Journal of General Internal Medicine

, Volume 30, Issue 7, pp 979–991 | Cite as

Association of Care Practices with Suicide Attempts in US Veterans Prescribed Opioid Medications for Chronic Pain Management

  • Jinwoo J. Im
  • Ross D. Shachter
  • Elizabeth M. Oliva
  • Patricia T. Henderson
  • Meenah C. Paik
  • Jodie A. Trafton
  • for the PROGRES Team
Original Research

ABSTRACT

IMPORTANCE

Patients receiving opioid therapy are at elevated risk of attempting suicide. Guidelines recommend practices to mitigate risk, but it is not known whether these are effective.

OBJECTIVE

Our aim was to examine associations between the receipt of guideline-recommended care for opioid therapy and risk of suicide attempt.

DESIGN, SETTING, AND PARTICIPANTS

This was a retrospective analysis of administrative data for all Veteran patients prescribed any short-acting opioids on a chronic basis or any long-acting opioids from the Veterans Health Administration during fiscal year 2010.

MAIN OUTCOMES AND MEASURES

Multivariate, mixed-effects logistic regression analyses were conducted to define the associations between the risk of suicide attempt and receipt of guideline-recommended care at the individual level and rates of use of recommended care at the facility level, while accounting for patient risk factors.

RESULTS

At the individual level, having a mood disorder was highly associated with suicide attempts (odds ratios [ORs] = 3.5, 3.9; 95 % confidence intervals [CIs] = 3.3–3.9, 3.3–4.6 for chronic short-acting and long-acting groups, respectively). At the facility level, patients on opioid therapy within the facilities ordering more drug screens were associated with decreased risk of suicide attempt (ORs = 0.2, 0.3; CIs = 0.1–0.3, 0.2–0.6 for chronic short-acting and long-acting groups, respectively). In addition, patients on long-acting opioid therapy within the facilities providing more follow-up after new prescriptions were associated with decreased risk of suicide attempt (OR = 0.2, CI = 0.0–0.7), and patients on long-acting opioid therapy within the facilities having higher sedative co-prescription rates were associated with increased risk of suicide attempt (OR = 20.3, CI = 1.1–382.2).

CONCLUSIONS AND RELEVANCE

Encouraging facilities to make more consistent use of drug screening, provide follow-up within 4 weeks for patients initiating new opioid prescriptions, and avoid sedative co-prescription in combination with long-acting opioids may help prevent suicide attempts. Some clinicians may selectively employ guideline-recommended practices with at-risk patients.

KEY WORDS

opioid therapy suicide attempt clinical practice guideline 

INTRODUCTION

Patients receiving opioid therapy (OT) are at elevated risk of attempting suicide,1 but definitive research to guide clinical practice for risk mitigation is lacking. Unmanaged severe, chronic and intermittent pain conditions increase risk of suicide attempt,2, 3, 4, 5, 6, 7, 8, 9 a finding that might encourage providers to take aggressive action to reduce chronic pain in at-risk patients. However, available opioids also provide means for attempting suicide,10 potentially discouraging prescribing of these analgesics. Competing pressures have led experts to focus on clinical strategies for reducing the risk of adverse events in patients prescribed opioids.

In 2010, the Veterans Health Administration (VHA) and Department of Defense released a Clinical Practice Guideline for the Management of Opioid Therapy for Chronic Pain (CPG for OT).11 Like other guidelines for OT for chronic pain,12,13 this guideline provides recommendations, based primarily on expert consensus, for recognizing patient populations at higher risk of opioid-related adverse events, and intensifying care or monitoring such patients to minimize risk. For all patients, especially higher risk patients, the guideline recommends intensified clinical management, such as timely follow-up after new prescriptions.

To track and encourage adherence to this emerging practice standard, a team including the guideline co-chairs; VHA national pain, pharmacy, and addictions policy leadership; primary care, specialty pain and mental health clinicians; and measurement experts developed a set of administrative data-based process measures to evaluate current use of key guideline-recommended practices.14 Examination of variation in use of recommended practices across VHA showed two common patterns: (1) for some recommendations, facility rates were consistent across the system, but indicated incomplete adherence to the recommendation; (2) for other recommendations, rates of adherence varied greatly across facilities. Because most guideline recommendations have been based on expert consensus rather than evidence-based research, it is not clear whether recommended care delivery, or the observed variations in clinical practice, impact patient risk for adverse outcomes.

Here, we examine associations between use of guideline recommendations for OT and risk of suicide attempt. Because clinical practices may be adapted based on patient characteristics associated with risk, solely examining patient-level or facility-level associations between clinical practice and outcomes can encourage logically flawed inferences regarding clinical practice effects.15 Thus, we aim to examine associations between individual-level and facility-level delivery of guideline-recommended care and individual-level suicide attempts. Notably, although the guideline provides detailed information to guide dosing of specific opioids during initiation, titration, and cessation, it does not specify prescription details such as choice of drug. Thus, such variables, while potentially relevant for suicide risk, were not included in these analyses.

METHODS

Data

All Veteran patients prescribed any short-acting opioids on a chronic basis (chronic short-acting, CSA) or any long-acting (LA) opioids from the VHA during fiscal year 2010 (FY10) were included in this analysis (see Appendix 1 for CSA and LA definitions). Chronic use of short-acting opioids was defined as having at least 90 days of supply in FY10.14 Notably, 91 % of the patients in the LA group also received short-acting opioids in FY10, but were exclusively counted in the LA group. Clinical expert advisors suggested that long-acting medications may pose greater risk for adverse events, and that these medications are typically prescribed by specialists and in non-primary care settings. Here, we examine populations receiving any long-acting and chronic short-acting opioids separately, to clarify if and where differences in the patient risk and care practices exist. All patients receiving long-acting prescriptions were included, rather than just those with more than 90 days of supply, to allow for comparison with other published data on this population.16 Given concerns about prescribing opioids to patients diagnosed with substance use disorder (SUD), additional analyses examined individual-level and facility-level factors associated with suicide attempts among the patient population.

Data were extracted from the VHA National Patient Care Database and VHA Decision Support System pharmacy and laboratory files; databases were linked by matching patients’ scrambled social security numbers. This study was approved and overseen by the Stanford University Human Research Protection Program and the VA Palo Alto Health Care System Research and Development Committee.

Measures

The dependent variable in this study is a binary indicator of whether a Veteran patient had completed or attempted suicide after being prescribed any CSA or LA opioids (hereafter referred to as “suicide attempts”). We included all documented incidents, confirmed or suspected, occurring in the first 180 days after any prescription was initiated during FY10 (see Appendix 2 for definition).

Individual-Level Predictors

Demographic variables included age, gender, and marital status. Age was categorized into three groups: younger than 31 years old, 31–55 years old, and greater than 55 years old. Physical/mental health status was represented by indicator variables for medical frailty, drug/alcohol/mood disorder, and traumatic brain injury (see Appendix 3 for definitions).

We used binary indicator variables to identify whether patients received guideline-recommended care. The covariates were chosen from the CPG for OT11 and employed metrics developed for VHA that measured delivery of guideline-recommended care.14 Here, we include the following guideline-recommended care delivery measures (see Appendix 4 for rationale and definitions): psychosocial assessment or therapy, sedative co-prescription (e.g., benzodiazepines, barbiturates, and carisoprodol [Soma]), follow-up, drug screening, medication management, avoidance of sole reliance on opioids, and SUD specialty treatment.

Facility-Level Predictors

We included facility-level guideline-recommended care delivery rates in the analysis. These rates were calculated for each VHA facility by dividing the number of patients on OT receiving each guideline-recommended service by the total number of patients on OT within the VHA facility.

Statistical Analyses

To examine individual-level and facility-level factors associated with patients’ suicide attempts, we conducted multivariate mixed-effects logistic regression, with a random effect for each facility to account for the clustering of patients within VHA facilities.15 Mixed-effects logistic regression is a branch of logistic regression having a binary outcome as a dependent variable (e.g., whether a patient attempted suicide after being prescribed only CSA or LA opioids). Traditional single-level logistic regression assumes observations are independent conditional on the covariates and uncorrelated residual errors, which may not hold when analyzing nested data.16,17 In contrast, mixed-effects logistic regression considers variations derived from the data’s hierarchical structure and allows for simultaneous examination of effects of facility-level and individual-level variables on individual-level outcomes while accounting for the non-independence of observations within facilities.17.

The analyses were performed for CSA and LA OT groups separately, and in addition, for SUD-diagnosed patients within each group. We chose a p value of < 0.05 as a threshold for statistical significance. All multivariate mixed-effects logistic regression analyses were conducted using the glmmPQL function in the MASS package18 of R statistical software (version 2.15.0).19.

RESULTS

Overview

Table 1 shows individual-level predictors of suicide attempts among patients on OT. During FY10, 487,462 Veteran patients received OT at 139 VHA facilities. Of these patients, 393,657(80.8 %) received CSA opioids, and 93,805(19.2 %) received LA opioids. Within the first 180 days after opioid prescriptions, 6,482(1.6 %) CSA patients and 1,982(2.1 %) LA patients attempted suicide. According to Table 2, 47,771(12.1 %) were diagnosed with SUD, and 3,440(7.2 %) of them attempted suicide among patients on CSA OT. Among patients on LA OT, 13,732(14.6 %) were diagnosed with SUD, and 1,144(8.3 %) of them attempted suicide.
Table 1.

Individual-Level Predictors and Suicide Attempts in the Entire Population Prescribed Opioid in the VHA in FY10

Type of opioid

CSAa

LAb

Number of cases

Suicide attempt 6,482 (100.0 %)

No suicide attempt 387,175 (100.0 %)

Suicide attempt 1,982 (100.0 %)

No suicide attempt 91,823 (100.0 %)

Demographic factors

 Age

    

  ≤ 30 (reference)

368 (5.7 %)

11,916 (3.1 %)

107 (5.4 %)

2,742 (3.0 %)

  31–55

3,109 (48.0 %)

105,276 (27.2 %)

960 (48.4 %)

26,891 (29.3 %)

  > 55

3,005 (46.4 %)

269,983 (69.7 %)

915 (46.2 %)

62,190 (67.7 %)

 Gender

    

  Female (reference)

616 (9.5 %)

25,249 (6.5 %)

159 (8.0 %)

5,988 (6.5 %)

  Male

5,866 (90.5 %)

361,926 (93.5 %)

1,823 (92.0 %)

85,835 (93.5 %)

 Currently married

7 missing

1,285 missing

1 missing

278 missing

  No (reference)

3,925 (60.6 %)

180,108 (46.5 %)

1,185 (59.8 %)

42,804 (46.6 %)

  Yes

2,550 (39.3 %)

205,782 (53.1 %)

796 (40.2 %)

48,741 (53.1 %)

Physical and mental health factors

 Medical frailtyc

 

2 missing

 

2 missing

  No (reference)

2,634 (40.6 %)

169,917 (43.9 %)

769 (38.8 %)

38,432 (41.9 %)

  Yes

3,848 (59.4 %)

217,256 (56.1 %)

1,213 (61.2 %)

53,389 (58.1 %)

 Drug use disorder

 

2 missing

 

2 missing

  No (reference)

3,641 (56.2 %)

360,346 (93.1 %)

969 (48.9 %)

82,882 (90.3 %)

  Yes

2,841 (43.8 %)

26,827 (6.9 %)

1,013 (51.1 %)

8,939 (9.7 %)

 Alcohol use disorder

 

2 missing

  

  No (reference)

3,618 (55.8 %)

349,672 (90.3 %)

1,154 (58.2 %)

82,802 (90.2 %)

  Yes

2,864 (44.2 %)

37,501 (9.7 %)

828 (41.8 %)

9,021 (9.8 %)

 Any mood disorderd

 

2 missing

 

2 missing

  No (reference)

803 (12.4 %)

238,743 (61.7 %)

190 (9.6 %)

52,900 (57.6 %)

  Yes

5,679 (87.6 %)

148,430 (38.3 %)

1,792 (90.4 %)

38,921 (42.4 %)

 Traumatic brain injury

    

  No (reference)

6,286 (97.0 %)

385,832 (99.7 %)

1,913 (96.5 %)

91,473 (99.6 %)

  Yes

196 (3.0 %)

1,343 (0.3 %)

69 (3.5 %)

350 (0.4 %)

Type of opioid

CSA

LA

Number of cases

Suicide attempt 6,482 (100.0 %)

No suicide attempt 387,175 (100.0 %)

Suicide attempt 1,982 (100.0 %)

No suicide attempt 91,823 (100.0 %)

Receipt of clinical practice guideline interventionse

 Psychosocial assessment or therapy

 

6 missing

 

2 missing

  No (reference)

850 (13.1 %)

227,340 (58.7 %)

220 (11.1 %)

50,703 (55.2 %)

  Yes

5,632 (86.9 %)

159,829 (41.3 %)

1,762 (88.9 %)

41,118 (44.8 %)

 Sedative co-prescription

    

  No (reference)

4,104 (63.3 %)

275,273 (71.1 %)

1,020 (51.5 %)

56,906 (62.0 %)

  Yes

2,378 (36.7 %)

111,902 (28.9 %)

962 (48.5 %)

34,917 (38.0 %)

 Follow-up

    

  No (reference)

3,849 (59.4 %)

253,109 (65.4 %)

1,316 (66.4 %)

62,952 (68.6 %)

  Yes

2,633 (40.6 %)

134,066 (34.6 %)

666 (33.6 %)

28,871 (31.4 %)

 Any drug screening

    

  No (reference)

2,720 (42.0 %)

311,571 (80.5 %)

712 (35.9 %)

67,555 (73.6 %)

  Yes

3,762 (58.0 %)

75,604 (19.5 %)

1,270 (64.1 %)

24,268 (26.4 %)

 Medication management

    

  No (reference)

3,113 (48.0 %)

302,321 (78.1 %)

871 (43.9 %)

69,006 (75.2 %)

  Yes

3,369 (52.0 %)

84,854 (21.9 %)

1,111 (56.1 %)

22,817 (24.8 %)

 Rehabilitation medicine

    

  No (reference)

699 (10.8 %)

107,917 (27.9 %)

192 (9.7 %)

23,511 (25.6 %)

  Yes

5,783 (89.2 %)

279,258 (72.1 %)

1,790 (90.3 %)

68,312 (74.4 %)

 Anti-inflammatory pharmacotherapy (NSAID or acetaminophen)

    

  No (reference)

2,984 (46.0 %)

217,460 (56.2 %)

976 (49.2 %)

54,096 (58.9 %)

  Yes

3,498 (54.0 %)

169,715 (43.8 %)

1,006 (50.8 %)

37,727 (41.1 %)

Receipt of clinical practice guideline interventions

 Specialty pain pharmacotherapy (TCAf)

    

  No (reference)

4,982 (76.9 %)

332,499 (85.9 %)

1,414 (71.3 %)

74,544 (81.2 %)

  Yes

1,500 (23.1 %)

54,676 (14.1 %)

568 (28.7 %)

17,279 (18.8 %)

 Specialty pain pharmacotherapy (SNRIg)

    

  No (reference)

4,634 (71.5 %)

325,417 (84.0 %)

1,275 (64.3 %)

72,589 (79.1 %)

  Yes

1,848 (28.5 %)

61,758 (16.0 %)

707 (35.7 %)

19,234 (20.9 %)

Type of opioid

CSA

LA

Number of cases

Suicide attempt 6,482 (100.0 %)

No suicide attempt 387,175 (100.0 %)

Suicide attempt 1,982 (100.0 %)

No suicide attempt 91,823 (100.0 %)

 Specialty pain pharmacotherapy (anticonvulsants)

    

  No (reference)

3,405 (52.5 %)

268,558 (69.4 %)

880 (44.4 %)

56,198 (61.2 %)

  Yes

3,077 (47.5 %)

118,617 (30.6 %)

1,102 (55.6 %)

35,625 (38.8 %)

a Short-acting opioid medications on a chronic basis (chronic short-acting)

b Long-acting

c Congestive heart failure, cardiac arrhythmia, valvular disease, pulmonary circulation disorder, peripheral vascular disorder, paralysis, other neurological disorder, chronic pulmonary disease, hypothyroidism, renal failure, liver disease, peptic ulcer disease - excluding bleeding, aids, lymphoma, metastatic cancer, solid tumor without metastasis, rheumatoid arthritis/collagen vascular, coagulopathy, weight loss, fluid and electrolyte disorders, blood loss anemia, or deficiency anemias

d Depression, anxiety disorder, PTSD, or affective psychosis (bipolar)

e Please refer to Appendix Table 4

f Tricyclic antidepressants

g Serotonin-norepinephrine reuptake inhibitors

Table 2.

Individual-Level Predictors and Suicide Attempts in the Population Diagnosed with Substance Use Disorder and Prescribed Opioid in the VHA in FY10

Type of opioid

CSA

LA

Number of cases

Suicide attempt 3,440 (100.0 %)

No suicide attempt 44,331 (100.0 %)

Suicide attempt 1,144 (100.0 %)

No suicide attempt 12,588 (100.0 %)

Demographic factors

 Age

    

  ≤ 30 (reference)

211 (6.1 %)

1,887 (4.3 %)

72 (6.3 %)

485 (3.9 %)

  31–55

1,901 (55.3 %)

18,069 (40.8 %)

597 (52.2 %)

5,223 (41.5 %)

  > 55

1,328 (38.6 %)

24,375 (55.0 %)

475 (41.5 %)

6,880 (54.7 %)

 Gender

    

  Female (reference)

219 (6.4 %)

2,010 (4.5 %)

65 (5.7 %)

585 (4.6 %)

  Male

3,221 (93.6 %)

42,321 (95.5 %)

1,079 (94.3 %)

12,003 (95.4 %)

 Currently married

4 missing

137 missing

1 missing

29 missing

  No (reference)

2,427 (70.6 %)

29,442 (66.4 %)

767 (67.0 %)

8,123 (64.5 %)

  Yes

1,009 (29.3 %)

14,752 (33.3 %)

376 (32.9 %)

4,436 (35.2 %)

Physical and mental health factors

 Medical frailty

    

  No (reference)

1,395 (40.6 %)

19,148 (43.2 %)

425 (37.2 %)

5,134 (40.8 %)

  Yes

2,045 (59.4 %)

25,183 (56.8 %)

719 (62.8 %)

7,454 (59.2 %)

 Drug use disorder

    

  No (reference)

689 (20.0 %)

19,571 (44.1 %)

157 (13.7 %)

4,203 (33.4 %)

  Yes

2,751 (80.0 %)

24,760 (55.9 %)

987 (86.3 %)

8,385 (66.6 %)

 Alcohol use disorder

    

  No (reference)

770 (22.4 %)

12,559 (28.3 %)

365 (31.9 %)

5,022 (39.9 %)

  Yes

2,670 (77.6 %)

31,772 (71.7 %)

779 (68.1 %)

7,566 (60.1 %)

 Any mood disorder

    

  No (reference)

183 (5.3 %)

15,309 (34.5 %)

50 (4.4 %)

3,974 (31.6 %)

  Yes

3,257 (94.7 %)

29,022 (65.5 %)

1,094 (95.6 %)

8,614 (68.4 %)

 Traumatic brain injury

    

  No (reference)

3,256 (94.7 %)

43,152 (97.3 %)

1,082 (94.6 %)

12,279 (97.5 %)

  Yes

184 (5.3 %)

1,179 (2.7 %)

62 (5.4 %)

309 (2.5 %)

Type of opioid

CSA

LA

Number of cases

Suicide attempt 3,440 (100.0 %)

No suicide attempt 44,331 (100.0 %)

Suicide attempt 1,144 (100.0 %)

No suicide attempt 12,588 (100.0 %)

Receipt of clinical practice guideline interventions

 SUD specialty treatment or SUD-specific pharmacotherapies

    

  No (reference)

550 (16.0 %)

18,597 (42.0 %)

232 (20.3 %)

5,407 (43.0 %)

  Yes

2,890 (84.0 %)

25,734 (58.0 %)

912 (79.7 %)

7,181 (57.0 %)

 Sedative co-prescription

    

  No (reference)

2,150 (62.5 %)

30,885 (69.7 %)

592 (51.7 %)

7,636 (60.7 %)

  Yes

1,290 (37.5 %)

13,446 (30.3 %)

552 (48.3 %)

4,952 (39.3 %)

 Follow-up

    

  No (reference)

1,939 (56.4 %)

25,905 (58.4 %)

564 (49.3 %)

6,583 (52.3 %)

  Yes

1,501 (43.6 %)

18,426 (41.6 %)

580 (50.7 %)

6,005 (47.7 %)

Receipt of clinical practice guideline interventions

 Regular drug screening

    

  No (reference)

1,615 (46.9 %)

31,276 (70.6 %)

594 (51.9 %)

8,726 (69.3 %)

  Yes

1,825 (53.1 %)

13,055 (29.4 %)

550 (48.1 %)

3,862 (30.7 %)

 Medication management

    

  No (reference)

1,499 (43.6 %)

29,101 (65.6 %)

443 (38.7 %)

7,804 (62.0 %)

  Yes

1,941 (56.4 %)

15,230 (34.4 %)

701 (61.3 %)

4,784 (38.0 %)

 Rehabilitation medicine

    

  No (reference)

328 (9.5 %)

8,441 (19.0 %)

88 (7.7 %)

2,157 (17.1 %)

  Yes

3,112 (90.5 %)

35,890 (81.0 %)

1,056 (92.3 %)

10,431 (82.9 %)

 Anti-inflammatory pharmacotherapy (NSAID or acetaminophen)

    

  No (reference)

1,507 (43.8 %)

22,155 (50.0 %)

524 (45.8 %)

6,723 (53.4 %)

  Yes

1,933 (56.2 %)

22,176 (50.0 %)

620 (54.2 %)

5,865 (46.6 %)

 Specialty pain pharmacotherapy (TCA)

    

  No (reference)

2,579 (75.0 %)

36,124 (81.5 %)

803 (70.2 %)

9,550 (75.9 %)

  Yes

861 (25.0 %)

8,207 (18.5 %)

341 (29.8 %)

3,038 (24.1 %)

 Specialty pain pharmacotherapy (SNRI)

    

  No (reference)

2,453 (71.3 %)

34,837 (78.6 %)

747 (65.3 %)

9,384 (74.5 %)

  Yes

987 (28.7 %)

9,494 (21.4 %)

397 (34.7 %)

3,204 (25.5 %)

Type of opioid

CSA

LA

Number of cases

Suicide attempt 3,440 (100.0 %)

No suicide attempt 44,331 (100.0 %)

Suicide attempt 1,144 (100.0 %)

No suicide attempt 12,588 (100.0 %)

 Specialty pain pharmacotherapy (anticonvulsants)

    

  No (reference)

1,748 (50.8 %)

28,236 (63.7 %)

495 (43.3 %)

6,974 (55.4 %)

  Yes

1,692 (49.2 %)

16,095 (36.3 %)

649 (56.7 %)

5,614 (44.6 %)

Table 3 shows facility-level guideline-recommended care delivery rates for patients receiving OT. For patients on both CSA and LA OT, the guideline-recommended care most frequently provided was rehabilitation medicine (72.4 and 74.7 % for patients on CSA and LA OT, respectively). The guideline-recommended care least frequently provided was specialty pain pharmacotherapy with TCAs (14.3 and 19.0 % for patients on CSA and LA OT, respectively). The standard deviations of facility-level propensities to order drug screens for patients on both CSA and LA OT were largest compared to their mean propensities. This indicates that drug screens were not provided consistently to patients on CSA or LA OT across facilities.
Table 3.

Facility-Level Guideline Adherence Rates for the Opioid Prescribed Population in the VHA in FY10

Type of opioid

Facility metric (Receipt of clinical practice guideline interventions)

Sample size

Mean % across facilities

Standard deviation across facilities

Minimum % across facilities

Maximum % across facilities

CSA

Psychosocial assessment or therapy

393,657 (Entire population)

42.0

9.7

24.5

89.6

Sedative co-prescription

29.0

2.0

23.7

35.5

Follow-up

34.7

6.2

23.7

66.0

Any drug screening

20.2

11.8

0.0

50.2

Medication management

22.4

9.7

4.3

78.9

Rehabilitation medicine

72.4

8.8

44.4

90.3

Anti-inflammatory pharmacotherapy (NSAID or acetaminophen)

44.0

3.5

34.7

53.5

Specialty pain pharmacotherapy (TCA)

14.3

1.9

9.6

20.9

Specialty pain pharmacotherapy (SNRI)

16.2

1.7

10.5

20.5

Specialty pain pharmacotherapy (anticonvulsants)

30.9

3.3

22.2

40.0

SUD specialty treatment or SUD-specific pharmacotherapies

47,771 (SUD population)

59.9

7.3

35.0

85.8

Regular drug screening

31.2

15.0

0.0

68.8

LA

Psychosocial assessment or therapy

93,805 (Entire population)

45.7

9.8

26.1

91.6

Sedative co-prescription

38.2

2.4

28.8

46.8

Follow-up

31.5

6.3

17.8

55.8

Any drug screening

27.2

15.0

0.2

67.6

Medication management

25.5

10.9

4.7

83.2

Rehabilitation medicine

74.7

8.3

47.3

91.0

Anti-inflammatory pharmacotherapy (NSAID or acetaminophen)

41.3

3.7

31.4

52.1

Specialty pain pharmacotherapy (TCA)

19.0

2.1

12.8

25.0

Specialty pain pharmacotherapy (SNRI)

21.3

2.4

15.5

28.0

Specialty pain pharmacotherapy (anticonvulsants)

39.2

3.7

27.9

50.5

SUD specialty treatment or SUD-specific pharmacotherapies

13,732 (SUD population)

58.9

9.7

32.4

89.5

Regular drug screening

32.2

16.7

0.0

64.6

Chronic Short-Acting Opioid Prescribed Population

Table 4 summarizes the multivariate, mixed-effects logistic regression results for patients receiving CSA OT. Insignificant variables are shaded in the table. At the individual level, suicide attempts were associated with being younger, female, currently unmarried, and having medical frailty, drug/alcohol/mood disorder, or traumatic brain injury. In particular, having a mood disorder was highly associated with suicide attempts (odds ratio [OR] = 3.5, 95 % confidence interval [CI] = 3.3–3.9). Moreover, patients receiving psychosocial assessment/therapy, sedative co-prescription, drug screening, medication management, rehabilitation medicine, and anti-inflammatory or specialty pain pharmacotherapy were associated with increased risk of suicide attempt. At the facility-level, patients prescribed CSA OT within VHA facilities ordering more drug screens were associated with decreased risk of suicide attempt (OR = 0.2, CI = 0.1–0.3).
Table 4.

Multivariate, Mixed-Effects Logistic Regression Model Predicting Suicide Attempts of the CSA Opioid Prescribed Population in the VHA

Overallh

 

Estimate

OR

SE

DF

t value

p value

(Intercept)

-5.448

 

0.814

392,202

-6.692

<0.001

Demographic factors

Age (reference: ≤ 30)

-0.295

0.745

0.024

392,202

-12.121

<0.001

Gender (reference: female)

-0.123

0.885

0.048

 

-2.540

0.011

Currently married (reference: no)

-0.133

0.875

0.029

 

-4.596

<0.001

Physical and mental health factors

Medical frailty (reference: no)

0.197

1.218

0.029

392,202

6.782

<0.001

Drug use disorder (reference: no)

0.885

2.424

0.034

 

26.145

<0.001

Alcohol use disorder (reference: no)

0.690

1.994

0.033

 

21.212

<0.001

Any mood disorder (reference: no)

1.266

3.548

0.045

 

28.330

<0.001

Traumatic brain injury (reference: no)

0.269

1.309

0.087

 

3.087

0.002

Individual-level receipt of clinical practice guideline interventions

Psychosocial assessment or therapy (reference: no)

0.861

2.366

0.044

392,202

19.431

<0.001

Sedative co-prescription (reference: no)

0.109

1.115

0.029

 

3.815

<0.001

Any drug screening (reference: no)

0.983

2.673

0.033

 

29.891

<0.001

Medication management (reference: no)

0.443

1.557

0.030

 

14.840

<0.001

Rehabilitation medicine (reference: no)

0.305

1.357

0.045

 

6.817

<0.001

Anti-inflammatory pharmacotherapy (NSAID or acetaminophen) (reference: no)

0.067

1.069

0.028

 

2.412

0.016

Specialty pain pharmacotherapy (TCA) (reference: no)

0.085

1.089

0.033

 

2.579

0.010

Specialty pain pharmacotherapy (SNRI) (reference: no)

0.080

1.083

0.031

 

2.586

0.010

Specialty pain pharmacotherapy (anticonvulsants) (reference: no)

0.223

1.250

0.028

 

8.005

<0.001

Facility-level receipt of clinical practice guideline interventions

% Psychosocial assessment or therapy (reference: no)

-0.576

0.562

0.407

128

-1.415

0.160

% Sedative co-prescription (reference: no)

-0.195

0.823

1.833

 

-0.106

0.915

% Follow-up (reference: no)

-1.289

0.275

0.668

 

-1.931

0.056

% Any drug screening (reference: no)

-1.782

0.168

0.347

 

-5.129

<0.001

% Medication management (reference: no)

0.332

1.394

0.387

 

0.857

0.393

% Rehabilitation medicine (reference: no)

-0.487

0.615

0.472

 

-1.032

0.304

% Anti-inflammatory pharmacotherapy (NSAID or acetaminophen) (reference: no)

0.394

1.482

1.271

 

0.310

0.757

% Specialty pain pharmacotherapy (TCA) (reference: no)

2.051

7.779

2.153

 

0.953

0.343

% Specialty pain pharmacotherapy (SNRI) (reference: no)

0.947

2.579

2.204

 

0.430

0.668

% Specialty pain pharmacotherapy (anticonvulsants) (reference: no)

0.456

1.578

1.259

 

0.362

0.718

SUDi

 

Estimate

OR

SE

DF

t value

p value

(Intercept)

-4.884

 

0.864

47,474

-5.653

<0.001

Demographic factors

Age (reference: ≤ 30)

-0.269

0.764

0.032

47,474

-8.316

<0.001

Gender (reference: female)

0.035

1.036

0.077

 

0.457

0.648

Currently married (reference: no)

-0.091

0.913

0.041

 

-2.233

0.026

SUDi

 

Estimate

OR

SE

DF

t value

p value

Physical and mental health factors

Medical frailty (reference: no)

0.222

1.249

0.039

47,474

5.731

<0.001

Drug use disorder (reference: no)

0.904

2.470

0.049

 

18.298

<0.001

Alcohol use disorder (reference: no)

0.594

1.811

0.047

 

12.519

<0.001

Any mood disorder (reference: no)

1.679

5.362

0.079

 

21.312

<0.001

Traumatic brain injury (reference: no)

0.258

1.295

0.086

 

2.999

0.003

Individual-level receipt of clinical practice guideline interventions

SUD specialty treatment or SUD-specific pharmacotherapies (reference: no)

0.410

1.507

0.052

47,474

7.867

<0.001

Sedative co-prescription (reference: no)

0.208

1.232

0.038

 

5.430

<0.001

Regular drug screening (reference: no)

0.685

1.984

0.042

 

16.303

<0.001

Medication management (reference: no)

0.373

1.451

0.040

 

9.346

<0.001

Rehabilitation medicine (reference: no)

0.233

1.262

0.063

 

3.724

<0.001

Anti-inflammatory pharmacotherapy (NSAID or acetaminophen) (reference: no)

0.046

1.047

0.037

 

1.231

0.218

Specialty pain pharmacotherapy (TCA) (reference: no)

0.090

1.094

0.043

 

2.099

0.036

Specialty pain pharmacotherapy (SNRI) (reference: no)

0.076

1.079

0.041

 

1.850

0.064

Specialty pain pharmacotherapy (anticonvulsants) (reference: no)

0.247

1.281

0.037

 

6.649

<0.001

Facility-level receipt of clinical practice guideline interventions

% SUD specialty treatment or SUD-specific pharmacotherapies (reference: no)

-1.231

0.292

0.493

128

-2.495

0.014

% Sedative co-prescription (reference: no)

-0.292

0.747

1.854

 

-0.158

0.875

% Follow-up (reference: no)

-1.111

0.329

0.702

 

-1.583

0.116

% Regular drug screening (reference: no)

-1.125

0.325

0.309

 

-3.645

<0.001

% Medication management (reference: no)

0.454

1.574

0.401

 

1.131

0.260

% Rehabilitation medicine (reference: no)

-0.785

0.456

0.478

 

-1.641

0.103

% Anti-inflammatory pharmacotherapy (NSAID or acetaminophen) (reference: no)

0.483

1.621

1.324

 

0.365

0.716

% Specialty pain pharmacotherapy (TCA) (reference: no)

2.344

10.426

2.205

 

1.063

0.290

% Specialty pain pharmacotherapy (SNRI) (reference: no)

1.206

3.339

2.241

 

0.538

0.592

% Specialty pain pharmacotherapy (anticonvulsants) (reference: no)

1.398

4.048

1.295

 

1.080

0.282

h Overall patient population prescribed CSA opioids

i Patient population diagnosed with SUD and prescribed CSA opioids

Table 4 also summarizes results for SUD-diagnosed patients on CSA OT. In general, the pattern of individual-level findings were similar to those for the entire CSA OT group; however, unlike the entire CSA OT group, gender and anti-inflammatory and specialty pain pharmacotherapy (SNRIs) were not significant predictors of suicide attempts for the SUD-diagnosed group on CSA OT. Similar to results for the entire CSA OT group, having a mood disorder was highly associated with suicide attempts (OR = 5.4, CI = 4.6–6.3). At the facility-level, SUD-diagnosed patients on CSA OT within VHA facilities ordering regular drug screens (defined as at least one drug screen for every 90 days of opioid supply) more consistently or providing more SUD specialty treatment/SUD-specific pharmacotherapies were associated with decreased risk of suicide attempt (ORs = 0.3, CI = 0.2–0.6).

Long-Acting Opioid Prescribed Population

Results for patients on LA OT (Table 5) were consistent with results for patients on CSA OT. For the entire LA OT group, suicide attempts were associated with being younger, currently unmarried, and having medical frailty, drug/alcohol/mood disorder, or traumatic brain injury. Similarly, having a mood disorder was highly associated with suicide attempts (OR = 3.9, CI = 3.3–4.6). Patients receiving psychosocial assessment/therapy, sedative co-prescription, drug screening, medication management, rehabilitation medicine, or specialty pain pharmacotherapy were associated with increased risk of suicide attempt. Consistent with the entire CSA OT group, the LA OT group within VHA facilities ordering more drug screens was associated with decreased risk of suicide attempt (OR = 0.3, CI = 0.2–0.6); in addition, the LA OT group within VHA facilities providing more follow-up after new prescriptions was associated with decreased risk of suicide attempt (OR = 0.2, CI = 0.0–0.7), and the LA OT group within VHA facilities having higher sedative co-prescription rates was associated with increased risk of suicide attempt (OR = 20.3, CI = 1.1–382.2).
Table 5.

Multivariate Mixed-Effects Logistic Regression Model Predicting Suicide Attempts of the LA Opioid Prescribed Population in the VHA

Overallj

 

Estimate

OR

SE

DF

t value

p value

(Intercept)

-7.289

 

0.870

93,367

-8.377

<0.001

Demographic factors

Age (reference: ≤ 30)

-0.266

0.766

0.044

93,367

-6.099

<0.001

Gender (reference: female)

0.032

1.032

0.092

 

0.348

0.728

Currently married (reference: no)

-0.167

0.846

0.051

 

-3.252

0.001

Physical and mental health factors

Medical frailty (reference: no)

0.160

1.173

0.052

93,367

3.067

0.002

Drug use disorder (reference: no)

1.041

2.832

0.057

 

18.276

<0.001

Alcohol use disorder (reference: no)

0.627

1.871

0.056

 

11.147

<0.001

Any mood disorder (reference: no)

1.352

3.867

0.086

 

15.664

<0.001

Traumatic brain injury (reference: no)

0.408

1.504

0.147

 

2.772

0.006

Individual-level receipt of clinical practice guideline interventions

Psychosocial assessment or therapy (reference: no)

0.896

2.450

0.082

93,367

10.884

<0.001

Sedative co-prescription (reference: no)

0.186

1.205

0.049

 

3.790

<0.001

Any drug screening (reference: no)

0.826

2.284

0.059

 

13.893

<0.001

Medication management (reference: no)

0.474

1.606

0.053

 

8.864

<0.001

Rehabilitation medicine (reference: no)

0.268

1.307

0.083

 

3.216

0.001

Anti-inflammatory pharmacotherapy (NSAID or acetaminophen) (reference: no)

0.040

1.041

0.050

 

0.804

0.421

Specialty pain pharmacotherapy (TCA) (reference: no)

0.054

1.055

0.055

 

0.980

0.327

Specialty pain pharmacotherapy (SNRI) (reference: no)

0.140

1.150

0.052

 

2.679

0.007

Specialty pain pharmacotherapy (anticonvulsants) (reference: no)

0.180

1.198

0.050

 

3.596

<0.001

Facility-level receipt of clinical practice guideline interventions

% Psychosocial assessment or therapy (reference: no)

-0.625

0.535

0.406

128

-1.538

0.127

% Sedative co-prescription (reference: no)

3.012

20.326

1.497

 

2.012

0.046

% Follow-up (reference: no)

-1.689

0.185

0.668

 

-2.528

0.013

% Any drug screening (reference: no)

-1.086

0.338

0.295

 

-3.678

<0.001

% Medication management (reference: no)

-0.471

0.625

0.356

 

-1.324

0.188

% Rehabilitation medicine (reference: no)

-0.294

0.745

0.496

 

-0.593

0.554

% Anti-inflammatory pharmacotherapy (NSAID or acetaminophen) (reference: no)

0.267

1.306

1.127

 

0.237

0.813

% Specialty pain pharmacotherapy (TCA) (reference: no)

-0.685

0.504

1.725

 

-0.397

0.692

% Specialty pain pharmacotherapy (SNRI) (reference: no)

2.837

17.062

1.539

 

1.843

0.068

% Specialty pain pharmacotherapy (anticonvulsants) (reference: no)

1.853

6.380

1.099

 

1.686

0.094

SUDk

 

Estimate

OR

SE

DF

t value

p value

(Intercept)

-7.284

 

1.028

13,546

-7.083

<0.001

Demographic factors

Age (reference: ≤ 30)

-0.221

0.802

0.055

13,546

-3.991

<0.001

Gender (reference: female)

0.131

1.140

0.136

 

0.963

0.336

Currently married (reference: no)

-0.073

0.930

0.067

 

-1.085

0.278

SUDk

 

Estimate

OR

SE

DF

t value

p value

Physical and mental health factors

Medical frailty (reference: no)

0.239

1.270

0.067

13,546

3.581

<0.001

Drug use disorder (reference: no)

1.090

2.974

0.094

 

11.541

<0.001

Alcohol use disorder (reference: no)

0.606

1.833

0.074

 

8.234

<0.001

Any mood disorder (reference: no)

1.775

5.899

0.144

 

12.296

<0.001

Traumatic brain injury (reference: no)

0.404

1.498

0.147

 

2.752

0.006

Individual-level receipt of clinical practice guideline interventions

SUD specialty treatment or SUD-specific pharmacotherapies (reference: no)

0.317

1.373

0.083

13,546

3.839

<0.001

Sedative co-prescription (reference: no)

0.223

1.250

0.063

 

3.549

<0.001

Regular drug screening (reference: no)

0.430

1.537

0.071

 

6.018

<0.001

Medication management (reference: no)

0.515

1.674

0.069

 

7.519

<0.001

Rehabilitation medicine (reference: no)

0.389

1.476

0.116

 

3.363

0.001

Anti-inflammatory pharmacotherapy (NSAID or acetaminophen) (reference: no)

0.098

1.102

0.063

 

1.538

0.124

Specialty pain pharmacotherapy (TCA) (reference: no)

0.003

1.003

0.069

 

0.042

0.967

Specialty pain pharmacotherapy (SNRI) (reference: no)

0.141

1.151

0.067

 

2.099

0.036

Specialty pain pharmacotherapy (anticonvulsants) (reference: no)

0.169

1.184

0.064

 

2.635

0.008

Facility-level receipt of clinical practice guideline interventions

% SUD specialty treatment or SUD-specific pharmacotherapies (reference: no)

-0.395

0.673

0.443

128

-0.892

0.374

% Sedative co-prescription (reference: no)

3.409

30.235

1.690

 

2.018

0.046

% Follow-up (reference: no)

-0.440

0.644

0.766

 

-0.575

0.566

% Regular drug screening (reference: no)

-0.481

0.618

0.345

 

-1.393

0.166

% Medication management (reference: no)

-0.560

0.571

0.401

 

-1.396

0.165

% Rehabilitation medicine (reference: no)

-1.156

0.315

0.537

 

-2.152

0.033

% Anti-inflammatory pharmacotherapy (NSAID or acetaminophen) (reference: no)

0.389

1.475

1.286

 

0.302

0.763

% Specialty pain pharmacotherapy (TCA) (reference: no)

-2.453

0.086

1.909

 

-1.285

0.201

% Specialty pain pharmacotherapy (SNRI) (reference: no)

4.130

62.165

1.708

 

2.417

0.017

% Specialty pain pharmacotherapy (anticonvulsants) (reference: no)

2.036

7.659

1.220

 

1.669

0.098

j Overall patient population prescribed LA opioids

k SUD patient population prescribed LA opioids

Table 5 also summarizes results for the SUD-diagnosed group on LA OT. The pattern of individual-level findings was identical to those for the entire LA OT group, except that being currently unmarried was not associated with suicide attempts for patients with SUD. Similar to the entire LA OT group, among SUD-diagnosed group on LA OT, having a mood disorder was highly associated with suicide attempts (OR = 5.9, CI = 4.4–7.8). At the facility-level, SUD-diagnosed group on LA OT within VHA facilities providing more rehabilitation medicine were associated with decreased risk of suicide attempt (OR = 0.3, CI = 0.1–0.9), while SUD-diagnosed patients within VHA facilities having higher sedative co-prescription rates and providing more SNRIs were associated with increased risk of suicide attempt (ORs = 30.2 and 62.2; CIs = 1.1–829.3 and 2.2–1,769.3, respectively).

DISCUSSION

Consistent with expectations, patients with medical frailty, drug/alcohol/mood disorder, and/or traumatic brain injury evidenced higher risk of suicide attempt.

A striking finding was a pattern of conflicting individual-level and facility-level associations with suicide attempts. We believe this pattern suggests that at the individual-level, guideline recommendations were applied to higher-risk patients selectively, as patient receipt of guideline-recommended care was associated with increased risk of suicide attempt across most measures.19 This suggests that, within VA, patients with increased risk of suicide attempt, most likely related to more severe or unmanaged chronic pain or comorbid mental health conditions, tend to receive more intensive, cautious, and comprehensive chronic pain and opioid management. We assume that this association is due to selective treatment of patients with greater pain or mental health severity or risk, rather than to guideline-recommended treatment increasing suicidality. An exception to this pattern was the recommendation to avoid co-prescribing sedative medications with opioids; patients on LA OT and co-prescribed sedatives were at higher risk of suicide attempts at both the individual and the facility level.

Examination of associations between facility-level guideline-recommended care delivery rates and risk of suicide attempt help to determine the value of regular or universal implementation of specific recommendations. Across CSA and LA populations, more consistent use of drug screening was associated with lower risk of suicide attempts. Drug screening is recommended to identify patients who may be using illicit substances or non-prescribed medications, so that the clinician can address risks and engage the patient in treatment for substance use problems. Active substance use is known to increase risk for suicide20; insofar as drug screening is a first step towards helping patients cease active substance use, it should reduce this risk. Moreover, identification of substance use should trigger clinicians to reduce a patient’s access to abusable medications that could be used in a suicide attempt. Reducing access to means of suicide is a well-established method for reducing suicidal behaviors.21 If drug screening causally reduces suicide attempt risk, we estimate that universal drug screening would reduce the risk of suicide attempt in patients prescribed CSA or LA opioids by a factor of 3 to 6 across the models. These findings support the guideline recommendation that all patients considered for or receiving an opioid prescription should be screened for drug use.

Consistently providing follow-up visits to patients initiating new LA opioids was associated with lower risk of suicide attempts. Follow-up within 4 weeks after new opioid prescriptions may help identify patients for whom opioids worsen mental health or are not effective in reducing severe pain. For patients on LA opioids, if follow-up is causally related to risk, consistently completing follow-up encounters within the time frame recommended in the guideline is estimated to reduce the risk of suicide by roughly 5.4 times.

Sedative drugs and/or alcohol are often found in fatal opioid poisonings, both intentional and accidental,22,23 and sedative prescription has been associated with higher risk of fatal accidental drug poisoning24 and suicidal ideation and attempts.25 Here, in both the overall and SUD-diagnosed subpopulation prescribed LA opioids, higher facility-level rates of sedative co-prescription were associated with much higher (20–30 times) risk of suicide attempt. Studies in VA populations have suggested that patients on high-dose opioids and with mental health disorders are more likely to also be co-prescribed sedatives.26,27 Acknowledging that it is possible that suicide attempts are more commonly observed in people co-prescribed opioids and benzodiazepines because these are the most anxious and depressed patients, our findings at the patient and facility levels provide the guideline recommendation that sedatives not be prescribed in combination with opioids, at least for patients on LA opioids.

Studies within and outside VA have suggested that patients diagnosed with SUD and other mental health disorders are more likely to receive opioids than patients without these conditions, and that prescription rates have increased more rapidly in these higher-risk populations.28 VA patients with SUD on chronic OT have also been found to be more likely to show aberrant behaviors that increase drug supply, such as borrowing medication and requesting early refill29; these behaviors may additionally increase risk of impulsive intentional overdose. The guideline suggests that SUD diagnosis should be an absolute contraindication for chronic OT unless the patient is receiving SUD treatment. Our findings support that recommendation: we found that (1) SUD-diagnosed patients have substantially higher rates of suicide attempt overall, and (2) among SUD-diagnosed patients prescribed CSA opioids, more consistent receipt of SUD treatment was associated with reduced suicide risk. If treatment is causally related to risk, universal SUD treatment in this population is estimated to reduce suicide attempt risk by a factor of roughly 3.4.

Encouragingly, SUD-diagnosed patients prescribed LA opioids whose care facilities consistently engaged them in rehabilitative treatments that focus on functional improvement had reduced risk of suicide attempt. These rehabilitative treatments may not only be effective for reducing pain, but may also improve function and decrease disability. Disability may contribute to suicidality30,31; rehabilitative treatments may limit suicide attempts by reducing functional impairment. The finding that SUD-diagnosed patients prescribed LA opioids have substantially elevated suicide attempt risk at facilities where SNRIs are prescribed at higher rates was unexpected, and should be explored in future studies before drawing inferences.

Our analysis has several limitations. First, this study examines associations in cross-sectional data; thus causality and directionality of identified relationships cannot be determined. Additionally, this study relies on administrative coding of diagnoses and adverse events in the electronic medical record. The accuracy and consistency of this coding may vary by provider. Moreover, VA may not be notified of all suicide attempts or deaths. In 2008, however, the VA Uniform Mental Health Services Handbook32 instituted a requirement that all VA facilities employ suicide prevention coordinators, whose role includes reliably documenting and flagging patients with suicide attempts in the medical record to facilitate proper management of these patients. We expect that the availability of these staff at each VA facility improved reliability of suicide attempt coding across VA facilities, though it is likely that there is still some under-counting of events. Additionally, this study looks only at use of practices from the CPG for OT and does not comprehensively consider health care practices that might reduce suicide risk for this population. Lastly, we did not have data regarding the severity of Veteran patient pain intensity, functional limitations, chronicity and response to pain treatments. These factors have associated with suicide risk33 and may underlie some of the associations observed in this study.

The associations identified between use of guideline recommendations for OT and risk of suicide attempt provide a rational basis for prioritizing implementation of guideline recommendations and encouraging facility-level adherence to the prioritized guideline recommendations. Future trials are needed to determine whether implementation of guideline recommendations for OT can reduce risk of suicide attempt for high risk populations. The findings here should help guide development and targeting of implementation interventions for such a trial.

Notes

Acknowledgements

This project was funded by grant RRP 10-106 entitled “Assessment of Gaps in Chronic Opioid Therapy Guideline Adherence” from the VA Substance Use Disorders Quality Enhancement Research Initiative. The authors gratefully acknowledge Dr. Margaret Brandeau for her editorial comments. The views expressed are those of the authors and do not necessarily reflect positions or policies of the Department of Veterans Affairs or of the United States government.

Conflict of Interest

The authors have no conflict of interest to report.

REFERENCES

  1. 1.
    Tang NK, Crane C. Suicidality in chronic pain: a review of the prevalence, risk factors and psychological links. Psychol Med. 2006;36:575–86.PubMedCrossRefGoogle Scholar
  2. 2.
    Ilgen MA, Zivin K, Austin KL, Bohnert AS, Czyz EK, Valenstein M, Kilbourne AM. Severe pain predicts greater likelihood of subsequent suicide. Suicide Life Threat Behav. 2010;40:597–608.PubMedCrossRefGoogle Scholar
  3. 3.
    Breslau N, Schultz L, Lipton R, Peterson E, Welch KM. Migraine headaches and suicide attempt. Headache. 2012;52:723–31.PubMedCrossRefGoogle Scholar
  4. 4.
    Braden JB, Sullivan MD. Suicidal thoughts and behavior among adults with self-reported pain conditions in the national comorbidity survey replication. J Pain. 2008;9:1106–15.PubMedCentralPubMedCrossRefGoogle Scholar
  5. 5.
    Hakansson AF, Schlyter F, Berglund M. Factors associated with history of non-fatal overdose among opioid users in the Swedish criminal justice system. Drug Alcohol Depend. 2008;94:48–55.PubMedCrossRefGoogle Scholar
  6. 6.
    Ilgen MA, Zivin K, McCammon RJ, Valenstein M. Pain and suicidal thoughts, plans and attempts in the United States. Gen Hosp Psychiatry. 2008;30:521–7.PubMedCentralPubMedCrossRefGoogle Scholar
  7. 7.
    Magni GS, Rigatti-Luchini S, Fracca F, Merskey H. Suicidality in chronic abdominal pain: an analysis of the Hispanic Health and Nutrition Examination Survey (HHANES). Pain. 1998;76:137–44.PubMedCrossRefGoogle Scholar
  8. 8.
    Ratcliffe GE, Enns MW, Belik SL, Sareen J. Chronic pain conditions and suicidal ideation and suicide attempts: an epidemiologic perspective. Clin J Pain. 2008;24:204–10.PubMedCrossRefGoogle Scholar
  9. 9.
    Theodoulou ML, Harriss L, Hawton K, Bass C. Pain and deliberate self-harm: an important association. J Psychosom Res. 2005;58:317–20.PubMedCrossRefGoogle Scholar
  10. 10.
    Cheatle MD. Depression, chronic pain, and suicide by overdose: on the edge. Pain Med. 2011;12:S43–S48.PubMedCentralPubMedCrossRefGoogle Scholar
  11. 11.
    VA/DoD Opioid Therapy for Chronic Pain Working Group. Clinical practice guideline: management of opioid therapy for chronic pain (2010). Available at: http://www.healthquality.va.gov/Chronic_Opioid_Therapy_COT.asp. Accessed on January 20, 2015.Google Scholar
  12. 12.
    Chou R, Fanciullo GJ, Fine PG, Adler JA, Ballantyne JC, Davies P, Donovan MI, Fishbain DA, Foley KM, Fudin J, Gilson AM, Kelter A, Mauskop A, O’Connor PG, Passik SD, Pasternak GW, Portenoy RK, Rich BA, Roberts RG, Todd KH, Miaskowski C. American pain society-American academy of pain medicine opioids guidelines panel. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. Clin J Pain. 2009;10:113–30.CrossRefGoogle Scholar
  13. 13.
    Kalso E, Allan L, Dellemijn PLI, Faura CC, Ilias WK, Jensen TS, Perrot S, Plaghki LH, Zenz M. Recommendations for using opioids in chronic non-cancer pain. Eur J Pain. 2003;7:381–386.PubMedCrossRefGoogle Scholar
  14. 14.
    Midboe AM, Lewis ET, Paik MC, et al. Measurement of adherence to clinical practice guidelines for opioid therapy for chronic pain. Transl Behav Med. 2012;2:57–64.PubMedCentralPubMedCrossRefGoogle Scholar
  15. 15.
    Finney JW, Humphreys K, Kivlahan DR, Harris AH. Why health care process performance measures can have different relationships to outcomes for patients and hospitals: understanding the ecological fallacy. Am J Public Health. 2011;101:1635–42.PubMedCentralPubMedCrossRefGoogle Scholar
  16. 16.
    Buscaglia AC, Paik MC, Lewis E, Trafton JA, VA Opioid Metric Development Team. Baseline variation in use of VA/DOD clinical practice guideline recommended opioid prescribing practices across VA health care systems. Clin J Pain. in press.Google Scholar
  17. 17.
    Li Y. Power Analysis for a Mixed Effects Logistic Regression Model. PhD Dissertation. Louisiana State University, Baton Rouge, 2006.Google Scholar
  18. 18.
    Venables WN, Ripley BD. Modern applied statistics with S. 4th ed. New York: Springer; 2002. ISBN:0-387-95457-0.CrossRefGoogle Scholar
  19. 19.
    R Development Core Team (2012). R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. ISBN 3-900051-07-0, URL http://www.R-project.org/.
  20. 20.
    Vijayakumar L, Kumar MS, Vijayakumar V. Substance use and suicide. Curr Opin Psychiatry. 2011;24(3):197–202.PubMedCrossRefGoogle Scholar
  21. 21.
    Mann JJ, Apter A, Bertolote J, Beautrais A, et al. Suicide prevention strategies: a systematic review. JAMA. 2005;294(16):2064–74.PubMedCrossRefGoogle Scholar
  22. 22.
    Toblin RL, Paulozzi LJ, Logan JE, Hall AJ, Kaplan JA. Mental illness and psychotropic drug use among prescription drug overdose deaths: a medical examiner chart review. J Clin Psychiatry. 2010;71:491–6.PubMedCrossRefGoogle Scholar
  23. 23.
    Häkkinen M, Launiainen T, Vuori E, Ojanperä I. Comparison of fatal poisonings by prescription opioids. Forensic Sci Int. 2012;222:327–31.PubMedCrossRefGoogle Scholar
  24. 24.
    Paulozzi LJ, Kilbourne EM, Shah NG, Nolte KB, Desai HA, Landen MG, Harvey W, Loring LD. A history of being prescribed controlled substances and risk of drug overdose death. Pain Med. 2012;13:87–95.PubMedCrossRefGoogle Scholar
  25. 25.
    Brower KJ, McCammon RJ, Wojnar M, Ilgen MA, Wojnar J, Valenstein M. Prescription sleeping pills, insomnia, and suicidality in the national comorbidity survey replication. J Clin Psychiatry. 2011;72:515–21.PubMedCrossRefGoogle Scholar
  26. 26.
    Kobus AM, Smith DH, Morasco BJ, Johnson ES, Yang X, Petrik AF, Deyo RA. Correlates of higher-dose opioid medication use for low back pain in primary care. Clin J Pain. 2012;13:1131–8.CrossRefGoogle Scholar
  27. 27.
    Seal KH, Shi Y, Cohen G, Cohen BE, Maguen S, Krebs EE, Neylan TC. Association of mental health disorders with prescription opioids and high-risk opioid use in US veterans of Iraq and Afghanistan. JAMA. 2012;307:940–7.PubMedGoogle Scholar
  28. 28.
    Edlund MJ, Martin BC, Devries A, Fan MY, Braden JB, Sullivan MD. Trends in use of opioids for chronic noncancer pain among individuals with mental health and substance use disorders: the TROUP study. Clin J Pain. 2010;26:1–8.PubMedCentralPubMedCrossRefGoogle Scholar
  29. 29.
    Morasco BJ, Dobscha SK. Prescription medication misuse and substance use disorder in VA primary care patients with chronic pain. Gen Hosp Psychiatry. 2008;30:93–9.PubMedCrossRefGoogle Scholar
  30. 30.
    Fisher BJ, Haythornthwaite JA, Heinberg LJ, Clark M, Reed J. Suicidal intent in patients with chronic pain. Pain. 2001;89:199–206.PubMedCrossRefGoogle Scholar
  31. 31.
    Pirkis J, Burgess P, Dunt D. Suicidal ideation and suicide attempts among Australian adults. Crisis. 2000;21:16–25.PubMedCrossRefGoogle Scholar
  32. 32.
    Veterans Health Administration, Department of Veterans Affairs. Uniform mental health services in VA medical centers and clinics (2008). Available at: http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1762. Accessed on January 20, 2015.
  33. 33.
    Tang NK, Crane C. Suicidality in chronic pain: a review of the prevalence, risk factors and psychological links. Psychol Med. 2006;36(5):575–86.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2015

Authors and Affiliations

  • Jinwoo J. Im
    • 1
    • 2
    • 3
  • Ross D. Shachter
    • 2
  • Elizabeth M. Oliva
    • 1
  • Patricia T. Henderson
    • 1
  • Meenah C. Paik
    • 1
  • Jodie A. Trafton
    • 1
    • 4
  • for the PROGRES Team
    • 1
  1. 1.Center for Health Care Evaluation, Department of Veterans AffairsMenlo ParkUSA
  2. 2.Department of Management Science and EngineeringStanford UniversityStanfordUSA
  3. 3.Management of Innovation ProgramDaegu Gyeongbuk Institute of Science and TechnologyDaeguSouth Korea
  4. 4.Department of Psychiatry and Behavioral Sciences and Center for Health PolicyStanford University School of MedicineStanfordUSA

Personalised recommendations