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.

Opioid prescribing has fallen across the US, both within and outside the US Veterans Administration. Although this change likely will prevent prescription-related harm for a number of patients, reports signal adverse events including suicide, for others. Where harm has occurred, it is crucial to know what factors, modifiable and nonmodifiable, played a role. Whereas much research has sought statistical associations between prescription opioid change and outcomes like suicide, we offer a different approach. We will recruit bereaved survivors of suicides following a prescription opioid change. We will carry out detailed survey, medical record review, and in-depth psychological autopsy interviews to learn which patient and clinical context factors could help to account for why the suicides took place. This research is descriptive. The research team includes scholarly experts and members of the affected communities. Working with VA partners, we seek actionable points of leverage for policy makers, and for health systems seeking to prevent these suicides from taking place.