The relationship between loss, depression, addiction, and suicide is complex. Individuals with chronic pain or mood disorders are both more likely to receive prescriptions for opioids and to die by suicide.1 While the risk of overdose in medication assisted treatment (MAT) is often discussed as part of recovery plans, most strategies to reduce opioid-overdose deaths fail to recognize the need to implement screening and tailor interventions for people who may be at risk of suicide.1 However, attention to the risks of suicide among individuals with opioid use disorder is increasing.
In 2017, more than 47,000 individuals died from an opioid-involved drug overdose, and an almost identical number of deaths from suicide were recorded.2 Most overdose deaths are recorded as accidental, but some estimate that the true percentage of suicides among opioid-involved overdoses ranges from 20 to 30 percent.1 It is critical to understand that opioid use disorder greatly increases risk of suicide. In particular, suicide risk escalates when a user returns to using opioids.
Approximately 45 percent of people who died by suicide were in contact with primary care providers within 1 month of the suicide. Until recently, attention to suicide was not seen as a primary care responsibility. However, the role of primary care providers in identifying and intervening for patients at risk of suicide can be likened to that of other risky conditions in primary care. For example, when patients present in primary care with chest pain, providers should assess their risk and distinguish who needs urgent attention from those whose risk is low.
In primary care generally, when assessing patients for suicide risk, the “yield may be low, but the stakes are high.”3 Universal screening for suicide is an emerging best practice but is not yet a consensus recommendation. However, The Joint Commission does recommend that providers screen all patients with behavioral health diagnoses or being assessed or treated for behavioral health diagnoses for suicide ideation using a brief, standardized, evidence-based screening tool.4 In patients being treated for opioid use disorder, the greatly increased risks and the new evidence about effective brief interventions suggest that attention to suicide risk is necessary and feasible.
Therefore, while we do not recommend universal screening for suicide in primary care, we do recommend use of targeted screening for suicidality among patients receiving treatment for opioid use disorder. We also recognize that some practices may use mental health screening tools such as the Patient Health Questionnaire-9 (PHQ-9), which includes a question about suicide and thus can serve as a suicide screening tool. Practices should develop an Office Protocol for Suicidal Patients to help providers and office staff prepare to respond when a patient at risk for suicide is identified.
Research has established the effectiveness of limited brief interventions (such as developing a safety plan and several supportive followup contacts) for individuals with suicide risk. Completing these brief interventions and connecting individuals with suicide risk with specialty care is appropriate for primary care. Only mental health practitioners with specialized competence should provide comprehensive “suicide care,” which is beyond the scope of primary care.
As detailed below, the Suicide Prevention Toolkit for Primary Care Practices offers a five-pronged approach to implementing suicide prevention strategies in primary care. We suggest adopting key elements of this approach specifically for patients with opioid use disorder.
Practices seek to identify all patients with opioid use disorder who are at risk for suicide by implementing routine, targeted screening at initial and designated followup visits. For patients whose suicide risk assessment indicates moderate to high risk, providers deliver brief interventions for safety planning and connect patients with additional care, as appropriate.
How Do You Do It?
Train Staff To Identify Warning Signs
The Suicide Prevention Resource Center offers five modules on Educating Clinicians and Office Staff (PDF—395 KB) about suicide prevention, as well as other trainings. All staff should be trained how to4:
- Recognize the common warning signs of suicide,
- Inquire about suicidal ideation, and
- Act in response.
Office staff in particular may be in a better position to observe concerning behavior changes and alert the patient’s providers.4 The strongest warning signs that may require immediate action include people threatening to hurt or kill themselves; trying to access firearms, pills, or other means; or talking about how they feel hopeless or have no reason to live.4
Screen for and Manage Depression and Other Common Mental Health Conditions
Co-occurring depression or anxiety among those with opioid use disorder can increase their risk for suicide, so the effective diagnosis and management of these conditions plus brief suicide-specific interventions can be key to preventing suicides and suicidal behaviors.4 The PHQ-9 (PDF—485 KB) is a brief, self-administered screening tool that can help identify symptoms or assess severity of depression.
Successful treatment of major depressive disorder often requires a combination of medications and therapy. Ideally, practices would have integrated behavioral health services or professionals available to assist in the treatment and management of depression among MAT patients. For example, the Collaborative Care model is an effective approach to the treatment of depression in primary care settings and may reduce risks or suicidal behavior.3 If Collaborative Care is not feasible in their practice, primary care providers can still deliver effective treatment of depression and anxiety by prescribing appropriate medications (while carefully monitoring their efficacy and side effects) and connecting patients with qualified mental health professionals.4
Identify Patients With Opioid Use Disorder at Risk for Suicide
Practices should aim to identify all patients being treated for opioid use disorder who also have a high risk of suicide. As previously discussed, providers may notice warning signs or learn of additional information that raises concerns, such as suspicions of self-harm or worrisome behaviors. Screening is not the only way to identify risk for suicide but can serve as a useful tool.
Initial Screening. Screening is accomplished by asking directly about thoughts of suicide. Therefore, practices can use the PHQ-9 as a time-efficient way to screen for suicidality, as the last of the nine items asks if the patient has “thoughts that you would be better off dead, or of hurting yourself.” Since thoughts of suicide indicate risk, but many patients will not act on them, a more thorough screening is often used to determine the degree of risk, such as the Columbia Suicide Severity Rating Scale (screening version). Table 1 provides guidance on incorporating screening into routine practice.
Below are some questions to consider and guidance for incorporating screening procedures into routine practice and workflows.
- At which visits will you screen or rescreen patients for suicide risk? Practices should determine how frequently they plan to screen patients with opioid use disorder for suicide risk. Patients should be screened at the initial visit and defined intervals thereafter. No standard frequency of screenings is recommended. For example, practices may consider rescreening after patients have stabilized on their MAT medications and then yearly thereafter. However, providers may decide some patients are at higher risk and need to be screened or checked more frequently.
- When will this screening be conducted within the office visit? Screening for suicidality can be integrated into the practice’s existing workflows for screening and assessments. Often, this screening may occur at the beginning of visits while the patient is waiting to see the provider.
- Will the screening be self-administered or conducted by a provider? Practices should consider how the screening will be administered and whether a provider needs to actively conduct the screening. Patients may be more likely to be honest if the assessment is self-administered.
- Who will review the results and follow up with the patient? It is crucial for an appropriate member of the care team to review the results and actively follow up. Usually, this team member will be the primary provider, nurse care manager, or care coordinator.
Suicide Risk Assessment. If a patient is identified as being at significantly elevated risk for suicide, then providers should conduct a suicide risk assessment. For example, the Suicide Assessment Five-Step Evaluation and Triage (SAFE-T) can help guide providers through the steps to assess the patient’s risk and protective factors for suicide and to identify appropriate interventions.
In a suicide risk assessment, providers should4:
- Identify warning signs and individual, social, and environmental risk factors for suicide;
- Assess protective factors that may help mitigate low to moderate suicide risk;
- Inquire about suicidal thoughts, prior attempts, plans, or intent; and
- Make a clinical judgment of suicide risk.
Providers should pay particular attention to the presence of anxiety and agitation, as they are often critical warning signs of suicide. Research has found that individuals with anxiety or impulse control disorders were more likely to move from suicidal ideation to making a plan or suicide attempt.3 Critically, taking immediate steps to help patients manage their suicidal thoughts by safety planning will affect risk and management decisions. If patients are able and willing to complete a safety plan, their immediate risk is significantly reduced.
Help Patients and Families Recognize Warning Signs of Suicide
Providers should offer basic information to patients and their loved ones about the warning signs of suicide and the appropriate response. Learn more about Patient Education Tools (PDF—415 KB). If warning signs are present, direct them to call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255). If local crisis mental health services are available, they are experienced in assessing and managing suicide risk as well. In an acute crisis, it may be necessary to get the individual to an emergency department or call 911.
Create a Safety Plan and Connect With Suicide Care
Safety Planning. If the assessment indicates the patient has significant risk for suicide (often indicating planning or intent in addition to thoughts of suicide), then providers should conduct a brief Safety Planning Intervention. A safety plan, or crisis response plan, should be developed in a collaborative manner between patient and provider to decrease the likelihood that the patient will attempt suicide.4
Resources for safety planning include:
- Patient Safety Plan Template.
- Safety Planning Guide: A Quick Guide for Clinicians (PDF—149 KB).
- Safety Planning Intervention for Suicide Prevention.
Referral to Treatment. In addition to safety planning, primary care providers should connect patients with ongoing care and evidence-based treatment. MAT programs should identify behavioral health professionals (ideally experienced with suicide care) with whom they can connect patients for additional mental health or substance use treatment services.
To build strong partnerships, program staff may consider modifying this template of an outreach letter (PDF—29 KB) to send to other mental health practices and providers. Agreements with these practices and providers can help ensure continuity of care during transitions and ongoing care coordination.6 Because many patients with suicidality do not want to engage in such care, followup with the provider within 48 hours of the initial visit and on a weekly basis thereafter is crucial to ensure the patient continues to receive recommended services.
Psychiatric Hospitalizations. If patients will not or cannot collaborate on a safety plan and self-harm is likely imminent, providers should consider working with patients and their loved ones to arrange psychiatric hospitalization. Practices should have a protocol to follow that considers the following4:
- Is a mobile mental health crisis program available?
- Where are the closest emergency departments or crisis stabilization units?
- What options are available to transport suicidal patients to the nearest emergency department or crisis service?
- Is a local mental health provider available who can help with an involuntary psychiatric admission?
Documentation and Followup. Throughout the care of suicidal patients, providers should carefully document the suicide risk assessment, management plan, actions taken, and any other referrals or consultations.4 This documentation can help ensure patients receive appropriate followup care. Providers should also maintain frequent contact with these patients and their families to learn how they are doing and whether they are following through on treatment recommendations.4
What Not To Do
- Don’t think that suicide risk is fixed. Risk of suicide may fluctuate over time depending on life stressors, so it is important to frequently rescreen or assess patients.
- Don’t screen for suicidality without a plan for how to respond if the results indicate a patient is at risk for suicide.
- Don’t think there’s nothing you can do for patients at risk for suicide if you’re not trained as a mental health practitioner. Screening tools and effective interventions are available that can be implemented in primary care or other health care settings.
- Don’t assume that screening is the only way to identify patients at risk for suicide. Be alert to other warning signs or cues you may encounter.
Treatment Improvement Protocol (TIP) 50: Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment
- Oquendo MA, Volkow ND. Suicide: a silent contributor to opioid-overdose deaths. N Engl J Med 2018;378(17):1567-69. https://www.ncbi.nlm.nih.gov/pubmed/29694805. Accessed June 12, 2019.
- National Institute on Drug Abuse: Overdose Death Rates. Bethesda, MD: National Institutes of Health; 2019. https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates. Accessed June 12, 2019.
- McDowell AK, Lineberry TW, Bostwick JM. Practical suicide-risk management for the busy primary care physician. Mayo Clin Proc 2011;86(8):792-800. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3146379/. Accessed June 12, 2019.
- Western Interstate Commission for Higher Education Mental Health Program (WICHE MHP) and Suicide Prevention Resource Center (SPRC). Suicide Prevention Toolkit for Primary Care Practices: A Guide for Primary Care Providers and Medical Practice Managers. Boulder, CO: WICHE MHP and SPRC. http://www.sprc.org/sites/default/files/Final%20National%20
Suicide%20Prevention%20Toolkit%202.15.18%20FINAL.pdf. Accessed June 12, 2019.
- Suicide Prevention Resource Center. Recommended Standard Care for People With Suicide Risk: Making Health Care Suicide Safe. Waltham, MA: Suicide Prevention Resource Center; 2018. https://www.sprc.org/resources-programs/recommended-standard-care-people-suicide-risk-making-health-care-suicide-safe. Accessed June 12, 2019.
- Suicide Prevention Resource Center. Primary Care. Suicide Prevention Resource Center; n.d. https:www.sprc.org/settings/primary-care. Accessed June 12, 2019.