Good afternoon and welcome to this webinar with Dr. Hilary Connery on Preventing Suicide and People with Opioid Use Disorder. This webinar is sponsored by the Suicide Prevention Resource Center in collaboration with American Psychiatric Association. Before Dr. Connery begins the presentation, we have just a few housekeeping items. Next slide. SPRC at the University of Oklahoma Health Science Center is sponsored by a grant from the Substance Abuse and Mental Health Services Administration or SAMHSA. The views, opinions, and content expressed in this product do not necessarily reflect those of SAMHSA or the Department of Health and Human Services. Next slide. There are no conflicts of interest to report for this webinar. Next slide. SPRC is the only federally funded resource center devoted to advancing implementation of the National Strategy for Suicide Prevention. Supported by SAMHSA, SPRC builds capacity and infrastructure for effective suicide prevention by working with state, tribal, health, and community systems, as well as professionals, partnerships, and other stakeholders. Next slide. We would like to make you aware that this activity is accredited and implemented by APA, which has designated the activity for one PRA Category 1 credit. Next slide. The handout for today's webinar can be downloaded from your screen. If you're using the desktop version of GoToWebinar, the file is located in the handouts area of the attendee control panel. If you've joined from the instant viewer, click the page symbol to display the handout icon. Next slide. During the Q&A portion of the webinar, you can use the questions area of the control panel to ask questions, which the speaker will address at the end of the presentation. Next slide. Now I'd like to introduce today's speaker, Dr. Hilary Connery. Dr. Connery is an assistant professor of psychiatry at Harvard Medical School and clinical director for McLean Hospital's Division of Alcohol, Drugs, and Addiction. Her expertise includes treatment of opioid use disorders and integrated treatments for co-occurring mental illness and substance use disorders. She is a distinguished fellow of the American Psychiatric Association and has served within the American Academy of Addiction Psychiatry as the New England Area Director, co-chair of the Policy Committee, and as a mentor through the National Providers Clinical Support System. She is an active researcher and advocate for more effective responses to suicide and drug overdose evidence. Dr. Connery, thank you and welcome. Thank you everybody. Is my sound okay? Yes. Great, thanks so much. Okay, so let's go into this. I'm going to be covering a lot of materials, so I'm going to move through it fairly quickly so that we can get to question and answers, and we'll start with the section here on suicide and substance intoxication. Just for some background, the Institute of Medicine in 2002 made it a national imperative that we reduce suicide, but also noted that there were barriers to doing so, some of which included that research on suicide is plagued by methodological problems, that definitions of suicide lack uniformity, that investigation and reporting of suicide is inaccurate and dependent on regional medical examiner and coroner resources, which, as everybody knows, in the era of both the opioid epidemic and now the pandemic, is more taxed than ever, and that some jurisdictions tend to call any deaths with prominent intoxication an accident. This raises the issue of suicides that may be missed in the setting of substance use disorder, and so we'll be looking at that topic today. For today's talk, I'd like to define suicide here for you so that we all understand what we're talking about. Suicidal self-directed violence has been defined as behavior that is self-directed and deliberately results in injury or the potential for injury to oneself. There is evidence, whether the evidence is implicit or explicit, of suicidal intent. Explicit evidence would be things that you can see, tangible things that are clear, such as a suicide note written by the person, finding internet searches for suicide methods, finding on social media a declaration of wanting to kill oneself, or a final communication to others. Implicit evidence is evidence that really conveys that it would be very difficult to find an alternative explanation. If somebody kills themselves in their own home with their own firearm, it would take evidence to say that that was not a suicide because the implicit circumstances suggest that that person had intention to die and means to die. Similarly, on your own property or being found in your own garage, a victim of carbon monoxide poisoning. Substance use itself is not implicit evidence of suicidal intent. Just a quick survey for any of you who may not be treating people with substance use disorder. This is a good way to remember the DSM-5 criteria. There are 11 criteria for substance use disorder that are scaled from mild to severe. A way to remember quickly in your assessment is what we call the three C's, which stand for control, craving, and consequences. You ask, over a 12-month consecutive period, was there any evidence of loss of control overtaking the substance? If the substance is not used in a safe and appropriate or self-regulated way, was there craving in the absence of the substance to use the substance? Does the person anticipate substance use with an urgency that seems disproportionate to other drives? Finally, consequences in that substance use is observed to be associated with negative health or other social outcomes. Those are the three C's that will help you to detect substance use disorder in a patient evaluation. There are many things that are known about substance intoxication and suicide. Some of these facts include that people with alcohol use disorder and opioid use disorder have 10 to 15 times higher rates of suicide deaths than the general population. People with substance use disorder have elevated suicide risk even during periods of remission from substance use or sustained abstinence. Alcohol and opioid intoxication is associated with more lethal suicide behaviors. All substance misuse is significantly associated with increased risk for experiencing suicidal thoughts and behaviors. One in four suicide deaths involve alcohol and one in five suicide deaths involve opioids. Why might substance use be associated with suicide risk? Substance use disorder and substance intoxication are significantly associated with impulsive behaviors and novelty seeking. Substance use disorder has high rates of co-occurring depressive disorders as well as grief. Depressive disorders themselves also elevate substance intoxication, which is a risk factor for acting on suicidal thoughts. Especially among opioid use disorders, frequent exposures to premature mortality. Knowing many people who have experienced a drug overdose death, which is really the common case for most severe substance use disorder patients with opioid use disorder, this constant interaction and contact with early death due to overdose may desensitize them to death and thereby increase their acquired capacity for self-harm behavior. When we think about suicide, that's an unnatural behavior. One of the theories about how people become more actively suicidal is that it's a learning process and they over time acquire more of an inclination towards behaving in ways that will end their own life. Then finally, there may be shared biological and social factors for substance use disorder as well as suicide risk. If we aim to save lives, first we need to understand the deaths that are happening. In other words, what are the right interventions for different categories of cause of death? One of the problems we have with drug poisoning deaths is that it's not easy for a coroner or medical examiner to determine whether or not there was an actual intention to die at the time of death. We can see that reflected in the data that when you compare suicide deaths by drug poisoning to suicide deaths by firearm or hanging, those that are classified as suicides, which are drug poisoning, will have almost twice the number of suicide notes documented, meaning really reflecting that without that note it's much more difficult to classify a drug poisoning death as intentional versus unintentional. This is national data I'm showing about U.S. deaths between 2015 and 2020. You can see, as many of you know, that deaths due to unintentional injuries have been rising, predominantly driven by opioid-related overdose deaths and other drug poisoning deaths. There's been an 11 percent increase. Actually, sadly, the numbers continue to rise with respect to drug poisoning deaths. I think it's also worth pointing out that these rates are up disproportionately among Black populations. When we look over time at suicide rates, we see that there has recently been a 5.6 percent decrease reported, which is good news and may mean that our suicide prevention efforts have been working, particularly in five states, with emphasis on prevention and firearm control. For one thing, there is also a racial disparity here nationally. The decrease seems to be mostly among White populations and not others. There is the question, as the drug poisoning deaths are increasing and suicides are decreasing, whether or not there may be some of those drug poisoning deaths that are actually misclassified suicides. We don't know. There's no way to know, but these are the trends that have been reported. In Massachusetts, if you look at suicide deaths between 2019 and 2020, we do see decreases among Whites and Blacks, but actually increases among Asians and Hispanics. Again, it's important to keep thinking about racial disparities in terms of how populations are being affected by trends. This is a study from South Carolina looking between the years of 2012 and 2013 about all pairs of adult services that provided services for people who admitted with intentional drug overdose. What they reported were significant racial disparities. Most importantly, non-Hispanic Blacks and people of other races and ethnicities were less likely than non-Hispanic Whites to receive a mental health assessment during a hospitalization for a deliberate drug overdose. That's something that was reported back then. This is data from back then and just reported recently in 2019. I think this is an area that we need to be following very closely so that suicide prevention efforts are received equally among all populations. Similarly, non-Hispanic Blacks were less likely than non-Hispanic Whites to be discharged to an inpatient psychiatric facility rather than to home after hospitalization for a deliberate drug overdose. Then persons with Medicare or private or other insurance were more likely than persons without insurance to be discharged to an inpatient psychiatric facility than to home following deliberate drug overdose hospitalization. Moving to what are the thoughts that may be associated just prior to an overdose in an opioid user. If you think about it, I use this graphic to try to emphasize that all these different cognitions from unintentional to fully intentional can be associated with overdose behavior, which can result in death or non-fatal overdose. On the fully unintentional side, a person may be thinking, I don't think I will die even though I'm misusing opioids and I know that there's risk with misusing opioids, but I don't think I'm going to die. Then fully intentional, my life is pointless, the despairing person who's stuck in opioid addiction saying, you know what? I give up. Today is a good day to die. Then there's a spectrum of thoughts that may be in between. If I were to die by opioids, that wouldn't be the worst way out. Not really intentional, but it's pretty ambivalent about their life. Then some who may say, mostly I don't want to die, but sometimes I do. Sometimes there's some intentionality, most of the time there's not. Then there are those who really just don't care. You'll hear this a lot from patients with opioid use disorder and other severe drug use disorders. If I could just go to sleep and never wake up, that would be fine by me. Again, not fully intentional, but really biased more toward life isn't worth living. Following this, we conducted studies, which are just cohort studies, to try to better understand desire to die and survivors of opioid overdose. We did this at McLean Hospital on the inpatient detoxification unit. Of 120 adults who came in with opioid use disorder, 41% female, mean age about 34, and most of them white. 45% of them reported a history of having survived an opioid overdose, which was defined very strictly as either requiring a naloxone rescue or having been requiring other medical intervention or been witnessed by somebody as they stopped breathing. When we asked them to please tell us how much desire to die they had just prior to the most recent overdose, we used a rating scale of zero to 10, where zero was I had no desire to die at all, and 10 was I definitely wanted to die. What we found was there was a spectrum of results where those reporting absolutely no desire to die at all were not that many more than those reporting I had a very strong desire to die just prior to my opioid overdose, so a rating of seven to 10, and then some self-reports that were in between, suggesting that if somebody is thinking about I want to die, is this something that we should be paying attention to as a prevention target? Maybe it's a cognition that biases risk taking. Maybe it's a cognition that makes it more likely that patients are going to be more dangerous or reckless in their drug use if they're already thinking about life's not that worth living. We did another study to replicate this and then also to look more closely at suicidal intention because desire to die is not the same thing as planning to kill yourself. Again, this was a small cohort, 59 opioid use disorder patients entering care with history of non-fatal overdose. We asked them just before your most recent overdose, how strongly did you want to die? Again, the same scale, zero to 10. I didn't want to die at all. I definitely wanted to die. We also asked, were you trying to kill yourself with zero being no, not at all, and 10, I was definitely trying to kill myself. These are the results. We essentially replicated the spectrum of responses on desire to die between none, low, moderate, and high. Then also found that while 80% of them reported no, I was not trying to kill myself, 20% of them endorsed that they actually had some intent to kill themselves prior to overdose. I think that these data are suggestive that the area needs more research. They're also suggestive that we should be perhaps thinking more uniformly, more universally around suicide prevention interventions with this very high-risk population of opioid use disorder. Back to the problem of what can we learn by studying overdose deaths, this is just a sample to essentially show that the ideal forensic investigation following an overdose death is actually pretty extensive and most deaths are not gonna have the benefit of this full ideal evaluation. There has been study of psychological autopsies of opioid positive deaths that have been classified into either accident or suicide. So I just show this because this is a little bit of the beginning of investigation that does tell us some useful things. Again, small numbers, 19 in each category, but there were no demographic predictors of whether or not an opioid positive death would be classified as accident or suicide. Both groups had multiple non-fatal suicide attempts. So a prior history of suicide attempt really didn't discern the two. And they were equal in multiple variables reflecting psychosocial stressors such as homelessness and incarceration. Neither differed by treatment receipt for substance use disorder, mental health or medication for opioid use disorder. Some of the findings were that in the accident category, there were more men than women associated with that, more severity in the substance use disorder, more likely to have a prior non-fatal overdose and family conflict being associated with it. In the suicide category, any depressive disorder, death planning or preparation was more likely to be found and number of total lifetime stressors was greater in the suicide category. So it does suggest here that we might wanna focus specifically in the opioid use disorder population on being better at diagnosing and treating any depressive disorder and also screening these patients for death planning or preparation. In addition to that, it would be useful to educate patients and families how to recognize and respond to suicide planning and preparation. And one note that I have here about the prior non-fatal overdose being associated more with accident, there is evidence in large population studies that prior non-fatal overdose is associated with both future fatal overdose and future suicide. So that's something worth keeping in mind. Suicide and opioids, what do we know from the literature? A lot of associations, so opioid users have elevated mortality risk for both drug poisoning and suicide, roughly three times that compared to the general population. And this risk persists into late life. We also know that it's not particularly important what type of opioid is being used or what it's being used for, that all opioid categories seem to carry this risk for increased suicidal planning and thoughts and attempts. So whether it's illicit or prescription opioid misuse, full opioid use disorder, or just chronic opioid prescription for pain, all of these have been associated with elevated risk. We also know from some studies that patients who are prescribed opioids for chronic pain who are known to be suicidal do self-report that they think about using their prescribed opioids as a means of suicide. We also know that suicide risk in opioid users is further elevated if it's combined with alcohol misuse. So the combination of alcohol and opioids is quite dangerous. And then among drug poisonings, opioids are five times more likely compared to any other substances that be lethal. Some novel risk screening tools have been piloted that look at screening for risk for overdose and suicide, but there's no evidence-based current standard that's currently in use. I also think when we talk about suicide, it's important to note that suicide is not associated with one type of mental health disorder, and it also doesn't always present as a single phenotype or a similar presentation behavior. So while they may look different between mental health disorders, all of them may be lethal. And it's important to remember this because sometimes depending on what the presentation is, people are treated as more or less of a suicide risk with some history of certain presentations being treated as just attention-seeking and not taken very seriously. Yet all of these folks presenting have elevated risk for dying by suicide. So here are some examples among psychotic disorder patients. The presentation may be that their hearing auditory command hallucinations to die and acting on that. Among mood disorders, you see both impulsive suicidal behavior or very carefully planned suicidal behavior. Among personality disorders, there's often suicidal behavior that follows a perceived interpersonal conflict. In substance use disorders, we often see suicidal thoughts and behaviors as a transient reaction to stress or reckless risk-taking when their life becomes intolerable. And this kind of presentation can also normalize relatively quickly compared to some other syndromes, which I think tends to give the false impression that somebody sobers up and therefore they no longer have suicide risk. But in fact, the suicide risk is persistently elevated. And then finally, you don't have to have a mental health condition in order to have risk for suicide. And frequently when we see this in people without a mental health condition, it happens in the context of some stressor that is a serious threat to the person's identity or security. I point you all to this opioid project, which we collaborated on, which you can find at the website listed here. Essentially, we were interested in having, inviting patients who had opioid use disorder of different types and a significant other to participate in essentially a narrative and expressive art activity where they painted pictures and wrote a brief narrative about their experience and then had an audio recording attached to it. And it's really, these kinds of interventions can be very healing for people. But this is an example of somebody participating who really displays the darkness and bleak shadows, as he referred to them, on one side of active severe addiction and the sunlight of recovery on the other. And talks about the pictures of my mom and I walking with our shadows show all the times we have felt lost or in limbo. I felt lost and so did my mom. She didn't know what to do. And I think it's important to remember that for many people with significant opioid use disorder, this feeling of being trapped, of being in some sort of a hopeless state that I can't break out of it and I keep relapsing. These are all the contexts in which it's likely that somebody is going to experience more depressive symptoms and potentially suicidal thoughts, plans, or behaviors. Let's go over some of the suicide warning signs. You might think of direct warning signs that require immediate actions to ensure a person's safety. And these would include the person communicates the desire or plan to die. The person is seeking means with which to end their life. This can include internet searches, purchase of firearm or another type of weapon, stockpiling their pills. Person is making final arrangements, saying goodbye to others, giving away their possessions. And then there are less direct warning signs, which really require further assessment for suicidal intent. And these could include examples such as a marked shift in mood, anxiety, or behavior, severe and persistent insomnia, relapse following a period of stability, agitation or rage, isolation, hopelessness, expressing that they feel like they don't belong, feeling like a burden to others, and family and significant others saying that this person's really just behaving differently, they're not him or herself. And then finally, recklessness that's atypical for the person's profile. We'll go over some of the determinants of risk and protection. So risk factors and protection. Here, a question that comes up a lot is what's the strongest predictor of future suicidal behavior? And among all of these possibilities that are associated with elevated risk for suicidal ideation, really suicide attempt is documented as the number one risk factor that is most consistently a predictor of future suicidal behavior. Among those with opioid use disorder entering treatment, 30 to 45% report at least one prior suicide attempt. So although this is not a modifiable factor, it's a factor that really highlights that they are at risk for future suicidal behavior and can be an important point of education if you're evaluating somebody entering treatment who has this history. Risk factors for suicide, more modifiable targets include stabilization of substance use disorders, other mental health disorders that require stabilization, sleep disorders, especially if somebody has a persistent and chronic insomnia, chronic pain disorders, and then trauma exposures, especially if they are recurrent because of the environment in which somebody lives or works. Likewise, there are many social determinants that are risk factors for suicide. And some of these are housing and food insecurity, social isolation, unemployment, having a firearm in the home, having domestic violence in the home, family stressors, healthcare access problems and barriers, and legal stressors. So as you can see, predicting suicide is a little bit complex because there are so many variables that serve as risk factors for suicide. In general terms, the more variables, the more elevated the risk is going to be. But all of these are things that can be addressed with social services and treatment. Protective factors against suicide, sort of the opposite of the last list. So biological determinants of good health and wellbeing, which could include a reduction in harmful substance use and ideally abstinence from substance use, as well as recovery care for all mental health disorders. Good sleep hygiene, adequate pain relief. And on the social side, security of food, housing, safety, and economics. Community alliances, having social connections and belonging. This is a very important piece because part of what we do in treatment is provide a link within that community support and connection. So never underestimate the value of your own therapeutic alliance with a patient in terms of preventing suicide. Also positive shared spiritual beliefs and connections are protective factors. And of course, having no firearm in the home and no substances in the home reduces lethal means and is therefore protective. Go over some prevention algorithms. I want to direct your attention to free resources that have wonderful online training and information as well as services that you can sign up for. So the Zero Suicide Organization provides a toolkit and I really encourage all of you to explore what they have to offer because it's very comprehensive. And from a structural point of view, they really emphasize having the organization really trained to recognize and know what their particular role is in suicide prevention for every person that's employed at the organization. They also have a nice emphasis on using tools that are integrated into the electronic health record as a way of guiding and tracking suicide prevention efforts. The Suicide Prevention Resource Center obviously is a fantastic place to find all kinds of information, training programs, and these are all free and available to you at any time. So there are online courses such as locating and understanding data for suicide prevention, a strategic planning approach to suicide prevention, there are courses on means reduction. So these are resources that are available to everybody and I really encourage you to explore what they may be able to do for your practice. Safety planning is something that you wanna think about as an ongoing longitudinal aspect of your treatment. With the first layer being that all during treatment, you're looking to identify risk factors so that you can help plan mitigation of risk. So this would include ongoing screening assessment and means reduction. And here's just a list, it's not an exhaustive list, but a list of common things that you're gonna be identifying as risk factors. Similarly, throughout treatment, you really wanna work closely to personalize the treatment by helping the person to identify their personal patterns and phenotypes. So when they're at greater risk for self-harm, what are the types of thoughts they generally start to have? What are behaviors that start to change? How does their mood change? Does their sleep change? And common triggers such as people, places and things. And then we're helping them to organize this as a way of enhancing their positive coping and being able to tolerate having these thoughts without actually acting on them. So positive coping can include just the skills of self-assessment and how to reach out for help when they recognize that their risk has gone up, creating reasons to live, really nurturing their connections to others, an emphasis on medication adherence, particularly when we're talking about medications for opioid use disorder and other mental health disorders, but also with respect to all medical disorders they may be living with. Abstinence as a goal of treatment, not always possible, but certainly good harm reduction to try to reduce risk associated with substance use. And then physical and spiritual self-care. When we talk about safety planning, this is sort of the global idea about safety planning, that it's a collaborative effort between the clinician and the patient. And one of the most widely adopted evidence-based safety planning tool is the Stanley Brown safety plan form. And they have a website that you can access at suicidesafetyplan.com, which also includes some brief online training videos. I encourage everybody to look at those and become familiar if you're not already. Here's some sample suicide risk screener item content, pulled from the PHQ as well as the Columbia suicide screening. So some that look at identification of depression, have you felt down, depressed or hopeless? Have you felt little interest or pleasure in doing things? And then on ideation or lifetime attempts, you have these items that ask, have you wished you were dead? Wished you could go to sleep and not wake up? Have you actually had thoughts of killing yourself? Have you ever attempted to kill yourself? And then how recently was that? The ASQ is a four item age appropriate suicide screening that's evidence-based and in the public domain. And it asks these four questions. This is the adult version. In the past few weeks, have you wished you were dead? Yes or no. In the past few weeks, have you felt that you or your family would be better off if you were dead? In the past week, have you been having thoughts about killing yourself? Have you ever tried to kill yourself? And then if there's any yes response to these four questions, there's a fifth question. Are you having thoughts of killing yourself right now? And then the next steps would be if the patient answers yes to the question about, are you thinking about killing yourself now? That's obviously the highest level of safety concern and you really need to contain the patient and make sure that an appropriate disposition will happen. With a mental health evaluation. If the answer to that is no, you still wanna do a suicide safety assessment and determine whether or not mental health evaluation is needed immediately at that time. It's universal, good practice to provide suicide prevention resources to all patients, which include the National Suicide Prevention Lifeline and the Crisis Text Line. Most of you have local resources as well. Patient engagement is such an important aspect of personalizing safety planning. So thinking about with the patient, what are their patient-specific warning signs, asking them who can support you and how can they support you, what can you do to reduce risk, what are you willing to do to reduce risk, encouraging them to put some of these things down on a written pocket reminder, which also may include important phone numbers, whether those are the crisis hotlines or phone numbers of people in their inner support circle, making connections with their other supports in the community to help engage them in risk management as well, use of medications that will target all of these active risk factors, using peer supports linkage and carrying outreach contacts, very helpful in keeping a patient engaged. Here are some conversation starters with opioid use disorder patients that I would recommend. Has it gotten so bad that you wished you were dead? I know that you're telling me about your relapse, but I'm actually more concerned that you're spending time thinking about your own death. You told me that you planned to use last week and that you were not going to carry your naloxone kit with you, which is different from before. What do you think about this? You're taking more risks than you usually do. What's going on? Here's access to the calm course, counseling on access to lethal means. It teaches you how to reduce access and will help you learn about how to counsel people who may be reluctant to part with lethal means. When you're treating a patient with substance use disorder, your means reduction should also include these following items, removing alcohol and drugs from the home whenever possible, removing controlled substance prescriptions when necessary, such as in a period of elevated risk, and monitoring all prescription supplies so that they're not stockpiling them. Checking the prescription drug monitoring program is just good to do as a matter of routine to make sure that they're not finding multiple sources for lethal means. Then on the harm reduction front, reducing the number of substances used with a special emphasis on lethality. If they're using many different substances, you would probably want to try to help them reduce their opioid use preferentially, since that is the most lethal among the substances in an overdose event. Avoiding driving or swimming or other things that are very dangerous to do while you're intoxicated and for opioid use disorders, carrying naloxone rescue. Actually, for any substance use disorder, we do recommend training in naloxone rescue because they may be able to save somebody as a bystander, even if they're not an opioid user themselves. The question comes up a lot from substance use treatment professionals about involuntary commitment. As all of you are aware, really the best practice for suicide prevention is to help them to stay safe in the least restrictive environment. I would say as a parallel, we really try to do the same thing in substance use disorder treatment. We want to help them reduce their use in the least restrictive environment possible. Some things to think about with respect to when would you involuntarily commit somebody. You can avoid that if the community setup that they have is supportive and the means reduction is adequate, but this does require that the patient is collaborating with you. In the case of community supports, that there's some participation there. Involuntary commitment might be necessary when you've got an acute biological state that you don't believe will resolve rapidly with a medication adjustment in an outpatient or emergency department setting. It is always necessary for the patient who confirms that they've got serious intent and plan as well as means. It is usually more likely to be necessary for a patient who's very socially isolated or disconnected. And then I have a reference list. With that, I am going to stop my screen share so we can do questions. Great. Thank you, Dr. Connery. That was very informative. If any of the webinar participants would like to submit a question in the time remaining, please use the panel on your screen to type it in. I'll read the question and then Dr. Connery can answer. Sorry. Great. There you go. Okay. Sorry about that. That's okay. I'll read our first question that's come in. Does the role opioid use plays in suicide risk, referring to slide 26, applied in buprenorphine and methadone? That is, do the studies that show opioid use correlated with depression risk ever look specifically at medication-assisted therapy treatments? And the secondary question is, should we be wary of higher doses of methadone and buprenorphine in patients at risk for depression and suicide as we would with higher dose-length opioid pain treatment? Okay. I'm going to take the first question first and then I'm going to ask you to repeat the second part of it because the first question is a really important one. Patients who are maintained on buprenorphine and methadone, you might consider these two medications as suicide prevention medications. They are really effective at stabilizing the opioid use disorder, number one, so they're going to reduce the risk that's associated with severe drug use and overdose risk in general. But on top of it, patients who are doing better with their opioid use disorder also feel much better. They're more hopeful. They have a chance at rebuilding their life. The stability that the medication provides them is something that they self-report as meaningfully better. And therefore, they tend in clinical treatment to, if they came in with suicidal thoughts or behaviors, they tend to really remit in the stability of having a successful treatment with buprenorphine or methadone. There are also some research reports that have shown that suicidal behaviors on population basis reduce with the use of these medications. So it's an important question. I think about these two medications as both very successful at reducing just unintentional overdose risk, but also as suicide prevention medication. And I think most people in the field would say the same thing. Could you repeat that second half of the question, please? Sure. The second part was, should we be wary of higher doses of methadone in buprenorphine patients at risk for major depression slash suicide as we would be with higher dose-length opioid pain treatments? Yeah, that's a good question, too. There's really no evidence to suggest that. The evidence would be that the dose that is adequate to provide stability for the patient from their opioid use disorder and opioid use behavior, that is the dose that you want to aim for. And because really the stability of that opioid use disorder is going to translate into positive outcomes on the mental health side as well. The one caveat, I guess, would be patients who are on methadone maintenance are at greater risk for drug interactions. So if you have somebody who's on a very high dose of methadone because that's what they require to stabilize their opioid use disorder, my recommendation would be that you do a lot of safety planning and education with that patient about suicide prevention and also about just drug-drug interactions, particularly benzodiazepines if they are being prescribed benzodiazepines as part of a mental health treatment or if they have a co-occurring benzodiazepine misuse problem, which many of the patients who are in methadone maintenance programs will have. It's not uncommon. So there, you just really want to educate and empower them to understand that the dose that they're on is a problem if they were to act in ways that are going to be harmful. But you don't want to discourage them about being on a dose that is what they need to control their opioid use disorder. Thank you. Another question is, in settings with limited staff resources, what factors would you consider as most salient in terms of risk of suicide in order to prioritize more intensive levels of treatment? So I think what you're asking about is, can we stratify patients in terms of saying, okay, I've got, you know, five admissions of opioid use disorder patients, which one gets suicide prevention preferentially? Is that the gist of the question? In case it is, let me ask that, and then you can clarify if that's not really what you were asking. Let me answer that. Because what I think is that all the evidence really supports very high risk for suicide in the opioid use disorder population period. So I think that universal screening for suicide risk is applicable in this population. And from the perspective of, I don't think that suicide screening itself should be something that's stratified. And in fact, you know, joint commission and best practices really recommend universal suicide screening. So on that front, I wouldn't stratify. Obviously, some patients are going to be at greater risk than others. So a patient who has a history of a prior suicide attempt and enters into treatment with severe major depressed episode or some other very severe depressive presentation, is somebody who we're going to want to do careful suicide assessment with and probably more intensive personalized safety planning. As opposed to a person with opioid use disorder who, you know, is a recreational user, does not endorse a depressed episode, has never made a suicide attempt, that person should still be screened and educated that they're at risk. But they're not going to need the more intensive safety planning algorithms that the other person would require. Great. The person who asked that question wrote and said you did understand the question. Thank you. Okay. Okay. And I hope I answered it wholly. I mean, I know that on everybody's mind is, you know, staffing resources are just tough. And the absence of adequate mental health treatment teams, you know, the three month or longer waits to see a mental health clinician is really something that is such a problem for anybody working in this field. Because if your community doesn't have the resources to refer easily to mental health care, and you know that the person needs mental health care, what do you do? And I think part of the reason to be providing talks like this is to empower people within the community to learn about what they can do for suicide prevention, to emphasize that everybody has a role that's really important. And it doesn't require, you know, a degree in mental health to be able to recognize risk factors and attempt to reduce them, to be able to recognize protective factors and attempt to nurture positive coping, and to provide meaningful connections with patients so that they're not feeling alone, and that they know that there are resources in the community, including, you know, reaching out to hotlines and local resources. In Massachusetts, we have the Samaritans, and they're available all the time to talk to somebody who needs somebody to talk to. So I think by necessity, we really all need to up our game in terms of empowering community stakeholders to understand more about suicide prevention and really know what they can do, and know and be rewarded by the fact that what they can do is not small or insignificant. It actually saves lives, and the better we get at it, the more lives we can save. That comment dovetails very nicely with our next question, which is about how mental health professionals can receive or get further training. Are there specific resources you might recommend for both substance use disorder training, and I'm also asking this about suicide prevention as well. Right. So I would really encourage the use of the Suicide Prevention Resource Center and Zero Suicide organizations for training specific to suicide prevention, because anything beyond that that you want to do that may be above and beyond, they'll be able to get you connected with the right resources for additional training, and all of the basic training is there and easily accessible to you. So I really recommend that. In terms of more training in substance use disorder, and especially if you're interested in opioid use disorder, we have the PCSS website. So that is the Prescribers Clinical Support System, and I'm a member of that. I mentor people who are new to, say, buprenorphine practice with opioid use disorder, and that website, which is found at www.pcssnow.org, has all kinds of training resources, everything from I want to get my buprenorphine waiver to archived webinars on a whole host of topics related to treatment of substance use disorders to free mentorship if you are starting to take more substance use disorder patients in your practice and you want a little bit of expert coaching on how to manage that. Terrific. So we are almost at time. If there are any remaining questions, I have a couple more minutes to submit them. One question is related to what you had mentioned about naloxone theory. Naloxone administered by a layperson has been championed as one solution for unintentional opioid overdoses, and the question is, is there a role for naloxone in safety planning, particularly regarding involving supportive others and people in the person's life who might be involved in the safety plan or become aware of it? I think there's definitely a role for naloxone in safety planning of anybody who has an active substance use disorder, but particularly somebody identified as an opioid user. I also think that safety planning with naloxone is important for somebody who's being treated with prescription opioids for chronic pain. Naloxone is very simple to understand and easy to use and should be readily available for anybody who has some elevated risk factors. So I would support that. As far as the patient who you're thinking about suicide prevention but is also a drug use disorder patient, if you think back to the ambivalence that somebody may have, they may not be fully intending to kill themselves, but they may be becoming more despairing, more not caring about whether they live or die, and that person likely is at greater risk for use that's dangerous and could result in an overdose, even if they weren't fully intending to kill themselves. It really wouldn't matter what the cognition was at the time. What would matter is was the naloxone there as part of their global safety planning to reverse, whether it's an unintentional or an intentional opioid overdose. Seeing no further questions at this time, I'd like to thank you, Dr. Connery, for your time today. It's a very informative webinar. We're also glad to see that so many joined the webinar. So I believe this concludes our webinar session. Thanks very much. I've really enjoyed being here.

webinar

Dr. Hilary Connery

preventing suicide

opioid use disorder

Suicide Prevention Resource Center

American Psychiatric Association

substance use disorders

suicidal intent

medication-assisted treatments