Individual- and Facility-Level Factors Associated with Higher Risk of Suicide Attempt among Veterans Receiving Opioid Therapy
BACKGROUND:
In 2010, VA and the DoD released a clinical practice guideline for the Management of Opioid Therapy for Chronic Pain (CPG for OT). Following this, guideline-recommended practices were evaluated, and findings across VA showed that for some recommendations facility rates were consistent, but there was incomplete adherence, and rates of adherence varied greatly across facilities. This retrospective study examined the associations between the receipt of guideline-recommended care for opioid therapy and risk of suicide-related events, assessing associations between individual-level and facility-level delivery of recommended care, and individual-level suicide-related events. Using VA administrative data, investigators identified all VA patients who were prescribed any chronic short-acting (CSA) opioids on a chronic basis – or any long-acting (LA) opioids from VA providers during FY2010. During this period, 487,462 Veterans received a prescription for opioid therapy (81% received CSA opioids and 19% received LA opioids) at any of 139 VA facilities. Possible patient risk factors also were examined, including physical and mental health status.
FINDINGS:
- Within 180 days following opioid prescription, 6,482 patients (1.6% of study population) on CSA opioids and 1,981 patients on LA opioids (2.1% of population) experienced suicide-related events.
- At the individual level, Veterans who received opioid therapy and had medical frailty, drug, alcohol, or mood disorder, and/or traumatic brain injury had a higher risk of suicide-related events.
- Patients on opioid therapy within VA facilities that ordered more drug screens were associated with a decreased risk of suicide-related events. Patients on long-acting opioid therapy within facilities that provided more follow-up after new prescriptions also were associated with decreased risk of suicide-related events. Patients on long-acting opioid therapy within facilities having higher sedative co-prescription rates had an increased risk of suicide -related events.
- Among the sub-population of patients with a substance use disorder and a short-acting opioid prescription, the facility rate use of specialty substance use disorder treatment was associated with lower risk of suicide-related events.
LIMITATIONS:
- This study examined associations in cross-sectional data, thus causality and directionality of identifed relationships could not be determined.
- This study relied on administrative data; accuracy and consistency may vary by provider.
- VA may not be notified of all suicide-related events, attempts or deaths.
IMPACT:
- Encouraging facilites to make more consistent use of drug screening, providing follow-up within four weeks for patients initiating new opioid prescriptions, avoiding sedative co-prescription in combination with long-acting opioids, and engaging patients with substance use disorders in specialty substance use treatment, may help prevent suicide-related events.
AUTHOR/FUNDING INFORMATION:
Drs. Oliva, and Trafton are part of HSR&D's Center for Innovation to Implementation. This study was funded by VA HSR&D's Quality Enhancement Research Initiative (RRP 10-106).
Im J, Shachter R, Oliva E, Henderson P, Paik M, and Trafton J for the PROGRES Team. Association of Care Practices with Suicide Attempts in US Veterans Prescribed Opioid Medications for Chronic Pain Management. Journal of General Internal Medicine. July 2015;30(7):979-991.
