Suicidal ideation and suicidal self-directed violence following clinician-initiated prescription opioid discontinuation among long-term opioid users

Demidenko, Michael I.; Dobscha, Steven K.; Morasco, Benjamin J.; Meath, Thomas H. A.; Ilgen, Mark A.; Lovejoy, Travis I.

doi:10.1016/j.genhosppsych.2017.04.011

Cited by 87 publications

(82 citation statements)

References 19 publications

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“…Patients and providers have expressed concern that non-consensual tapering and discontinuation of COT risk destabilization and illicit opioid use, severe opioid withdrawal, worsening pain, loss of function, and/or suicidality. [17][18][19] This study's finding that overdose death was increased in patients discontinued from COT could relate to interruption of other medical care, loss of tolerance, and/or destabilization of an underlying opioid use disorder. Estimates of risk of opioid use disorder in patients on COT vary widely, but recent data suggest the risk is dose related and higher than previously thought, up to 122-fold for patients on very high doses.…”

Section: Discussionmentioning

confidence: 99%

Mortality After Discontinuation of Primary Care–Based Chronic Opioid Therapy for Pain: a Retrospective Cohort Study

et al. 2019

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BACKGROUND: Despite known risks of using chronic opioid therapy (COT) for pain, the risks of discontinuation of COT are largely uncharacterized. OBJECTIVE: To evaluate mortality, prescription opioid use, and primary care utilization of patients discontinued from COT, compared with patients maintained on opioids. DESIGN: Retrospective cohort study of patients with chronic pain enrolled in an opioid registry as of May 2010. PARTICIPANTS: Patients with chronic pain enrolled in the opioid registry of a primary care clinic at an urban safety-net hospital in Seattle, WA. MAIN OUTCOMES AND MEASURES: Discontinuation from the opioid registry was the exposure of interest. Pre-specified main outcomes included mortality, prescription and primary care utilization data, and reasons for discontinuation. Data was collected through March 2015. KEY RESULTS: The study cohort comprised 572 patients with a mean age of 54.9 ± 10.1 years. COT was discontinued in 344 patients (60.1%); 254 (73.8%) discontinued patients subsequently filled at least one opioid prescription in Washington State, and 187 (54.4%) continued to visit the clinic. During the study period, 119 (20.8%) registry patients died, and 21 (3.7%) died of definite or possible overdose: 17 (4.9%) discontinued patients died of overdose, whereas 4 (1.75%) retained patients died of overdose. Most patients had at least one provider-initiated reason for COT discontinuation. Discontinuation of COT was associated with a hazard ratio for death of 1.35 (95% CI, 0.92 to 1.98, p = 0.122) and for overdose death of 2.94 (1.01-8.61, p = 0.049), after adjusting for age and race. CONCLUSIONS: In this cohort of patients prescribed COT for chronic pain, mortality was high. Discontinuation of COT did not reduce risk of death and was associated with increased risk of overdose death. Improved clinical strategies, including multimodal pain management and treatment of opioid use disorder, may be needed for this highrisk group.

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Section: Discussionmentioning

confidence: 99%

Mortality After Discontinuation of Primary Care–Based Chronic Opioid Therapy for Pain: a Retrospective Cohort Study

et al. 2019

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“…Preoperative weaning interventions may also be infeasible because available evidence has not yet clarified how to best support patients to taper their opioid use (45). What's more, opioid tapering is not necessarily a risk-free endeavor, as there are concerns about it resulting in patients being at an increased risk of suicidal thoughts and behaviors (46), or transitioning to heroin use (10,47). There is clearly a need for further research into the safety, efficacy, and feasibility of preoperative opioid tapering, given that such an intervention may both reduce rates of persistent opioid use and improve surgical outcomes more generally.…”

Section: Risks Associated With Opioid Use Prior To Surgerymentioning

confidence: 99%

The Surgeon's Role in the Opioid Crisis: A Narrative Review and Call to Action

et al. 2020

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“…Overlooking these key patient factors may greatly undermine patient response to opioid tapering because (1) nocebo increases distress and amplifies pain; (2) nocebo opposes opioid analgesia; and (3) forced tapers may contaminate the doctor-patient bond and its positive influence on treatment outcomes; (4) the placebo context of the medical environment can quickly shift to a nocebo context with detrimental effects. Forced tapers have questionable clinical value, amplify patient suffering and may contribute to self-harm and suicide (Demidenko et al, 2017). Compassionate opioid tapering requires attention to patient preference and willingness to taper and applying placebo optimization to cultivate patient engagement, placebo effects, and enhanced outcomes.…”

Section: Introductionmentioning

confidence: 99%

Optimizing Placebo and Minimizing Nocebo to Reduce Pain, Catastrophizing, and Opioid Use: A Review of the Science and an Evidence-Informed Clinical Toolkit

Darnall

Colloca

2018

International Review of Neurobiology

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Pain, a noxious psychosensory experience, motivates escape behavior to assure protection and survival. Psychological factors alter the experience and trajectory of pain, as well as behavior and treatment response. In the context of pain, the placebo effect (expectation for pain relief) releases endogenous opioids and facilitates analgesia from exogenously administered opioids. Nocebo hyperalgesia (expectation for persistent or worsening pain) opposes endogenous opioid analgesia and patient engagement in prescription opioid tapering. Reductions in nocebo hyperalgesia and pain catastrophizing may enhance descending modulation of pain, mediate adaptive structural brain changes and promote patient engagement in opioid tapering. Interventions that minimize nocebo and optimize placebo may adaptively shape the central nervous system toward pain relief and potentially opioid reduction. Here we provide a critical description of catastrophizing and its impact on pain, placebo and nocebo effects. We also consider the importance of minimizing nocebo and optimizing placebo effects during prescription opioid tapering, and offer a clinical toolkit of resources to accomplish these goals clinically.

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Suicidal ideation and suicidal self-directed violence following clinician-initiated prescription opioid discontinuation among long-term opioid users

Cited by 87 publications

References 19 publications

Mortality After Discontinuation of Primary Care–Based Chronic Opioid Therapy for Pain: a Retrospective Cohort Study

Mortality After Discontinuation of Primary Care–Based Chronic Opioid Therapy for Pain: a Retrospective Cohort Study

The Surgeon's Role in the Opioid Crisis: A Narrative Review and Call to Action

Optimizing Placebo and Minimizing Nocebo to Reduce Pain, Catastrophizing, and Opioid Use: A Review of the Science and an Evidence-Informed Clinical Toolkit

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