Clinical context of SuicIde following OPIOID transitionS in Veterans, CSI:OPIOIDS-V

背景：2012年至2020年间，退伍军人管理局的阿片类药物处方量下降了64% (VA)高剂量处方减少77%。虽然这一变化可能会防止处方相关的 伤害退伍军人，一些报告信号不良事件-事件不太清楚-包括自杀。 在伤害发生的地方，关键是要知道哪些因素，可改变的和不可改变的，发挥了作用。 通过试验研究自杀的因果机制的努力提出了伦理挑战。大型数据库 评估可能无法揭示医疗记录中缺乏的关键信息。心理解剖 研究提供了一种方法来收集和分析离散的，描述性的数据有关的临床背景 在阿片类药物过渡期间自杀，包括逐渐减少或停止。 意义：本提案响应的征集（HX-21-024）优先考虑了解“益处 以及减量和/或停药的危害。”目前，几个联邦机构已经宣布， 承诺在阿片类药物减量期间避免自杀。但到目前为止，我们对为什么 自杀事件时有发生，因此难以规划预防和缓解行动。准备的下一个合理步骤 卫生系统的应对措施是深入研究事件本身。 创新和影响：尽管许多研究都是为了辨别 处方阿片类药物的变化和结果（包括自杀），该项目采取了不同的方法， 运用心理解剖技术这种研究的先决条件是有能力 招募那些可能会感到耻辱和经常对医疗保健系统怀有不信任的失去亲人的幸存者。我们 该团队多年来一直致力于与社区建立联系，并与自杀学家结盟，以便 招聘成为可能。此外，通过评估退伍军人和非退伍军人自杀之间的差异，我们 的定位，以协助其独特的资产和负债的VA，以减轻后者的目标。 具体目标： 目标1。描述100人（50）中与自杀相关的患者和临床背景因素 退伍军人和50名非退伍军人）在阿片类药物过渡（停止或 减少），通过调查，结构化访谈的死者家属和病历审查。 目标2.确定退伍军人阿片类药物过渡后自杀的独特因素， 非退伍军人，注意退伍军人在VA护理内外的经验差异。 方法：我们将从公众中招募退伍军人和非退伍军人的家庭幸存者， 在阿片类药物过渡的背景下死于自杀。我们将与幸存者合作， 从内部或外部VA，审查他们，并进行结构化的采访传统的心理 尸检通过审查所产生的报告，一个多学科研究小组（包括阿片类药物专家） 减量，自杀，成瘾，卫生服务研究和医学人类学）将应用社会生态学 识别共同的个人和背景因素的框架，以识别临床互动的各个方面， 似乎突出这些事件，并确定这些自杀事件之间的显着对比， 在阿片类药物过渡期间，退伍军人与非退伍军人相反。 后续步骤/实施：我们打算每季度向患者/家属利益相关者团队提交调查结果 和VA合作伙伴（心理健康和自杀预防办公室，VA国家项目主任， 疼痛管理），以便对早期和可操作的见解进行分类以采取行动。我们研究的整理 调查结果和我们的利益相关者的反应和反馈，使这个项目作为第一步， 干预规划过程（“需求评估”），进而导致设计首选成果， 干预设计和测试。

Background: Opioid prescribing has declined 64% between 2012 and 2020 in the Veterans Administration (VA),1 with high dose prescriptions declining 77%. Although this change likely will prevent prescription-related harm to Veterans, some reports signal adverse events - events that are not well understood - including suicide. Where harm has occurred, it is crucial to know what factors, modifiable and nonmodifiable, played a role. Efforts to examine causal mechanisms for suicide through trials present ethical challenges. Large database assessments may not reveal crucial information that is lacking from medical records. Psychological autopsy research provides a method to collect and analyze discrete, descriptive data concerning the clinical contexts for suicide during opioid transitions, including taper or stoppage. Significance: The solicitation to which this proposal responds (HX-21-024) prioritizes learning about “benefits and harms of tapering and/or discontinuation.” At present, several federal agencies have declared a commitment to averting suicide during opioid taper. But thus far, we lack a deep understanding as to why the suicides occur, which makes preventive and mitigating action difficult to plan. The next logical step in preparing a health system response is in-depth study of the events themselves. Innovation and Impact: Whereas much research has gone toward discerning statistical associations between prescription opioid change and outcomes (including suicide), this project takes a different approach, by applying techniques of psychological autopsy. The pre-requisite challenge to such research is the ability to recruit bereaved survivors who may perceive stigma and who often harbor distrust of health care systems. Our team has invested years in building connections to the community, and allying with suicidologists, so that recruitment becomes possible. Also, by assessing differences between Veteran and non-Veteran suicides, we are positioned to assist VA of its unique assets and liabilities, with the goal of mitigating the latter. Specific Aims: Aim 1. Characterize the patient and clinical context factors associated with suicide among 100 persons (50 Veterans and 50 non-Veterans) who have died by suicide in the context of opioid transition (stoppage or reduction) through survey, structured interview of bereaved family members, and medical record review. Aim 2. Identify factors that may be unique to suicides following opioid transition in Veterans as opposed to non-Veterans, with attention to differences in experience for Veterans in and outside of VA care. Methodology: We will recruit, from the public, family survivors of Veterans and non-Veterans with pain who have died by suicide in the context of an opioid transition. We will work with survivors to solicit medical records from within or outside VA, to review them, and to carry out structured interviews traditional for psychological autopsy. From review of the resulting reports, a multidisciplinary research team (including experts in opioid taper, suicide, addiction, health services research and medical anthropology) will apply the Social-Ecological Framework to identify common personal and contextual factors, to identify aspects of clinical interaction that appear salient to these events, and to identify notable contrasts between those suicides occurring among Veterans as opposed to non-Veterans during opioid transition. Next Steps/Implementation: We intend to present findings quarterly to our patient/family Stakeholder Team and to VA partners (Office of Mental Health and Suicide Prevention, VA National Program Director for Pain Management), so that early and actionable insights are triaged for action. The collation of our research findings and our stakeholder response and feedback allows this project to serve as the first step of the Intervention Mapping process (“Needs Assessment”), which leads in turn to design of preferred outcomes, intervention design and testing.