Psychiatric Association, welcome to today's webinar, Preventing Suicide in People with Opiate Use Disorder. Today's activity is presented on behalf of the SAMHSA-funded Providers Clinical Support System, a program operated collaboratively by 19 medical specialty organizations, including the APA. I will now indicate how we can download handouts. Slides from the presentation today are available in the handout area founded in the lower portion of your control panel. Select the link to download the PDF. We will reserve 10 to 15 minutes at the end of the presentation today for Q&A. Please feel free to submit your questions throughout the presentation by typing them into the questionnaire found in the lower portion of your control panel. Now I would like to introduce you to the faculty for today's webinar, Dr. Hilary S. Connery, Co-Director of the Division of Alcohol, Drugs, and Addiction at McLean Hospital and Assistant Professor at Harvard Medical School Department of Psychiatry. Dr. Connery's expertise includes treatment of opiate use disorders and integrated treatments for co-occurring substance use disorders and other mental illnesses. Her current research efforts are directed towards public health prevention strategies for addressing self-injury mortality and patient-focused investigation regarding suicidal motivations contributing to drug overdose. I welcome you to today's session, Dr. Connery. Thank you very much for leading our webinar. Thank you, Dr. Renner. It's really a privilege to be here with you all today. I have no financial relationships or conflicts of interest to report to you. And I just want to emphasize what a wonderful organization the PCSS is. It provides free training for professionals in evidence-based practices for prevention and treatment of opioid use disorders and particularly in prescribing medication for substance use disorder. And I've really enjoyed my part in this great organization. The objectives for today are to describe how suicide risks are elevated for both prescription opioid and illicit opioid misuse, to define psychological and social risk factors commonly experienced by opioid use disorder patients, and to discuss how opioids have the highest lethality among suicide poisonings and apply personalized suicide prevention planning approaches to enhance care and reduce premature death. As all of you know, the opioid and other drug overdose epidemic has gotten worse by the year. So I think it's a good time for all of us to continue to think creatively about ways that we may be able to have interventions that will prevent death. And so focusing on suicide prevention may be something useful for that purpose. We'll start by reviewing aspects of suicide and how it relates to substance intoxication. So reducing suicide, a national imperative, was put out first by the Institute of Medicine in 2002 and has been updated. And just in the past year, really, the Surgeon General emphasized the imperative to really implement all pieces of action necessary to reduce the growing suicide problem in the United States. But research on suicide is plagued by many methodological problems. Definitions of suicide have lacked uniformity. The investigation and reporting of suicide is inaccurate and also dependent on regional medical examiner and coroner resources. Some jurisdictions have tended to call any deaths with prominent intoxication an accident, basically because of the burden to provide enough evidence that one could call it a suicide rather than an unintended death. We'll go over some of the suicide definitions, starting with suicidal self-directed violence. And that is behavior that is self-directed and deliberately results in injury or the potential for injury to oneself. There is evidence, whether it's implicit or explicit evidence of suicidal intent. So explicit evidence of suicidal intent would include that the person has written a note stating that they are killing themselves, or other evidence such as the person was researching on the internet methods for suicide death, declaring it on social media as their intention, or making final communications to others. Those are all examples of explicit suicide evidence. Implicit is really more when it wouldn't be another explanation that would be readily available. So for instance, if a person owns a firearm and is found having shot him or herself with the owned firearm, it's pretty clear that that person was trying to end their life prematurely. Same with hanging in somebody's own house or on their own property, or being found with carbon monoxide poisoning in their own garage or vehicle. All of these are examples of what would be called implicit evidence for suicidal intent. Substance use itself is not implicit evidence of suicidal intent. So just a review for the DSM-5 criteria to label somebody as qualifying for substance use disorder. There are 11 criteria over a 12-month period, and a simple way of thinking about how those criteria are categorized is by remembering the three Cs, control, craving, and consequences. So criteria related to control really asks the question about whether or not substance use is self-moderated in a safe and appropriate way. Craving was a criteria that was added with DSM-5, and refers to whether or not the person has anticipatory expectations around substance use, or experiences any kind of psychological urgency with respect to wanting to use that really is out of proportion to other natural drives. And consequences refer to the fact that substance use is commonly observed to be associated with negative health and other social outcomes. Substance use disorder is also dimensional and is coded from mild to severe. I want to review a few things that are known about substance intoxication and suicide. People with alcohol use disorder and opioid use disorder have 10 to 15 times higher rates of suicide deaths compared with the general population. And people with substance use disorder also have elevated suicide risk even during abstinence and remission from substance use. So even when a person with substance use disorder is in good recovery and doing well, their suicide risk may still be elevated compared to the general population. Alcohol and opioid intoxication is associated with more lethal suicide behaviors. And all substance misuse is significantly associated with increased risk for suicidal thoughts as well as behaviors. One in four suicide deaths involve alcohol, and one in five suicide deaths involve opioids in the United States. Why might substance use be associated with suicide risk? Well, substance use disorder and substance intoxication are significantly associated with impulsive behaviors, which may make it a lower threshold for somebody to act on suicidal thoughts as well as novelty seeking. Substance use disorder has high rates of co-occurring depressive disorders and grief. Both might be risk factors for suicidal thoughts. Depressive disorders also, in turn, elevate substance intoxication risk, often from a wish to try to change the mental state that one finds oneself in. And especially among opioid use disorders, frequent exposure to premature mortality, because almost every opioid use disorder patient that you meet these days knows somebody who has died because of an opioid overdose. And the frequency with which people experience this, both within their closer social network, but also in the community at large, may desensitize the person to death and increase an individual's acquired capacity for self-harm behavior. And finally, there may be shared biological and social factors for substance use disorder as well as suicide risk. So if we're looking to save lives, one of the things we have to begin with is really understanding some of the complexity around what we know about deaths, especially deaths related to drug poisoning. And one of the problems for Karners and medical examiners is that there's really a higher threshold for somebody to have confidence when they are examining the drug poisoning death that this could have been a suicidal act. And if you look at studies of U.S. database across the country, classifying a drug poisoning death as a suicide will more often cite evidence of a suicide note being present or history of a prior suicide attempt or mood disorder compared with classifying a firearm or hanging death as a suicide death. And this really just reflects the burden that medical examiners face in the field. If they don't have that kind of additional information, it's not easy for them to classify a death as suicide. The other problem, of course, is that in the current days, the resources and the strain on the system makes gathering those kinds of pieces of evidence much more difficult. Here I just wanted to look at this table. I apologize for the small print here, but I'll walk you through what I want you to see. This is a table of the number of deaths for leading causes of death in the United States between 2015 and 2020. If you focus on the unintentional injuries, this is primarily comprised of drug poisoning deaths and the rise in it is reflective of increasing opioid-related deaths. We see that over this time period, there was an 11% increase. But it's also important to ask the question of whether or not that is across the board because it isn't. And we do know that rates have been up disproportionately among Black populations. So the rise in the increase has been disproportionate for Blacks. If you look at suicide, that has also been increasing until just 2020 when it was reported to have a 5.6% decrease. Hopefully that is true. And what we see is what we get. But it's something that I think it's hard to be certain of and time will tell because it could be possible that that decrease was hidden in the rise in the drug poisoning deaths in the unintentional injury column. That's a possibility. It also could be that actually prevention is working, especially in states that are implementing good firearm control and prevention emphasis. The other thing is that the majority of this improvement, if we believe that there's been a decrease, seems to be more specific for White populations. And here's some state example of that. These are Massachusetts suicide deaths between 2019 and 2020. And what I want to show here is simply that when you break it out into race and ethnicity, we see actual increases in the suicide deaths among the Asian non-Hispanic and Hispanic Latinx, while we see decreases in White non-Hispanic, but also in Black non-Hispanic. So sometimes looking more granularly at the data and who is being affected by what and then trying to link that to appropriate prevention interventions is going to be very important. We also know that there are racial disparities in how our systems respond to intentional drug overdose suicides. So this is just an example from a study from South Carolina, looking at all payers of adult services between 2012 and 2013. And what they reported was that non-Hispanic Blacks and people of other races and ethnicities were less likely than non-Hispanic Whites to receive a mental health assessment during hospitalization for what had been determined a deliberate drug overdose. They also found that non-Hispanic Blacks were less likely than non-Hispanic Whites to be discharged to an inpatient psychiatric facility than to home after hospitalization for deliberate drug overdose. And persons with Medicare, private or other insurance were more likely than persons without insurance to be discharged to an inpatient psychiatric facility than to home after hospitalization for deliberate drug overdose. So this is an important report because our systems really need to be made much more fair in terms of response to drug poisoning deaths, whether intentional or unintentional. When you consider the intentional mindset of an opioid user, there's really a spectrum of intent that you could imagine that moves from fully unintentional to fully intentional. And then these thoughts that are driving the using behavior, if there is an overdose, it may end in death or it may end in a non-fatal overdose. But on the unintentional side of the spectrum, an opioid user could be thinking, I know there's risk opioids are dangerous, but I don't think I will die even though I'm misusing them. So there's no actual intent there, although there is awareness that the person is taking a potentially lethal risk. They're just not thinking about it. They're optimistic that they're going to get high. A little bit less unintentional, the thought could be if I were to die by opioids, that wouldn't be the worst way out. So a person is actually thinking about death, but not thinking that they were doing anything to hurry that along, just sort of acknowledging that maybe life isn't so great and dying by overdose wouldn't be the worst thing that could happen to them. Then in the middle somewhere, there's the fluctuation or ambivalence about life. Mostly I don't want to die, but sometimes I do. And then further along today, I don't care if I die or not. If I don't wake up, it doesn't matter, which again, isn't fully intentional, but it might be in that category that is often referred to as tempting fate. And finally, there's fully intentional where somebody says, my life is pointless and today is a good day to die. And what I want you to appreciate here is that the more that the cognitive, the more that the thought content becomes towards the intentional side, the more likely that kind of thought process is to bias behavior in a risk-taking direction. So here's a little data from a study that we did at McLean Hospital, looking at desire to die in those who had survived an opioid overdose. So among 120 adults who entered an inpatient medical withdrawal management unit for opioid use disorder treatment, 45% of them or 54 patients reported a history of previous overdose. And you can see the sample is very white and more men than women in their 30s. We asked them just prior to your most recent opioid overdose, how much did you want to die? How much desire did you have to die? And it was scaled from zero to 10, where zero is none and 10 was a strong desire to die. And what I want to point out here is that what we saw was dimensional responses. So about 40% of the sample reported that they had no desire to die just before their previous overdose, but the rest of the sample reported at least some, and 36% of the sample had a strong desire to die. So we wanted to replicate this study and also ask more about intention to die, which is a separate question than just having a desire to die, which might be considered more passive suicidal ideation. So here, another relatively small pilot sample, 59 opioid use disorder patients who are entering care who endorsed a history of nonfatal opioid overdose. And we asked them the same question about wanting to die or not wanting to die, scaled the same. And we also asked, were you trying to kill yourself? And scaled that from zero, not at all, to 10, I was definitely trying to kill myself. And what we found was that the desire to die looked very similar to the first sample, a little bit different in that a little bit more than half the sample reported no desire to die, but the remaining part of the sample had this dimensional response rating as far as desire to die. And on the intention to die, 80% of the sample said no, not at all, but 20% endorsed some intention to die just prior to the most recent overdose. And there was a small percentage that actually ranked their intention as very high. So I think these are pilot results, you can't make a lot of very small samples in a particular psychiatric setting and composed of mostly white treatment-seeking opioid use disorder patients, but I think that this is an area of interest for further research because it did replicate. And if in fact we have these results that replicate more broadly, then it does suggest that new interventions that are more systematically applied to try to identify which of our patients may have desire to die or intention to die and do something to heal that, we will be able to bend the curve on the growing numbers of overdose deaths. And this is just to outline what really is required for an ideal overdose death checklist. And it includes a lot of things that aren't commonly done by routine. So completely thorough medical legal investigation, full autopsy, comprehensive toxicology, review of the medical records with special attention to behavioral health, speaking with relevant individuals, investigating the cell phone, personal emails, social media accounts, and talking with family and friends. It's something that, you know, is often referred to as a psychological autopsy, and while we don't have that as routine, there have been studies of forensic psychological autopsies of confirmed opioid positive deaths, and those deaths having been assigned either accident or suicide cause. So really comparing these two categories with an N of 19 each, in order to try to understand what differences popped out. There weren't any demographic predictors, and both groups had multiple non-fatal suicide attempts and were equal in multiple variables reflecting psychosocial stressors, such as homelessness or incarceration, and neither of these groups in the study differed by treatment receipt for substance use disorder, mental health, or medication for opioid use disorder, but what they did find was that the group that was classified as suicide more likely had any depressive disorder or had some evidence that they were planning their death or preparing it, and had a greater number of total lifetime stressors, whereas the accident group were more commonly men than women, had more severe substance use disorder, had history of prior non-fatal overdose, and family conflict. This study suggests that diagnosis and effective treatment of the depressive symptoms is particularly important in terms of suicide prevention in opioid overdose deaths, so screening carefully for any history of suicide planning or preparation, educating patients and their families how to recognize and respond to suicide planning and preparation, and while prior non-fatal overdose was more commonly seen in the accident category, it's important to know that large population studies associate prior non-fatal overdose with both future fatal overdose accidental and future suicide. So what do we know about suicide in opioids? Opioid users have elevated mortality risk for both drug poisoning and suicide with a standard mortality ratio about three times that of the general population, and this persists through age 65, so it's an enduring risk. Illicit and prescription opioid misuse, opioid use disorder, and chronic opioid prescription for pain are all associated with elevated suicidal ideation planning and attempts compared with general population. Suicidal pain patients do plan to overdose on prescription opioids. There have been published studies of this. Suicide risk in opioid users is further elevated when it's combined with alcohol misuse, and suicide poisonings, the highest fatality occur when the poisonings include opioids with a relative risk compared to other substances of about five times higher lethality. Finally, novel risk screening tools have been piloted, but there isn't a current standard for population. Then another thing to think about is that when we see patients in care, suicide presents itself differently depending on many factors, some personal but also the type of mental health syndrome that the person may be experiencing, and I think it's important when we look at these different presentations, in the past they have been interpreted as some are more serious or should be taken more seriously than others, but the reality is all of these presentations may be lethal and really require universal interventions for suicide prevention, so as by way of example, psychotic disorder patients often present with auditory command hallucinations to die. Mood disorder patients may have impulsive or carefully planned, well-thought-out suicide plans. With personality disorders, you frequently see abrupt suicidal behavior following a perceived interpersonal conflict. Substance use disorders present often with a transient reaction to stress or reckless risk-taking when life becomes intolerable, and I think this category has frequently been treated as less lethal and more associated with some sort of immediate secondary gain, but that is not the reality of the suicide risk in this category. And finally, you don't have to have a mental health condition to have a significant suicide risk, and in these populations oftentimes we will observe this when somebody has a life crisis that involves loss of identity or loss of their personal security. It's always good to learn from what our patients will share with us and their unique experiences, so I list this link for all of you. I encourage you to just take a look at some personal narratives. We have three different cases on this website of the Opioid Project, which McLean participated in collaboration with the Opioid Project, and it really does express different ways in which patients with opioid use disorder are experiencing loneliness, despair, and overt suicidality. We're going to move to suicide warning signs, and so these might be termed direct warning signs. These are things that are directly observable or reportable and require immediate actions to ensure a person's safety. So first, the person communicates a desire or plan to die. The person is seeking means with which to harm themselves, and that could be internet searches for how to die, purchase of a firearm or another weapon, stockpiling pills. A person is making their final arrangements, saying goodbye to others, giving away possessions. So all of those require immediate action, and there are what might be called indirect warning signs, which are more of a red flag and require further assessment for whether or not there might be any suicidal intent present, and this would include just a marked shift in mood, anxiety, or behavior, something that's out of the ordinary for that particular person. Severe and persistent insomnia, which has been linked with elevated risk for acting on suicidal thoughts. A relapse following a period of stability may involve suicidal thinking. Agitation or rage. Isolation. Hopelessness. A person reports that they don't belong, reports that they feel like a burden to others. Family or significant others saying, you know, I'm not quite sure what's going on, but he's not him or she's not herself. Recklessness. So behavior that's atypical and seems to be involving more serious risk-taking. All of those would be warning signs to get to know in the patient that you're treating and to do some prevention planning with. Here we're going to talk about determinants of risk and protection, and first, what is the strongest predictor of future suicidal behavior? So among these, intense suicidal ideation, suicide planning, history of previous suicide attempt, or severe substance use disorder. Suicide attempt is the number one risk factor for future suicide death and behavior. It's the most consistent predictor. Any of the others can be associated with future suicidal behavior, but this is the most consistent predictor, and therefore we use it in many of our screening tools and our clinical assessments. For the population of opioid use disorder who are treatment-seeking, across studies, 30 to 45 percent report at least one prior suicide attempt, so it's a pretty high rate in this population, which tells us that this population is significantly at risk for future suicidal behavior. And while it's not modifiable, it can be a focus for education and the need to create a personalized safety plan when you're working with a patient. So really it's a point of education in your patient care. When we think about risk factors for suicide, we can think about what are modifiable targets and also modifiable social determinants of health. So modifiable targets, in other words, things that can be stabilized that will reduce risk for suicide include treatment of substance use disorders, other mental health disorders, treatment of sleep disorders, treatment of chronic pain disorders, and preventing traumatic exposures. On the social determinants side, improvement in housing or food insecurity, social isolation is one of the greatest risk factors for suicide, so remember the importance of your own relationship with the patient as far as reducing a risk factor of importance. Unemployment, firearm in the home, domestic violence, family stressors, health care access or lack thereof, and legal stressors. And when you look at this list of different risk factors, we can see why suicide and its prevention is somewhat complicated because you could imagine any number of combinations of these and different circumstances for different people. But I think, rule of thumb, the more of these risk factors you have, the more you need to be very active in putting in some risk mitigation interventions. What are protective factors against suicide? Some would include the biological, such as maintaining abstinence if you are somebody with substance use disorder, and remaining in recovery care for all mental health disorders, practicing sleep hygiene, and obtaining significant pain relief if you suffer from a pain syndrome. The social determinants being the opposite of what the risk factors are, so having security of food, housing, safety, and economics, having good strong community alliances, social connections, and belonging. Positive shared spiritual beliefs and connections have been demonstrated in several studies to protect against suicide. And not having lethal means in the home in particular, so not having a firearm, and also if you have substances that may be used in a lethal way, keeping those out of the home to the extent that that's possible. We'll walk through some prevention algorithms here and just introduce you to some of the free online resources that are very powerful and really can provide all kinds of different training, whether it's on-demand training or personalized consultation for your own practice or for your institution. So the Zero Suicide Toolkit is a model that operationalizes the core components necessary, especially for health care systems, to implement suicide prevention. And they have also a very good focus on ways in which using the electronic medical record in a way that's designed to build in the suicide screening and prevention algorithms can be highly effective as part of routine care. Then there's the Suicide Prevention Resource Center, which has several really wonderful online training courses that you can access, and also lots of updates and things that you can receive through email about the latest data and information on suicide statistics in this country and new studies. And looking at safety planning, I'm going to describe it in detail, but there's also probably the most commonly used safety planning tool is the Stanley Brown, which can be obtained online free and is very easy to use and to implement with patients and is a simplified version and form to fill out with a patient of what I'm going to introduce here. So safety planning essentially begins with identifying what are the risks for somebody in terms of suicide risks. And really, this is not just an evaluation process. This is something that constitutes screening in an ongoing longitudinal fashion. And so you're identifying risk and your goal is to identify what it is, screen the patient, and explicitly work with them to identify what their risk factors are, to assess how much risk is there, and then to reduce any means to mitigate their risk. So here's just a list. It's not exhaustive of common factors that elevate risk for suicide, depressed mood, hopelessness, having severe guilt, a person who's really feeling like they just can't handle another day, articulating desire to die, thoughts to self-harm, plans to self-harm, means to self-harm, and then behaviors such as they've already interrupted a self-harm episode or they've actually self-harmed, and then looking at other modifiable risk factors that may be, you know, sociocultural. With your patients, you want to identify very personal patterns because as is common with all mental health syndromes, each person has sort of their unique combination of early warning signs and symptoms that will emerge as risk gets higher, and so looking at what happens to thoughts, behaviors, mood, sleep when they are in a higher suicide risk state, and then helping them to identify are there common triggers, people, places, and things that will increase the likelihood that they're going to experience suicidal thoughts or feel out of control of their behavior, and these types of patterns will repeat so they can be used very well in treatment to help the person to be involved in their own self-assessment and to identify the earliest signs that their suicide risk may be increasing, which then will allow them to apply some positive coping, and so positive coping would include things like constructing a list of their reasons to want to stay alive, constructing lists of their connections to others and how they relate to others, in particular others that they feel they can trust to reach out to if they're in a crisis, or just that being with certain others tends to elevate or lift their mood. Also, stressing medication adherence to remove the problem that if patients are not adherent to their medication, they may have consequences that elevate their suicide risk, maintaining abstinence from substance use or at least a very active harm reduction program, and physical self-care as well as spiritual self-care. So this is safety planning in a nutshell, and it's important to really think of this as an ongoing part of your contacts and your medical care. This is just to show some sample screener item content. This is a brief screener called ED Safe, which borrows items from the PHQ-2 and the Columbia Suicide Severity Rating Scale. So when the PHQ-2, which is screening for depression, two of the items are used there. Have you felt down, depressed, or hopeless? Have you felt little interest or pleasure in doing things? And then from the Columbia, there are a couple of items from ideation section and a couple items from behavior. So ideation over the past two weeks, have you wished you were dead or wished you could go to sleep and not wake up, which reflects passive ideation? Or have you had thoughts of killing yourself, which reflects more active ideation? And then behavior, have you ever attempted to kill yourself? And that reflects a lifetime screener. And then when did this happen? And if there was an attempt within the last six months, it's considered recent. There's also the free ASQ screener, which is a four-item screening tool that is also free, and it is specialized for different populations. This is the general adult one. You can find instructions on how to use it. But similarly, you're asking the patient in the past few weeks, have you wished you were dead? In the past few weeks, have you felt that you or your family would be better off if you were dead? In the past week, have you been having thoughts about killing yourself? And have you ever tried to kill yourself? And if the patient answers yes to any of those questions, you would follow up with the question, are you having thoughts of killing yourself right now? So if the patient says yes to question five, this is an acute positive screen, meaning that the patient is at very high risk and requires a full safety and mental health evaluation. And really, that's the intervention to try to put together a community-safe plan, and if not possible, you would take steps to potentially hospitalize a patient. If the answer to question five is no, then really that's a lower risk, but still the patient requires a brief suicide safety assessment and a determination of whether or not a follow-up mental health evaluation would be warranted. And all patients, no matter how they answer, are provided these resources for suicide prevention lifelines and crisis text lines. So those are good examples. Patient engagement is really important with personalized safety planning. So you would work with a patient to identify their specific warning signs, and who specifically can support you, and how can they support you? What can you do, the patient, to reduce risk, and what are you willing to do? This is an important question because so much of it is going to rely on their willingness to self assess and to engage in maintaining safe behavior. Written pocket reminders of the safety plan is very helpful for people, and also working with other collateral, whether it's people or treatment teams, to engage the community around the patient in risk management. Using medications that target the risk factors, so stabilizing active mental health and substance use disorders or active pain. Linking these patients with peer supports and providing caring outreach contacts, some sort of personal follow-up or frequent light touch contacts have been demonstrated to be helpful for many patients. Here's some conversation starters that are useful specifically with opioid use disorder patients. Has it gotten so bad that you wished you were dead? I know that you're telling me about your relapse, but I'm actually more concerned that you're spending time thinking about your own death. You told me that you planned to use last week and that you were not going to carry your naloxone kit with you, which is different from before. What do you think about this? You're taking more risks than you usually do. What's going on? Reducing lethal means is a really important part of suicide prevention, and there's a great course on the Zero Suicide website, Counseling on Access to Lethal Means, or the CALM course. So I would encourage everybody to pursue that. When you're talking about means reduction in patients with substance use disorder, it will also include consideration of the following, removing alcohol and drugs from the home or the environment whenever it's possible to do so, removing controlled substance prescriptions when necessary, and also monitoring prescription supplies more generally. Checking the prescription drug monitoring program to make sure that the patient doesn't have access you're not aware of. And on the harm reduction strategies, reducing the numbers of substances used, having a patient avoid driving or swimming or operating machinery when they're using, and carrying a naloxone rescue kit, and knowing how to use it, being trained in it. When would you consider involuntary commitment in a substance use disorder patient? Often it can be avoided if containment in the community and means reduction is adequate, which is why this work is so important. But it does require that the patient and whatever community linkages they have are in full participation. Involuntary commitment may be necessary for acute biological states that will not resolve rapidly with medication adjustments in the outpatient or emergency department setting. So somebody who's very psychotic or frankly manic may need commitment rather than medication adjustment. It may be necessary for the patient who confirms a very serious intent with a plan. Oftentimes that would be necessary. And it's more likely to be necessary for a patient who is socially isolated or disconnected where the risk is greater that they just don't have the supports they're going to need to be able to implement successfully their safety planning. And with that, I will move to questions and answers. Thank you very much, Dr. Connery. That was a really informative, very useful presentation. Let's take a few minutes to go through questions from the audience. As a reminder, you can submit your questions throughout the presentation by typing them into the question area found in the lower portion of your control panel. I wanted to begin with one thing, Dr. Connery. You haven't mentioned fentanyl. And I know that in the last year or two as the number of fatal overdoses has gone up considerably, we've been under both stress from COVID and more fentanyl use. And I wondered particularly whether you think the availability or use of fentanyl has had any effect or significant effect on this overdose rate or whether it has not been a driver of some of this behavior. No, I think there's no question that fentanyl is the current driver of drug poisoning deaths and that that shift is definitely contributing to the rate increase. But I don't see that as a reason to not consider the suicide prevention aspect of opioid use disorder because the reality is with fentanyl out there, all it takes, the stakes are higher. All it takes is one particularly lethal use for a person to end up dead. And so if a person has suicide risk factors that are associated with the likelihood of how they are going to use, whether it's more risky use, whether it's not being as careful as they normally would be and not thinking about it, then fentanyl is going to be a driver of those deaths as well. So I'm imagining that somebody with serious suicide risk factors might be in a kind of a give up mode. And in that mode, may be more likely to relapse if they had been in treatment and were abstinent. In that mode, they may be more likely to break with their harm reduction program because they just don't care enough anymore. Or they may just be more impulsive and reckless in the way that they use. So I would see that as associated with a problem of where desire to die and intent to die is going to be made more of a factor because the fentanyl out there is so lethal. I certainly would share that. I was also struck by your presentation in the sense that there seem to be fair similarities between the way we deal with relapse and substance use disorder and the way you're dealing with suicide as a relapsing behavior, if you will, that analyzing what's happened in some ways, I think introducing the patient to cognitive behavioral approaches, if you will, or trying to handle their relapse or their thoughts about suicide. You have any particular comments on those relationships or that parallel? Yes, yes. In fact, when I'm doing a training with frontline substance use disorder clinicians, I emphasize that because a lot of them don't have prior training in suicide prevention and it's very scary for them to think about it. But I emphasize that all of the logic that they use for relapse prevention planning is very similar to suicide prevention planning. And so they can feel more comfortable and confident once they understand what the suicide prevention specifics are and have a little bit of training in that, that the thought process is, it follows the same thought process that they're already very expert at using around relapse prevention planning. And so to try to decrease how scary suicide prevention is for frontline clinicians, I think is helpful. Yeah, I think that's a very important point. I would wonder to the degree to which we need to, I guess I'm struck by the changes in suicide intervention and treatment over the last 20, 25 years. I think before when we started this, we were often thinking about making contracts with the patient that they're gonna be safe for the next 24 hours or whatever. And that language isn't in the current approaches at all. And I'm wondering whether there is significant data showing how effective these current approaches are compared to what we were doing 20 years ago. Is any of that stuff looked at? Yes, yes. These approaches have been well-researched and are very effective evidence-based approaches and certainly a great improvement over the contract approach. And I think importantly, these are all very collaborative approaches. So you're not sitting there sort of in an authoritarian position or in judgment. You're really helping the patient to be able to articulate very sometimes shameful thoughts and feelings or scary thoughts and feelings that they usually don't feel that comfortable just talking about with anybody. And you may be really the most important as a clinician, the most important person that they are able to express their thoughts, their behaviors and weigh those in a systematic approach so that it's not an automatic, if I talk about this, I'm gonna end up in a hospital unit, but rather a trusted collaborative approach where the goal is staying well and staying safe. And there's a recognition that at some times when they're not safe, it may be best for them to take measures that will increase their safety. Yeah. I would think that you might have some fears from people who are not familiar with this approach to worry that, well, if they talk about it, it's going to make it more prominent, that that will really encourage their behavior. And I think you're doing something very different in the sense that you're asking patients to take responsibility for their own recovery and to be more of an active partner in the treatment process than we were before. Do you find that there are some patients who resist doing that, or do you think patients welcome that or do they respond in a more positive sense when you use that approach? The most common resistance is really around the patient being afraid that they are going to lose control over, in particular, hospitalization, but lose control over potentially other things like their housing, et cetera. And I think it's important to begin by saying, if we talk about this, you're not going to be put in a hospital. This is something that is very important for me to understand where you are and how you're thinking and what we can come up with together to keep you safely living the life you want to live. The sort of the, I'm on your side, my goal is to keep you as independent as possible. But in order to do that, we have to talk about it so that we can catch it early and put the appropriate steps into place rather than you sitting, hiding with that secret and allowing it to grow into something that at some point requires a more heavy-handed intervention. Right, and in a sense, you make it safe for them to articulate what's going on. And I think of the parallel with substance abuse treatment where many years ago, we would have shied away from the notion about tell me how good you feel when you use drugs or what's the motivation that's driving your drug use because we're focused very much on don't do it. And I think that we've learned sometimes exploring the attitudes that shape the behavior or drive the behavior can be a very effective way to intervene. Yes, my experience is that patients are very grateful for the opportunity to talk about it when it's presented as, that there are evidence-based approaches that we can take to help you get well. And that, so there's a solution. It's not just let's talk about it. It's a, let's talk about it because there are things we can do about it together. Yeah, I had a question from one of our viewers. You mentioned the demographic evidence on frequency of suicide. They wondered whether this has been subdivided into the groups. For instance, do urban black men in a certain age range, say 40 to 60, have a higher risk rather than the data which just categorizes people according to their racial groups but doesn't tell us much more? Well, I think that data is emerging. I think that people, you know, the research is really understanding that we have to look, we have to look at changing trends in a much more local way and more specific way in order to understand who's at risk currently, what are the factors contributing to that? And the fact is that these patterns will change. It's not as if there's something inherent about one's race or ethnic background that's going to act as a risk factor. It really has more to do with what is happening, what is the situation for them? And of course, other biological contributors. But I think that one thing that is being learned is that if we want to do better at bending the curve and preventing suicide, we really have to follow real-time data and follow changing patterns and trends so that we can understand, you know, in this particular region, this particular factor seems to be driving the suicide deaths. But in a different region, it's something else that's driving the deaths. And if we don't have that real-time, you know, fine-tuned data, we're going to have to act in more global prevention ways, which that's not a bad thing. We need to have universal prevention. But then to get really more effective at it, we have to have more of an active surveillance feedback loop which will help us know what factors need to be addressed. Thank you. One of our participants asked you to comment on a thought they have, and I think this would be rather interesting. They note that getting high on opioids is like a little death, that it might make death seem more pleasurable or desirable, more pleasant, less permanent. Would you have any comments on that? It's like people are taking risks repeatedly and desensitizing themselves to the risk they're taking. I think that what you just said is definitely true, that the more risks you take, the more desensitized you are to risk, and generally the greater risk you are willing to take in the future. I'm not sure that I would agree that getting high is a little death because it really depends on the person. So for some people, you know, getting high is the greatest thing in the world, and it's more of just an active, pleasurable act that nothing else gives them that sense of peace and well-being or euphoria, and a person like that is hoping to get high, understanding they might die, but really what they're hoping for is they're betting on, I'm gonna get high and I won't die. But then there are plenty of opioid users whose lives are miserable, and I think for those people, the experience of it as an escape, a transient ability to just block the world out, and avoid all of the pain that they're experiencing, that's more like the little death that the person is commenting on. So it's different. We have time for one more question, Dr. Conner, if we can. The comment is that if a patient with active substance use disorder who's suicidal and needs inpatient treatment, would you recommend inpatient sort of treatment in a substance abuse program versus inpatient psychiatric treatment? So you've got a patient with classic dual diagnosis, if you will. Yes. Would you have any preference as to which option you would follow in terms of any treatment requirement for inpatient? I would. I think if the suicide risk is severe and it appears to be associated with a specific mental health disorder, then probably a psychiatric unit would be preferable. I think that if suicide risk is significant, but the person has no mental health history, no prior suicide attempts, then it may be something that would be managed fine in a substance use disorder treatment unit as opposed to a psychiatric unit. So some of it really depends on the patient profile and the severity of the suicide risk. Okay, well, I think at this point, we have to end our question and answer section. I want to thank you very much for participating in this, Dr. Conner. It's been very helpful and informative. I want to thank all of our audience for participating. I would like to invite people to please visit www.pcssnow.org and see the variety of helpful resources that are offered, including the free PCSS Mentor Program, which offers general information to clinicians about evidence-based clinical practices in prescribing medication for opioid use disorders. PCSS mentors have expertise in medication for substance use treatment and clinical education. You can also find the PCSS Discussion Forum, a simple and direct way to receive an answer related to your medications for substance use treatment. Participants who complete an evaluation of today's session can obtain free CME or a Certificate of Participation. Attendees will receive instructions via email one hour after the webinar concludes. The email will have a link to the evaluation survey and an access code. To claim credit, complete the survey linked in the follow-up email. You will then be directed to the credit claim page, which will ask for the access code. If you have any issues claiming credit, please reach out to educmeatpsych.org. Additionally, today's session was recorded. The presentation slides and video recording will be posted on the Providers Clinical Support System website in two weeks following today's event. Today's activity was presented on behalf of the SAMHSA-funded Providers Clinical Support System. A program operated collaboratively by 19 medical specialty organizations, including the APA. I would like to invite you to our next webinar. Our presenter is Dr. Kathleen Brady. She will be discussing women, gender, and substance use disorder. This presentation will be on March 8th at noon Eastern time. Again, thank you all very much for participating today, and I hope that we will see you again soon.

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