The Need to Assess Suicidal Risk in the Checklist for Prescribing Opioids

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The Need to Assess Suicidal Risk in the Checklist for Prescribing Opioids

To the Editor: On March 15, 2016, the Centers for Disease Control and Prevention published a "Guideline for Prescribing Opioids for Chronic Pain" providing 12 recommendations for safer and more effective treatment of chronic pain outside of active cancer, palliative care, and end-of-life care.1 Recommending that clinicians evaluate risk factors for opioid-related harms without specifically discussing suicidal risk caused us concern.

On the one hand, a meta-analysis showed that physical pain was associated with increased risk of suicidal ideation, suicide attempt, and death by suicide,2 raising the question of an increased risk of intentional overdose with prescribed opioids in pain patients. Further, in 2010, Department of Veterans Affairs and Department of Defense treatment guidelines3 described high suicide risk as a relative contraindication for opioid therapy.

On the other hand, opioid prescription (but not non-opioid analgesic prescription) was associated to a previous history of suicide attempt in an elderly sample from the general population.4 Moreover, in a recent case-control study including 123,946 veterans receiving opioids for a chronic non-cancer pain condition, an increased risk of suicide mortality was found in subjects receiving higher doses of opioids.5 The evidence thus leads toward viewing opioid consumption, in particular high doses, as a specific marker of elevated risk for suicide, beyond an increase in access to a potentially lethal means of suicide.

Suicidal vulnerability might be related to a modified pain perception (oversensitivity), possibly linked to the opioid system. Oversensitivity to pain in patients carrying suicidal vulnerability may involve perception of physical pain but also of social pain (caused by real or perceived social exclusion or devaluation), as both rely on common neural pathways and are modulated by the μ-opioid system.6 Finally, evidence has shown that use of opioids for chronic pain may actually worsen pain by potentiating pain perception, suggesting that we should be even more attentive to the risk of suicide.

To conclude, although recommendations about use of opioids in chronic pain highlight the risk of overdose, they should specify the risk of accidental and intentional overdoses. Consequently, clinicians must be aware of and assess suicidal risk before starting and while continuing opioid therapy.

References

1. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016. JAMA. 2016;315(15):1624-1645. PubMed doi:10.1001/jama.2016.1464

2. Calati R, Laglaoui Bakhiyi C, Artero S, et al. The impact of physical pain on suicidal thoughts and behaviors: meta-analyses. J Psychiatr Res. 2015;71:16-32. PubMed doi:10.1016/j.jpsychires.2015.09.004

3. Department of Veterans Affairs and Department of Defense. VA/DoD Clinical Practice Guideline for the Management of Opioid Therapy for Chronic Pain (Version 2.0). Washington, DC: Veterans Health Administration/Department of Defense; 2010.

4. Olié E, Courtet P, Poulain V, et al. History of suicidal behaviour and analgesic use in community-dwelling elderly. Psychother Psychosom. 2013;82(5):341-343. PubMed doi:10.1159/000350504

5. Ilgen MA, Bohnert AS, Ganoczy D, et al. Opioid dose and risk of suicide. Pain. 2016;157(5):1079-1084. PubMed doi:10.1097/j.pain.0000000000000484

6. Eisenberger NI. The pain of social disconnection: examining the shared neural underpinnings of physical and social pain. Nat Rev Neurosci. 2012;13(6):421-434. PubMed doi:10.1038/nrn3231

Emilie Olié, MD, PhDa

[email protected]

Philippe Courtet, MD, PhDa

aDepartment of Psychiatric Emergency and Acute Care, Lapeyronie Hospital, CHU Montpellier—Inserm U1061, University of Montpellier, Montpellier, France

Potential conflicts of interest: None.

Funding/support: None.

J Clin Psychiatry 2016;77(12):1719

dx.doi.org/10.4088/JCP.16l10978

© Copyright 2016 Physicians Postgraduate Press, Inc.