1. Initiation of a prescription opioid is associated with a more than doubled risk of suicidal behavior in adolescents and young adults.
2. However, when adjusting for confounding variables such as the presence of pain, this increased risk of suicidal behavior is significantly reduced to only 19%.
Level of evidence assessment: 2 (good)
Overview of the study: Teenage suicide by opioid overdose has been on the rise in recent years. Despite this fact, the association of suicide with initiation of prescribed opioids is not well studied. This retrospective cohort study aimed to investigate how initiation of a prescription opioid contributes to suicide risk in adolescents and young adults by comparing data from prescription opioid initiators to non-initiators. This study also attempted to control for pain as an independent risk factor for suicide by comparing prescription opioid initiators to prescription nonsteroidal anti-inflammatory drug (NSAID) initiators. While the researchers found that initiators of prescription opioids had a more than doubled risk of suicidal behavior compared to non-initiators, this risk was significantly reduced compared to initiators of NSAIDs. Ultimately, opioid initiators had a 19% increased risk of suicidal behavior compared to NSAID initiators, suggesting that pain is a more important factor in suicidal behavior than prescription opioid initiation. . These findings should be considered when health care providers weigh the potential benefits and harms of prescribing opioids to youth and young adults. This study is strengthened by its large national cohort and its robust sensitivity analyses. However, the retrospective design makes it impossible to distinguish between correlation and causation. Additionally, data collected from diagnostic coding may not be reliable and may not represent the true incidence of suicidal behaviors, including suicidal behaviors that were never identified by a health care provider.
Click to read the PEDIATRIC study
Relevant reading: Association of opioid prescribing patterns with prescription opioid overdose in adolescents and young adults
In depth [retrospective cohort]: This study collected data on a national Swedish cohort of youth and young adults aged 9-29 years. The data was collected from several national population and health registers under the aegis of Statistics Sweden. The birth cohort included nearly 2 million people with no prior opioid prescription, of whom 201,433 initiated a new opioid prescription during the 2007-2013 study period. The primary outcome of this study was reported suicidal behavior, determined using International Classification of Diseases, Tenth Revision (ICD-10) and recorded causes of death. Researchers found that prescription opioid initiators had an almost doubled risk of suicidal behavior compared to non-initiators (HR 2.64, 95% CI 2.47-2.81). However, the researchers also used an active comparator design to adjust for pain as a confounder, comparing prescription opioid initiators with prescription NSAID initiators. With this comparison, it was found that the increased risk of suicidal behavior was still significant but much lower in opioid initiators compared to NSAID initiators (HR 1.19, 95% CI 2.1-2 ,4). These results were supported by numerous sensitivity analyses, including adjustments for depression, cancer pain, age, etc.
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