CIPC Blog

This is the 4th and final part of a 4-blog post series where Dr. Edwin Boudreaux chats with us about his work recently highlighted by NIH: HEAL Research Spotlight, Taking Suicide Prevention into Primary Care Settings. 

Read part 1 here, part 2 here, and part 3 here.

About Edwin D. Boudreaux, PhD:

Dr. Boudreaux approaches the challenge associated with solving seemingly intractable barriers to deliver high-quality behavioral healthcare by working with interdisciplinary teams who have complementary expertise and perspectives and figuring out the right balance between human centered approaches and the use of technology to facilitate workflow.

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Our Center for Integrated Primary Care has a focus on Opioid Use Disorder, could you tell us a little bit about the study you’re involved in about how suicide prevention connects with Opioid Use Disorder?

It’s a huge overlap between individuals who have opioid use disorder and individuals with suicide risk. We’ve helped establish that evidence by interviewing individuals who present at the emergency department, for example with opioid use disorder, usually opioid overdose, or some sort of medical complications related to their opioid use like an abscess. We’ve interviewed patients who present primarily for suicide risk and we’ve looked at their opioid use history. We find that approximately 35% of the opioid use disorder patients have a strong suicide risk history and vice versa, those who present with suicide risk have a strong opioid use disorder history. So, there is an intersection of patients who have both, who are suicidal and who are patients with OUD and you can imagine that a real toxic combination because they have the access to lethal means. 

This is a big part of suicide prevention. Part of safety planning and what we are trying to promote in primary care is assessing access to lethal means and then taking action to restrict a person's access to those lethal means. Suicide is often an impulsive action. So, if the person has a firearm, how can we put distance between them and the firearm so that it’s not immediately available. With a person who is using opioids, it is often hard to do that, because they have access to the opioids and therefore access to lethal means. What we try to do first is treat the opioid use disorder and therefore restrict the access to the means to kill themselves, and then we also try to work with the patient’s suicide risk. Often their suicide risk decreases if they can get a handle on their opioid use because it’s their opioid use that is driving suicide. They feel hopeless, they feel trapped, like they can’t break out of that cycle. If we can treat their opioid use disorder, then we typically find that suicidal thoughts decrease. 

Not always though,, because sometimes OUD is wrapped up in another psychiatric disorder. If the person has OUD and major depressive disorder for example, their suicidal thoughts can be persistent even if their opioid use disorder is managed. So, we really do have to do a good job at teasing those things out and treating the individual who has both. Figure out how we’re going to address each problem separately if needed, is important to reduce the patient’s overall suicide risk. 

Thank you so much for taking the time to chat, is there anything else you’d like to share or shine a spotlight on?

What we’ve done, and what we’ve tried to do at Umass is really incorporate the frontline provider’s perspective in what we’re doing. We have primary champions like Steve Erban, who is a primary care physician, and Dan Mullin, who is a behavioral health provider and others who contribute to helping us with creating something that will improve the care for patients.  They help us to identify and mitigate suicide risk in our patients and at the same time are sensitive to provider autonomy, which is really important. Providers don’t want to be painted into a corner and said “you have to do this” - because the patients often are highly variable and really require the judgment of a trained clinician to know how to treat a patient. 

We’ve tried to keep our processes as flexible as possible while still providing good guidance and what the best practices are. We want to continue to do that, and as we roll out, and as we train people, what we do is get feedback, we do audits. We use a real strong quality improvement approach and then we use that feedback to try to update and adapt our protocols so that they become an even better fit for both the patient population and the clinicians. That last part is an essential part of a real effective roll out, if you don’t have a continuous quality improvement approach, and you’re not adapting and updating your approach based off of experience in the field, then you end up with protocols that don’t really evolve and aren’t really sensitive to the real needs the patients and providers. We’re hoping that overtime we can build up our protocols so that they’re even better. That usually takes at least 6 to 12 months, so it’s a long haul but in the end, it will work best for the patients and their health care team.

Resources: 

https://zerosuicide.edc.org/

https://zerosuicide.edc.org/sites/default/files/suicidesafercareguideforprimarycareproviders.pdf