Chronic Pain Among Suicide Decedents, 2003 to 2014: Findings From the National Violent Death Reporting System

Identification of Oxidative Stress-Related Biomarkers for Pain-Depression Comorbidity Based on Bioinformatics

Oxidative stress has been identified as a major factor in the development and progression of pain and psychiatric disorders, but the underlying biomarkers and molecular signaling pathways remain unclear. This study aims to identify oxidative stress-related biomarkers and signaling pathways in pain-depression comorbidity. Integrated bioinformatics analyses were applied to identify key genes by comparing pain-depression comorbidity-related genes and oxidative stress-related genes. A total of 580 differentially expressed genes and 35 differentially expressed oxidative stress-related genes (DEOSGs) were identified. By using a weighted gene co-expression network analysis and a protein-protein interaction network, 43 key genes and 5 hub genes were screened out, respectively. DEOSGs were enriched in biological processes and signaling pathways related to oxidative stress and inflammation. The five hub genes, RNF24, MGAM, FOS, and TKT, were deemed potential diagnostic and prognostic markers for patients with pain-depression comorbidity. These genes may serve as valuable targets for further research and may aid in the development of early diagnosis, prevention strategies, and pharmacotherapy tools for this particular patient population.

Surveillance for Violent Deaths - National Violent Death Reporting System, 48 States, the District of Columbia, and Puerto Rico, 2021

Problem/Condition

In 2021, approximately 75,000 persons died of violence-related injuries in the United States. This report summarizes data from CDC's National Violent Death Reporting System (NVDRS) on violent deaths that occurred in 48 states, the District of Columbia, and Puerto Rico in 2021. Results are reported by sex, age group, race and ethnicity, method of injury, type of location where the injury occurred, circumstances of injury, and other selected characteristics. This report introduces additional incident and circumstance variables, which now include child victim-specific circumstance information. This report also incorporates new U.S. Census Bureau race and ethnicity categories, which now account for more than one race and Native Hawaiian or other Pacific Islander categories and include updated denominators to calculate rates for these populations.

Period Covered

2021.

Description of System

NVDRS collects data regarding violent deaths from death certificates, coroner and medical examiner records, and law enforcement reports. This report includes data collected for violent deaths that occurred in 2021. Data were collected from 48 states (all states with exception of Florida and Hawaii), the District of Columbia, and Puerto Rico. Forty-six states had statewide data, two additional states had data from counties representing a subset of their population (31 California counties, representing 64% of its population, and 13 Texas counties, representing 63% of its population), and the District of Columbia and Puerto Rico had jurisdiction-wide data. NVDRS collates information for each violent death and links deaths that are related (e.g., multiple homicides, homicide followed by suicide, or multiple suicides) into a single incident.

Results

For 2021, NVDRS collected information on 68,866 fatal incidents involving 70,688 deaths that occurred in 48 states (46 states collecting statewide data, 31 California counties, and 13 Texas counties), and the District of Columbia. The deaths captured in NVDRS accounted for 86.5% of all homicides, legal intervention deaths, suicides, unintentional firearm injury deaths, and deaths of undetermined intent in the United States in 2021. In addition, information was collected for 816 fatal incidents involving 880 deaths in Puerto Rico. Data for Puerto Rico were analyzed separately. Of the 70,688 deaths, the majority (58.2%) were suicides, followed by homicides (31.5%), deaths of undetermined intent that might be due to violence (8.2%), legal intervention deaths (1.3%) (i.e., deaths caused by law enforcement and other persons with legal authority to use deadly force acting in the line of duty, excluding legal executions), and unintentional firearm injury deaths (<1.0%). The term "legal intervention" is a classification incorporated into the International Classification of Diseases, Tenth Revision, and does not denote the lawfulness or legality of the circumstances surrounding a death caused by law enforcement.Demographic patterns and circumstances varied by manner of death. The suicide rate was higher for males than for females. Across all age groups, the suicide rate was highest among adults aged ≥85 years. In addition, non-Hispanic American Indian or Alaska Native (AI/AN) persons had the highest suicide rates among all racial and ethnic groups. Among both males and females, the most common method of injury for suicide was a firearm. Among all suicide victims, when circumstances were known (84.4%), suicide was most often preceded by a mental health, intimate partner, or physical health problem or by a recent or impending crisis during the previous or upcoming 2 weeks. The homicide rate was higher for males than for females. Among all homicide victims, the homicide rate was highest among persons aged 20-24 years compared with other age groups. Non-Hispanic Black or African American (Black) males experienced the highest homicide rate of any racial or ethnic group. Among all homicide victims, the most common method of injury was a firearm. When the relationship between a homicide victim and a suspect was known, the suspect was most frequently an acquaintance or friend for male victims and a current or former intimate partner for female victims. Homicide most often was precipitated by an argument or conflict, occurred in conjunction with another crime, or, for female victims, was related to intimate partner violence. Nearly all victims of legal intervention deaths were male, and the legal intervention death rate was highest among men aged 30-34 years. The legal intervention death rate was highest among AI/AN males, followed by Black males. A firearm was used in the majority of legal intervention deaths. When circumstances were known, the most frequent circumstances reported for legal intervention deaths were as follows: the victim used a weapon in the incident and the victim had a substance use problem (other than alcohol use). Other causes of death included unintentional firearm injury deaths and deaths of undetermined intent. Unintentional firearm injury deaths were most frequently experienced by males, non-Hispanic White (White) persons, and persons aged 15-24 years. These deaths most frequently occurred while the shooter was playing with a firearm and were precipitated by a person unintentionally pulling the trigger. The rate of deaths of undetermined intent was highest among males, particularly among AI/AN and Black males, and among adults aged 30-54 years. Poisoning was the most common method of injury in deaths of undetermined intent, and opioids were detected in nearly 80% of decedents tested for those substances.

Interpretation

This report provides a detailed summary of data from NVDRS on violent deaths that occurred in 2021. The suicide rate was highest among AI/AN and White males, whereas the homicide rate was highest among Black males. Intimate partner violence precipitated a large proportion of homicides for females. Mental health problems, intimate partner problems, interpersonal conflicts, and acute life stressors were primary precipitating circumstances for multiple types of deaths examined.

Public Health Action

Violence is preventable, and data can guide public health action. NVDRS data are used to monitor the occurrence of violence-related fatal injuries and assist public health authorities in developing, implementing, and evaluating programs, policies, and practices to reduce and prevent violent deaths. NVDRS data can be used to enhance prevention efforts into actionable strategies. States or jurisdictions have used their Violent Death Reporting System (VDRS) data to guide suicide prevention efforts and highlight where additional focus is needed. For example, North Carolina VDRS program data have played a significant role in expanding activities related to firearm safety and injury prevention. The program served as a primary data source for partners, which led to the creation of the Office of Violence Prevention in the state, focusing on combatting firearm-related deaths. In Maine, the VDRS provided data on law enforcement officer suicides that were used to help support a bill mandating mental health resiliency and awareness training in the state's law enforcement training academy, along with plans for similar training addressing mental health, substance use, and alcohol problems among corrections officers. In addition, states and jurisdictions have also used their VDRS data to examine factors related to homicide in their state or jurisdiction. For example, Georgia VDRS collaborated with the City of Atlanta Mayor's Office of Violence Reduction to develop two public dashboards that not only offer comprehensive data on violent deaths but also present data on the geographic distribution of populations disproportionately affected by violence to help inform violence prevention interventions.

Suicide Among Roofers: Injury, Pain & Substance Misuse

OBJECTIVE

CDC has called for suicide research on the construction industry, an industry with a high suicide rate. The present study addresses this gap and focuses on roofers. It assesses which risk factors distinguish suicides by roofers from those of the general population. Alcohol and drug misuse, related to their high incidence of injury and pain, are seen as key potential drivers of roofer suicide.

METHODOLOGY

Data refer to 30,570 suicides and are taken from the National Violent Death Reporting System (NVDRS). Drawing from previous work on the health professions, 15 core predictors are selected, representing psychiatric morbidity, social strains, and demographics. Since the analysis seeks to differentiate roofers' suicides from others, the dependent variable is a dichotomy where roofers' suicides (=1) and other suicides (=0).

RESULTS

After adjusting for the other 14 risk factors, a multivariate logistic regression analysis found that roofers' suicides were 76% more apt (Odds ratio = 1.76, CI: 1.18, 2.63) than other suicides to have a known substance or alcohol problem that contributed to their suicide. Other constructs differentiating roofers' suicides from other suicides included marital status, gender, and race. Roofers were less protected by marriage.

CONCLUSION

The results inform prevention efforts and substance misuse can serve as a key warning sign for roofers' suicide. This is the first investigation of the drivers of suicide among roofers, and one of a few drawing links between occupational injury and suicide.

Suicide in individuals with no psychiatric disorders: what makes you vulnerable?

Globally, hundreds of thousands of people die by suicide every year. Suicides are usually associated with psychiatric illness. However, considerable evidence suggests that a significant number of individuals who die by suicide do not have diagnosable psychiatric disorders. The goal of this article is to attract attention to an overlooked issue of suicide in persons with no psychiatric disorders and to discuss some aspects of this issue. Research on identification and prevention of suicidal behavior in people with no psychiatric disorders is very limited. The available data indicate that suicides in individuals without psychiatric disorders are related to life stressors, lack of social support, and certain personality traits such as impulsivity. Suicide risk may be increased in military veterans with no psychiatric disorders. Many physical disorders, especially conditions associated with pain increase suicide risk in individuals with no diagnosable psychiatric disorders. Developmental, genetic and physical factors may play a role in the psychobiology of suicide in people with no psychiatric conditions. Promoting resilience may reduce suicide risk in the general population. Clinicians who work with medical or surgical patients need to have sufficient training in suicide prevention. Possibly, shifting some suicide prevention resources from individuals who are regarded as high-risk suicide patients to the general population may reduce suicide rates. Public education and better awareness about suicide may reduce suicide deaths among people with no psychiatric disorders.

Intimate partner violence and suicide mortality: a cross-sectional study using machine learning and natural language processing of suicide data from 43 states

INTRODUCTION

Intimate partner violence (IPV) is associated with suicidal ideation, yet it remains unclear how often IPV precipitates suicide mortality. To overcome limitations with national data, we applied novel methods to: (1) document the prevalence of IPV-related suicide in the USA and (2) identify correlates for IPV-related suicide.

METHODS

Using National Violent Death Reporting System data (NVDRS, 2015-2019, n=1 30 550), we recorded IPV circumstances (yes/no) by leveraging prior textual reviews of death narratives and applying a validated natural language processing tool. We could not systematically differentiate IPV perpetration versus victimisation given limited details in NVDRS. Logistic regression compared IPV-related suicides with referent group suicides (no evidence of IPV), stratified by sex.

RESULTS

7.1% of suicides were IPV related (n=9210), most were isolated suicide events (82.8%, n=7625; ie, not homicide suicide). There were higher odds of IPV circumstances when the decedent had civil legal problems (aOR for men: 3.6 (3.3 to 3.9), aOR for women: 2.6 (2.2 to 3.2)), criminal legal problems (aOR men: 2.3 (2.2 to 2.5), aOR for women: 1.7 (1.4 to 2.1)), or used a firearm (aOR men: 1.9 (1.8 to 2.0), aOR for women: 1.9 (1.7 to 2.1)). There were lower odds of IPV circumstances when the decedent had a current mental health problem (aOR men: 0.7 (0.7 to 0.8), aOR for women: 0.7 (0.6 to 0.8)).

CONCLUSIONS

IPV circumstances contribute to a notable proportion of suicides. IPV-related suicides are distinct from other suicide deaths. Targeted suicide screening and intervention in IPV settings may be beneficial for prevention.

Machine learning-based evaluation of spontaneous pain and analgesics from cellular calcium signals in the mouse primary somatosensory cortex using explainable features

Introduction

Pain that arises spontaneously is considered more clinically relevant than pain evoked by external stimuli. However, measuring spontaneous pain in animal models in preclinical studies is challenging due to methodological limitations. To address this issue, recently we developed a deep learning (DL) model to assess spontaneous pain using cellular calcium signals of the primary somatosensory cortex (S1) in awake head-fixed mice. However, DL operate like a "black box", where their decision-making process is not transparent and is difficult to understand, which is especially evident when our DL model classifies different states of pain based on cellular calcium signals. In this study, we introduce a novel machine learning (ML) model that utilizes features that were manually extracted from S1 calcium signals, including the dynamic changes in calcium levels and the cell-to-cell activity correlations.

Method

We focused on observing neural activity patterns in the primary somatosensory cortex (S1) of mice using two-photon calcium imaging after injecting a calcium indicator (GCaMP6s) into the S1 cortex neurons. We extracted features related to the ratio of up and down-regulated cells in calcium activity and the correlation level of activity between cells as input data for the ML model. The ML model was validated using a Leave-One-Subject-Out Cross-Validation approach to distinguish between non-pain, pain, and drug-induced analgesic states.

Results and discussion

The ML model was designed to classify data into three distinct categories: non-pain, pain, and drug-induced analgesic states. Its versatility was demonstrated by successfully classifying different states across various pain models, including inflammatory and neuropathic pain, as well as confirming its utility in identifying the analgesic effects of drugs like ketoprofen, morphine, and the efficacy of magnolin, a candidate analgesic compound. In conclusion, our ML model surpasses the limitations of previous DL approaches by leveraging manually extracted features. This not only clarifies the decision-making process of the ML model but also yields insights into neuronal activity patterns associated with pain, facilitating preclinical studies of analgesics with higher potential for clinical translation.

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.

Management of trigeminal neuralgia: A multi-centre case study in general practice

Background and aims

Patients often first present with symptoms of trigeminal neuralgia (TN) to primary care. However, there has been little research to determine whether the diagnosis and management of this condition is carried out according to current guidelines. Furthermore, there is little up-to-date information regarding the prevalence of TN in the UK. The aim is to estimate the prevalence of TN and to audit the diagnosis and management process of TN in primary care.

Methods

Between 2019 and 2020 a search was made at five UK GP practices with a total patient population of 55,842 using EMIS and SystmOne patient record systems to review patient consultations to identify patients coded with TN or facial pain (FP). These records were reviewed to ascertain the basis for diagnosis, management in primary care and referral to secondary care.

Results

157 patients were identified; 54 coded with FP and 103 with TN. These results indicate a prevalence of 22.3 in 10,000. There was no difference in documented symptoms between the two groups. Seven patients had all ICDH3 criteria recorded, with two meeting the requirements for TN diagnosis. 58.8% of patients with TN were started on carbamazepine, the current gold standard treatment, compared with 16.7% in the FP group. 38.2% of TN patients were referred to a range of different specialities.

Conclusion

The prevalence of TN may be higher than previously thought. Key diagnostic criteria are often omitted, leading to potential misdiagnosis or delays in diagnosis. Relatively few referrals are made, though all patients should be considered for imaging.

Mental Defeat and Suicidality in Chronic Pain: A Prospective Analysis

Living with chronic pain has been identified as a significant risk factor for suicide. Qualitative and cross-sectional studies have reported an association between mental defeat and suicidal thoughts and behavior in patients with chronic pain. In this prospective cohort study, we hypothesized that higher levels of mental defeat would be associated with increased suicide risk at a 6-month follow-up. A total of 524 patients with chronic pain completed online questionnaires measuring variables related to suicide risk, mental defeat, sociodemographic, psychological, pain, activity, and health variables. At 6 months, 70.8% (n = 371) of respondents completed the questionnaires again. Weighted univariate and multivariable regression models were run to predict suicide risk at 6 months. The clinical suicide risk cutoff was met by 38.55% of the participants at baseline and 36.66% at 6 months. Multivariable modeling revealed that mental defeat, depression, perceived stress, head pain, and active smoking status significantly increased the odds of reporting higher suicide risk, while older age reduced the odds. Receiver operating characteristic (ROC) analysis showed that assessment of mental defeat, perceived stress, and depression is effective in discriminating between 'low' and 'high' suicide risk. Awareness of the prospective links from mental defeat, depression, perceived stress, head pain, and active smoking status to increased suicide risk in patients with chronic pain may offer a novel avenue for assessment and preventative intervention. PERSPECTIVE: Results from this prospective cohort study suggest that mental defeat is a significant predictor of increased suicide risk among patients with chronic pain, along with depression, perceived stress, head pain, and active smoking status. These findings offer a novel avenue for assessment and preventative intervention before risk escalates.

Prevalence of suicidal behavior in patients with chronic pain: a systematic review and meta-analysis of observational studies

Objective

Chronic pain is a leading cause of disability, severely impairing an individual's daily activity and quality of life. In addition, this condition may contribute to suicidal thoughts by leading to neuropsychological impairments, a perceived lack of meaning in life, and pain-related catastrophizing. This systematic review aimed to comprehensively investigate the prevalence and associated factors of suicidal behaviors (SBs) including suicidal ideation (SI) and suicide attempt (SA) or its complete, in individuals with chronic pain.

Methods

Five electronic databases were searched up to October 4, 2022. Only observational studies investigating the prevalence of SB in individuals with chronic pain were included. The methodological quality of the included studies was assessed using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement. A meta-analysis was conducted to quantify the prevalence of SB in the population, and the command "Metaprop" was used in STATA/MP 16. In addition, factors explaining the association between chronic pain and SB identified through regression analysis were investigated.

Results

A total of 19 studies were included in this review (N = 3,312,343). The pooled lifetime prevalence of SI and SA was 28.90% (95% confidence interval, 17.95 to 41.26%) and 10.83% (5.72 to 17.30%), respectively, in a mixed sample comprising various chronic pain conditions. Importantly, the pooled prevalence of past 2-week SI was as high as 25.87% (18.09 to 34.50%). The methodological quality of the included studies was not optimal, and studies using validated SB assessment tools were lacking. Potential protective factors against SB in this population included pain coping and self-efficacy, older age, certain race/ethnicity groups, and marriage.

Conclusion

This systematic review and meta-analysis demonstrated the high prevalence of SB in individuals with chronic pain. Specifically, around 1 in 4 individuals with chronic pain had SI within the last 2 weeks. However, there was considerable heterogeneity in the pooled prevalence of SB in this population.

Activation of G-protein-coupled receptor 183 initiates inflammatory pain via macrophage CCL22 secretion

Chronic pain is a major public health problem with limited effective therapeutic options. G-protein-coupled receptors play a significant role in pain modulation; however, whether and how G-protein-coupled receptor 183 participates in pain regulation remain unclear. In the present study, we found that G-protein-coupled receptor 183 expression was specifically upregulated in the hind paws of mice in various inflammatory pain models. Activation of G-protein-coupled receptor 183 induced acute pain, whereas inhibition or silencing of this receptor alleviated mechanical allodynia and thermal hyperalgesia in complete Freund's adjuvant (CFA) model. Mechanistically, activating G-protein-coupled receptor 183 triggers pain responses via the upregulation of C-C motif chemokine 22(CCL22) in macrophages while blocking the CCL22 receptor C-C motif chemokine receptor 4 (CCR4) attenuates pain hypersensitivity. Taken together, our findings indicate that the G-protein-coupled receptor 183-CCL22 axis has a critical role in the development and maintenance of inflammatory pain.

Suicide among men: Risk assessment and mitigation in primary care

ABSTRACT

In the US each year, 80% of suicide deaths occur among men. As primary care is often the front door to identification and treatment of mental health problems, NPs in this setting are poised, with training in appropriate skills and tools, to recognize warning signs and risk factors in these patients as well as deliver necessary care and interventions to them. By being aware of known risk factors, identifying warning signs, communicating in a therapeutic manner, screening with standardized tools, assessing lethal means, developing safety plans, and making treatment referrals, primary care NPs can mitigate suicidal behaviors among men and save lives.

Characterizing Female Firearm Suicide Circumstances: A Natural Language Processing and Machine Learning Approach

INTRODUCTION

Since 2005, female firearm suicide rates increased by 34%, outpacing the rise in male firearm suicide rates over the same period. The objective of this study was to develop and evaluate a natural language processing pipeline to identify a select set of common and important circumstances preceding female firearm suicide from coroner/medical examiner and law enforcement narratives.

METHODS

Unstructured information from coroner/medical examiner and law enforcement narratives were manually coded for 1,462 randomly selected cases from the National Violent Death Reporting System. Decedents were included from 40 states and Puerto Rico from 2014 to 2018. Naive Bayes, Random Forest, Support Vector Machine, and Gradient Boosting classifier models were tuned using 5-fold cross-validation. Model performance was assessed using sensitivity, specificity, positive predictive value, F1, and other metrics. Analyses were conducted from February to November 2022.

RESULTS

The natural language processing pipeline performed well in identifying recent interpersonal disputes, problems with intimate partners, acute/chronic pain, and intimate partners and immediate family at the scene. For example, the Support Vector Machine model had a mean of 98.1% specificity and 90.5% positive predictive value in classifying a recent interpersonal dispute before suicide. The Gradient Boosting model had a mean of 98.7% specificity and 93.2% positive predictive value in classifying a recent interpersonal dispute before suicide.

CONCLUSIONS

This study developed a natural language processing pipeline to classify 5 female firearm suicide antecedents using narrative reports from the National Violent Death Reporting System, which may improve the examination of these circumstances. Practitioners and researchers should weigh the efficiency of natural language processing pipeline development against conventional text mining and manual review.

The benefits of making peace with pain: chronic pain acceptance moderates the indirect effect of perceived burdensomeness between pain severity and suicidal cognitions

OBJECTIVE

The purpose of this study was (1) to examine the degree to which perceived burdensomeness mediates the relationship between pain severity and suicidal cognitions and (2) to determine whether this mediated relationship was moderated by pain acceptance. We predicted that high levels of pain acceptance would buffer relationships on both paths of the indirect effect.

METHODS

Two-hundred seven patients with chronic pain completed an anonymous self-report battery of measures, including the Chronic Pain Acceptance Questionnaire, the Interpersonal Needs Questionnaire, the Suicidal Cognitions Scale, and the pain severity subscale of the West Haven-Yale Multidimensional Pain Inventory. Conditional process models were examined with Mplus.

RESULTS

Chronic pain acceptance significantly moderated both paths of the mediation model. Results from the conditional indirect effect model indicated that the indirect effect was significant for those with low (b = 2.50, P = .004) and medium (b = 0.99, P = .01) but not high (b = 0.08, P = .68) levels of pain acceptance and became progressively stronger as pain acceptance scores decreased. The nonlinear indirect effect became nonsignificant at acceptance scores 0.38 standard deviation above the mean-a clinically attainable treatment target.

CONCLUSIONS

Higher acceptance mitigated the relationship between pain severity and perceived burdensomeness and the relationship between perceived burdensomeness and suicidal cognitions in this clinical sample of patients experiencing chronic pain. Findings indicate that any improvement in pain acceptance can be beneficial, and they provide clinicians with a clinical cut-point that might indicate lower vs higher suicide risk.

Simulation Models for Suicide Prevention: A Survey of the State-of-the-Art

Suicide is a leading cause of death and a global public health problem, representing more than one in every 100 deaths in 2019. Modeling and Simulation (M&S) is widely used to address public health problems, and numerous simulation models have investigated the complex, dependent, and dynamic risk factors contributing to suicide. However, no review has been dedicated to these models, which prevents modelers from effectively learning from each other and raises the risk of redundant efforts. To guide the development of future models, in this paper we perform the first scoping review of simulation models for suicide prevention. Examining ten articles, we focus on three practical questions. First, which interventions are supported by previous models? We found that four groups of models collectively support 53 interventions. We examined these interventions through the lens of global recommendations for suicide prevention, highlighting future areas for model development. Second, what are the obstacles preventing model application? We noted the absence of cost effectiveness in all models reviewed, meaning that certain simulated interventions may be infeasible. Moreover, we found that most models do not account for different effects of suicide prevention interventions across demographic groups. Third, how much confidence can we place in the models? We evaluated models according to four best practices for simulation, leading to nuanced findings that, despite their current limitations, the current simulation models are powerful tools for understanding the complexity of suicide and evaluating suicide prevention interventions.

Surveillance for Violent Deaths - National Violent Death Reporting System, 48 States, the District of Columbia, and Puerto Rico, 2020

Problem/Condition

In 2020, approximately 71,000 persons died of violence-related injuries in the United States. This report summarizes data from CDC's National Violent Death Reporting System (NVDRS) on violent deaths that occurred in 48 states, the District of Columbia, and Puerto Rico in 2020. Results are reported by sex, age group, race and ethnicity, method of injury, type of location where the injury occurred, circumstances of injury, and other selected characteristics.

Period Covered

2020.

Description of System

NVDRS collects data regarding violent deaths obtained from death certificates, coroner and medical examiner records, and law enforcement reports. This report includes data collected for violent deaths that occurred in 2020. Data were collected from 48 states (all states with exception of Florida and Hawaii), the District of Columbia, and Puerto Rico. Forty-six states had statewide data, two additional states had data from counties representing a subset of their population (35 California counties, representing 71% of its population, and four Texas counties, representing 39% of its population), and the District of Columbia and Puerto Rico had jurisdiction-wide data. NVDRS collates information for each violent death and links deaths that are related (e.g., multiple homicides, homicide followed by suicide, or multiple suicides) into a single incident.

Results

For 2020, NVDRS collected information on 64,388 fatal incidents involving 66,017 deaths that occurred in 48 states (46 states collecting statewide data, 35 California counties, and four Texas counties), and the District of Columbia. In addition, information was collected for 729 fatal incidents involving 790 deaths in Puerto Rico. Data for Puerto Rico were analyzed separately. Of the 66,017 deaths, the majority (58.4%) were suicides, followed by homicides (31.3%), deaths of undetermined intent (8.2%), legal intervention deaths (1.3%) (i.e., deaths caused by law enforcement and other persons with legal authority to use deadly force acting in the line of duty, excluding legal executions), and unintentional firearm deaths (<1.0%). The term "legal intervention" is a classification incorporated into the International Classification of Diseases, Tenth Revision, and does not denote the lawfulness or legality of the circumstances surrounding a death caused by law enforcement.Demographic patterns and circumstances varied by manner of death. The suicide rate was higher for males than for females. Across all age groups, the suicide rate was highest among adults aged ≥85 years. In addition, non-Hispanic American Indian or Alaska Native (AI/AN) persons had the highest suicide rates among all racial and ethnic groups. Among both males and females, the most common method of injury for suicide was a firearm. Among all suicide victims, when circumstances were known, suicide was most often preceded by a mental health, intimate partner, or physical health problem or by a recent or impending crisis during the previous or upcoming 2 weeks. The homicide rate was higher for males than for females. Among all homicide victims, the homicide rate was highest among persons aged 20-24 years compared with other age groups. Non-Hispanic Black (Black) males experienced the highest homicide rate of any racial or ethnic group. Among all homicide victims, the most common method of injury was a firearm. When the relationship between a homicide victim and a suspect was known, the suspect was most frequently an acquaintance or friend for male victims and a current or former intimate partner for female victims. Homicide most often was precipitated by an argument or conflict, occurred in conjunction with another crime, or, for female victims, was related to intimate partner violence. Nearly all victims of legal intervention deaths were male, and the legal intervention death rate was highest among men aged 35-44 years. The legal intervention death rate was highest among AI/AN males, followed by Black males. A firearm was used in the majority of legal intervention deaths. When a specific type of crime was known to have precipitated a legal intervention death, the type of crime was most frequently assault or homicide. When circumstances were known, the three most frequent circumstances reported for legal intervention deaths were as follows: the victim's death was precipitated by another crime, the victim used a weapon in the incident, and the victim had a substance use problem (other than alcohol use).Other causes of death included unintentional firearm deaths and deaths of undetermined intent. Unintentional firearm deaths were most frequently experienced by males, non-Hispanic White (White) persons, and persons aged 15-24 years. These deaths most frequently occurred while the shooter was playing with a firearm and were precipitated by a person unintentionally pulling the trigger. The rate of deaths of undetermined intent was highest among males, particularly among AI/AN and Black males, and among adults aged 30-54 years. Poisoning was the most common method of injury in deaths of undetermined intent, and opioids were detected in nearly 80% of decedents tested for those substances.

Interpretation

This report provides a detailed summary of data from NVDRS on violent deaths that occurred in 2020. The suicide rate was highest among AI/AN and White males, whereas the homicide rate was highest among Black male victims. Intimate partner violence precipitated a large proportion of homicides for females. Mental health problems, intimate partner problems, interpersonal conflicts, and acute life stressors were primary circumstances for multiple types of violent death.

Public Health Action

Violence is preventable, and states and communities can use data to guide public health action. NVDRS data are used to monitor the occurrence of violence-related fatal injuries and assist public health authorities in developing, implementing, and evaluating programs, policies, and practices to reduce and prevent violent deaths. For example, the Colorado Violent Death Reporting System (VDRS), Kentucky VDRS, and Oregon VDRS have used their VDRS data to guide suicide prevention efforts and generate reports highlighting where additional focus is needed. In Colorado, VDRS data were used to examine the increased risk for suicide among first and last responders in the state. Kentucky VDRS used local data to highlight how psychological and social effects of the COVID-19 pandemic might increase risk for suicide, particularly among vulnerable populations. Oregon VDRS used their data to develop a publicly available data dashboard displaying firearm mortality trends and rates in support of the state's firearm safety campaign. Similarly, states participating in NVDRS have used their VDRS data to examine homicide in their state. Illinois VDRS, for example, found that state budget cuts were associated with notable increases in homicides among youths in Chicago. With an increase of participating states and jurisdictions, this report marks progress toward providing nationally representative data.

Research utility and limitations of textual data in the National Violent Death Reporting System: a scoping review and recommendations

BACKGROUND

Many studies of injury deaths rely on mortality data that contain limited contextual information about decedents. The National Violent Death Reporting System (NVDRS) is unique among such data systems in that each observation includes both quantitative variables and qualitative texts (called "narratives") abstracted from original source documents. These narratives provide rich data regarding salient circumstances that can be used to inform prevention efforts. This review provides a comprehensive summary of peer-reviewed research using NVDRS narratives over the past 20 years, including the limitations of these texts and provides recommendations on utilizing and improving narrative quality for researchers and practitioners.

MAIN BODY

Studies that used narratives to examine deaths related to suicide, homicide, undetermined intent, accidental firearm, or legal intervention were identified by a title/abstract screening, followed by a full-text review. The search was conducted on English-language, peer-reviewed literature and government reports published from 2002 to 2022 in PubMed, PsycInfo, Scopus, and Google Scholar. Abstracted elements focused on the methodologies used to analyze the narratives, including approaches to explore potential biases in these texts. Articles were abstracted independently by two reviewers, with disagreements resolved through consensus discussion. During the 20-year period, 111 articles used narratives. Two-thirds studied suicide (n = 48, 43%) and homicides (n = 25, 23%). Most studies analyzed the narratives using manual review (n = 81, 73%) and keyword searches (n = 9, 8%), with only 6 (5%) using machine learning tools. Narratives were mainly used for case finding (n = 49, 44%) and characterization of circumstances around deaths (n = 38, 34%). Common challenges included variability in the narratives and lack of relevant circumstantial details for case characterization.

CONCLUSION

Although the use of narratives has increased over time, these efforts would be enhanced by detailed abstraction of circumstances with greater salience to injury research and prevention. Moreover, researchers and practitioners would benefit from guidance on integrating narratives with quantitative variables and standardized approaches to address variability in the completeness and length of narratives. Such efforts will increase the reliability of findings and set the stage for more widespread applications of data science methods to these texts.

Association of Frailty With Risk of Suicide Attempt in a National Cohort of US Veterans Aged 65 Years or Older

Importance

Frailty is associated with reduced physiological reserve, lack of independence, and depression and may be salient for identifying older adults at increased risk of suicide attempt.

Objectives

To examine the association between frailty and risk of suicide attempt and how risk differs based on components of frailty.

Design, Setting, and Participants

This nationwide cohort study integrated databases from the US Department of Veterans Affairs (VA) inpatient and outpatient health care services, Centers for Medicare & Medicaid Services data, and national suicide data. Participants included all US veterans aged 65 years or older who received care at VA medical centers from October 1, 2011, to September 30, 2013. Data were analyzed from April 20, 2021, to May 31, 2022.

Exposures

Frailty, defined based on a validated cumulative-deficit frailty index measured using electronic health data and categorized into 5 levels: nonfrailty, prefrailty, mild frailty, moderate frailty, and severe frailty.

Main Outcomes and Measures

The main outcome was suicide attempts through December 31, 2017, provided by the national Suicide Prevention Applications Network (nonfatal attempts) and Mortality Data Repository (fatal attempts). Frailty level and components of the frailty index (morbidity, function, sensory loss, cognition and mood, and other) were assessed as potential factors associated with suicide attempt.

Results

The study population of 2 858 876 participants included 8955 (0.3%) who attempted suicide over 6 years. Among all participants, the mean (SD) age was 75.4 (8.1) years; 97.7% were men, 2.3% were women, 0.6% were Hispanic, 9.0% were non-Hispanic Black, 87.8% were non-Hispanic White, and 2.6% had other or unknown race and ethnicity. Compared with patients without frailty, risk of suicide attempt was uniformly higher among patients with prefrailty to severe frailty, with adjusted hazard ratios (aHRs) of 1.34 (95% CI, 1.27-1.42; P < .001) for prefrailty, 1.44 (95% CI, 1.35-1.54; P < .001) for mild frailty, 1.48 (95% CI, 1.36-1.60; P < .001) for moderate frailty, and 1.42 (95% CI, 1.29-1.56; P < .001) for severe frailty. Lower levels of frailty were associated with greater risk of lethal suicide attempt (aHR, 1.20 [95% CI, 1.12-1.28] for prefrail veterans). Bipolar disorder (aHR, 2.69; 95% CI, 2.54-2.86), depression (aHR, 1.78; 95% CI, 1.67-1.87), anxiety (aHR, 1.36; 95% CI, 1.28-1.45), chronic pain (aHR, 1.22; 95% CI, 1.15-1.29), use of durable medical equipment (aHR, 1.14; 95% CI, 1.03-1.25), and lung disease (aHR, 1.11; 95% CI, 1.06-1.17) were independently associated with increased risk of suicide attempt.

Conclusions and Relevance

This cohort study found that among US veterans aged 65 years or older, frailty was associated with increased risk of suicide attempts and lower levels of frailty were associated with greater risk of suicide death. Screening and involvement of supportive services across the spectrum of frailty appear to be needed to help reduce risk of suicide attempts.

Piloting Smart Home Sensors to Detect Overnight Respiratory and Withdrawal Symptoms in Adults Prescribed Opioids

BACKGROUND

Novel strategies are needed to curb the opioid overdose epidemic. Smart home sensors have been successfully deployed as digital biomarkers to monitor health conditions, yet they have not been used to assess symptoms important to opioid use and overdose risks.

AIM

This study piloted smart home sensors and investigated their ability to accurately detect clinically pertinent symptoms indicative of opioid withdrawal or respiratory depression in adults prescribed methadone.

METHODS

Participants (n = 4; 3 completed) were adults with opioid use disorder exhibiting moderate levels of pain intensity, withdrawal symptoms, and sleep disturbance. Participants were invited to two 8-hour nighttime sleep opportunities to be recorded in a sleep research laboratory, using observed polysomnography and ambient smart home sensors attached to lab bedroom walls. Measures of feasibility included completeness of data captured. Accuracy was determined by comparing polysomnographic data of sleep/wake and respiratory status assessments with time and event sensor data.

RESULTS

Smart home sensors captured overnight data on 48 out of 64 hours (75% completeness). Sensors detected sleep/wake patterns in alignment with observed sleep episodes captured by polysomnography 89.4% of the time. Apnea events (n = 118) were only detected with smart home sensors in two episodes where oxygen desaturations were less severe (>80%).

CONCLUSIONS

Smart home technology could serve as a less invasive substitute for biologic monitoring for adults with pain, sleep disturbances, and opioid withdrawal symptoms. Supplemental sensors should be added to detect apnea events. Such innovations could provide a step forward in assessing overnight symptoms important to populations taking opioids.

Suicide: An Overview for Clinicians

Most suicides have a diagnosable psychiatric disorder, most frequently, a mood disorder. Psychosocial issues and neurobiological abnormalities such as dysregulation in stress response systems contribute to suicidal behavior. All psychiatric patients need to be screened for the presence of suicidal ideation. Clinicians are expected to gather information about patient's clinical features and to formulate decisions about patient's dangerousness to self and the treatment plan. As psychiatric disorders are a major risk factor for suicide their pharmacologic and psychological treatment is of utmost importance to prevent suicide. Restriction of access to lethal means is important for suicide prevention.

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.

Remotely Delivered Psychologically Informed Mindful Movement Physical Therapy for Pain Care: A Framework for Operationalization

Background

While there is recognition by the greater medical community and physical therapists to address the biopsychosocial needs of people with chronic, persistent pain, there are challenges in implementation and delivery including wide variability in interventions, lack of clear rationale, and absence of clinical models that are feasible and acceptable on a large scale. Important components for psychologically informed physical therapy (PiPT) for pain care include behavioral approaches (e.g., Acceptance and Commitment Therapy), mindfulness, pain neuroscience education, motivational interviewing (MI), and interoceptive skills-building. The Empower Veterans Program (EVP) Mindful Movement framework blends these components and emphasizes a mindfulness and self-compassion approach with MI and body-based experiential learning. This program was offered in-person at the Atlanta and Maryland VA Health Care Centers with published positive Patient Reported Outcomes (PRO) pre-COVID 19 crisis and shifted to entirely remote delivery in March 2020.

Objective

This paper offers an evidence-based and theory driven framework to operationalize a remotely delivered group-based psychologically informed mindful movement physical therapy intervention as part of an interdisciplinary pain care program.

Methods

Since 2021 PRO and demographics are collected using a survey administered through Qualtrics over a 12-month period at baseline, immediately post TelePain EVP, at 6 months, and at 12 months, with findings forthcoming.

Discussion/Results

Tele-pain EVP offers 6-9 groups a week with 7-9 veterans from Atlanta based team and 3-4 groups a week with 5-9 veterans from Maryland based team. Adaptations for remote delivery optimized mindfulness and active learning strategies including interoceptive skills-building and use of MI to support self-efficacy to trust, restore a sense of safety in the body, and explore adaptations for safe movement.

Conclusion

TelePain-EVP Mindful Movement provides a framework for other programs to translate for their populations and systems to further develop best practices in PiPT for pain care and integration into interdisciplinary care.

Suicidal intent disclosure among adult suicide decedents: Four age group comparisons

Research on who does/does not disclose suicidal intent (SI) and related factors has important implications for suicide risk management. In this paper based on the 2017-2019 National Violent Death Reporting System, we compared four age groups (18-24, 25-44, 45-64, and 65+ years) of suicide decedents with respect to associations between SI disclosure and (1) suicide contributing/precipitating factors, and (2) suicide means. The results shows that those age 18-44 were more likely to disclose SI than those age> =45, especially among those with relationship problems. Physical health problems and death/suicide of family/friend increased the likelihood of SI disclosure in the 65+ age group.

Tuina for peripherally-induced neuropathic pain: A review of analgesic mechanism

Peripherally-induced neuropathic pain (pNP) is a kind of NP that is common, frequent, and difficult to treat. Tuina, also known as massage and manual therapy, has been used to treat pain in China for thousands of years. It has been clinically proven to be effective in the treatment of pNP caused by cervical spondylosis, lumbar disc herniation, etc. However, its analgesic mechanism is still not clear and has been the focus of research. In this review, we summarize the existing research progress, so as to provide guidance for clinical and basic studies. The analgesic mechanism of tuina is mainly manifested in suppressing peripheral inflammation by regulating the TLR4 pathway and miRNA, modulating ion channels (such as P2X3 and piezo), inhibiting the activation of glial cells, and adjusting the brain functional alterations. Overall, tuina has an analgesic effect by acting on different levels of targets, and it is an effective therapy for the treatment of pNP. It is necessary to continue to study the mechanism of tuina analgesia.

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.

CDC Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022

This guideline provides recommendations for clinicians providing pain care, including those prescribing opioids, for outpatients aged ≥18 years. It updates the CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016 (MMWR Recomm Rep 2016;65[No. RR-1]:1-49) and includes recommendations for managing acute (duration of <1 month), subacute (duration of 1-3 months), and chronic (duration of >3 months) pain. The recommendations do not apply to pain related to sickle cell disease or cancer or to patients receiving palliative or end-of-life care. The guideline addresses the following four areas: 1) determining whether or not to initiate opioids for pain, 2) selecting opioids and determining opioid dosages, 3) deciding duration of initial opioid prescription and conducting follow-up, and 4) assessing risk and addressing potential harms of opioid use. CDC developed the guideline using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Recommendations are based on systematic reviews of the scientific evidence and reflect considerations of benefits and harms, patient and clinician values and preferences, and resource allocation. CDC obtained input from the Board of Scientific Counselors of the National Center for Injury Prevention and Control (a federally chartered advisory committee), the public, and peer reviewers. CDC recommends that persons with pain receive appropriate pain treatment, with careful consideration of the benefits and risks of all treatment options in the context of the patient's circumstances. Recommendations should not be applied as inflexible standards of care across patient populations. This clinical practice guideline is intended to improve communication between clinicians and patients about the benefits and risks of pain treatments, including opioid therapy; improve the effectiveness and safety of pain treatment; mitigate pain; improve function and quality of life for patients with pain; and reduce risks associated with opioid pain therapy, including opioid use disorder, overdose, and death.

High-frequency electrical stimulation attenuates neuronal release of inflammatory mediators and ameliorates neuropathic pain

BACKGROUND

Neuroinflammation is an important driver of acute and chronic pain states. Therefore, targeting molecular mediators of neuroinflammation may present an opportunity for developing novel pain therapies. In preclinical models of neuroinflammatory pain, calcitonin gene-related peptide (CGRP), substance P and high mobility group box 1 protein (HMGB1) are molecules synthesized and released by sensory neurons which activate inflammation and pain. High-frequency electrical nerve stimulation (HFES) has achieved clinical success as an analgesic modality, but the underlying mechanism is unknown. Here, we reasoned that HFES inhibits neuroinflammatory mediator release by sensory neurons to reduce pain.

METHODS

Utilizing in vitro and in vivo assays, we assessed the modulating effects of HFES on neuroinflammatory mediator release by activated sensory neurons. Dorsal root ganglia (DRG) neurons harvested from wildtype or transgenic mice expressing channelrhodopsin-2 (ChR2) were cultured on micro-electrode arrays, and effect of HFES on optogenetic- or capsaicin-induced neuroinflammatory mediator release was determined. Additionally, the effects of HFES on local neuroinflammatory mediator release and hyperalgesia was assessed in vivo using optogenetic paw stimulation and the neuropathic pain model of chronic constriction injury (CCI) of the sciatic nerve.

RESULTS

Light- or capsaicin-evoked neuroinflammatory mediator release from cultured transgenic DRG sensory neurons was significantly reduced by concurrent HFES (10 kHz). In agreement with these findings, elevated levels of neuroinflammatory mediators were detected in the affected paw following optogenetic stimulation or CCI and were significantly attenuated using HFES (20.6 kHz for 10 min) delivered once daily for 3 days.

CONCLUSION

These studies reveal a previously unidentified mechanism for the pain-modulating effect of HFES in the setting of acute and chronic nerve injury. The results support the mechanistic insight that HFES may reset sensory neurons into a less pro-inflammatory state via inhibiting the release of neuroinflammatory mediators resulting in reduced inflammation and pain.

Midlife suicide: A systematic review and meta-analysis of socioeconomic, psychiatric and physical health risk factors

Suicide is an increasing contributing cause of mortality in middle-aged adults; however, knowledge to guide prevention is limited. This first systematic review and meta-analysis of studies on midlife suicide has provided an overview of published research on this issue and synthesized the evidence on socioeconomic and physical and mental health factors associated with this mortality. Using PRISMA guidelines MEDLINE, Embase, PsycINFO, Scopus and Web of Science were searched for English-language publications that involved persons aged 35 to 65, used individual-level data, and reported prevalence of exposure(s) or relative risks. The search identified 62 studies on midlife suicides and associated factors (28 for SES, 22 for psychiatric disorder and 23 for physical illness). All studies were from high income countries, and most (80.6%) used data from population registries. Meta-analyses showed that the pooled prevalence of exposure in suicide decedents was 57.8% for psychiatric disorder, 56.3% for low income, 43.2% for unemployment, and 27.3% for physical illness. The associated pooled risk ratio was 11.68 (95% confidence intervals: 5.82-23.47) for psychiatric illness of any type, 12.59 (8.29-19.12) for mood disorders, 3.91 (2.72-5.59) for unemployment, 3.18 (2.72-3.72) for being separated or divorced, 2.64 (2.26-3.10) for cancer, 2.50 (0.96-6.38) for central nervous system illness, and 2.26 (1.16-4.41) for low income. In conclusion, midlife suicide is strongly associated with socioeconomic difficulties and physical and psychiatric illnesses that are common in this age population. Future investigations should consider the interactions between risk factors, the intersectionality of sex and ethnicity, and include data from low- and middle-income countries.

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.

Health care Professionals' Attitudes Toward Patients with Chronic Pain: Scale Development Study

BACKGROUND

One of the obstacles in chronic pain management is the attitude of healthcare professionals. Although literature reports that the negative attitudes of healthcare professionals such as stigmatizing their patients with chronic pain and applying inadequate treatment cause failure in chronic pain management, there is no scale to measure the attitudes of healthcare professionals towards patients with chronic pain.

PURPOSE

This study aimed to develop a scale for identifying healthcare professionals' attitudes towards patients with chronic pain.

METHOD

We prepared a draft scale in the form of five-point Likert. We applied the draft scale to 379 voluntary healthcare professionals working in two hospitals in 2019. Internal consistency and testretest methods were employed to determine the reliability of the scale. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were used for construct validity.

FINDINGS

According to the EFA, the scale had two factors explaining 45.68 of the total variant. We labelled the first factor "sensitivity orientation" and the second factor was labelled "misconception orientation". Cronbach Alpha coefficients were 0.88 and 0.75 for the first and second factors respectively. Test-retest method reliability was r = 0.83 in the first factor and r = 0.75 in the second factor. The CFA showed that they were within the limits of acceptable fit values.

CONCLUSIONS

Our study found that the scale for healthcare professionals' attitudes towards patients with chronic pain is a valid and reliable tool.

Design, synthesis, and biological evaluation of low-toxic lappaconitine derivatives as potential analgesics

The C₁₈-diterpenoid alkaloid lappaconitine (LA) is a non-addictive analgesic used in China. The toxicity (LD₅₀ = 11.7 mg/kg) limits its application. Two series of LA derivatives, including amides and sulfonamides (1-93), were designed and synthesized by modification on their C4 acetamidobenzoate side chains in this work. In vivo analgesic activity and toxicity of all derivatives were evaluated, and the structure-activity relationship was summarized. Six lead compounds (35, 36, 39, 49, 70, and 89) exhibited approximate analgesic activity to LA but with significantly reduced toxicity. The therapeutic index of these compounds is 14-30 times that of LA. In vivo metabolism study of the lead compounds 39, 49, 70, and 89 were conducted by UPLC-MS^E, indicating the reason for the low toxicity of the potential derivatives might be they are difficult to metabolize to toxic metabolite N-deacetyllappaconitine compared to LA. The effects of lead compounds on sodium channels and hERG channels were also studied by ion channel reader (ICR) which further revealed their analgesic and toxicity-attenuating mechanisms. Sodium channel assay revealed that the analgesic mechanism of these lead compounds was inhibiting the Na_v 1.7 channels. Taken together, compound 39 was provided as a new analgesic lead compound with significantly low toxicity and comparable activity to LA.

Long term evaluation of a multidisciplinary trigeminal neuralgia service

BACKGROUND

Trigeminal neuralgia is an episodic severe neuralgic pain and can be managed both medically and surgically. If possible, this should be directed by a Multidisciplinary Team (MDT) of specialised surgeons, physicians, dentists, psychologists and specialist nurses with access to all treatment modalities, which enables patients to make an informed decision about their future management.

OBJECTIVE

The aim of this study was to review the outcomes of patients managed by an MDT clinic, in a single institute over an eleven-year period.

METHODS

A prospective database was used to identify patients with trigeminal neuralgia or its variants who had attended a joint MDT clinic. The electronic notes were examined for demographics, onset and duration of trigeminal neuralgia, medications history, pain scores and details of surgical procedures if any by two independent assessors.

RESULTS

Three hundred thirty-four patients attended the MDT between 2008-2019. Forty-nine of them had surgery before being referred to the service and were included but analysed as a subgroup. Of the remaining patients, 54% opted to have surgery following the MDT either immediately or at a later date. At the last reported visit 55% of patients who opted to have surgery were pain free and off medications, compared to 15.5% of medically managed patients. Surgical complications were mostly attributable to numbness and in the majority of cases this was temporary. All patients who were not pain free, had complications after surgery or opted to remain on medical therapy were followed up in a facial pain clinic which has access to pain physicians, clinical nurse specialists and a tailored pain management program. Regular patient related outcome measures are collected to evaluate outcomes.

CONCLUSION

An MDT clinic offers an opportunity for shared decision making with patients deciding on their personal care pathway which is valued by patients. Not all patients opt for surgery, and some continue to attend a multidisciplinary follow up program. Providing a full range of services including psychological support, improves outcomes.

Substance use related violent deaths among racial/ethnic groups in the United States

While prior research highlights the overlap of substance use and violent death, few examine this overlap among different racial/ethnic groups or how patterns change over time. This study examines how substance use related deaths differ by racial/ethnic groups in the United States. We use data from the National Violent Death Reporting System (NVDRS), which includes violent deaths from 43 states in the U.S., collected for the decade between 2009 and 2019 (N = 226,459). Fixed-effects multivariate models examined whether race/ethnicity was associated with substance use-related death over time, controlling for additional demographic and clinical factors. Results showed a significantly larger rate of increase over time for African American and Hispanic (any race) persons compared to White non-Hispanic persons for most types of substance use-related deaths. While current rates of substance use may show little variability between African American, Hispanic, and White non-Hispanic individuals, this research suggests that the consequences for substance use, including death, may be disproportional.

Pain and suicide: what should we tell our trainees?

Chronic pain is a debilitating medical condition affecting a significant percentage of the population worldwide. Considerable evidence suggests that pain is an independent risk factor for suicide and inadequately managing pain has been identified as a risk for suicidal behaviour. Additionally, medications used to treat pain may also contribute to suicidal behaviour. Extensive research on pain highlights deficiencies in the clinical management on pain with more gaps in care when patients have pain in combination with mental illness and suicidal behaviour. Providing trainees additional knowledge and equipping them with relevant tools to screen and manage chronic pain efficiently is a potential strategy to mitigate suicide risk. Also, trainees need to be educated on how to screen for suicidality in individuals with pain and apply suicide prevention interventions. This paper will emphasise the necessity to improve education about pain, its close relationship with suicide and effective suicide screening as well as management strategies for medical providers. With additional research, it is the hope that novel treatment modalities will be developed to treat pain to improve the quality of life of individuals suffering from this condition and to decrease suicide risk in this patient population.

Intimate partner violence victimization and perpetration as precursors to suicide

It remains unclear how often and under what circumstances intimate partner violence (IPV) precedes suicide. Available research on IPV and suicide focuses largely on homicide-suicide, which is a rare event (<2% of suicides). We focus instead on single suicides (i.e., suicides unconnected to other violent deaths), which are the most common type of fatal violence in the US.

Unfortunately, information about IPV circumstances is often unavailable for suicides. To address this gap, we sought to identify the proportion of single suicides that were preceded by IPV in North Carolina (NC), to describe the prevalence of IPV victimization and perpetration as precursors to suicide, and to explore how IPV-related suicides differ from other suicides. We used data from the NC Violent Death Reporting System (2010–2017, n = 9682 single suicides) and hand-reviewed textual data for a subset of cases (n = 2440) to document IPV circumstances.

We had robust inter-rater reliability (Kappa: 0.73) and identified n = 439 IPV-related suicides. Most were males who had perpetrated nonfatal IPV (n = 319, 72.7%) prior to dying by suicide. Our findings suggest that IPV was a precursor for at least 4.5% of single suicides.

Next, we conducted logistic regression analyses by sex comparing IPV-related suicides to other suicides. For both men and women, IPV was more common when the person who died by suicide had recently disclosed suicidal intent, was younger, used a firearm, and was involved with the criminal legal system, even after controlling for covariates. We also found sex-specific correlates for IPV circumstances in suicide.

Combined with homicide-suicide data (reported elsewhere), IPV is likely associated with 6.1% or more of suicides overall. Results suggest clear missed opportunities to intervene for this unique subpopulation, such as suicide screening and referral in IPV settings (e.g., batterer intervention programs, Family Justice Centers) that is tailored by sex.

•

Intimate partner violence is a precipitating factor for 4.5% of single suicides.

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Most IPV-related single suicides were of men who perpetrated nonfatal IPV.

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Decedents in IPV-related suicides often used a firearm and disclosed intent.

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Integrated prevention strategies to target both IPV and suicide may be appropriate.

•

When combined with homicide-suicide data, IPV influences 6.1% of suicides overall.

Surveillance for Violent Deaths - National Violent Death Reporting System, 42 States, the District of Columbia, and Puerto Rico, 2019

PROBLEM/CONDITION

In 2019, approximately 67,000 persons died of violence-related injuries in the United States. This report summarizes data from CDC's National Violent Death Reporting System (NVDRS) on violent deaths that occurred in 42 states, the District of Columbia, and Puerto Rico in 2019. Results are reported by sex, age group, race and ethnicity, method of injury, type of location where the injury occurred, circumstances of injury, and other selected characteristics.

PERIOD COVERED

2019.

DESCRIPTION OF SYSTEM

NVDRS collects data regarding violent deaths obtained from death certificates, coroner and medical examiner records, and law enforcement reports. This report includes data collected for violent deaths that occurred in 2019. Data were collected from 39 states with statewide data (Alabama, Alaska, Arizona, Colorado, Connecticut, Delaware, Georgia, Hawaii, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Rhode Island, South Carolina, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin, and Wyoming), three states with data from counties representing a subset of their population (30 California counties, representing 57% of its population, and 47 Illinois counties and 40 Pennsylvania counties, representing at least 80% of their populations), the District of Columbia, and Puerto Rico. NVDRS collates information for each violent death and links deaths that are related (e.g., multiple homicides, homicide followed by suicide, or multiple suicides) into a single incident.

RESULTS

For 2019, NVDRS collected information on 50,374 fatal incidents involving 51,627 deaths that occurred in 42 states (39 states collecting statewide data, 30 California counties, 47 Illinois counties, and 40 Pennsylvania counties), and the District of Columbia. In addition, information was collected for 831 fatal incidents involving 897 deaths in Puerto Rico. Data for Puerto Rico were analyzed separately. Of the 51,627 deaths, the majority (64.1%) were suicides, followed by homicides (25.1%), deaths of undetermined intent (8.7%), legal intervention deaths (1.4%) (i.e., deaths caused by law enforcement and other persons with legal authority to use deadly force acting in the line of duty, excluding legal executions), and unintentional firearm deaths (<1.0%). The term "legal intervention" is a classification incorporated into the International Classification of Diseases, Tenth Revision, and does not denote the lawfulness or legality of the circumstances surrounding a death caused by law enforcement. Demographic patterns and circumstances varied by manner of death. The suicide rate was higher for males than for females. Across all age groups, the suicide rate was highest among adults aged 45-54 years. In addition, non-Hispanic American Indian or Alaska Native (AI/AN) and non-Hispanic White (White) persons had the highest suicide rates among all racial and ethnic groups. Among males, the most common method of injury for suicide was a firearm, whereas poisoning was the most common method of injury among females. Among all suicide victims, suicide was most often preceded by a mental health, intimate partner, or physical health problem or by a recent or impending crisis during the previous or upcoming 2 weeks. The homicide rate was higher for males than for females. Among all homicide victims, the homicide rate was highest among persons aged 20-24 years compared with other age groups. Non-Hispanic Black (Black) males experienced the highest homicide rate of any racial or ethnic group. Among all homicide victims, the most common method of injury was a firearm. When the relationship between a homicide victim and a suspect was known, the suspect was most frequently an acquaintance or friend for male victims and a current or former intimate partner for female victims. Homicide most often was precipitated by an argument or conflict, occurred in conjunction with another crime, or, for female victims, was related to intimate partner violence. Nearly all victims of legal intervention deaths were male, and the legal intervention death rate was highest among men aged 25-29 years. The legal intervention death rate was highest among AI/AN males, followed by Black males. A firearm was used in the majority of legal intervention deaths. When a specific type of crime was known to have precipitated a legal intervention death, the type of crime was most frequently assault or homicide. The three most frequent circumstances reported for legal intervention deaths were as follows: the victim's death was precipitated by another crime, the victim used a weapon in the incident, and the victim had a mental health or substance use problem (other than alcohol use). Unintentional firearm deaths were most frequently experienced by males, White persons, and persons aged 15-24 years. These deaths most frequently occurred while the shooter was playing with a firearm and were precipitated by a person unintentionally pulling the trigger or mistakenly thinking the firearm was unloaded. The rate of deaths of undetermined intent was highest among males, particularly among Black and AI/AN males, and among adults aged 30-44 years. Poisoning was the most common method of injury in deaths of undetermined intent, and opioids were detected in nearly 80% of decedents tested for those substances.

INTERPRETATION

This report provides a detailed summary of data from NVDRS on violent deaths that occurred in 2019. The suicide rate was highest among AI/AN and White males, whereas the homicide rate was highest among Black males. Mental health problems, intimate partner problems, interpersonal conflicts, and acute life stressors were primary circumstances for multiple types of violent death.

PUBLIC HEALTH ACTION

Violence is preventable, and data can guide public health action. NVDRS data are used to monitor the occurrence of violence-related fatal injuries and assist public health authorities in developing, implementing, and evaluating programs, policies, and practices to reduce and prevent violent deaths. For example, the New Hampshire Violent Death Reporting System (VDRS), Indiana VDRS, and Colorado VDRS have used their VDRS data to guide suicide prevention efforts and generate reports highlighting where additional focus is needed. In New Hampshire, VDRS data have been used to monitor the increase in suicide rates during 2014-2018 and guide statewide collaborative prevention efforts. Indiana VDRS used local data to demonstrate differences in suicide and other related mental health problems among Black persons and highlight a need for improved suicide awareness and culturally competent mental health care. The Colorado VDRS conducted geospatial and demographic analysis, considering local VDRS data with existing suicide prevention efforts and resources, to identify regions with high suicide rates regions and populations at high risk for suicide. Similarly, states participating in NVDRS have used their VDRS data to examine related to homicide in their state. In North Carolina for example, where homicide rates among AI/AN and Black persons were approximately 2.5 times higher than the statewide homicide rate, the North Carolina VDRS program aims to partner with historically Black colleges and universities in the state to train researchers to use VDRS data to address health equity issues in and around their immediate community.

The role of context in shaping the relationship between physical health and suicide over the life course

U.S. suicide rates are at a thirty-year high while physical health, as measured by life expectancy and pain, has declined, particularly for those without a college degree. We investigate how these patterns may be related by exploring the role of physical health problems in suicide deaths using 2019 data from the National Violent Death Reporting System. We estimate multilevel logistic regression models to examine (1) how individual risk factors are associated with the likelihood of a physical health circumstance underlying a suicide over the life course and (2) how context – the socioeconomic, health and policy environment of the state in which a decedent resides – may play a role. Physical health circumstances were present in about 20% of all suicides and in over half of suicide deaths for the older population in 2019. A gender crossover effect exists, in which women are more likely to have a physical health problem contribute to a suicide prior to age 60, but men surpass women after age 60 in that probability. Net of individual characteristics, we find significant variation across states in the likelihood of physical health circumstances. For all age groups, physical health circumstances are more likely in states that are less densely populated with weaker gun control laws and higher suicide rates. Among decedents younger than 65, the likelihood is elevated in states with limited health care access. This study highlights the critical interaction between physical and mental well-being, the ways in which that interaction may be experienced differently by gender, and the important role of social safety nets in prevention.

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Poor physical health is an important risk factor for suicide.

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Overall, women and older suicide decedents are more likely to have a physical health circumstance.

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A gender crossover effect exists, with older men more likely to have a physical health circumstance.

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State health and policy environment affects the likelihood of a physical health circumstance.

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Improving physical health and social support is an avenue to suicide prevention.

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.

Surveillance for Violent Deaths - National Violent Death Reporting System, 39 States, the District of Columbia, and Puerto Rico, 2018

PROBLEM/CONDITION

In 2018, approximately 68,000 persons died of violence-related injuries in the United States. This report summarizes data from CDC's National Violent Death Reporting System (NVDRS) on violent deaths that occurred in 39 states the District of Columbia, and Puerto Rico in 2018. Results are reported by sex, age group, race and ethnicity, method of injury, type of location where the injury occurred, circumstances of injury, and other selected characteristics.

PERIOD COVERED

2018.

DESCRIPTION OF SYSTEM

NVDRS collects data regarding violent deaths obtained from death certificates, coroner and medical examiner reports, and law enforcement reports. This report includes data collected for violent deaths that occurred in 2018. Data were collected from 36 states with statewide data (Alabama, Alaska, Arizona, Colorado, Connecticut, Delaware, Georgia, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Rhode Island, South Carolina, Utah, Vermont, Virginia, Washington, West Virginia, and Wisconsin), three states with data from counties representing a subset of their population (21 California counties, 28 Illinois counties, and 39 Pennsylvania counties), the District of Columbia, and Puerto Rico. NVDRS collates information for each death and links deaths that are related (e.g., multiple homicides, homicide followed by suicide, or multiple suicides) into a single incident.

RESULTS

For 2018, NVDRS collected information on 52,773 fatal incidents involving 54,170 deaths that occurred in 39 states and the District of Columbia. In addition, information was collected on 880 fatal incidents involving 975 deaths in Puerto Rico. Data for Puerto Rico were analyzed separately. Of the 54,170 deaths, the majority (64.1%) were suicides, followed by homicides (24.8%), deaths of undetermined intent (9.0%), legal intervention deaths (1.4%) (i.e., deaths caused by law enforcement and other persons with legal authority to use deadly force acting in the line of duty, excluding legal executions), and unintentional firearm deaths (<1.0%). (The term "legal intervention" is a classification incorporated into the International Classification of Diseases, Tenth Revision, and does not denote the lawfulness or legality of the circumstances surrounding a death caused by law enforcement.) Demographic patterns and circumstances varied by manner of death. The suicide rate was higher among males than among females and was highest among adults aged 35-64 years and non-Hispanic American Indian or Alaska Native (AI/AN) and non-Hispanic White persons. The most common method of injury for suicide was a firearm among males and hanging, strangulation, or suffocation among females. Suicide was most often preceded by a mental health, intimate partner, or physical health problem, or a recent or impending crisis during the previous or upcoming 2 weeks. The homicide rate was highest among persons aged 20-24 years and was higher among males than females. Non-Hispanic Black males experienced the highest homicide rate of any racial or ethnic group. The most common method of injury for homicide was a firearm. When the relationship between a homicide victim and a suspect was known, the suspect was most frequently an acquaintance or friend for male victims and a current or former intimate partner for female victims. Homicides most often were precipitated by an argument or conflict, occurred in conjunction with another crime, or, for female victims, were related to intimate partner violence. Homicide suspects were primarily male and the highest proportion were aged 25-44 years. When race and ethnicity information was known, non-Hispanic Black persons comprised the largest group of suspects overall and among those aged ≤44 years, and non-Hispanic White persons comprised the largest group of suspects among those aged ≥45 years. Almost all legal intervention deaths were experienced by males, and the legal intervention death rate was highest among males aged 30-34 years. Non-Hispanic AI/AN males had the highest legal intervention death rate, followed by non-Hispanic Black males. A firearm was used in the majority of legal intervention deaths. When a specific type of crime was known to have precipitated a legal intervention death, the type of crime was most frequently assault or homicide. The most frequent circumstances reported for legal intervention deaths were use of a weapon by the victim in the incident and a mental health or perceived substance use problem (other than alcohol use). Law enforcement officers who inflicted fatal injuries in the context of legal intervention deaths were primarily males aged 25-44 years. Unintentional firearm deaths were most frequently experienced by males, non-Hispanic White persons, and persons aged 15-24 years. These deaths most often occurred while the shooter was playing with a firearm and most frequently were precipitated by a person unintentionally pulling the trigger or mistakenly thinking that the firearm was unloaded. The rate of deaths of undetermined intent was highest among males, particularly among non-Hispanic Black and non-Hispanic AI/AN males, and among persons aged 45-54 years. Poisoning was the most common method of injury in deaths of undetermined intent, and opioids were detected in approximately 80% of decedents tested for those substances.

INTERPRETATION

This report provides a detailed summary of data from NVDRS on violent deaths that occurred in 2018. The suicide rate was highest among non-Hispanic AI/AN and non-Hispanic White males, and the homicide rate was highest among non-Hispanic Black males. Mental health problems, intimate partner problems, interpersonal conflicts, and acute life stressors were primary circumstances for multiple types of violent death. Circumstances for suspects of homicide varied by age group and included having prior contact with law enforcement and involvement in incidents that were precipitated by another crime, intimate partner violence, and drug dealing or substance use.

PUBLIC HEALTH ACTION

NVDRS data are used to monitor the occurrence of violence-related fatal injuries and assist public health authorities in developing, implementing, and evaluating programs, policies, and practices to reduce and prevent violent deaths. For example, Arizona and Wisconsin used their state-level VDRS data to support suicide prevention efforts within their respective states. Wisconsin VDRS used multiple years of data (2013-2017) to identify important risk and protective factors and subsequently develop a comprehensive suicide prevention plan. Arizona VDRS partners with the Arizona Be Connected Initiative to provide customized community-level data on veteran suicide deaths in Arizona. Similarly, states participating in NVDRS have used their VDRS data to examine intimate partner violence-related deaths to support prevention efforts. For example, data from the South Carolina VDRS were used to examine intimate partner homicides that occurred in South Carolina during 2017. South Carolina VDRS found that 12% of all homicides that occurred in 2017 were intimate partner violence-related, with females accounting for 52% of intimate partner homicide-related victims. These data were shared with domestic violence prevention collaborators in South Carolina to bolster their efforts in reducing intimate partner violence-related deaths. In 2018, NVDRS data included four additional states compared with 2017, providing more comprehensive and actionable violent death information for public health efforts to reduce violent deaths.

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.

Pain-driven emergency department visits and food insecurity: a cross-sectional study linking Canadian survey and health administrative data

BACKGROUND

As the leading cause of emergency department visits in Canada, pain disproportionately affects socioeconomically disadvantaged populations. We examine the association between household food insecurity and individuals' pain-driven emergency department visits.

METHODS

We designed a cross-sectional study linking the Canadian Community Health Survey 2005-2017 to the National Ambulatory Care Reporting System 2003-2017. Food insecurity was measured using a validated questionnaire. We excluded individuals with missing food insecurity status, individuals younger than 12 years and jurisdiction-years with partial emergency department records. We assessed emergency department visits driven by pain at different sites (migraine, other headaches, chest-throat pain, abdomen-pelvis pain, dorsalgia, joint pain, limb pain, other pain) and their characteristics (frequency, cause, acuity and time of emergency department visit) in Ontario and Alberta. We adjusted for sociodemographic characteristics, lifestyle and prior non-pain-driven emergency department visits in the models.

RESULTS

The sample contained 212 300 individuals aged 12 years and older. Compared with food-secure individuals, marginally, moderately and severely food-insecure people had 1.42 (95% confidence interval [CI] 1.20-1.68), 1.64 (95% CI 1.37-1.96) and 1.99 (95% CI 1.61-2.46) times higher adjusted incidence rates of pain-driven emergency department visits, respectively. The association was similar across sexes and significant among adults but not adolescents. Food insecurity was further associated with site-specific pain, with severely food-insecure individuals having significantly higher pain incidence than food-secure individuals. Severe food insecurity predicted more frequent, multicause, high-acuity and after-hours emergency department visits.

INTERPRETATION

Household food insecurity status is significantly associated with pain-driven emergency department visits in the Canadian population. Policies targeting food insecurity may reduce pain and emergency department utilization.

Pentylenetetrazol-like stimulus is not produced following naloxone-precipitated mitragynine withdrawal in rats

RATIONALE

Kratom (Mitragyna speciosa Korth), a native medicinal plant of Southeast Asia, is proposed to exhibit potential therapeutic value as an opioid substitute. However, studies of its negative emotional states resulting from withdrawal particularly of its main psychoactive compound, mitragynine (MG), are limited.

OBJECTIVES

Using the pentylenetetrazol (PTZ) discrimination assay, this study aims to investigate the effects of MG in responding to the PTZ stimulus and to assess the generalisation effects of withdrawal from MG to the PTZ stimulus.

METHODS

Rats (n = 20) were trained on a tandem (FR-10, VI-15) schedule of food reinforcement to press one lever after administration of the anxiogenic compound PTZ (16 mg/kg, i.p.) and an alternate lever after vehicle. Following acute tests, training was suspended, and rats were chronically treated with MG or morphine at 8-h intervals for 9 days and withdrawal was precipitated on the tenth day using naloxone (1 mg/kg, i.p.). The rats were tested for generalisation to PTZ at 2, 8 and 24 h after the last dose of MG or morphine administration.

RESULTS

Unlike morphine that produced dose-related PTZ-like stimulus, MG at 3, 10, 30 and 45 mg/kg doses showed no substitution to the PTZ discriminative stimulus. In contrast to morphine which produced a time-dependent generalisation to the PTZ stimulus, naloxone did not precipitate withdrawal effects in MG-treated rats as they selected the vehicle lever at three withdrawal time points.

CONCLUSION

These results demonstrate that MG produces a very different response to morphine withdrawal that is not associated with anxiogenic-like subjective symptoms. These characteristics of MG may provide further support for use as a novel pharmacotherapeutic intervention for managing opioid use disorder.

Suicidal behaviour: emergency department attendance for suicidal recurrence and other psychiatric or medical reasons in the 6 months following the index episode

The prevention of a complex phenomenon, such as suicide, requires an interdisciplinary approach that provides a comprehensive response to the care needs of people with suicidal behavior (SB). The aim of this study is to investigate the clinical and healthcare features of people presenting thoughts and/or attempts of suicide to define risk factors for recurrence.

Suicide by Opioid: Exploring the Intentionality of the Act

Opioid toxicity can result in life-threatening respiratory depression. Opioid-overdose mortality in the United States is high and increasing, but it is difficult to determine what proportion of those deaths might actually be suicides. The exact number of Americans who died of an opioid overdose but whose deaths might be classified as suicide remains unknown. It is important to differentiate between those who take opioids with the deliberate and unequivocal objective of committing suicide, that is, those with active intent, from those with passive intent. The passive-intent group understands the risks of opioid consumption and takes dangerous amounts, but with a more ambiguous attitude toward suicide. Thus, among decedents of opioid overdose, a large population dies by accident, whereas a small population dies intending to commit suicide; but between them exists a sub-population with equivocal intentions, waxing and waning between their desire to live and the carelessness about death. There may be a passive as well as active intent to commit suicide, but less is known about the passive motivation. It is important for public health efforts aimed at reducing both suicides and opioid-use disorder to better understand the range of motivations behind opioid-related suicides and how to combat them.

Development and field testing of primary care screening tools for harms of long-term opioid therapy continuation and tapering to discontinuation: a study protocol

INTRODUCTION

Despite calls for screening tools to help providers monitor long-term opioid therapy (LTOT) harms, and identify patients likely to experience harms of discontinuation, such screening tools do not yet exist. Current assessment tools are infeasible to use routinely in primary care and focus mainly on behaviours suggestive of opioid use disorder to the exclusion of other potential harms. This paper describes a study protocol to develop two screening tools that comprise one integrated instrument, Screen to Evaluate and Treat (SET). SET1 will indicate if LTOT may be harmful to continue (yes or no), and SET2 will indicate if tapering to discontinue opioids may be harmful to initiate (yes or no). Patients receiving LTOT who screen positive on the SET tools should receive subsequent additional assessment. SET will give providers methods that are feasible to implement routinely to facilitate more intensive and comprehensive monitoring of patients on LTOT and decision-making about discontinuation.

METHODS AND ANALYSIS

We will develop the screening tools, SET1 and SET2, concurrently. Tool development will be done in stages: (1) comprehensive literature searches to yield an initial item pool for domains covered by each screening tool; (2) qualitative item analyses using interviews, expert review and cognitive interviewing, with subsequent item revision, to yield draft versions of each tool; and (3) field testing of the draft screening tools to assess internal consistency, test-retest reliability and convergent and discriminant validity.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Institutional Review Boards of Stanford University and the University of California, San Francisco for the VA Palo Alto Health Care System, and the VA San Francisco Healthcare System, respectively. Findings will be disseminated through peer-reviewed manuscripts and presentations at research conferences.