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

Abstract

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