Hello everyone and thank you for joining us today. We'll be getting started momentarily. Hi, good afternoon, everyone, and welcome to today's webinar titled Suicide and Opioids Intersections and Opportunities for Prevention, hosted by the Providers Clinical Support System in partnership with the National Council for Mental Well-Being. Thank you all for joining us today. Next slide, please. Before we begin, I'd like to cover a few housekeeping notes. Today's webinar is being recorded and all participants will be kept in listen-only mode. The recording and slides will be made available on the PCSS website within two weeks. There will be an opportunity to ask questions at the end of the webinar, so we encourage you to submit your questions throughout the webinar in the Q&A box located at the bottom of your screen. Next slide, please. Okay, so today's presenter is Ellie Stout. Ellie is the U.S. Director of Community Suicide Prevention at Education Development Center. Ellie specializes in public health and suicide prevention with diverse populations. In her role overseeing EDC Suicide Prevention Resource Center contracts, she leads a team working to build suicide prevention systems and infrastructure nationwide at the state, community, health system, and national levels. Ellie has over 20 years of experience in public health, cross-sector collaboration, and health communications, including over 15 years supporting suicide prevention efforts in school, health care, state, and community settings. Ellie has served on numerous expert panels and committees, including the advisory group for the 2021 American Academy of Pediatrics Blueprint for Youth Suicide Prevention. Ellie presents regularly on suicide prevention around the country and has co-authored articles published in the Journal of Primary Prevention and Journal of Rural Mental Health. Ellie holds a master's of science in health communications from the Tufts University School of Medicine and a bachelor's of science in international relations law and organization from the Georgetown University School of Foreign Service. Next slide, please. Ellie Stout does not have any disclosures. Next slide, please. The overarching goal of PCSS is to train health care professionals in evidence-based practices for the prevention and treatment of opioid use disorders, particularly in prescribing medications, as well as for the prevention and treatment of substance use disorders. Next slide, please. At this time, I'd like to turn it over to Ellie, who will review the educational objectives and begin the presentation. Thanks so much, Emma, and good afternoon, good morning, depending on what time zone you're in. It's really great to see so many folks coming to have an exchange around this important topic. This is sort of the overview of what we hope you'll get out of this webinar. We'll start with painting the broader picture of suicide in the U.S. and what we know about suicide prevention. Then we'll narrow in a bit more on the relationship between suicide and substance misuse, and specifically opioid use disorders. And then we'll talk about some clinical intervention and prevention strategies and resources to help all of you address suicidality and OUD in your work. So just a little bit about my organization, EDC. We're a global non-profit that works in education, health, and economic development. I work for our U.S. division in the health portfolio. And you heard a little bit about my work. We do a lot of work in behavioral health, including a lot of work in health systems. And I'll share some of the resources that we've developed over the years in this presentation. So Emma's going to bring us through the slides. So Emma's going to bring up an opening poll. You've heard a little bit about me and my organization, but I'm very curious to know more about your professional role and sort of where you're coming from as we go through some of this content. So Emma, if you could pull up that poll. And we won't spend a lot of time. I have a couple of polls for you. But if you could just click on, and please select all that apply. Many of you probably have multiple roles. But click on what represents you the best. And I'm just going to keep an eye on the time and give you another, say, 20 seconds to respond. If none of them apply, please click on other. And you can type into the chat. I tried to think of as many as I could of who might be here. All right. Still some answers coming in. Let's give it 10 more seconds. All right. Why don't we go ahead and close it? Things are slowing down a little bit. Thank you all for participating. If you could, Emma, can you share the results? Thank you. All right. So we have a number of mental health and substance use disorder treatment providers, staff, and leaders. Great to have some leaders here in the room, because certainly health systems are going to make an important difference in this area. Hi to my fellow public health professionals. Great to see we have state, local, and other folks represented. Thank you so much for giving me a sense of who's in the room. And it's great to have such a diverse group here with us today. So let's start by talking a bit about suicide in the United States and sort of what that looks like. This is the most recent snapshot we have on some injury-related death rates. And I chose this one because it reflects both poisoning, which includes overdose deaths, as well as suicide. So poisoning is the blue line, suicide is the green. And you can see that both of those have consistently increased over the past 15 years, whereas we've seen some drops, although some of our progress is reversing in recent years in motor vehicle deaths and homicide deaths. But suicide and poisoning deaths are at the highest, and suicide death rates have been increasing for the last couple of decades. We actually saw, and you see in this graph, a slight decrease in 2019 and 2020. But unfortunately, this is the provisional 2021 data, which is a little bit more than what we had in 2019. We're seeing another increase in the most recent year where we have provisional data. And you'll notice in that description that we don't have final data for 2021 yet. So I will be referring to data up to 2020. And unfortunately, can't comment beyond that. So those are suicide deaths. But here's a snapshot of the broader public health issue of suicide. For every death that we see in that data, there are a lot of people who are suffering. There are over a million people report suicide attempts each year, and these are over 18. So there are also youth attempts we know about. But if you look at that bottom tier, there's really a lot of distress going on. And this has been the picture for some time now. In terms of racial and ethnic demographic groups, we do see that the highest rates from a national data perspective are among American Indian and Alaska Native populations. I do want to say there are some challenges with that data around people who identify as multiple races or people who are categorized as Hispanic Latino. So that data is somewhat problematic, but I did want to highlight that this slide kind of shows that white populations have a high rate as well. And I think in the field, we are noting that the fact that white populations are highlighted in this way kind of masks some emerging concerns for other populations. And so this is the slide that I actually prefer to share when we're looking at some of these different groups. Here, we're looking at the percent change in suicide death rates for these different groups. And you can see in the last 10 years, we've seen much more significant increases among American Indian, Black, and Latino populations than we have for whites. We've also seen very significant increases in younger populations, which historically have lower rates than older age groups. And you can see some interesting geographic distribution as well. So things are shifting, and we want to make sure we're thinking about those populations with these more dramatic increases in recent years. So this is not a comprehensive list of people who are disproportionately affected by suicide, but I wanted to just highlight the groups that we have focused on over the years in our national suicide prevention work. LGBTQ youth, we know there are high levels of suicidal thoughts and behaviors. We don't know about death rates because we don't have good data on LGBTQ status. You saw the data on rural areas. Males have higher suicide rates than females in terms of deaths. And then also looking at lower income or education levels, veterans, I'm sure you've heard in recent years, concern about veteran suicide rates. And just wanted to highlight that individuals experiencing substance use disorder, or SMI, are also at increased risk. And obviously, we're going to get into that in more depth in this session. So there are many suicide risk and protective factors. And for some specific populations, those can vary somewhat. But these are the broad evidence-based risk and protective factors nationwide, population-wide. You'll probably see some you recognize here that overlap with substance misuse, and we'll get into that overlap more specifically later. And I'm not going to spend too much time on this because I have a lot to share with you today. Oh, I'm sorry. I went the wrong way. There we go. I guess the takeaway from the risk and protective factors and from this slide is that suicide is very complex. So no one risk factor is solely responsible for someone's suicide, death, or attempt. And here we see precipitating factors. So things that are associated with someone's suicide death. So this is a CDC review where they look at suicide deaths and things that were associated with that death in recent weeks. And you'll see here, by the way, that problematic substance use is almost a third of these deaths they were looking at. They were looking across 27 states around the US. But you also see some non-behavioral health experiences here, relationship problems, physical health problems, challenges with job, financial, housing issues, legal issues, and some kind of crisis. So again, it's a very multifaceted health issue. So that sounds really complicated. It's an important public health issue. It's very complex. So what do we know about prevention? And before I talk a bit about that, I'm imagining that a lot of you are touching suicide prevention in some way, even if that is not your main professional focus. So I'm hoping that Emma can pull up our next poll and that you can share a bit about your involvement, if any, and if you're not involved, that's okay too. But in my experience with groups like this, many people are already engaged in some way in suicide prevention. So if you could go ahead and let us know a bit. And please, again, check all that apply. And if there's some way you're involved that I haven't thought of, I invite you to share that in the chat. And I do apologize. There's a lot of activity in the chat. I'm not following it super closely. I'm going to give folks another 15 seconds. Sorry, I don't mean to rush, but I definitely want to hear from you, but also want to tell you even more. All right. It looks like a lot of people are... Actually, Emma, you can go ahead and share the results, if you don't mind. Yeah, great that many of you, like almost half of people who replied, have been part of some kind of training and also do... It's so great to see that you're doing some screening and assessment, and we'll get into that very shortly. Also nice to see that you all are involved in coalitions and task forces, but it looks like you all are involved in many ways. So thank you for your contributions to suicide prevention. And I knew I wasn't wrong to think that you are probably already contributing. And the other thing I'll say before moving on is treating substance use disorders and doing substance misuse prevention is suicide prevention. And we're going to get into that in just a moment. But first, very quickly, I just want to say these are our national guiding documents for suicide prevention efforts in the United States. On the left is the national strategy that has 13 goals and 60 objectives. And you'll see it's 10 years old. In 2021, national experts sort of revisited the national strategy, was it time to be updated? And in fact, found that the goals and objectives are still sound, they still match what we know about suicide prevention, the challenges, they haven't been implemented nationwide. And so the Surgeon General implemented a call to action to implement the national strategy that pulled out six key actions that experts feel are critical to amplify in order to really shift the course of those suicide death rates that you saw at the start. And these are the actions that are recommended in that call to action. I wanted to highlight that actions three, four, and five are all related to a clinical space or can be. Lethal means safety is something that can be part of safety planning and lethal means counseling in a clinical setting. So those of you working in clinical settings are really kind of in the center of suicide prevention priorities for the nation. The CDC also has done an evidence review. This used to be called their technical package on suicide prevention. Now it's the suicide prevention resource for action. They just released an updated version in November. And this really looks at what do we know from the literature? Where is there evidence for strategies and approaches that are likely to reduce suicidal thoughts and behaviors? And you see certainly there's some health system is front and center once again in terms of suicide care and identifying and supporting people at risk. I do want to highlight that in creating protective environments, we're talking about not just lethal means, but also reducing substance use. So once again, substance misuse and substance use disorders are really front and center in suicide prevention efforts. We also have examples, not a huge number, but examples of comprehensive approaches that have worked both at the community level, which is the study on the left, and in clinical healthcare systems, which is the study on the right. I don't have time to tell you about these studies, but if you all clamor for it, I can tell you a bit more in the Q&A. And when you get the slides, you'll also see in the references that I have the citations so you can check them out. But suicide is preventable and we can reduce suicide at this population level by leveraging some of those recommendations and evidence-based strategies I just reviewed. The last thing I wanted to cover just from the national suicide prevention stage is 988. Hopefully you've heard about 988. It is the biggest development in suicide prevention in this country for a long time. 988 is the three-digit number to dial for suicidal crisis, mental health crisis, and substance use crisis. It went live in July of this year. And this replaces the previous suicide prevention lifeline and obviously expands upon it. And it's part of a broader national vision to transform crisis services to make sure that individuals get the level of care they need for their behavioral health needs. So that may be counseling during the call itself. That might be activating mobile crisis response, providing safe spaces through crisis respite centers, and other levels of care. So really moving us away from sort of a 911 law enforcement emergency department boarding kind of response that often happens in our country for crisis. So there'll be a lot more coming out from SAMHSA and other national partners on 988, but wanted to highlight this as a really important development. And I think it's really meaningful that substance use crisis is included in this number. And I hope that gives us more opportunities to work across fields of substance misuse and suicide prevention. So the topic you actually came here to hear more about today. Thank you for letting me lay the stage around suicide prevention. But now let's talk a bit about suicide and substance misuse and opioid misuse. And here I have a different kind of multiple choice question please select only one answer for this poll. But what do you think for an adult who has a past year substance use disorder how much higher is their risk of suicidal thoughts? Would you say twice as high, three times, four times five times, or pretty much the same? And I see people are already voting. Oh, hi, Laurel from AFSP. Nice to see you. All right, I'm gonna give it five more seconds. Get your votes in. We've got a nice bell curve going. Emma, do you wanna close the poll and share results? Thank you. All right, so we're clustering around four times as high as most popular choice, three times as high as next, five times as high as next. So I'm gonna show you, it's actually, you're kind of right. It's between four and five times higher. So that question was about serious thoughts of suicide. Those with a past year substance use disorder have almost five times the risk as those with no past year substance use disorder. And you can see a similar sort of level of increased risk across suicide plans and suicide attempts. And so substance use disorders are a risk factor for suicide, for sure. And somebody, sorry, I am just glimpsing the chat briefly. This is from SAMHSA's NSDUH study. So it's self-reported substance use disorders. I'm not entirely sure how they ask the question about a diagnosed substance use disorder or how they measure that self-report, but it is self-reported SUD and self-reported suicide thoughts, plans, and attempts. This is another glimpse. This is a slightly older SAMHSA analysis looking at adults who used illicit drugs specifically. So it's use, not necessarily use disorders, but just to kind of quantify the very large number of people who used illicit drugs in the past year who had serious thoughts of suicide. The smaller concentric circles have to do with plans and attempts. So there's definitely a significant intersection here. So what is behind this? Like, why might we be seeing such a significant overlap here? And the literature does shed some light. We see higher levels of ambivalence toward death among individuals with substance use disorders. And that kind of ambivalence is very typical of a person who is suicidal. And I also wanted on this slide to point to the importance of comorbidities. As I'm sure I'm preaching to the choir, I'm sure you know that a lot of folks who have substance use disorders also have co-occurring mental health challenges. And there's sort of a third intersecting area of chronic pain, and those comorbidities can also further increase risk for suicidal thoughts. And I should say, I'm not sure we said, we do have time for Q&A at the end. So please keep putting in your questions. I probably can't pause to answer all of them now, but we will try to address as many as we can in the Q&A. And now I'm getting a little more focused on opioids. And here is the snapshot of, I mean, even more dramatic increased risk of suicide thoughts among those who abused pain relievers in the past year. Again, we only have the way SAMHSA asks the questions. So we don't have the direct opioid use disorder and suicide sort of population level data from this survey. But we are looking at almost six times higher risk for those abusing pain relievers. And that has been consistent over the last couple of years, as you can see. Looking at the literature, we also see a dose response connection between opioid abuse and suicide. So higher doses of opioids increases the risk for suicide. There's also a correlation with more frequent use. So those abusing opioids weekly are more likely to engage in suicidal planning and attempts. And one study estimates that people with OUD have dramatically elevated risk of suicide deaths compared with those who do not. So we're seeing some very concerning risk for suicidality among those with OUD. I thought this study from looking at emergency department patients who have survived an opioid overdose was very interesting. So I think we're all familiar, sort of even just in the general discourse of the very high risk for people who are released after an opioid overdose they've survived, that their chance of a non-intentional overdose death is very high. But honestly, I had not, until I read this study, had not understood that being in an emergency department for opioid overdose then also increases your risk of dying by suicide within the following year after you're discharged. So again, opportunities perhaps for prevention in certain spaces, but also really this overall test in certain spaces, but also really this overall takeaway that individuals using opioids and experiencing OUDs are at significantly higher risk for suicide. And here, there's also some shared risk and protective factors. There are a lot more shared risk and protective factors across substance misuse and suicide, but I'm zooming in here on suicide and overdose. And I think one big takeaway here is that for both looking at risk factors and protective factors, access to healthcare and behavioral health challenges are really strong through lines. And that's the space, the clinical space is what we're gonna be getting into in just a moment. I won't go into too much depth on this slide, but I think we've all been thinking about how those risk factors may have increased in the COVID era. And there are so many additional stressors that people have been experiencing in the wake of COVID that we all know for those of you who've worked in sort of post-disaster response, that these ripple effects are likely to continue even though things are sort of feeling mostly normal and mostly back to normal in most parts of the country after COVID. And also these stressors are experienced disproportionately by certain groups. So there's even more need for us to act across both issues and ensure that people who are experiencing risk across overdose and suicide don't fall through the cracks. Oops, and I keep going the wrong way. Here we go. So what does prevention look like at this intersection of suicide and opioid use disorder? And here, I am going to look at the chat, which has a couple of really interesting questions that we'll get to in the Q&A, but I'm curious sort of what you all are doing. You're all here, you're thinking about this issue and I think a lot of us are sort of thinking very actively about this intersection. So I invite you to share in the chat and I do have the chat screen open over here. So I'll be taking a look. Well, we can talk a bit about overdose, whether overdoses are suicide. Thank you, there we go. So safe storage and disposal, great. That is stigma reduction, excellent. Excellent, looking across at screening across both areas, cultural responsiveness, talking about things, emergency department interventions, harm reduction. Oh, excellent, overdose fatality review teams. That's excellent. Work with schools, staff training, harm reduction, NARCAN, wonderful. CSSRS, that's great. Working with law enforcement, 988 training, wow. Asking the question, this is really great. Thank you guys for sharing. I wish we had more of a chance to have a interactive conversation. Yep, mental health first aid. Excellent, well, thank you all for sharing. I'm sorry, I don't have time to pause for longer to read all of your responses, but it sounds like you guys are already doing some really great work. So hopefully your sharing in the chat is informative to others, and I'll share some other ideas with you right now. So I have already been hinting at how important healthcare settings are. And it's great that so many of you are involved in healthcare settings and you're doing this work because healthcare settings are a really great way to reach people at risk. And again, I'm going to my suicide prevention information here, but this is very compelling data to me. On the left, you see a SAMHSA analysis showing that people who are engaged with the mental health or behavioral health system have significantly higher risk for suicidal thoughts and behaviors. Now, possibly the reason they're seeking care in behavioral health is because they experienced a behavioral health challenge that does increase their risk. But what we are seeing is that we are able to reach people in our behavioral health systems who are at increased risk for suicide and likely increased risk for opioid use disorder and overdose as well. The study on the right looked at people who had died by suicide. So it was assessing sort of what had they done in the year before their deaths. And 83% of them had some sort of contact with healthcare. It's a staggering number to me. Most people who die by suicide had some kind of healthcare visit. Now, yes, many of them had a primary care visit and there's a lot of work to do in primary care settings too, but that was 64%. The rest was with some kind of a specialty service and probably many of those visits were in behavioral health systems. So the takeaway here is, I think we often hear about folks not seeking care, not being in treatment. And there absolutely are people who are at risk for suicide and overdose who are not in our health systems, but we have reached to people in our client population who are at higher risk for suicide. And we really need to be prepared in health systems to detect risk and work with those people who are experiencing suicidal risk to make sure they're connected to the supports that they need. And in our work with Zero Suicide, I'll tell you a bit about Zero Suicide in a moment, but we, EDC does a survey. This is about 10,000 people that we had talked to a couple of years ago, asking them about their readiness to work with suicidal individuals. And you see 90% of them, the vast majority believe suicide prevention was part of their role, but half had never been trained in suicide screening, assessment or evidence-based treatment for suicidality. And almost two thirds are in a health system where there's no standard tool to assess for risk. So we have a lot to do in health systems. And I wanna emphasize health systems because while providers can do their best and do a really great job, it's the system around them that really facilitates improved suicide care. And so I just wanted to highlight a couple of resources for health systems around incorporating suicide care. This report from the National Action Alliance for Suicide Prevention is an excellent resource that really compellingly lays out the evidence for and feasibility of specific brief interventions that should be practiced across all of these different kinds of healthcare systems. You'll see across the board that detecting risk is a critical factor, looking at safety planning and other brief interventions, caring contacts and ensuring the person is linked to care. So even though not every system or not every kind of health provider is able to provide evidence-based treatment for suicidality, everyone within a health system does have a role to play in making sure that folks don't fall through the cracks. So that report is sort of the minimum that we hope that health systems would do. And this model, the Zero Suicide Model is the gold standard, let's say. So Zero Suicide outlines the core components for systems change in health and behavioral health systems to improve suicide care sustainably across the whole organization and system. And I know we had a few leaders in the room and many more of you may have a voice in health or behavioral health care systems or organizations. I do encourage you to visit this website, find out more. There's a free toolkit and many resources at the website. And it's one of the models that has shown significant effectiveness in reducing suicide deaths in behavioral health client populations. And thanks for the shout outs in the chat there. So those are some systems, best practices. Thinking further, and those are related to suicide specifically, as we think more about integrating our work for opioid use disorder treatment and suicide care, these are a few ways in which we can address both issues, both risk areas in our clinical practice. So I'm sure, I think some folks mentioned this in the last chat question, trauma-informed culturally responsive systems obviously are most effective in working with anybody who is experiencing a behavioral health challenge. And I'm sure many of you are very actively engaged in that kind of work. I think that encourages us to ask questions and think about more than just the one health issue that the person came to us with. Screening across suicide risk and substance use. SBIRT has been adapted in clinical and non-clinical settings to screen for risk across both areas. I know for overdose screening is a little more challenging but certainly making sure we're asking that question as someone said in the chat, across both areas is critical in being able to provide support across areas. I'll talk about safety planning in a bit. Several of you mentioned lethal means and harm reduction. And I do think there is some intersection there around safe storage, certainly of opioids. Opioids can be a method for suicide. And thinking about lethal means safety as an extension of harm reduction can be a way to integrate the two. I think peer supports are essential across both areas and that's certainly a more emerging area for suicide treatment, but very critically important to bring that lived experience support. And there are some treatment modalities that address both kinds of disorders. So there's also a specific way to do safety planning, which I mentioned previously. So safety planning is an evidence-based brief intervention for preventing suicide. And it has to do with collaboratively and I'm preaching to the choir. I'm also not a clinician. So thank you for bearing with me. It has to do with collaboratively identifying sort of what are the warning signs or triggers when somebody might start down the path of thinking about suicide and what are actions they can take, the client can take to sort of distract or reduce the impact of those warning signs and triggers. Lethal means are a critical part of safety planning, making sure if the person has a specific method in mind for suicide. So again, thinking about lethal means and harm reduction efforts in making the environment safe. And then also engaging family about lethal means and substances, adding in relapse prevention plan and medication considerations are ways in which we can take that suicide prevention brief intervention and add opioid use disorder and overdose prevention components. Yes, and Narcan, thank you for that addition. So the other thing I wanted to mention is care transitions that we've been talking a lot about in suicide prevention. And I think this is also really relevant in terms of that data that we saw earlier on about the very high risk for both overdose and suicide that people experience after their discharge from care. So knowing this is a high risk moment, I think this is a space where we can really collaborate across fields. This is another Action Alliance report focusing on care transitions for individuals with suicide risk and it's specific to inpatient care, but I think some of these key strategies that it outlines probably will resonate with those of you who work with people who have opioid use disorder or who've lived through an overdose, where these kinds of interventions, again, mirror some of what we've already talked about with safety planning, the role of peers, but also emphasizing collaboration and communication across organizations, the importance of follow-up, and making sure we're checking that what we're doing is working and working as planned. And I'll leave it there. Many of you are also involved in your community, at the state level, in advocacy, so I I want to re-emphasize some ways in which clinicians and health systems can be leaders in the community, and I pulled out a few in the list on the left, I pulled out a few highlights of where I really think that clinical practitioners and health systems and behavioral health systems can play a strong role in the community. There's also a late-breaking resource that I'm going to drop in the chat. Through a CDC-funded project, EDC just launched a new website on community suicide prevention, which I think I just put in the chat, but the chat is going so fast, so we'll make sure to add that when the materials get sent out to you. But I think in suicide prevention, and probably in substance use disorder treatment, I think clinical settings are often somehow addressed separately, but clinical health systems and clinicians exist in communities, and are often pillars for community prevention efforts. So these are just some ways in which I thought that beyond the walls of the healthcare system, that you all could play a role in prevention across these two areas. Oh, thank you, Grace. All right. No, I'm not sure ID is the right link, actually. Communitysuicideprevention.org should be the correct link. Sorry about that. And so obviously, though, health systems can't do it all on their own, and so I just wanted to point to, I am, as you heard in the introduction, involved with the Suicide Prevention Resource Center Project. Thanks, Andrea. We have a lot of collaboration tools and resources, including the Substance Abuse and Suicide Prevention Collaboration Continuum, which includes tools and stories around different levels of collaboration between suicide prevention and substance misuse prevention and substance use disorder treatment providers. We also have a lot of other kinds of collaboration modules. You see some examples here on the right. And I added a couple of other resources on community collaboration and engagement. Obviously, with such a complex issue, we need a lot of partners at the table. So I want to make sure I'm not giving you the assignment to implement the national strategy all on your own. That's actually it. I zoomed through it a little fast because I was worried I had too much to say. So we actually have, so you will get these slides. I have two pages of resources. I have two pages of references. It's helpful to know there's an error in Chrome. Thank you, Grace. And that is what I have for you. And we now have a solid chunk of time for questions. So Emma and Aaron have been monitoring the Q&A, which I haven't had open, and the chat. So I'm going to ask them what questions have come in. Yeah. Thank you so much, Ellie, for a comprehensive and informative presentation. So we are ready to take questions from the audience. Our first question is that I recently came across a study out of University of Chicago that found that folic acid is associated with the decrease in suicide attempts and self-harm. Have you heard about this? And if so, would you be able to share more? I have not heard about this. The thing I've heard more about is ketamine, but I'm happy to take a look at that study. I think, you know, with suicidality, there are chemical factors and there are social factors. So for any one of those risk and protective factors that you saw, any one of those risk factors, most people who have a behavioral health challenge or who have substance use disorder or who have experienced childhood trauma don't go on to die by suicide. So it's really this constellation of risk factors and precipitating events that are kind of like, it's like if a water glass was filled up to the brim that, you know, that relationship problem caused it to overflow. So, you know, I appreciate, and there's a lot of brain science going on, trying to figure out what's going on inside the brain and how to prevent that way. So that's important research, but I also think we need to continue to think about, you know, social determinants of health and other, you know, clinical and community supports that really address some of those other factors that are outside of the person. I know that's not really an answer. I'm totally going to check out the folic acid article. Great. Thank you, Ellie. Our next question is, is there any information that we could get for the families of victims of overdose and or suicide? That's a really good question. Here, I'm based, EDC is based in Boston and I'm here in Massachusetts. And in Massachusetts, there's actually been work to take what suicide prevention has done around, it's not even really aftercare, the people who are left behind after a suicide, we call supporting them postvention. And there's been a lot of work done in this space. There, a lot of states have postvention protocols, schools have them, there are loss teams, the American Foundation for Suicide Prevention often supports responding to the immediate suicide event, but also providing support groups. And I see people are throwing resources into the chat. So in Massachusetts, there's been some work to take some of that and apply it to people who have lost someone to overdose because it's a very, in some ways, it could be seen as a similar kind of sudden traumatic loss of a loved one. And we know so much about how to provide some of those supports through suicide prevention. I'm not sure, there is a postvention section on the SPRC website. I'm not entirely sure, but though I can check in with my colleague in Massachusetts who's leading some of that work, and we can see if we can get a link or a contact for more information on that. And I see lots of people are also doing some of that work around the country. Great. So our next question is, can you speak to the correlation between overdose and later death by suicide? So we know there's an association. I think the mechanism, I'm not sure we're certain of. The research that I presented that talked about that ambivalence around living or dying, there are some who look at poisoning deaths in its own category and don't differentiate between unintentional and intentional and think of it as a spectrum of self-destructive behavior. However, I know a lot of people in the substance misuse prevention field who strongly disagree with that characterization. And a lot of people in recovery who don't agree that opioid use or abuse is a suicidal act. It's really tricky in how you determine intent. So I'm not, I don't really have an answer, but I guess I do want to recall those shared risk factors, those shared stressors that so many people have experienced in the wake of COVID, but also prior to that, people are really, I think the common through line is people are really suffering. And so that's, I think that's an important part of the prevention picture as well is how do we also get upstream and reduce people's level of distress so that they don't, yeah, deaths of despair. There is some literature on sort of a phenomenon called deaths of despair that links that links overdose deaths, suicide deaths, and alcohol related deaths. And then some, again, somewhat, some people really love that idea and some feel like it's oversimplifying, but I do think there is a through line of suffering that we can all sort of, you know, focus on those shared risk factors and think about how do we get upstream. Yeah. Thank you so much, Ellie. Our next question is, is there any information or research regarding using screening for coping tools as a tool used for prevention? And if so, what is the tool? Sorry, can you say that one again? Yes. Is there any information or research regarding using screening tools for coping skills as a tool used for prevention? And if so, what is the tool? Oh, I see. I believe there is a literature around, you know, assessing coping skills, life skills. There are, you know, school-based interventions around social emotional learning and behavioral regulation. And so there probably are measures. I'm not really sure it's ever been applied in a screening. I'm sure it has been applied. Sorry, ever. I haven't really heard a lot about it being applied in a screening way, but I do think there is some interest in sort of finding ways to measure resilience and focus on those coping skills, those protective factors that buffer the risk for suicide and opioid use. And I think that's a really important area to continue to explore. We want to reduce the risk factors, but we also want to increase some of those protective factors. So I think it's a really interesting idea. Okay, great. Thanks. Our next question is, are there any differences in the maternal population in the stats? I'm sorry, can you say it again? I apologize. Yes. The person asked if there are any differences in the maternal population, I believe in the stats that you shared. I see. Maternal population. It is a concern in terms of postpartum depression and suicide risk. However, in the national statistics and state-level statistics, men have dramatically higher suicide rates than women. And one big factor is the means that tend to be used. Men are much more likely to use firearms, which are much more lethal. However, that doesn't mean, and again, you know, that national data sort of masks areas of concern. And there has been a lot of interest in the last few years around sort of postpartum depression and women. And yes, you're right. And yes, you're right. Older populations have had higher rates, but younger populations have been increasing. I took the CEU reviewers thought I had too many data slides. So I took a few of them out. But if you go to the SPRC website and you click on about the problem, you'll get all of the rich data that you can digest. Okay, great. Thanks. The next question is, are you doing any work in the area of how traumatic brain injuries, suicide and SUD slash OUD are linked? There has been some work on traumatic brain injury and suicide risk, especially from the Department of Defense, but also in regard to child sports injuries. And so there has been some work done on that. I'm, I'm a suicide prevention person. And I'm not always as up to date on substance use disorder linkages. But that's a very interesting, you know, I'm sure there's probably that kind of clustering of risk with substance use as well. I think that's very interesting. Oh, and thanks, folks for pasting in additional links. Okay, great. I believe we have time for just one more. The last question starts off saying, thank you, Ellie, wonderful presentation. I appreciate your sensitivity and experience on this topic. In New Mexico, suicide rates are extremely high but not increasing. However, overdose death rates have skyrocketed. I would like to know your thoughts regarding categorization on death certificates and the work of coroners or medical investigators. If more deaths were categorized as suicide rather than overdose, would it make an impact for prevention? Yeah. So the CDC did some work on this a number of years back. It's definitely not consistent in the death records. Every state has a different sort of level of certainty that you need in order to determine that it is a suicide death. If there is a suicide note, that is a, an easier case to make, but there are a fairly large proportion of suicides don't leave a note. And so it is a challenge. And so it's not just, you know, coroners versus medical examiners and sort of the level of medical training, but it's also the death scene investigation. And, you know, it's certainly, especially with an overdose, if there's no notes and the cops have the next call to go to, they might not do an in-depth review. I, somebody mentioned fatality reviews, overdose fatality reviews. What a great idea. There, there are, as you know, child death reviews that happen in most states and some states have done suicide death reviews to really get at, it's really a exploration of all the circumstances surrounding that person's death in a very in-depth way. So, so I think it would be interesting. It would be interesting to figure out a way to, to create an overdose and suicide death review committee. And of course there's resource constraints across the board. I do think it is, it's important to determine intent for the data, but I think the resources aren't always there to really investigate. And so I do think I think we need to find better ways to, to have more consistent data across the country and to really look into some of those circumstances surrounding the death. Oh, great. Yes. And some counties do death reviews. That's really great to know, James. Thanks for sharing that. Yeah, perfect. So that's all the time that we have for questions today. I'd like to thank Ellie again for presenting. We are so appreciative of your willingness to share your knowledge and expertise with everyone. As a reminder, the recording and slides will be posted on the PCSS website within two weeks from today. Next slide, please. So before we leave, I'd like to make you all aware of two resources offered through PCSS that may be of interest to you all. First, the PCSS mentor program is designed to offer mentoring assistance to those in need of more one-on-one interactions with one of our colleagues to address clinical questions. You have the option of requesting a mentor from the mentor directory or PCSS can pair you up with one. For more information, please visit the PCSS website noted on this slide. Next slide, please. Secondly, PCSS offers a discussion forum comprised of PCSS mentors and other experts in the field who help provide prompt responses to clinical cases and questions. There's a mentor on call each month who's available to address any submitted questions through the discussion forum. You can create a new login account by clicking the image on the slide to access the registration page. Next slide, please. This slide lists the consortium of lead partner organizations that are part of the PCSS project. Next slide, please. Finally, the PCSS website contact information and social media handles are listed here if you would like to find out more information about resources and trainings offered. Thank you all again for joining our webinar today and we hope you all have a great rest of your day and week. Thanks, everyone.

Suicide and Opioids

Intersections

Opportunities for Prevention

Substance Use Disorders

Suicidal Thoughts

Safety Planning

Access to Care

Zero Suicide Model

Health Systems

Collaboration