Research Pinpoints Who Is in the Most Danger
By Brenda L. Mooney
New research adds critical information to those efforts by finding that veterans who have drug or alcohol problems are more than twice as likely to die by suicide as their peers. An estimated 20 veterans die by suicide each day —a much higher rate than in the general population.
The report, published in the journal Addiction, points out that the increased risk is even greater for women veterans with substance use disorders (SUD). Their risk of suicide is five times more than for similarly-situated veterans without SUDs.
The study by researchers from the University of Michigan and the VA, which funded it, also was able to pinpoint the type of substance abuse that is most likely to increase suicide risks. Overall, misusers of prescription sedative medications, such as tranquilizers, have the highest suicide risks, the report noted. An especially high risk of suicide also was identified for women veterans who improperly use opioid painkillers.
“We hope these findings will help clinicians and health systems care for people with substance use disorders, with mental health conditions, and with both—and focus suicide prevention efforts accordingly,” said lead author Kipling Bohnert, PhD, a researcher with the VA Center for Clinical Management Research who also is an assistant professor of psychiatry at the U-M Medical School. “Substance use disorders may be important markers for suicide risk.”
In fact, Bohnert and his co-authors suggest that much of the difference in suicide risks for veterans might be explained by the nexus of mental health conditions and substance use issues.
To determine that, the researchers looked at all 4.9 million VHA users in fiscal year 2005 who were alive at the beginning of FY 2006, comparing them to FY 2006-2011 National Death Index (NDI) records on suicides. At the same time, current substance abuse diagnoses were determined using the FY 2004-2005 VHA National Patient Care Database (NPCD) records.
In unadjusted analyses, results indicated that a diagnosis of any current SUD—and the specific current diagnoses of alcohol, cocaine, cannabis, opioid, amphetamine and sedative use disorders—were all associated significantly with increased risk of suicide for both males and females.
Overall, 8.3% of men and 3.4% in the study group had a diagnosis for substance use disorder recorded in 2004-2005. During follow-up, 9,087 of those veterans took their own lives.
In all, the suicide rate was 75.6 per 100,000 for veterans with any substance use disorder, compared with 34.7 for veterans overall.
Hazard ratios (HRs) ranged from 1.35 for cocaine use disorder to 4.74 for sedative use disorder in men, and 3.89 for cannabis use disorder to 11.36 for sedative use disorder in women.
As a whole, suicide risk was found to be highest for veterans of both genders who misused sedatives—171.4 per 100,000—and significantly elevated for women who misused opioids, at 98.6 per 100,000. Men who misused amphetamines also had a suicide rate of 95 per 100,000. The study was unable to determine if the misused agents were prescribed or obtained improperly or illegally.
The relationship between any SUD, alcohol, cocaine and opioid use disorders and suicide were significantly stronger for women than men, according to the researchers, who said that persisted even after adjustment for other factors, most notably comorbid psychiatric diagnoses.
Study authors emphasized that their results underscore the need to focus more veteran suicide-prevention efforts on those who have substance use disorders, especially if they also have depression, schizophrenia, bipolar disorder, post-traumatic stress disorder or anxiety.
According to the national Centers for Disease Control and Prevention (CDC), the age-adjusted suicide rate for all Americans rose from 10.5 to 13.0 per 100,000 between 1999 and 2014, with an uptick in the rate after 2006. Among veterans, the rate was three to four times as high during that interval.
The suicide rate among veterans fluctuated between a high of 39.9 per 100,000 in 2001, a low of 34.9 per 100,000 in 2005 and 39 per 100,000 in 2014, according to an August report detailing the results of the VA’s analysis of 55 million veteran records from 1979 to 2014. The rate may be a more important indicator of the effectiveness of VA programs developed to reduce these deaths than the number of veteran suicides per day, which the VA recently recalculated as 20, rather than the 22 previously reported.
“Mathematically, we had 700 fewer deaths in 2014 than we estimated in 2010,” now-VA Secretary David J. Shulkin, MD, said at the time. “We’re not saying this is progress, the rate is actually increasing, because the number of veterans is decreasing. This is one of those situations where you don’t want to declare victory or say we’re making progress; that’s why we’re being so aggressive.”
Observing that two-thirds of the suicides in the study involved firearms, researchers explained that firearm safety is tantamount in efforts to reduce suicides for military veterans. They also pointed to a more surprising finding—that one-quarter of suicides among veterans with substance use disorders were by intentional poisoning—and called for strategies to prevent that form of suicide.
“Assessment and treatment of co-existing psychiatric conditions, in addition to substance use, may be important in lowering the risk of suicide among individuals who have substance use disorders,” Bohnert explained.
Extended Prescribing Dropped from 9.5% in 2012 to 6.2% in 2016 By Brenda L. Mooney IOWA CITY, IA—Long-term prescribing of opioid painkillers is on the decline at the VA, in contrast to what appears to be happening outside of federal medicine.
Despite their issues with chronic pain, veterans who served in Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF) and Operation New Dawn (OND) use opioids at about the same rate as the overall U.S. population.