Suicide and Substance Abuse: Challenge and Opportunity. Richard McKeon Ph.D., MPH Branch Chief, Suicide Prevention SAMHSA

Transcription

1 Suicide and Substance Abuse: Challenge and Opportunity Richard McKeon Ph.D., MPH Branch Chief, Suicide Prevention SAMHSA

2 Suicide and Substance Use With suicide increasing and given the magnitude of the relationship between suicide and substance use, this issue must be addressed Frequent presence of substance use with deaths by suicide and attempts, High prevalence of suicidality of those in substance abuse treatment Many overdose deaths are suicides 2

3 Substance Use and Suicide Data from 17 states NVDRS 22% of suicides involve alcohol intoxication, (30-40% of suicide attempts) Opiates, including heroin and prescription painkillers present in 20% of U.S. suicide deaths. Marijuana-10%,cocaine- 4%,amphetamines-3% 3

4 SUICIDE AND SUBSTANCE ABUSE Substance abuse is second only to mood disorders in its association with suicide Comorbidity increases the risk even further Suicide mortality can be impacted by changes in alcohol control policy Drinking age increase associated with decreased mortality-estimate 600 annually Binge drinking vs per capita consumption (short term vs long term risk)

5 Suicide and Substance Abuse NSDUH data 2 million adults treated each year in facilities for substance abuse Of those 17% (395,000) report suicidal thoughts, and 5% (106,000) attempted suicide in the past year An intervention with 50% effectiveness could prevent 53,000 attempts

6 MISSED OPPORTUNITIES = LIVES LOST 77 percent of individuals who die by suicide had visited their primary care doctor within the year 6 THE QUESTION OF SUICIDE WAS SELDOM RAISED 45 percent had visited their primary care doctor within the month

7 TIP 50 TIP 50: Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment High prevalence of suicidal thoughts and attempts among persons with SA problems who are in treatment. TIP 50 helps SA counselors work with adult clients who may be suicidal Clinical supervisors and administrators Free at: Training video: SAMHSA YouTube channel SPRC Webinar:

8 DAILY DISASTER OF UNPREVENTED AND UNTREATED M/SUDs Any MI: 45.1 million SUD: 22.5 million Diabetes: 25.8 million Heart Disease: 81.1 million Hypertension: 74.5 million 37.9 % receiving treatment 18.3 % receiving treatment 84 % receiving treatment 74.6 % receiving screenings 70.4% receiving treatment

9 Suicide Prevention as a Core Component of Health Care Screening and risk assessment (SBIRT?) The clinical workforce is routinely trained Collaborative safety planning Availability of effective treatments (Spirito, DBT-S) Continuity of care during high-risk transition times is assured. Deaths by suicide are routinely monitored and reviewed to help guide suicide prevention efforts. Continuous quality improvement efforts focused on suicide prevention are conducted.

10 Tough Realities : 55% in emergency department visits for drug-related suicide attempts by men 21 to 34 Every year > 650,000 persons receive treatment in emergency rooms following suicide attempts : 49% in emergency department visits for drug-related suicide attempts by women 50+

11 CHALLENGES IN THE EMERGENCY DEPARTMENT Suicidal substance abusers may receive fragmented care in the ED Medical staff frequently see suicide as a mental health issue and want MH to take charge MH typically wants the patient medically cleared i.e. BAL has dropped before an evaluation Inpatient Psychiatry may see the patient as a substance abuser who needs detox/rehab Detox/rehab sees as needing mental health because suicidal

12 CHALLENGES IN THE EMERGENCY DEPARTMENT (CONT.) As a result, the intoxicated patient may be held for hours or overnight, and when evaluated by MH may no longer be suicidal and be released Several significant problems with this The absence of suicidal ideation or suicidal intent when sober is a poor predictor of suicide risk when intoxicated Family members who could be valuable informants are unlikely to be present when the evaluation finally takes place Follow up post discharge is likely to be poor

13 Juvenile Justice Data-Utah 63% of youth suicide completers had contact with the Juvenile Court System (n=95 of 151). 54% of the 95 subjects involved with Juvenile Court had a referral(s) for substance possession, use, or abuse (n=51 of 95).

14 Adverse Childhood Experiences (ACEs) As ACEs score goes up, so does risk for Risky Behaviors Physical Inactivity, Smoking, Drug/Alcohol Abuse, Early Sexual Activity Chronic Disease Obesity, COPD, Asthma, Diabetes, Liver Disease, Heart Disease Other Health Outcomes Teen Pregnancy, STDs, Miscarriage, Depression, Suicide Attempts, Early Death, Job Problems/Lost Time from Work, Perpetration of IPV Source: Centers for Disease Control and Prevention, Adverse Childhood Experiences Study. Available at:

15 Common Risk Factors for Premature Death HOMICIDE MVAs & Accidental Poisoning Suicide Legal System Involvements Emergency Room Visits Mental Health & Chemical Dependency Treatment Contacts Prevention & Intervention Opportunities Indicated & Clinical Emerging Behavioral Problems & Mental Health Disturbances School Difficulties Alcohol and Substance Misuse Disruptive Family Factors Disadvantaged Economic & Social Factors Selective & Indicated Universal & Selective

16 Acute Alcohol Use as a Near-Term Risk Factor for Suicide Attempts Courtney L. Bagge, Ph.D. University of Mississippi Medical Center 16

17 Timeline Follow-Back for Suicide Attempts (Bagge et al., 2013a,b,c; 2014) Calendar method: Recreate 48 hrs. prior to attempt Anchors: location, who they are with, activities Hourly presence of behaviors/events: Substance use (alcohol and other specific drugs) Negative life events Intensity of suicidal ideation: 0 (not at all) to 5 (extremely) Prospective hrly ratings right before an attempt? Even with high-risk samples, few attempts EMA prompts to be hourly undue burden 17

18 Mechanisms: AAU Suicide See Bagge & Sher, 2008; Conner et al., 2008; & Hufford, 2001 for reviews May risk for attempts by dysphoria; intensity of suic ideation (Bagge et al, 2014) AAU SI in next hr over the 24 hrs before the attempt Even after adjusting for prior hour SI alcohol myopia (similar to cognitive constriction) Tunnel vision (on salient cues) Less access to alternative cues/inhibiting factors (RFL) response inhibition likelihood of extreme behaviors (e.g., violence, drunk driving) Acute transition from ideation to attempt? 18

19 Clinical Implications Psychoeducation Alcohol typically Exacerbates, rather than relieves, neg. emotions. Focuses attention on current (negative) emotions Harder to integrate inhibiting factors Makes it harder to inhibit impulses for extreme behavior Prepare a Distress Safety Plan (to cope w/) Urges to use substances Emergence or in distress or suicidal ideation 19

20 Suicide and Addiction: Prevention and Intervention Prevention and treatment needs to be holistic and comprehensive Shared risk and protective factors contribute to the potential for illness and health recovery Screening for suicide across the prevention and treatment continuum is imperative Your role is critical in shifting the addiction paradigm

21 Prevention Strategies Its never too early or too late - prevention is effective across the lifespan Know your community needs - track your community s surveillance of shared risk and protective factors Educate the public about the risk for substance misuse (i.e. overdose) and suicide - Universal population service points Train gatekeepers on SUD screening and structured suicide screening and safety planning - Selective and Indicated population service points Integrate, connect, and formalize the continuum with: Suicide prevention Child welfare Criminal Justice and diversion School based services Churches, spiritual centers, etc Medical and community based treatment service centers

22 CONTACT INFORMATION AND RESOURCES Richard McKeon, Ph.D., M.P.H. Branch Chief, Suicide Prevention, SAMHSA (240) Substance Abuse and Mental Health Services Administration Suicide Prevention Resource Center National Suicide Prevention Lifeline ( )