Higher Risk of Suicidal Ideation and Suicidal Self-Directed Violence following Discontinuation of Long-term Opioid Therapy
Recent clinical guidelines, including the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain and 2017 VA/DoD Clinical Practice Guideline on Management of Opioid Therapy for Chronic Pain, discourage use of opioids as a primary analgesic therapy. Despite this, 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. 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. The study cohort included 300 patients with a substance use disorder (SUD) diagnosis and 300 propensity score-matched patients without a substance use disorder diagnosis. All patients had been prescribed long-term opioid therapy for chronic (non-cancer) pain, with 509 Veterans discontinued from opioid therapy by their opioid-prescribing clinician. Patient electronic health records were manually reviewed to identify discontinuation reasons and the presence of SI or SSV in the 12 months following discontinuation.
- A substantial proportion of Veterans with SUD diagnoses and similar matched patients experienced suicidal ideation or suicidal self-directed violence following discontinuation of long-term opioid therapy by their opioid-prescribing clinicians, most of whom represent new onset cases. Approximately 12% of patients in this sample (n = 59) had SSV and/or SI documented in the medical record in the 12 months following discontinuation of opioid therapy: 47 patients had SI only, while 12 had SSV.
- Half of patients with SSV attempted suicide by overdose, most commonly with benzodiazepines.
- Mental health diagnoses associated with having SI/SSV included PTSD and psychotic disorders.
- The majority of patients (75%) were discontinued from opioid therapy due to aberrant behaviors.
- Healthcare providers should pay special attention to safety when patients are discontinued from long-term opioid therapy, particularly patients with PTSD or psychotic disorders.
- Investigators excluded patients who had died in the year following discontinuation of opioid therapy. Thus, the study sample may underestimate the proportion of Veterans that experienced SI/SSV.
- SI/SSV was ascertained based solely on medical chart review, which likely underestimates actual rates of SI/SSV in this patient population.
- Cohort size limitations precluded an examination of demographic, medical comorbidity, and other clinical variables associated with SSV alone.
- As the study focused on opioid discontinuation, impacts of opioid tapering were not examined.
This study was funded by HSR&D, and Dr. Lovejoy is supported by an HSR&D Career Development Award. All authors, except Dr. Ilgen, are part of HSR&D's Center to Improve Veteran Involvement in Care (CIVIC), Portland, OR.
Demidenko M, Dobscha S, Morasco B, Meath T, Ilgen M, and Lovejoy T. 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.