < .001). Interaction analysis found that opioid misuse was associated with higher odds for having a suicide plan (OR = 1.89, p < .01), and having a suicide attempt among those with disabilities (OR = 2.57, p < .01). Conclusion: Results indicated that opioid misuse is a risk factor for suicide, and people with disabilities were at greater risk. Health workers can serve as a nexus point in effectively engaging at-risk people with disabilities in substance use and mental health prevention and recovery services.

Psychological Evaluation and Management of Chronic Pancreatitis

Chronic pancreatitis is a chronic digestive disorder that greatly diminishes the quality of life and is associated with significant psychological distress. A best practice recommendation in treating chronic pancreatitis is offering care in a multidisciplinary model that includes access to a behavioral health provider among other medical professionals. Behavioral interventions for patients with chronic pancreatitis have promise to improve the management of pain, comorbid psychiatric symptoms, and quality of life. If surgical interventions such as a total pancreatectomy islet autotransplant are considered, evaluating and mitigating psychosocial risk factors may aid the selection of appropriate candidates.

U.S. Military veterans and the opioid overdose crisis: a review of risk factors and prevention efforts

U.S. military veterans have been heavily impacted by the opioid overdose crisis, with drug overdose mortality rates increasing by 53% from 2010-2019. Risk for overdose among veterans is complex and influenced by ongoing interaction among physiological/biological, psychological, and socio-structural factors. A thorough understanding of opioid-related overdose among veterans, one that goes beyond simple pharmacological determinism, must examine the interplay of pain, pain treatment, and stress, as well as psychological and social experiences-before, during, and after military service. Comprehensive efforts to tackle the overdose crisis among veterans require interventions that address each of these dimensions. Promising interventions include widespread naloxone distribution and increased provision of low-threshold wrap-around services, including medications for opioid use disorder (MOUD) and holistic/complementary approaches. Interventions that are delivered by peers - individuals who share key experiential or sociodemographic characteristics with the population being served - may be ideally suited to address many of the barriers to opioid-related risk mitigation common among veterans. Community care models could be beneficial for the large proportion of veterans who are not connected to the Veterans Health Administration and for veterans who, for various reasons including mental health problems and the avoidance of stigma, are socially isolated or reluctant to use traditional substance use services. Interventions need to be tailored in such a way that they reach those more socially isolated veterans who may not have access to naloxone or the social support to help them in overdose situations. It is important to incorporate the perspectives and voices of veterans with lived experience of substance use into the design and implementation of new overdose prevention resources and strategies to meet the needs of this population. Key messagesU.S. military veterans have been heavily impacted by the opioid overdose crisis, with drug overdose mortality rates increasing by 53% from 2010-2019.The risks for overdose that veterans face need to be understood as resulting from an ongoing interaction among biological/physiological, psychological, and social/structural factors.Addressing drug overdose in the veteran population requires accessible and non-judgemental, low threshold, wraparound, and holistic solutions that recognise the complex aetiology of overdose risk for veterans.

Opioid poisoning cases aged 50+ in the 2015-2020 National Poisoning Data System: suspected suicides versus unintentional poisoning and other intentional misuse/abuse

High rates of opioid overdose and suicide among the 50+ age group call for an examination of suicidal intent in overdose incidents. Using 2015-2020 National Poison Data System opioid poisoning cases aged 50+ (n = 83 153), we examined the types of opioids and other substances associated with suspected suicides compared to intentional misuse/abuse without suicidal intent. During the six years, prescription opioid cases decreased, while illicit opioid cases increased. Among both types of opioid poisoning cases, the proportions of suspected suicides decreased and those of intentional misuse/abuse without suicidal intent increased. However, due to the large increase in illicit opioid cases, the number of suspected suicide cases involving illicit opioids increased. Multivariable analyses showed that among prescription opioids, acetaminophen with opioid (IRR = 1.17, 95% CI = 1.11-1.24) and tramadol (IRR = 1.12, 95% CI = 1.06-1.47) were associated with higher risk of suspected suicides than intentional misuse/abuse without suicidal intent. Among illicit opioid cases, fentanyl poisoning cases were associated with lower risk of suspected suicides (IRR = 0.40, 95% CI = 0.17-0.94). Of other medications, use of benzodiazepines and antipsychotics was consistently associated with higher risk of suspected suicides in both prescription and illicit opioid cases. Alcohol and cocaine were also associated with higher risk of suspected suicide. Along with continued reductions in opioid prescribing, more effective monitoring of individual patient misuse/abuse behaviors and suicide risk assessment are needed. Healthcare professionals should also review other prescription medications frequently co-prescribed with opioids that may have additive effects on suicidal behaviors among older adults.

The effect of pill mill legislation on suicides

OBJECTIVE

To examine the effect of pill mill legislation on suicides and drug-related suicides in the United States.

DATA SOURCES

We use state-level restricted use mortality data from the National Vital Statistics System for the period 2000-2016, along with state level sociodemographic data from the US Census Bureau and Bureau of Labor Statistics and opioid-related state health policy data from publicly available sources for the analysis.

STUDY DESIGN

The analyses use a difference-in-differences regression approach.

DATA COLLECTION/EXTRACTION METHODS

Publicly available secondary data were collected and merged with restricted use mortality data files from the National Vital Statistics System for the analysis.

PRINCIPAL FINDINGS

Our results show that pill mill legislation is associated with an 8.5% (p < 0.01) reduction in the drug related suicide rate, a 4.9% (p < 0.05) reduction in suicides among females, and a 4.7% (p < 0.05) reduction in suicides among individuals between age 45 and 64 years.

CONCLUSIONS

The findings indicate that pill mill legislation has been effective in reducing total suicides among females in the age group 45-64, and drug-related suicides in the population resulting in 658 fewer drug-related suicides for a given year if pill mill laws are adopted by every state.

Multiple suicide attempts associated with addiction to tramadol

BACKGROUND

The opioid tramadol is used as analgesic drug, and more recently was also proposed for the management of major depressive disorder. However, growing evidence suggests a link between opioid system dysfunction and suicidal behaviors, raising the question of tramadol use in view of the high addictive and suicidal risk. Here, we present the case of a young adult woman with multiple suicide attempts related to tramadol addiction.

CASE PRESENTATION

A 25-year-old woman was admitted for suicide attempt by phlebotomy in the Department of Psychiatric Emergency and Acute Care, Montpellier (France), in March 2020. The suicide attempt occurred 3 days after an abrupt tramadol withdrawal. In 2018, due to spinal disc herniation, she had a first prescription of tramadol to which she became addicted. The patient described an effect on psychological pain and suicidal ideation. However, she had to increase tramadol dose to obtain the desired effects, and for several months her intake was 2 000 mg per day. When she could not obtain tramadol any longer, suicidal ideation and psychological pain increased, leading to the suicide attempt. At the time of a worldwide opioid crisis that contributes to increasing suicidal behaviors, this case raises questions about tramadol prescription (often considered to be less addictive and with lower abuse potential) to individuals at risk of suicide.

Risk of self-harm or suicide associated with specific drug use disorders, 2004-2016: a population-based cohort study

BACKGROUND AND AIMS

Drug use disorders are associated with increased risk of self-harm. Risk differences associated with specific types of drug use disorders are yet to be comprehensively reported. This study aimed to examine the risk of self-harm or suicide associated with different drug use disorders in Hong Kong.

DESIGN

Population-based cohort study.

SETTING

The Clinical Data Analysis and Reporting System (CDARS) managed by the Hong Kong Hospital Authority.

PARTICIPANTS

Cases were people ages 10 years or older who visited a hospital Accident and Emergency department between 1 January, 2004 and 31 December, 2016 with any of 10 specific drug use disorders (comprising opioid; ketamine; methamphetamine; sedative, hypnotic, or anxiolytic; amphetamine or related stimulant; cocaine; cannabis; hallucinogen; unspecified or other drug; and polydrug). Each case was matched with two controls, selected from a subset of people in CDARS sharing the same gender, age and psychiatric profile. A total of 8270 cases and 16 540 matched controls were included.

MEASUREMENTS

Incidence and adjusted hazard ratio (aHR) of subsequent self-harm or suicide for each specific drug use disorder were estimated.

FINDINGS

The most prevalent drug use disorder was opioid use disorder (2523; 30.51%) and the least prevalent was hallucinogen use disorder (77; 0.93%). The crude incidence of self-harm or suicide ranged from 26.57 (95% CI, 14.23-44.55) per 1000 person-years for cannabis use disorder to 91.97 (77.32-108.37) for polydrug use disorder. The highest risk of self-harm or suicide was observed in ketamine (aHR, 16.36; 95% CI, 11.03-24.29) and opioid (15.97; 10.73-23.23) use disorders.

CONCLUSIONS

In Hong Kong, all types of drug use disorders appear to be significantly associated with increased risk of self-harm or suicide, but risk levels vary by type of drug use disorder.

A Theoretical Endogenous Opioid Neurobiological Framework for Co-occurring Pain, Trauma, and Non-suicidal Self-injury

PURPOSE OF REVIEW

Individuals with chronic pain are significantly more likely to have experienced overwhelming trauma early and often in key developmental years. There is increasing acknowledgment that childhood trauma disrupts how individuals process and cope with both physical and emotional pain. Emerging studies acknowledge elevated rates of non-suicidal self-injury (NSSI) in chronic pain populations. This review provides a theoretical framework to understand the relationship between NSSI behavior and pain experience in persons with chronic pain and childhood trauma histories. We discuss how NSSI may act to regulate neurobiological (e.g., endogenous opioid systems) and psychological (e.g., heightened negative affect and emotion dysregulation) systems affected by childhood trauma, leading to temporary pain relief and a cycle of negative reinforcement perpetuating NSSI. As these concepts are greatly understudied in pain populations, this review focuses on key areas relevant to chronic pain that may provide a testable, conceptual framework to support hypothesis generation, future empirical investigation, and intervention efforts.

RECENT FINDINGS

See Fig. 1. See Fig. 1.

Race Differences in Opioid Misuse and Adolescent Suicidality

PURPOSE

The rise of the opioid epidemic coincided with the increased risk of suicide as the leading causes of death among adolescents in the United States. Past research has linked non-medical prescription opioid use (NMPOU) with adolescent suicide. Less focus has been placed on race and ethnic differences among adolescents impacted by the opioid epidemic. This study examined the relationship of adolescent NMPOU and suicidality, stratified by race.

METHOD

The 2016 National Survey on Drug Use and Health (NSDUH) was used for this study. Weighted multivariate logistic regression analyses were conducted on a sample of 11,489 adolescent respondents to examine the effect of past-year NMPOU with the odds for serious thoughts of suicide, having a suicide plan, and making a suicide attempt.

RESULTS

Findings indicated a higher prevalence of suicidality among adolescents who engaged in NMPOU compared to non-users. Adolescent opioid misuse was associated with 68% higher odds for having a suicide plan in the past year (OR = 1.68, 95% CI: [1.07, 2.63], p < 0.05). Interaction analysis found that among Asian adolescents, NMPOU was associated with higher odds for having a suicide plan compared to other race groups (OR=1.53, 95% CI: [1.04, 2.23], p < 0.05).

DISCUSSION

Results indicated that adolescent opioid misuse is a risk factor for suicide, and Asians compared to other race groups were at greater risk. Social workers can serve as a nexus point in effectively engaging at-risk adolescents in substance use and mental health prevention and recovery services.

Opioid use as a proximal risk factor for suicidal behavior in young adults

INTRODUCTION

There is a concomitant rise in suicide rates with the prevalence of opioids involved in overdose deaths, especially among adolescents and young adults. However, there are limited studies on whether opioid use prospectively predicts suicidal behavior in youth.

METHODS

Our sample included 183 psychiatric patients (18-30 years) admitted for a suicide attempt (SA), have current suicidal ideation (SI), and psychiatric controls without ideation or attempt (PC). Suicidal behavior was assessed using the Columbia Suicide Severity Rating Scale. We also recruited a healthy control group (HC; n = 40). Patients and controls were followed over a year. ANOVA, regression, and cox regression were used.

RESULTS

Suicide attempt (β = 0.87, CI [0.1-1.6], p = 0.02) and SI [(β = 0.75, CI [0.03-1.5], p = 0.04) were significantly more likely than HCs to have used opioids in the past year at baseline. Opioid use was associated with increased anxiety symptoms (β = 0.75, CI [0.001-1.5], p = 0.05), PTSD symptoms (β = 3.90, CI [1.1-6.7], p = 0.01), and aggression (β = 0.02, CI [0.01-0.04], p = 0.02). Opioid use in the month prior to hospitalization predicted SA at 6 months (OR = 1.87, CI [1.06-3.31], p = 0.032).

CONCLUSIONS

Opioid use is a proximal predictor for SA. These findings may help clinicians better identify patients at risk for suicidal behavior, allowing for more personalized treatment approaches.

Veteran drug overdose mortality, 2010-2019

BACKGROUND

Prior work documents that Veteran drug overdose mortality increased from 2010 to 2016. The present study assessed trends from 2010 to 2019, by drug type and recent receipt of Veterans Health Administration (VHA) services, and compared rates for Veteran and non-Veteran US adults.

METHODS

This retrospective cross-sectional study used data from Veterans Affairs (VA) medical records, the VA/Department of Defense Mortality Data Repository, and CDC WONDER. Trends were compared using Joinpoint regression.

RESULTS

From 2010-2019, age-adjusted overdose mortality rates increased 53.2% among Veterans and 79.0% among non-Veterans. Age-adjusted rates of overdose mortality among Veterans rose from 19.8/100,000 in 2010 to 32.6/100,000 in 2017, before falling to 30.3/100,000 in 2019. Despite the decrease from 2017 to 2019 in overall overdose mortality, rates of overdose deaths involving synthetic opioids other than methadone and involving psychostimulants continued to increase through 2019. In 2019, overdose mortality was lower for male Veterans than male non-Veterans (standardized rate ratio (SRR) = 0.81, 95% confidence interval (CI): 0.77-0.84). Among male Veterans, rates were higher in all years for those with recent VHA use than those without (2019: SRR=1.69, 95% CI: 1.56-1.83). From 2010-2019, overdose mortality rates increased faster among female Veterans without VHA use than those with VHA use.

CONCLUSIONS

From 2015 onward, Veteran men experienced lower age-adjusted overdose rates than non-Veteran men. In all years, overdose rates were higher among male Veterans with recent VHA use than those without recent use. While overall rates of Veteran overdose deaths declined from 2017 to 2019, rates involving psychostimulants and synthetic opioids continued to rise.

Opioid-related variables did not improve suicide risk prediction models in samples with mental health diagnoses

Background

Suicide risk prediction models derived from machine learning of electronic health records and insurance claims are an innovation in suicide prevention. Some models do not include opioid-related variables despite the relationship between opioids and suicide. This study evaluated whether inclusion of opioid-related variables improved suicide risk prediction models developed by the Mental Health Research Network.

Methods

Approximately 630 opioid-related variables and interactions terms were introduced into existing suicide prediction models run in datasets of patient visits in mental health care (n = 27,755,401 visits) or primary care when a mental health diagnosis was given (n = 19,340,461 visits). Training and validation datasets were created. LASSO regression with 10-fold validation identified variables to be added to the models.

Results

The new models predicting suicide attempts and suicide deaths in the mental health specialty visit sample performed as well as the existing models (new C-statistic for attempts model = 0.855, CI: 0.853-0.857 versus original C-statistic = 0.851, CI 0.848-0.853; death model = 0.868, CI: 0.856-0.879 versus 0.861, CI 0.848-0.875). The new model for suicide death in the primary care sample improved (0.855, CI: 0.837-0.874 versus 0.833, CI 0.813-0.853) while performance of the new model for suicide attempt in that sample degraded (0.843, CI: 0.839-0.847 versus 0.853, CI 0.849-0.857).

Limitations

Analyses did not include patients without recent care, data did not include illicit opioid use or unrecognized opioid use disorder.

Conclusions

Among patients with mental health diagnoses, inclusion of opioid-related variables did not improve prediction of suicide risk beyond mental health predictors.

Initiation of Opioid Prescription and Risk of Suicidal Behavior Among Youth and Young Adults

BACKGROUND AND OBJECTIVES

Opioids are involved in an increasing proportion of suicide deaths. This study examined the association between opioid analgesic prescription initiation and suicidal behavior among young people.

METHODS

We analyzed Swedish population-register data on 1 895 984 individuals ages 9 to 29 years without prior recorded opioid prescriptions. We identified prescriptions dispensed from January 2007 onward and diagnosed self-injurious behavior and death by suicide through December 2013. We first compared initiators with demographically matched noninitiators. To account for confounding, we applied an active comparator design, which examined suicidal behavior among opioid initiators relative to prescription nonsteroidal antiinflammatory drug (NSAID) initiators while inverse-probability-of-treatment weighting with individual and familial covariates.

RESULTS

Among the cohort, 201 433 individuals initiated opioid prescription. Relative to demographically matched noninitiators, initiators (N = 180 808) had more than doubled risk of incident suicidal behavior (hazard ratio = 2.64; 95% confidence interval [CI], 2.47-2.81). However, in the active comparator design, opioid initiators (N = 86 635) had only 19% relatively greater risk of suicidal behavior compared with NSAID initiators (N = 255 096; hazard ratio = 1.19; 95% CI,: 1.11-1.28), corresponding to a weighted 5-year cumulative incidence of 2.2% (95% CI, 2.1-2.4) for opioid and 1.9% (95% CI, 1.9-2.0) for NSAID initiators. Most sensitivity analyses produced comparable results.

CONCLUSIONS

Opioid initiation may make only a small contribution to the elevated risk of suicidal behavior among young people receiving pharmacologic pain management. In weighing benefits and harms of opioid initiation, our results suggest that increased risk of suicidal behavior may not be a major concern.

A Systematic Review of Risk Factors for Suicide Among Persons Living with HIV (1996-2020)

Persons living with HIV (PWH) are at elevated risk for suicide. We conducted a systematic literature review following PRISMA-P guidelines to examine risk factors associated with suicide as a cause of morbidity among PWH. We searched six electronic databases using search terms (suicide, suicide attempt, self-harm, self-injurious behavior, HIV, AIDS, PWH). We focused on factors that were specific to HIV infection (CD4 count, HIV-1 RNA, and antiretroviral therapy [ART]). The initial search yielded N = 2657 studies. Eligible studies included suicide as an outcome, quantitative study design, and publication in peer-reviewed journals from 1996 through 2020. Fourteen studies met inclusion criteria. PWH share risk factors for suicide found in the general population: psychiatric illness, previous suicide attempt, drug and alcohol misuse. PWH also have HIV-specific risk factors for suicide. HIV diagnosis in the past two years and transmission related to injection drug use were associated with increased risk; HIV-1 RNA, ART, and AIDS-defining illness were not.

Impact of changes in opioid funding and clinical policies on rapid tapering of opioids in Ontario, Canada

ABSTRACT

Reports have emerged of abrupt tapering among recipients of long-term prescription opioids to conform new prescribing guidelines. We conducted a population-based, repeated cross-sectional time-series study among very high-dose (≥200 MME) opioid recipients in Ontario, Canada, to examine changes in the monthly prevalence of rapid tapering from 2014 to 2018, defined as recipients experiencing either a ≥50% reduction in daily doses or abrupt discontinuation sustained for 30 days. Interventional autoregressive integrated moving average models were used to test for significant changes following key guidelines and drug policies and programs. A sensitivity analysis examined rapid tapering sustained for 90 days. The monthly prevalence of rapid tapering events was stable from January 2014 to September 2016 (average monthly prevalence: 1.4%) but increased from 1.4% in October 2016 to 1.8% in April 2017 (P = 0.001), coincident with Ontario's Fentanyl Patch-for-Patch Return Program implementation. Transient spikes in the prevalence of rapid tapering also occurred 2 months after Ontario's delisting of publicly funded high-strength opioids and the release of updated Canadian Opioid Prescribing Guideline for Chronic Pain, reaching 2.3% in March 2017 and July 2017, respectively. However, this prevalence decreased to 1.2% in December 2018 (P < 0.0001). Although the prevalence of abrupt opioid discontinuation was lower, similar trends were observed. Our sensitivity analysis examining long-lasting rapid tapering found similar trends but lower prevalence, with no changes in complete discontinuation. These temporary increases in rapid tapering events highlight the need for improved communication and evidence-based resources for prescribers to minimize negative consequences of evolving policies and guidelines.

Suicidal ideation and attempts following nonmedical use of prescription opioids and related disorder

BACKGROUND

Since 1999, the rate of fatal prescription opioid overdoses and of suicides has dramatically increased in the USA. These increases, which have occurred among similar demographic groups, have led to the hypothesis that the opioid epidemic contributed to increases in suicidal behavior, though the underlying association remains poorly defined. We examine the association between nonmedical use of prescription opioids/opioid use disorder and suicidal ideation/attempts.

METHODS

We used longitudinal data from a national representative sample of the US adult population, the National Epidemiologic Survey on Alcohol and Related Conditions. Participants (n = 34 653) were interviewed in 2001-2002 (wave 1) and re-interviewed approximately 3 years later (wave 2). A propensity score analysis estimated the association between exposure to prescription opioids at wave 1 and prevalent/incident suicidal behavior at wave 2.

RESULTS

Heavy/frequent (⩾2-3 times a month) prescription opioid use was associated with prevalent suicide attempts [adjusted risk ratio (ARR) = 2.75, 95% CI 1.35-5.60]. Prescription opioid use disorder was associated with prevalent (ARR = 1.98, 95% CI 1.20-3.28) and incident suicidal ideation (ARR = 2.59, 95% CI 1.25-5.37), and prevalent attempts (ARR = 4.19, 95% CI 1.71-10.27). None of the exposures was associated with incident suicide attempts.

CONCLUSIONS

Heavy/frequent opioid use and related disorder were associated with prevalent suicide attempts; opioid use disorder was also associated with the incident and prevalent suicidal ideation. Given population increases in nonmedical use of prescription opioids and disorder, the opioid crisis may have contributed to population increases in suicidal ideation.

Multidisciplinary Care for Adults With Chronic Pancreatitis: Incorporating Psychological Therapies to Optimize Outcomes

ABSTRACT

Chronic pancreatitis (CP) is associated with a high disease burden, extensive negative impact on quality of life, increased rates of depression and anxiety, and significant health care utilization and expenditures. Pain is a hallmark feature of CP, present in up to 90% of patients with this condition, and can lead to high rates of disability, hospitalization, and opioid medication use. Current perspectives on the management of CP have evolved to advocate a multidisciplinary approach which offers new pathways for helping patients manage symptoms. Psychologists play an important role in a multidisciplinary team effort by applying scientifically based psychological principles and techniques to improve pain and adaptation to chronic illness. This review will detail the fundamentals of delivering psychological interventions for adults with CP managed in an outpatient setting. Recommendations for integrating psychological care in multidisciplinary management of CP will be offered. Future directions for psychological care in CP multidisciplinary teams are also discussed.

Concomitant opioid and benzodiazepine use and risk of suicide attempt and intentional self-harm: Pharmacoepidemiologic study

BACKGROUND

Overdose due to concomitant use of opioids and benzodiazepines has been raised as a major public health concern, although little research has examined whether this risk extends to intentional overdose or other self-harm. This study examined whether prescription opioids and benzodiazepines interact to increase the rate of suicide attempt and intentional self-harm.

METHODS

The study analyzed 4,762,438 users of opioids, benzodiazepines, both drugs concomitantly, or neither drug from the MarketScan Commercial Claims and Encounters databases (2014-2016). The four groups were matched using inverse probability of treatment weighting and a difference in difference design was used to examine associations with risk of suicide attempt, intentional self-harm and drug overdose, including suicide death resulting in a medical claim.

RESULTS

There was a small association for opioids (HR=1.23; 95% CI 1.06-1.43) but a larger association for benzodiazepines (HR=2.55; 95% CI 2.12-3.05) with suicide attempt, intentional self-harm, and drug overdose. The medication interaction was opposite to the expected direction (HR=0.70; 95% CI 0.55-0.89), indicating that risk associated with concomitant use was lower than would be expected on an additive basis. Sensitivity analyses found no evidence of increased risk due to interaction between the two drug classes.

CONCLUSIONS

Increased risk of suicide attempt, intentional self-harm and drug overdose for concomitant use of opioids and benzodiazepines is in large part attributable to benzodiazepine use alone. In typically prescribed quantities, opioids and benzodiazepines may not represent a drug interaction in terms of yielding increased risk of suicide attempt and intentional self-harm resulting in medical care.

The Relationship Between Pain Severity, Insomnia, and Suicide Attempts Among a National Veteran Sample Initiating Pain Care

OBJECTIVE

We assessed the longitudinal association of suicide attempts by moderate to severe pain and insomnia before and after the initiation of pain services among veterans.

METHODS

A cohort of 221,817 veterans initiating pain care was divided into four subgroups: a) no/mild pain + no insomnia (LowPain-NoINS), b) no/mild pain + insomnia (LowPain-INS), c) moderate/severe pain + no insomnia (HighPain-NoINS), and d) moderate/severe pain + insomnia (HighPain-INS). Data on diagnoses, pain severity, demographics, medications, and suicide attempts were extracted from Veterans Health Administration data sets.

RESULTS

Overall, there were 2227 (1.0%) suicide attempts before initiating pain services and 1655 (0.8%) after initiating pain services. Cox proportional hazard models accounting for key covariates revealed that patients in the HighPain-INS group were significantly more likely to attempt suicide in the year after the initiation of pain services relative to all subgroups (versus LowPain-NoINS: hazard ratio [HR] = 1.44, 95% confidence interval [CI] = 1.21-1.72; versus LowPain-INS: HR = 1.71, 95% CI = 1.23-2.38; versus HighPain-NoINS: HR = 1.17, 95% CI = 1.01-1.34) even after accounting for prior attempts. Adjusted logistic regression analyses found that patients with moderate/severe pain and insomnia had higher odds of attempting suicide in the year before initiating pain services compared to all subgroups (versus LowPain-NoINS: HR = 1.75, 95% CI = 1.50-2.05; versus LowPain-INS: HR = 1.41, 95% CI = 1.09-1.82; versus HighPain-NoINS: HR = 1.21, 95% CI = 1.07-1.37).

CONCLUSIONS

These results suggest that those with both moderate/severe pain and insomnia are more likely to have a history of suicide attempts and are at greater risk of a suicide attempt relative to those with insomnia with low/mild pain and those with moderate/severe pain with no insomnia. Suicide prevention efforts for chronic pain and insomnia could address pain and insomnia within the same intervention or in parallel.

A cross sectional study of non-medical use of prescription opioids and suicidal behaviors among adolescents

Background

Non-medical use of prescription opioids (NMUPO), defined as taking an opioid in a manner or dose other than prescribed, taking someone else’s, or for the feelings that it produces, has been reported by 5 to 20% of adolescents, and is associated with a two fold increase in suicidal behaviors among adolescents. Adolescents with long-term health problems (LTHP) have poorer mental health and may seek NMUPO for pain relief that is not obtained through standard care. For this study, we measured the association between NMUPO and suicidal behaviors, and further assessed effect modification by LTHP hypothesizing the association between NMUPO and suicidal behaviors was stronger for adolescents with LTHP.

Findings

For students with LTHP, 13.5% reported suicide ideation, while 8.0% of students without LTHP reported suicide ideation. For suicide attempt, 4.4% of students with LTHP reported a suicide attempt, while 2.1% of students without LTHP reported a suicide attempt. The proportion of students who reported suicide ideation and attempts increased with higher occasions of NMUPO. Adjusted logistic regression models found increased odds of suicide ideation (OR (95% CI): 1–5 occasions: 2.3 (2.0–2.6); > 6 occasions: 2.7 (2.2–3.8)) and suicide attempts (OR (95% CI): 1–5 occasions: 3.2 (2.7–3.7); > 6 occasions: 4.1 (3.1–5.3)) for students who reported NMUPO. An interaction term for NMUPO and LTHP was then added to the models. Effect modification was not present on the multiplicative scale. On the additive scale, evidence of effect modification was observed: higher risk was indicated for students with LTHP versus no LTHP for both suicide ideation (Predicted risk (95%CI): > 6 occasions NMUPO, LTHP: 0.24 (0.18–0.29); No LTHP: 0.16 (0.13–0.18)) and attempt (Predicted risk (95%CI): 1–5 occasions NMUPO, LTHP: 0.08 (0.07–0.10); No LTHP: 0.05 (0.05–0.06); > 6 occasions NMUPO, LTHP: 0.11 (0.07–0.15); No LTHP: 0.06 (0.05–0.08)).

Conclusions

The results affirmed that NMUPO is associated with suicidal behaviors among adolescents. A pattern also emerged of higher risk of suicidal behaviors for those with LTHP who reported NMUPO. Areas of further inquiry should explore chronic medical or pain conditions as possible modifying pathways that could exacerbate the effects of NMUPO on suicidal behaviors specific to an adolescent population.

"We Need to Taper." Interviews with Clinicians and Pharmacists About Use of a Pharmacy-Led Opioid Tapering Program

OBJECTIVE

To identify factors that influence or interfere with referrals by primary care providers (PCPs) to a pharmacist-led telephone-based program to assist patients undergoing opioid tapering. The Support Team Onsite Resource for Management of Pain (STORM) program provides individualized patient care and supports PCPs in managing opioid tapers.

DESIGN

Qualitative interviews were conducted with referring PCPs and STORM staff. Interview guides addressed concepts from the RE-AIM framework, focusing on issues affecting referral to the STORM program.

SETTING

An integrated healthcare system (HCS) in the Northwest United States.

SUBJECTS

Thirty-five interviews were conducted with 20 PCPs and 15 STORM staff.

METHODS

Constant comparative analysis was used to identify key themes from interviews. A codebook was developed based on interview data and a qualitative software program was used for coding, iterative review, and content analysis. Representative quotes illustrate identified themes.

RESULTS

Use of the STORM opioid tapering program was influenced by PCP, patient, and HCS considerations. Factors motivating use of STORM included lack of PCP time to support chronic pain patients requiring opioid tapering and the perception that STORM is a valued partner in patient care. Impediments to referral included PCP confidence in managing opioid tapering, patient resistance to tapering, forgetting about program availability, and PCP resistance to evolving guidelines regarding opioid tapering goals.

CONCLUSIONS

PCPs recognized that STORM supported patient safety and reduced clinician burden. Utilization of the program could be improved through ongoing PCP education about the service and consistent co-location of STORM pharmacists within primary care clinics.

Sex differences in the associations of nonmedical use of prescription drugs with self-injurious thoughts and behaviors among adolescents: A large-scale study in China

Background To investigate the sex differences in the associations of nonmedical use of opioids and sedatives with non-suicidal self-injury (NSSI), suicidal thoughts, and suicide attempts. Methods This study presents secondary analyses of the 2015 National School-based Chinese Adolescents Health Survey. A total of 152, 527 students (aged 10-20 years) completing standard questionnaires were included in analyses. Appropriate sampling weights were utilized. Results After adjusting for the demographic profile, academic pressure, and depressive symptoms, nonmedical use of opioids (adjusted odds ratio [aOR]=1.82, 95% confidence interval [CI]=1.69~1.96) and sedatives (aOR=2.03, 95% CI=1.90~2.18) remain positively associated with NSSI, and adolescents who reported opioids or sedatives misuse were at a higher risk for suicidal thoughts and suicide attempts. A significant sex difference was found in the effects of nonmedical use of sedatives on NSSI, with the effects in girls stronger than that in boys (Ratio of two odds ratio [ROR]=1.18, P=0.011). Girls reporting nonmedical use of opioids and sedatives also had an increased risk of suicidal thoughts than boys (opioids misuse: ROR=1.25, P=0.002; sedatives misuse: ROR=1.21, P=0.006). Limitations Causal inference could not be tested due to the cross-sectional design. Conclusion Although nonmedical use of opioids or sedatives was associated with the increased risks of NSSI, suicidal thoughts, and suicide attempts among both boys and girls, there exist significant sex differences in these associations, and girls exhibited a higher risk of NSSI and suicidal thoughts than boys. Intervention strategies are needed to help vulnerable adolescents (e.g., those involved in NMUPD), with a focus on girls.

Suicidal behavior, opioid use disorder, and behavioral health treatment: Prevalence and correlates among adults in the United States 2015-2018

BACKGROUND

Past research shows that individuals with opioid use disorder (OUD) have a higher rate of co-occurring mental health conditions, but little research has examined suicidal behavior (suicidal ideation and/or attempts) and utilization of behavioral health services among individuals with OUD using a nationally representative sample.

METHODS

Using the 2015-2018 National Survey of Drug Use and Health, this study examines the risk of suicidal behavior among individuals with OUD. In addition, the study examines how utilization of behavioral health treatment among individuals with OUD might mitigate the risk of suicidal behavior.

RESULTS

The rate of suicidal behavior was higher among individuals with OUD (22%) than among those without OUD (4%). Among those with OUD, 43% reported receiving neither substance use disorder nor mental health treatment. Multivariable logistic regression estimates indicate that individuals with OUD had odds of suicidal behavior 2.9 times as high as those without OUD. Odds of suicidal behavior among people with OUD were 49% lower with substance use disorder treatment, 5% lower with mental health treatment, and 28% lower with both.

CONCLUSION

Individuals with OUD have a high risk of suicidal behavior, which can be mitigated with utilization of behavioral health treatment. These findings underscore the importance of policy initiatives directed at increasing treatment utilization among those with OUD.

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.