Category: Federal Forum Posters
Purpose: VA work groups are evaluating risk factors for suicidality in Veterans, which includes the continuation or discontinuation of medications including opioid therapy. To validate some of these findings, we evaluated the relationship between opioid continuation and discontinuation with suicide and/or overdose. Our primary objective was to compare suicide risk factors between those who discontinued and continued opioid therapy. Secondarily we evaluated suicide risk factors in those previously prescribed chronic versus intermittent opioid therapy, and assessed opioid, mental health (MH) or black box warning medications that patients were taking prior to their date of death amongst those who discontinued therapy.
Methods: A retrospective chart review was conducted using a random sample of Veterans from fiscal year (FY) 2011 and 2014 with a death due to suicide and/or overdose and opioid exposure of at least one day in the year prior to their date of death (index date). Data collected from chart reviews included: cause of death, time since last VA visit, VA and provider services used, medications and diagnoses, history of suicide attempts, family history of suicide, tour of duty, recent life events, and demographic information. We collected opioid and non-opioid pain medications, and MH and black box warning medications. Continuation status was defined by the difference in last possession date and index date – continuers were defined by a difference of 0-7 days; discontinuers defined by a difference of ≥8 days. Chronic use was defined as a history of ≥90 days of continuous opioid therapy with a maximum of 14 day gap; intermittent use was defined as Veterans who did not meet the chronic use criteria (intermittent users). Descriptive statistics to assess proportions of baseline characteristics, differences by FY for continuers and discontinuers, and chronic versus intermittent users were conducting utilizing t-tests and chi2 tests. Stata version 14.2 was used.
Results: A total of 694 charts were reviewed, with 491 meeting inclusion criteria. Two hundred and thirty-seven Veterans (48.3%) were identified as “chronic” opioid users, and 254 (51.7%) as intermittent users. A total of 193/491 (39.3%) were characterized as continuers, and 298 (60.7%) as discontinuers. The chronic users made up a majority of continuers (N=169, 87.6%), with no significant difference by FY (p=0.74). Of chronic users, 169 (87.6%) continued opioids and 68 (22.8%) discontinued. Continuers and discontinuers had similar suicide attempt history (30.2% vs. 29.4%, p=0.952), and history of attempts in the last year (4.1% vs. 5.9% p=0.609). Personality disorder was more frequent in discontinuers versus continuers (9.5% vs. 20.5%, p=0.02). There was no other significant difference in number or type of MH comorbidities or medications between groups. Rates of depression (64.5% vs. 63.2%), substance use disorder (20.7% vs. 25%), anxiety (30.2% vs. 30.9%) and alcohol use disorder (28.4% vs. 30.9%) were high in both group. Mood stabilizers (5.9% vs 2.9%), benzodiazepines (38.5% vs. 26.5%), and non-benzodiazepines hypnotics (15.4% vs. 10.3%) were more common in continuers. Continuers were more likely to have been seen in the 30 days prior to the index date by any VA professional (52.7% vs. 39.7%, p=0.027).
Conclusion: In this evaluation, a high percentage of Veterans discontinued their opioid prior to the index date. However, a majority of continuers were chronic users. There was little difference between chronic opioid use discontinuers versus continuers, and no difference in discontinuation or proportion of chronic users by FY. Both discontinuers and continuers were highly comorbid, prescribed many MH medications, and had high rates of documented suicide risk factors. Low rates of MH service visits combined with high rates of diagnosed depression, anxiety and substance and alcohol use disorder, highlight the need to improve MH care access amongst Veterans.
Sydney Springer– Fellow, Veterans Health Administration, Pittsburgh, PA