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.