Health Services Research & Development

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Opioids

Opioid Risk Reduction and Suicide Prevention

December 20, 2017

In 2017, VA health services researchers published 64 journal articles examining the burden of suicide and risky opioid use among Veterans—and testing strategies to address these dual VA priorities. Findings from these research studies have helped shape VA programs including the Opioid Safety Initiative, the Recovery Engagement and Coordination for Health—Veterans Enhanced Treatment (VA REACH-VET) program, as well as other elements of VA's suicide prevention strategy.

Key Findings in 2017

  • Fewer Veterans are receiving high doses of opioids or concomitant interacting medicines such as benzodiazepines, and more Veterans are receiving non-opioid pain therapies, naloxone, and treatment for substance use disorders. [Gellad WF, Good CB, and Shulkin DJ. Addressing the opioid epidemic in the United States: Lessons from the Department of Veterans Affairs. JAMA Internal Medicine. May 2017;177(5):611-612.]

  • Veterans who use both VA and Medicare pharmacies to fill opioid prescriptions are three times as likely to be taking unsafe levels of opioids. [Suda K, Smith B, Bailey L, et al. Opioid dispensing and overlap in Veterans with noncancer pain eligible for Medicare Part D. Journal of the American Pharmacists Association. May-June 2017;57(3):333-340.]

  • Among Veterans who discontinue long-term opioids, the decision to do so is initiated by clinicians 85% of the time, usually (75% of the time) because patients have exhibited aberrant behaviors associated with opioids. [Lovejoy T, Morasco B, Demidenko M, et al. Reasons for discontinuations of long-term opioid therapy in patients with and without substance use disorders. Pain. March 2017;158(3):526-534.]

  • Approximately 23% of all OEF/OIF Veterans received opioid medications, usually moderate doses for short periods (median 30-40 days). The strongest risk factor for chronic use of opioids was back pain. [Hudson T, Painter J, Martin B, et al. Pharmacoepidemiologic analyses of opioid use among OEF/OIF/OND Veterans. Pain. June 2017;158(6):1039-1045.]

  • A systematic review of 67 studies found several types of interventions have been shown to be effective for reducing dose among long-term opioid users, and studies suggested reductions resulted in improved pain, function, and quality of life. [Frank J, Lovejoy T, Becker W, et al. Patient outcomes in dose reduction or discontinuation of long-term opioid therapy: A systematic review. Annals of Internal Medicine. August 2017;167(3):181-191.]

  • An analysis of 13 years of data across all VHA inpatient mental health units reported 141 reports of suicide within 7 days of discharge, and a large proportion (43%, n = 61) followed an unplanned discharge. Flaws in the design and execution of processes of care as well as deficits in communication may contribute to post-discharge suicide. Inpatient teams should be aware of the potentially heightened risk for suicide among patients with unplanned discharges. [Riblet N, Shiner B, Young-Xu Y, et al. Death by Suicide Within 1 Week of Hospital Discharge: A Retrospective Study of Root Cause Analysis Reports. The Journal of Nervous and Mental Disease. June 2017; 205(6):436-442.]

  • Among 509 Veterans whose clinicians discontinued opioids, 9% had suicidal ideation and 2% suicidal selfdirected violence. [Demidenko M, Dobscha S, Morasco B, et al. Suicidal ideation and suicidal self-directed violence following clinician-initiated prescription opioid discontinuation among long-term opioid users. General Hospital Psychiatry. July-August 2017;47:29-35.]

  • A comprehensive review of suicide prevention among Veteran and military populations found 6 of 8 population- level interventions lowered suicide rates. [Nelson H, Denneson L, Low A, et al. Suicide risk assessment and prevention: A systematic review focusing on Veterans. Psychiatric Services. October 1, 2017;68(10):1003-1015.]