Elsevier

General Hospital Psychiatry

Volume 47, July 2017, Pages 29-35
General Hospital Psychiatry

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

https://doi.org/10.1016/j.genhosppsych.2017.04.011Get rights and content

Abstract

Objective

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

Method

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

Results

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

Conclusions

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

Introduction

Opioids are commonly prescribed to treat chronic pain [1], [2]. Estimates of the prevalence of receipt of prescription opioid therapy among U.S. patients with chronic pain are as high as 20% [3]. However, recent clinical guidelines, including the 2016 CDC guidelines for prescribing opioids for chronic pain [4], discourage use of opioids as a primary analgesic therapy. Guidelines further recommend that clinicians weigh the benefits and risks of opioid therapy for each patient and discontinue opioid therapy when risks outweigh benefits. In addition, recent data from the Veterans Health Administration (VHA) indicate that the overall rate of high-dose opioid prescribing is decreasing and that the rate of decrease may have accelerated with the implementation of national strategies designed to reduce risky opioid prescribing [5]. These trends suggest that a sizeable proportion of patients in the U.S. prescribed long-term opioid therapy may have their opioid doses lowered and, in some cases, discontinue opioid therapy in the coming years.

While some patients may discontinue opioid therapy of their own volition, data suggest that the majority of opioid discontinuations are initiated by opioid-prescribing clinicians, due to patient high-risk behaviors such as use of other illicit or prescribed controlled substances, opioid misuse, opioid diversion, poor-adherence to the treatment plan, or other patient safety concerns [6]. Despite the heightened risk these patients may face for opioid-related adverse events, some clinicians have expressed concerns about discontinuing opioid therapy for patients they deem to be unstable or who may possess fewer pain coping resources and pain self-management skills [7]. Of particular concern to clinicians is the possibility that discontinuing opioid therapy may cause or exacerbate suicidal ideation in some patients [8]. Concerns about suicide risk are warranted given that those with chronic pain are at elevated risk for suicide and this risk is even greater in those receiving higher opioid doses [9], [10]. However, the extent to which opioid discontinuation is associated with suicide risk has not been examined previously.

The primary objective of this study was to identify predictors of suicidal ideation (SI) and non-fatal suicidal self-directed violence (SSV) following clinician-initiated discontinuation of long-term opioid therapy. A secondary objective was to examine incidence and correlates of SI and SSV among patients who did not have SI or SSV prior to opioid discontinuation.

Section snippets

Methods

This study was approved by the U.S. Department of Veterans Affairs Portland Health Care System Institutional Review Board.

Results

This study sample comprised 509 patients prescribed long-term opioid therapy for chronic pain, predominantly musculoskeletal pain (85%), whose clinicians discontinued patients' prescriptions for opioid therapy. Similar to the population of veterans prescribed opioid therapy through VHA [12], [19], the study sample had a mean age of 55 years, was predominantly male (94%), non-Hispanic white (71%), and resided in urban locations (74%). Sixty-one percent of patients in this sample received a

Discussion

In this national sample of VHA patients with substance use disorder diagnoses and similar matched patients who were discontinued from long-term opioid therapy by their opioid-prescribing clinicians, nearly 12% had documentation in the medical record of SI/SSV in the year following discontinuation—9.2% with SI only and 2.4% with SSV. This is higher than the 12-month incidence of self-reported suicidal ideation (3.8%) and attempts (0.4%) found in a community sample of veterans in two U.S. states

Disclaimer

The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the U.S. Department of Veterans Affairs or U.S. Government.

Acknowledgments

This work was supported by Locally Initiated Project Award # QLP 59-048 (PI: Lovejoy) from the United States (U.S.) Department of Veterans Affairs Substance Use Disorder Quality Enhancement Research Initiative. Dr. Lovejoy received additional support from Career Development Award IK2HX001516 from the U.S. Department of Veterans Affairs Health Services Research and Development during preparation of this manuscript. We thank the VA Portland Health Care System and the U.S. Department of Veterans

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