PROJECT SUMMARY/ABSTRACT Significance: Suicide and opioid misuse are related epidemics that are both increasing and devasting. The parent R01 System of Safety (SOS) is studying implementation of the Zero Suicide Essential Elements of Care across the emergency departments, inpatient medical and behavioral health units, and primary care clinics of a large healthcare system. It has created a rich repository of suicide-related and other clinical electronic health record (EHR) and vital statistics data. The proposed revision will expand that repository and use natural language processing to detect opioid problem-related encounters, allowing us to (1) explore the relation between suicide risk and opioid misuse and (2) test whether the Zero Suicide model's intervention effect is moderated by opioid misuse and whether it can also help to reduce opioid-related harm. Investigators: The team proposing this revision has extensive expertise in suicide risk screening, assessment, intervention, and care transitions (Boudreaux, Larkin); opioid misuse (Boudreaux, Carreiro, Davis- Martin); implementation science, healthcare systems change, and effectiveness trial design (Kiefe, Wang); and data science and natural language processing (Liu, Yu). This complimentary, transdisciplinary team is very well prepared to answer the important research questions posed in this proposal. Innovation: The SOS pioneers the implementation of system-wide suicide risk identification and prevention efforts and has gathered rich data on suicidal ideation, attempts, and suicide-related care processes on hundreds of thousands of patients. This proposal will use innovative methods to validate and extract opioid-related data from the EHR to enhance the SOS repository to create a singular database available to the SOS investigators and, eventually, public access through the NIMH archive. Approach: Aim 1 will extract opioid-related EHR data using a combination of diagnostic codes and natural language processing, validated by structured manual chart review using a standardized procedure. Aim 2 will analyze the interplay between suicide risk and opioid problems in encounters and patients within the repository. Aim 3 will assess the effect of Zero Suicide implementation on prospective fatal and non-fatal suicidal behavior in patients with an opioid problem and examine whether the implementation had an effect on the incidence of opioid-related outcomes, including intentional overdose. Environment: Having supported successful, NIH funded studies in the domains of suicide, opioid use disorders, data science, and natural language processing, UMass has clearly established its capability of successfully supporting this revision. Impact: The combined innovation of the parent SOS and this revision positions it for a significant impact on the fields of suicide prevention, opioids, and effectiveness trial design and analysis. The deliverables will have broad significance across care settings, medical and behavioral populations, and age groups.

PROJECT NARRATIVE The potential public health impact of this revision to the System of Safety (SOS) study is profound, because it will advance our understanding of how opioid misuse relates to suicide risk and whether a system-level intervention for suicide risk can reduce opioid-related harm. The effort transcends settings of care, encompasses medical and behavioral health clinicians, and targets adults and children, as well as leveraging big data and natural language processing, to set an ambitious scope. Reducing suicide and opioid-related outcomes have far-reaching impact on mortality, morbidity, personal suffering, and healthcare costs.