Self-harm and suicide during and after opioid agonist treatment among primary care patients in England: a cohort study

Prianka Padmanathan*, Harriet J Forbes, Maria Theresa Redaniel, David J Gunnell, Dan Lewer, Paul A Moran, Ben J Watson, Louisa Degenhardt, Matt Hickman

*Corresponding author for this work

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Abstract

Summary
Background The first 4 weeks after initiation and cessation of opioid agonist treatment for opioid dependence are associated with an increased risk of all-cause mortality and overdose. We aimed to investigate whether the rate of self-harm and suicide among people who were prescribed opioid agonist treatment differs during initiation, cessation, and the remainder of time on and off treatment.

Methods
We did a retrospective cohort study and used health-care records from UK Clinical Practice Research Datalink, linked to mortality and hospital admission data, for adults (age 18–75 years at cohort entry) who were prescribed opioid agonist treatment at least once in primary care in England between Jan 2, 1998, and Nov 30, 2018.
We estimated rates and adjusted risk ratios (aRRs) of hospital admissions for self-harm and death by suicide, comparing time during and after treatment, as well as comparing stable periods of time on treatment with treatment initiation, cessation, and the remaining time off treatment.

Findings
Between Jan 2, 1998, and Nov 30, 2018, 8070 patients (5594 [69·3%] men and 2476 [30·7%] women) received 17 004 episodes of opioid agonist treatment over 40 599 person-years. Patients were mostly of White ethnicity (7006 [86·8%] patients). 807 episodes of self-harm (1·99 per 100 person-years) and 46 suicides (0·11 per 100 person years) occurred during the study period. The overall age-standardised and sex-standardised mortality ratio for suicide was 7·5 times (95% CI 5·5–10·0) higher in the study cohort than in the general population. Opioid agonist treatment was associated with a reduced risk of self-harm (aRR in periods off treatment 1·50 [95% CI 1·21–1·88]), but was not
significantly associated with suicide risk (aRR in periods off treatment 1·21 [0·64–2·28]). Risk of self-harm (aRR 2·60
[95% CI 1·83–3·70]) and suicide (4·68 [1·63–13·42]) were both elevated in the first 4 weeks after stopping opioid
agonist treatment compared with stable periods on treatment.

Interpretation
Stable periods of opioid agonist treatment are associated with reduced risk of self-harm, emphasising the importance of improving retention of patients in treatment. The first month following cessation of opioid agonist treatment is a period of increased risk of suicide and self-harm, during which additional psychosocial support is required.
Original languageEnglish
Number of pages9
JournalLancet Psychiatry
Early online date15 Dec 2021
DOIs
Publication statusE-pub ahead of print - 15 Dec 2021

Bibliographical note

Funding Information:
LD reports investigator-initiated educational grant funding from Indivior, Mundipharma, Seqirus, and Reckitt Benckiser, outisde of the submitted work. MH reports speaker honoraria from MSD, Gillead, and Abbvie, outside of the submitted work. BW reports honoraria from and has been a member of an advisory board for Takeda, outside of the submitted work. DG is a member of England's National Suicide Prevention Strategy Advisory Group. PM was the chief investigator, and PP was a co-applicant, on a grant awarded to University of Bristol by Bristol and Weston Hospitals Charity (formerly known as Above & Beyond) focusing on suicide prevention for people presenting to the Emergency Department with self-harm and harmful substance use. All other authors declare no competing interests.

Funding Information:
The views expressed in this publication are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care. PP was funded by the Medical Research Council Addiction Research Clinical Training programme (MR/N00616X/1). MTR was supported by the National Institute for Health Research (NIHR) Applied Research Collaboration West (ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust (core NIHR infrastructure funded: NIHR200181). DG, MH, and PM were supported by the NIHR Biomedical Research Centre at University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol. DL was funded by a NIHR Doctoral Research Fellowship (DRF-2018-11-ST2-016). MH was supported by NIHR Health Protection Research Unit in Behavioural Science and Evaluation. LD was supported by an Australian National Health and Medical Research Council Senior Principal Research Fellowship (APP1135991) and a US National Institutes of Health NIDA grant (R01 DA144740 PI: Degenhardt). We would like to acknowledge Tim Jones (Population Health Sciences, University of Bristol, Bristol, UK) and Martha Elwenspoek (National Institute for Health Research Applied Research Collaboration West, Bristol, UK) for extracting the data used in this paper.

Publisher Copyright:
© 2021 Elsevier Ltd

Structured keywords

  • SASH

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