Suicide Prevention

Grand Rounds August 9, 2024: Does Starting Buprenorphine Prevent Suicidal Behavior: What Trial Should We Emulate? (Gregory Simon, MD, MPH; Susan Shortreed, PhD)

Posted on by Sophia Ramirez

Speakers

Gregory Simon, MD, MPH
Investigator
Kaiser Permanente Washington Health Research Institute

Susan Shortreed, PhD
Investigator
Kaiser Permanente Washington Health Research Institute

Keywords

Buprenorphine; Self-Harm; Overdose; Target Trial Emulation

Key Points

  • There is some overlap between the two public health crises of our time: suicidal behavior and the Opioid Use Disorder (OUD)/opioid overdose crisis.
  • The research team looked at whether starting (vs not starting) buprenorphine reduces the subsequent risk of a self-harm event or suicide attempt among people diagnosed with OUD.
  • They conducted an observational study with target trial emulation, emulating a randomized trial where people with an OUD diagnosis might be randomly assigned to start or not start buprenorphine during an outpatient visit. They tracked the rates of self-harm, adverse outcomes more broadly, and overdose over 90 days.
  • Their analysis found that starting buprenorphine didn’t reduce the risk of self-harm behavior and (surprisingly) had no protective or beneficial effect when it came to opioid poisoning or overdose.
  • They found that when they stopped tracking outcomes for those who changed course – i.e. had initiated buprenorphine but stopped or had initially declined but initiated later – they observed protective effects consistent with previous findings. The risk of self-harm for people who stopped or had their treatment interrupted increased four-fold, and the risk of opioid overdose or poisoning increased five- or six-fold.
  • These findings reinforce concerns about high risk of adverse outcomes soon after stopping or interrupting buprenorphine treatment.
  • These findings also raise questions about the kind of target trials researchers should be emulating and what pragmatic trials might be considered for follow-up. Given these results, the research team is interested in research questions that center on the stopping or interruption of buprenorphine treatment.

 

Discussion Themes

Given that buprenorphine is often prescribed in shorter supply (7 – 14 days worth), the researchers were able to track the timing of events more accurately than they’d be able to with other chronic conditions. The profit motive of healthcare systems (i.e. billing insurance for treating an overdose) also improved their ascertainment of those events.

One limitation of the study is that they don’t have any way of ascertaining self-harm events or overdoses that never came to medical attention.

At the individual clinician level and at the policy level, the decision to treat OUD with buprenorphine is informed by the knowledge that interruptions in treatment are fairly common and can have adverse effects.

Another study design option is to compare people before and after initiating buprenorphine treatment, as opposed to comparing people who initiate and people who don’t. The tricky thing about that design is that an individual’s state is not consistent; there may have be an initiating event that precipitates the decision to start treatment.

 

 

May 8, 2019: Dr. Greg Simon Receives National Suicide Prevention Award

Posted on by Karen Staman

At the Lifesavers Gala in New York last night, Dr. Greg Simon received the American Foundation for Suicide Prevention (AFSP’s) Research Award for his contributions to suicide prevention. Dr. Simon leads the Suicide Prevention Outreach Trial (SPOT), an NIH Collaboratory Trial that builds on previous work demonstrating that patients who answer “yes” to thoughts of self-harm on routinely administered PHQ-9 questionnaires at primary care visits are more likely to attempt suicide. For these high-risk patients, SPOT explores different modes of outreach (care management or online skills training versus usual care) to prevent suicide.

“There’s a conspiracy of silence around suicidal thoughts, because it’s awkward to discuss. So we’ve found that we have to incorporate talking about it into our standard care. Our suicide prevention work is a great example of how research and care keep influencing each other to improve our patients’ health. When research springs from clinicians’ and patients’ questions, ‘learning health systems’ can put results into practice much faster than the oft-cited 17-year lag.” — Dr. Greg Simon, from the Kaiser Permanente Washington Health Research Institute Press Release

Dr. Simon and his colleagues are also studying how machine-learning models can be used to predict risk of suicide. The models combine the PHQ-9 mental health questionnaire responses with information from electronic health records, including prior suicide attempts and mental health and substance use diagnoses. In a blog post regarding his research (and recent publication) on machine learning, Dr. Simon compares machine learning to warning lights on cars:

Our paper prompted many questions from clinicians and health system leaders about the practical utility of risk predictions:

“Are machine learning algorithms accurate enough to replace clinicians’ judgment?” our clinical partners asked.

“No,” I answered, “but they are accurate enough to direct clinicians’ attention.”

The AFSP also honored four others, including Anderson Cooper, a CNN and 60-minutes correspondent, and Kate Snow, an NBC news correspondent, for their work raising public awareness of suicide prevention.

Read more about what inspired Dr. Simon to study mental health.

Groundbreaking Suicide Prevention Trial has Enrolled Initial Patients

Posted on by Karen Staman

March 5, 2015

Dr. Greg Simon and the Suicide Prevention Team have enrolled the first participants in the Pragmatic Trial of Population-Based Programs to Prevent Suicide Attempt. This groundbreaking study was developed by researchers at Group Health Cooperative in Seattle, Washington, Health Partners Medical Group in Minnesota, and Kaiser Permanente of Colorado, in collaboration with patients who have experienced suicidal thoughts or survived suicide attempts themselves.

Over 9 million adults in the United States experience suicidal thoughts, and more than 1 million adults attempt suicide each year. However, patients at risk for suicidal behavior are not routinely identified, and successful interventions for depression and suicide are not routinely implemented. New evidence suggests that patients who report frequent thoughts of death or self-harm on a commonly-used depression questionnaire are at higher risk for suicide attempt and death over the following year.

This study aims to address the significant problem of suicide by identifying patients who are at risk for suicidal behavior and testing two suicide prevention strategies. Patients at participating institutions will complete a standard depression severity questionnaire during routine clinical care, and the results will be stored in their electronic health records (EHR). Investigators will use the responses in the EHR to identify at-risk individuals, and once identified, the patients will be randomly assigned to either usual care or to two treatment programs. The first is a collaborative care-management approach; the second is an online skills training program called “Now Matters Now,” which is designed to help people manage painful emotions and stressful situations.

Over the next 5 years, the team plans to enroll 19,500 adult patients. The study is an NIH Collaboratory Trial being overseen by the National Institute of Mental Health (NIMH).

Congratulations to Dr. Simon and his team for their achievement!