Pain, Opioids, and Suicide

Stephanie Nichols, PharmD, BCPS, BCPP, FCCP
Associate Professor of Pharmacy Practice
University of New England

This session is available at https://aapp.org/ed/course/pain-opioids-and-suicide

“Deaths of despair”, including overdose and suicide, are rising in the United States.¹ How did we get here and how do we treat patients with chronic pain, while minimizing the risk of opioid overdose and death by suicide?

Dr. Noah Nesin, MD, FAAFP, shared his experience with treatment of pain, compassionate opioid tapering, and suicide prevention during CPNP’s 2020 Annual Meeting. His live, virtual presentation, titled Pain, Opioids, and Suicide, was full of point-of-care tools and tips. Dr. Nesin is the Chief Medical Officer of Penobscot Community Health Care.

The session began with an audience poll involving consideration of the most important piece of information needed in a given case. The majority of participants would explore a “history of suicidal thoughts or suicide attempts”, but many other participants felt it was important to learn about “other substance use history” or to assess “psychological trauma history”. Dr. Nesin explained that all of these were important, but that history of trauma may be particularly important to consider and is sometimes missed.

Dr. Nesin detailed four myths that led to the current opioid crisis. First, opioids are effective and appropriate for chronic pain. Next, opioids are safe for chronic pain. Third, he described the data² that led to the myth that the risk of addiction was low with opioids use in “legitimate” pain. Finally, he described the myth of pseudoaddiction and stated it was the most pernicious. Dr. Nesin explored the complex interplay between pain, opioids, overdose, and suicide, listing alterations in reward neurocircuitry that arise with pain and describing the association of opioid dose with deaths of despair. Suicide risk factors and rates were detailed, with the highest rates in people who are white, middle-aged, and male.³

The risk of overdose and death by suicide can be reduced by employing compassionate opioid tapering and intensive engagement after the taper. He went on to describe that compassionate opioid tapering information should be disseminated to a wide range of providers and via a variety of methods. Dr. Nesin listed multiple platforms to disseminate this information including publications, one-on-one academic detailing sessions, and virtual community provider education. An example of scripting was provided. Other tools were presented for clinicians to employ in their practices. Suicide prevention tools that were described in the presentation include: Stratification Tool for Opioid Risk Mitigation (STORM), Suicide Assessment Five-step Evaluation and Triage, Current Opioid Misuse Measure, and The Zero Suicide Model.⁴

An audience poll towards the end of the session asked participants to assess a case and identify which option they would avoid doing. This case described a patient with treated depression and who has just completed an opioid taper. A vast majority of participants (88%) responded that it would be inappropriate to “ask the patient to schedule a follow-up appointment in 3 months”.

The session closed with a call for action asking participants to “attend to potential suicidality by properly assessing for risk factors associated with suicide and for suicidality itself, by assessing for misuse of opioids and OUD, by offering evidence-based treatment for chronic pain, mental illness, trauma, and substance use disorders, and by using evidence-based interventions for suicidality”.

There were many questions and more responses are available on the CPNP website. One audience member asked about the risk of suicide being higher in those with undertreated pain despite high opioid doses. Dr. Nesin responded by referring to the data³ and described the likely influence of opioid-induced hyperalgesia. A question was posed regarding methods of prescriber education regarding compassionate tapering versus abrupt discontinuation. Dr. Nesin stated that convincing providers of the value, employing them with skills including scripting, and talking about patient safety are key steps to facilitate this important education.

Take-Home Points

1. Deaths of despair, including opioid overdose and suicide, are rising.
2. Chronic pain, opioid use disorder, mental illness, adverse childhood experiences, and chronic daily opioids increase suicide rates.
3. Opioids are not known to be effective for chronic pain and are often harmful.
4. Quality of life and function improve when opioids are tapered compassionately and evidence-based and multimodal interventions for chronic pain are used.
5. Intensive engagement after tapering is critical and reduces the risk of death by suicide.

References

1. Case A, Deaton A. Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century. Proc Natl Acad Sci Usa. 2015;112(49):15078- 15083. DOI: 10.1073/pnas.1518393112. PubMed PMID: 26575631; PubMed Central PMCID: PMC4679063.
2. Porter J, Jick H. Addiction Rare in Patients Treated With Narcotics. N Engl J Med.1980;302(2):123.
3. Bohnert ASB, Ilgen MA. Understanding Links among Opioid Use, Overdose, and Suicide. Ingelfinger JR. N Engl J Med. 2019;380(1):71- 79. DOI: 10.1056/NEJMra1802148. PubMed PMID: 30601750.
4. Oliva EM, Bowe T, Tavakoli S, Martins S, Lewis ET, Paik M, et al. Development and applications of the Veterans Health Administration’s Stratification Tool for Opioid Risk Mitigation (STORM) to improve opioid safety and prevent overdose and suicide. Psychological Serv. 2017;14(1):34- 49. DOI: 10.1037/ser0000099. PubMed PMID: 28134555.