Fran Lowry

December 13, 2016

BONITA SPRINGS, Florida – Primary care patients who use illicit substances are at much higher risk for suicide than their non–drug using peers, and for this reason, primary care providers should screen for risk factors such as suicide ideation and past suicide attempts, a new study suggests.

"Suicide is a significant public health issue, especially among people who use illicit drugs," lead author Kevin Hallgren, PhD, from the Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, told Medscape Medical News.

"In our study, we wanted to look at the incidence of suicide attempts and suicidal ideation for people who were drug users and who were coming to primary care, and also at what predicts suicidal ideation and suicide attempts in these individuals," Dr Hallgren said.

Dr Kevin Hallgren

"We found that suicide rates were about 10 to 14 times higher in this population than in the general population, so it's a very at-risk group. Primary care could be a good place for providers to reach people and to intervene on suicidality, particularly because these patients were in primary care but were not receiving or seeking any treatment for their drug addiction. They were just keeping their primary care appointments for other healthcare reasons," he said.

The study was presented here at the American Academy of Addiction Psychiatry (AAAP) 27th Annual Meeting.

Primary Care Setting

The investigators assessed the incidence as well as the predictors of suicid ideation and suicide attempts during a 1-year period among 868 substance-using individuals attending primary care clinics.

The study participants were recruited from the waiting rooms of seven safety-net primary care clinics in Seattle. All participants were 18 years of age or older, had used an illegal drug or nonprescribed medication in the 90 days prior to their visit, and planned to continue receiving primary care at the clinic.

Most of them were male, unmarried, unemployed, and receiving welfare benefits, and almost a third of the sample reported being homeless in the past 90 days.

Participants were asked whether they had thought about suicide in the past 30 days or had ever attempted suicide.

Other variables that were assessed were use of alcohol and various classes of drugs, as well as psychiatric symptoms, violent behavior, psychosocial stressors, employment status, housing status, pending legal charges, treatment service utilization, and health-related quality of life.

Participants were followed at 3, 6, 9, and 12 months after their clinic visit.

During the 1-year follow-up period, 25.9% of participants reported suicide ideation on at least one occasion (95% confidence interval [CI], 22.8% - 29.3%), and 7.1% (95% CI, 6.0% - 9.9%) had attempted suicide at least once.

The researchers found that baseline depression and anxiety, suicide ideation in the past 30 days, and any lifetime suicide attempt were predictive of subsequent suicide ideation.

Additionally, baseline violent behavior, assessed on the basis of self-reports by patients, as well as suicide ideation in the past 30 days and any lifetime suicide attempt were predictive of subsequent suicide attempt.

"The 1-year incidence of suicide ideation and suicide attempt in this group was markedly higher compared to the 1-year incidence of suicide ideation and suicide attempt in the general population, which is 3.7% and 0.5%, respectively. But this group also had a substantial degree of homelessness, unemployment, psychiatric and medical problems that might also increase their suicide risk," said Dr Hallgren.

"Still, our study shows that primary care providers may be able to reach out to such people to intervene on suicidality. When working with individuals who use substances, primary care providers are advised to screen for risk factors, including any lifetime suicide attempt, recent suicide ideation, difficulty with violent behavior, depression, and anxiety," he said.

Suicidal Behavior "Strikingly High"

"This is a nicely done study in a large population of primary care patients who use drugs," Carla Marienfeld, MD, director of addiction services and medical director, Addiction Recovery and Treatment Program, University of California, San Diego, told Medscape Medical News.

"The incidence of suicidal ideation and attempts in this population of primary care patients with drug use is strikingly high, especially compared with the incidence in the general population. This speaks to the need to assess for risk in this population and the importance of this work in helping to identify risk factors so that we can better stratify risk in our patients," Dr Marienfeld, who was not part of the study, said.

"For example, knowing that those with psychiatric comorbidities, nicotine- or stimulant-related disorders, or poor health-related quality of life are at high risk allows us to focus screening and supports in those populations," she said.

The study was funded by the National Institute on Drug Abuse. Dr Hallgren and Dr Marienfeld report no relevant financial relationships.

American Academy of Addiction Psychiatry (AAAP) 27th Annual Meeting Paper 2, presented December 10, 2016.

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