Federal Practitioner

Suicide is the 10th leading cause of death in the US. In 2017, there were 47,173 deaths by suicide (14 deaths per 100,000 people), representing a 33% increase from 1999.¹ In 2017 veterans accounted for 13.5% of all suicide deaths among US adults, although veterans comprised only 7.9% of the adult population; the age- and sex-adjusted suicide rate was 1.5 times higher for veterans than that of nonveteran adults.^2,3

Among veteran users of Veterans Health Administration (VHA) services, mental health and substance use disorders, chronic medical conditions, and chronic pain are associated with an increased risk for suicide.³ About one-half of VHA veterans have been diagnosed with chronic pain.⁴ A chronic pain diagnosis (eg, back pain, migraine, and psychogenic pain) increased the risk of death by suicide even after adjusting for comorbid psychiatric diagnoses, according to a study on pain and suicide among US veterans.⁵

One-quarter of veterans received an opioid prescription during VHA outpatient care in 2012.⁴ Increased prescribing of opioid medications has been associated with opioid overdose and suicides.^6-10 Opioids are the most common drugs found in suicide by overdose.¹¹ The rate of opioid-related suicide deaths is 13 times higher among individuals with opioid use disorder (OUD) than it is for those without OUD.¹² The rate of OUD diagnosis among VHA users was 7 times higher than that for non-VHA users.¹³

In the US the age-adjusted rate of drug overdose deaths increased from 6 per 100,000 persons in 1999 to 22 per 100,000 in 2017.¹⁴ Drug overdoses accounted for 52,404 US deaths in 2015; 33,091 (63.1%) were from opioids.¹⁵ In 2017, there were 70,237 drug overdose deaths; 67.8% involved opioids (ie, 5 per 100,000 population represent prescription opioids).¹⁶

The VHA is committed to reducing opioid use and veteran suicide prevention. In 2013 the VHA launched the Opioid Safety Initiative employing 4 strategies: education, pain management, risk management, and addiction treatment.¹⁷ To address the opioid epidemic, the North Florida/South Georgia Veteran Health System (NF/SGVHS) developed and implemented a multispecialty Opioid Risk Reduction Program that is fully integrated with mental health and addiction services. The purpose of the NF/SGVHS one-stop pain addiction clinic is to provide a treatment program for chronic pain and addiction. The program includes elements of a whole health approach to pain care, including battlefield and traditional acupuncture. The focus went beyond replacing pharmacologic treatments with a complementary integrative health approach to helping veterans regain control of their lives through empowerment, skill building, shared goal setting, and reinforcing self-management.

The self-management programs include a pain school for patient education, a pain psychology program, and a yoga program, all stressing self-management offered onsite and via telehealth. Special effort was directed to identify patients with OUD and opioid dependence. Many of these patients were transitioned to buprenorphine, a potent analgesic that suppresses opioid cravings and withdrawal symptoms associated with stopping opioids. The clinic was structured so that patients could be seen often for follow-up and support. In addition, open lines of communication and referral were set up between this clinic, the interventional pain clinic, and the physical medicine and rehabilitation service. A detailed description of this program has been published elsewhere.¹⁸

The number of veterans receiving opioid prescription across the VHA system decreased by 172,000 prescriptions quarterly between 2012 and 2016.¹⁹ Fewer veterans were prescribed high doses of opioids or concomitant interacting medicines and more veterans were receiving nonopioid therapies.¹⁹ The prescription reduction across the VHA has varied. For example, from 2012 to 2017 the NF/SGVHS reported an 87% reduction of opioid prescriptions (≥ 100 mg morphine equivalents/d), compared with the VHA national average reduction of 49%.¹⁸

Vigorous opioid reduction is controversial. In a systematic review on opioid reduction, Frank and colleagues reported some beneficial effects of opioid reduction, such as increased health-related quality of life.²⁰ However, another study suggested a risk of increased pain with opioid tapering.²¹ The literature findings on the association between prescription opioid use and suicide are mixed. The VHA Office of Mental Health and Suicide Prevention literature review reported that veterans were at increased risk of committing suicide within the first 6 months of discontinuing opioid therapy.²² Another study reported that veterans who discontinued long-term opioid treatment had an increased risk for suicidal ideation.²³ However, higher doses of opioids were associated with an increased risk for suicide among individuals with chronic pain.¹⁰ The link between opioid tapering and the risk of suicide or overdose is uncertain.

Bohnert and Ilgen suggested that discontinuing prescription opioids leads to suicide without examining the risk factors that influenced discontinuation is ill-informed.⁷ Strong evidence about the association or relationship among opioid use, overdose, and suicide is needed. To increase our understanding of that association, Bohnert and Ilgen argued for multifaceted interventions that simultaneously address the shared causes and risk factors for OUD,⁷ such as the multispecialty Opioid Risk Reduction Program at NF/SGVHS.

Because of the reported association between robust integrated mental health and addiction, primary care pain clinic intervention, and the higher rate of opioid tapering in NF/SGVHS,¹⁸ this study aims to describe the pattern of overdose diagnosis (opioid overdose and nonopioid overdose) and pattern of suicide rates among veterans enrolled in NF/SGVHS, Veterans Integrated Service Network (VISN) 8, and the entire VA health care system during 2012 to 2016.The study reviewed and compared overdose diagnosis and suicide rates among veterans across NF/SGVHS and 2 other levels of the VA health care system to determine whether there were variances in the pattern of overdose/suicide rates and to explore these differences.

Methods

In this retrospective study, aggregate data were obtained from several sources. First, the drug overdose data were extracted from the VA Support Service Center (VSSC) medical diagnosis cube. We reviewed the literature for opioid codes reported in the literature and compared these reported opioid International Classification of Diseases, Ninth Revision (ICD-9) and International Classification of Diseases, 10th Revision (ICD-10) codes with the local facility patient-level comprehensive overdose diagnosis codes. Based on the comparison, we found 98 ICD-9 and ICD-10 overdose diagnosis codes and ran the modified codes against the VSSC national database. Overdose data were aggregated by facility and fiscal year, and the overdose rates (per 1,000) were calculated for unique veteran users at the 3 levels (NF/SGVHS, VISN 8, and VA national) as the denominator.

Each of the 18 VISNs comprise multiple VAMCs and clinics within a geographic region. VISN 8 encompasses most of Florida and portions of southern Georgia and the Caribbean (Puerto Rico, US Virgin Islands), including NF/SGVHS.

In this study, drug overdose refers to the overdose or poisoning from all drugs (ie, opioids, cocaine, amphetamines, sedatives, etc) and defined as any unintentional (accidental), deliberate, or intent undetermined drug poisoning.²⁴ The suicide data for this study were drawn from the VA Suicide Prevention Program at 3 different levels: NF/SGVHS, VISN 8, and VHA national. Suicide is death caused by an intentional act of injuring oneself with the intent to die.²⁵

This descriptive study compared the rate of annual drug overdoses (per 1,000 enrollees) between NF/SGVHS, VISN 8, and VHA national from 2012 to 2016. It also compared the annual rate of suicide per 100,000 enrollees across these 3 levels of the VHA. The overdose and suicide rates and numbers are mutually exclusive, meaning the VISN 8 data do not include the NF/SGVHS information, and the national data excluded data from VISN 8 and NF/SGVHS. This approach helped improve the quality of multiple level comparisons for different levels of the VHA system.

Results

Figure 1 shows the pattern of overdose diagnosis by rates (per 1,000) across the study period (2012 to 2016) and compares patterns at 3 levels of VHA (NF/SGVHS, VISN 8, and VHA national). The average annual rate of overdose diagnoses for NF/SGVHS during the study was slightly higher (16.8 per 1,000) than that of VISN 8 (16 per 1,000) and VHA national (15.3 per 1,000), but by the end of the study period the NF/SGVHS rate (18.6 per 1,000) nearly matched the national rate (18.2 per 1,000) and was lower than the VISN 8 rate (20.4 per 1,000). Additionally, NF/SGVHS had less variability (SD, 1.34) in yearly average overdose rates compared with VISN 8 (SD, 2.96), and VHA national (SD, 1.69).

From 2013 to 2014 the overdose diagnosis rate for NF/SGVHS remained the same (17.1 per 1,000). A similar pattern was observed for the VHA national data, whereas the VISN 8 data showed a steady increase during the same period. In 2015, the NF/SGVHS had 0.7 per 1,000 decrease in overdose diagnosis rate, whereas VISN 8 and VHA national data showed 1.7 per 1,000 and 0.9 per 1,000 increases, respectively. During the last year of the study (2016), there was a dramatic increase in overdose diagnosis for all the health care systems, ranging from 2.2 per 1,000 for NF/SGVHS to 3.3 per 1,000 for VISN 8.

Figure 2 shows the annual rates (per 100,000 individuals) of suicide for NF/SGVHS, VISN 8, and VHA national. The suicide pattern for VISN 8 shows a cyclical acceleration and deceleration trend across the study period. From 2012 to 2014, the VHA national data show a steady increase of about 1 per 100,000 from year to year. On the contrary, NF/SGVHS shows a low suicide rate from year to year within the same period with a rate of 10 per 100,000 in 2013 compared with the previous year. Although the NF/SGVHS suicide rate increased in 2016 (10.4 per 100,000), it remained lower than that of VISN 8 (10.7 per 100,00) and VHA national (38.2 per 100,000).

Discussion

This study described and compared the distribution pattern of overdose (nonopioid and opioid) and suicide rates at different levels of the VHA system. Although VHA implemented systemwide opioid tapering in 2013, little is known about the association between opioid tapering and overdose and suicide. We believe a retrospective examination regarding overdose and suicide among VHA users at 3 different levels of the system from 2012 to 2016 could contribute to the discussion regarding the potential risks and benefits of discontinuing opioids.

First, the average annual rate of overdose diagnosis for NF/SGVHS during the study period was slightly higher (16.8 per 1,000) compared with those of VISN 8 (16.0 per 1,000) and VHA national (15.3 per 1,000) with a general pattern of increase and minimum variations in the rates observed during the study period among the 3 levels of the system. These increased overdose patterns are consistent with other reports in the literature.¹⁴ By the end of the study period, the NF/SGVHS rate (18.6 per 1,000) nearly matched the national rate (18.2 per 1,000) and was lower than VISN 8 (20.4 per 1,000). During the last year of the study period (2016), there was a dramatic increase in overdose diagnosis for all health care systems ranging from 2.2 per 1,000 for NF/SGVHS to 3.3 per 1,000 for VISN 8, which might be because of the VHA systemwide change of diagnosis code from ICD-9 to ICD-10, which includes more detailed diagnosis codes.

Second, our results showed that NF/SGVHS had the lowest average annual suicide rate (9.1 per 100,000) during the study period, which is one-fourth the VHA national rate and 2.6 per 100,000 lower than the VISN 8 rate. According to Bohnert and Ilgen,programs that improve the quality of pain care, expand access to psychotherapy, and increase access to medication-assisted treatment for OUDs could reduce suicide by drug overdose.⁷ We suggest that the low suicide rate at NF/SGVHS and the difference in the suicide rates between the NF/SGVHS and VISN 8 and VHA national data might be associated with the practice-based biopsychosocial interventions implemented at NF/SGVHS.

Our data showed a rise in the incidence of suicide at the NF/SGVHS in 2016. We are not aware of a local change in conditions, policy, and practice that would account for this increase. Suicide is variable, and data are likely to show spikes and valleys. Based on the available data, although the incidence of suicides at the NF/SGVHS in 2016 was higher, it remained below the VISN 8 and national VHA rate. This study seems to support the practice of tapering or stopping opioids within the context of a multidisciplinary approach that offers frequent follow-up, nonopioid options, and treatment of opioid addiction/dependence.

Limitations

The research findings of this study are limited by the retrospective and descriptive nature of its design. However, the findings might provide important information for understanding variations of overdose and suicide among VHA enrollees. Studies that use more robust methodologies are warranted to clinically investigate the impact of a multispecialty opioid risk reduction program targeting chronic pain and addiction management and identify best practices of opioid reduction and any unintended consequences that might arise from opioid tapering.²⁶ Further, we did not have access to the VA national overdose and suicide data after 2016. Similar to most retrospective data studies, ours might be limited by availability of national overdose and suicide data after 2016. It is important for future studies to cross-validate our study findings.

Conclusions

The NF/SGVHS developed and implemented a biopsychosocial model of pain treatment that includes multicomponent primary care integrated with mental health and addiction services as well as the interventional pain and physical medicine and rehabilitation services. The presence of this program, during a period when the facility was tapering opioids is likely to account for at least part of the relative reduction in suicide.

Suicide is the 10th leading cause of death in the US. In 2017, there were 47,173 deaths by suicide (14 deaths per 100,000 people), representing a 33% increase from 1999.¹ In 2017 veterans accounted for 13.5% of all suicide deaths among US adults, although veterans comprised only 7.9% of the adult population; the age- and sex-adjusted suicide rate was 1.5 times higher for veterans than that of nonveteran adults.^2,3

Among veteran users of Veterans Health Administration (VHA) services, mental health and substance use disorders, chronic medical conditions, and chronic pain are associated with an increased risk for suicide.³ About one-half of VHA veterans have been diagnosed with chronic pain.⁴ A chronic pain diagnosis (eg, back pain, migraine, and psychogenic pain) increased the risk of death by suicide even after adjusting for comorbid psychiatric diagnoses, according to a study on pain and suicide among US veterans.⁵

One-quarter of veterans received an opioid prescription during VHA outpatient care in 2012.⁴ Increased prescribing of opioid medications has been associated with opioid overdose and suicides.^6-10 Opioids are the most common drugs found in suicide by overdose.¹¹ The rate of opioid-related suicide deaths is 13 times higher among individuals with opioid use disorder (OUD) than it is for those without OUD.¹² The rate of OUD diagnosis among VHA users was 7 times higher than that for non-VHA users.¹³

In the US the age-adjusted rate of drug overdose deaths increased from 6 per 100,000 persons in 1999 to 22 per 100,000 in 2017.¹⁴ Drug overdoses accounted for 52,404 US deaths in 2015; 33,091 (63.1%) were from opioids.¹⁵ In 2017, there were 70,237 drug overdose deaths; 67.8% involved opioids (ie, 5 per 100,000 population represent prescription opioids).¹⁶

The VHA is committed to reducing opioid use and veteran suicide prevention. In 2013 the VHA launched the Opioid Safety Initiative employing 4 strategies: education, pain management, risk management, and addiction treatment.¹⁷ To address the opioid epidemic, the North Florida/South Georgia Veteran Health System (NF/SGVHS) developed and implemented a multispecialty Opioid Risk Reduction Program that is fully integrated with mental health and addiction services. The purpose of the NF/SGVHS one-stop pain addiction clinic is to provide a treatment program for chronic pain and addiction. The program includes elements of a whole health approach to pain care, including battlefield and traditional acupuncture. The focus went beyond replacing pharmacologic treatments with a complementary integrative health approach to helping veterans regain control of their lives through empowerment, skill building, shared goal setting, and reinforcing self-management.

The self-management programs include a pain school for patient education, a pain psychology program, and a yoga program, all stressing self-management offered onsite and via telehealth. Special effort was directed to identify patients with OUD and opioid dependence. Many of these patients were transitioned to buprenorphine, a potent analgesic that suppresses opioid cravings and withdrawal symptoms associated with stopping opioids. The clinic was structured so that patients could be seen often for follow-up and support. In addition, open lines of communication and referral were set up between this clinic, the interventional pain clinic, and the physical medicine and rehabilitation service. A detailed description of this program has been published elsewhere.¹⁸

The number of veterans receiving opioid prescription across the VHA system decreased by 172,000 prescriptions quarterly between 2012 and 2016.¹⁹ Fewer veterans were prescribed high doses of opioids or concomitant interacting medicines and more veterans were receiving nonopioid therapies.¹⁹ The prescription reduction across the VHA has varied. For example, from 2012 to 2017 the NF/SGVHS reported an 87% reduction of opioid prescriptions (≥ 100 mg morphine equivalents/d), compared with the VHA national average reduction of 49%.¹⁸

Vigorous opioid reduction is controversial. In a systematic review on opioid reduction, Frank and colleagues reported some beneficial effects of opioid reduction, such as increased health-related quality of life.²⁰ However, another study suggested a risk of increased pain with opioid tapering.²¹ The literature findings on the association between prescription opioid use and suicide are mixed. The VHA Office of Mental Health and Suicide Prevention literature review reported that veterans were at increased risk of committing suicide within the first 6 months of discontinuing opioid therapy.²² Another study reported that veterans who discontinued long-term opioid treatment had an increased risk for suicidal ideation.²³ However, higher doses of opioids were associated with an increased risk for suicide among individuals with chronic pain.¹⁰ The link between opioid tapering and the risk of suicide or overdose is uncertain.

Bohnert and Ilgen suggested that discontinuing prescription opioids leads to suicide without examining the risk factors that influenced discontinuation is ill-informed.⁷ Strong evidence about the association or relationship among opioid use, overdose, and suicide is needed. To increase our understanding of that association, Bohnert and Ilgen argued for multifaceted interventions that simultaneously address the shared causes and risk factors for OUD,⁷ such as the multispecialty Opioid Risk Reduction Program at NF/SGVHS.

Because of the reported association between robust integrated mental health and addiction, primary care pain clinic intervention, and the higher rate of opioid tapering in NF/SGVHS,¹⁸ this study aims to describe the pattern of overdose diagnosis (opioid overdose and nonopioid overdose) and pattern of suicide rates among veterans enrolled in NF/SGVHS, Veterans Integrated Service Network (VISN) 8, and the entire VA health care system during 2012 to 2016.The study reviewed and compared overdose diagnosis and suicide rates among veterans across NF/SGVHS and 2 other levels of the VA health care system to determine whether there were variances in the pattern of overdose/suicide rates and to explore these differences.

Methods

In this retrospective study, aggregate data were obtained from several sources. First, the drug overdose data were extracted from the VA Support Service Center (VSSC) medical diagnosis cube. We reviewed the literature for opioid codes reported in the literature and compared these reported opioid International Classification of Diseases, Ninth Revision (ICD-9) and International Classification of Diseases, 10th Revision (ICD-10) codes with the local facility patient-level comprehensive overdose diagnosis codes. Based on the comparison, we found 98 ICD-9 and ICD-10 overdose diagnosis codes and ran the modified codes against the VSSC national database. Overdose data were aggregated by facility and fiscal year, and the overdose rates (per 1,000) were calculated for unique veteran users at the 3 levels (NF/SGVHS, VISN 8, and VA national) as the denominator.

Each of the 18 VISNs comprise multiple VAMCs and clinics within a geographic region. VISN 8 encompasses most of Florida and portions of southern Georgia and the Caribbean (Puerto Rico, US Virgin Islands), including NF/SGVHS.

In this study, drug overdose refers to the overdose or poisoning from all drugs (ie, opioids, cocaine, amphetamines, sedatives, etc) and defined as any unintentional (accidental), deliberate, or intent undetermined drug poisoning.²⁴ The suicide data for this study were drawn from the VA Suicide Prevention Program at 3 different levels: NF/SGVHS, VISN 8, and VHA national. Suicide is death caused by an intentional act of injuring oneself with the intent to die.²⁵

This descriptive study compared the rate of annual drug overdoses (per 1,000 enrollees) between NF/SGVHS, VISN 8, and VHA national from 2012 to 2016. It also compared the annual rate of suicide per 100,000 enrollees across these 3 levels of the VHA. The overdose and suicide rates and numbers are mutually exclusive, meaning the VISN 8 data do not include the NF/SGVHS information, and the national data excluded data from VISN 8 and NF/SGVHS. This approach helped improve the quality of multiple level comparisons for different levels of the VHA system.

Results

Figure 1 shows the pattern of overdose diagnosis by rates (per 1,000) across the study period (2012 to 2016) and compares patterns at 3 levels of VHA (NF/SGVHS, VISN 8, and VHA national). The average annual rate of overdose diagnoses for NF/SGVHS during the study was slightly higher (16.8 per 1,000) than that of VISN 8 (16 per 1,000) and VHA national (15.3 per 1,000), but by the end of the study period the NF/SGVHS rate (18.6 per 1,000) nearly matched the national rate (18.2 per 1,000) and was lower than the VISN 8 rate (20.4 per 1,000). Additionally, NF/SGVHS had less variability (SD, 1.34) in yearly average overdose rates compared with VISN 8 (SD, 2.96), and VHA national (SD, 1.69).

From 2013 to 2014 the overdose diagnosis rate for NF/SGVHS remained the same (17.1 per 1,000). A similar pattern was observed for the VHA national data, whereas the VISN 8 data showed a steady increase during the same period. In 2015, the NF/SGVHS had 0.7 per 1,000 decrease in overdose diagnosis rate, whereas VISN 8 and VHA national data showed 1.7 per 1,000 and 0.9 per 1,000 increases, respectively. During the last year of the study (2016), there was a dramatic increase in overdose diagnosis for all the health care systems, ranging from 2.2 per 1,000 for NF/SGVHS to 3.3 per 1,000 for VISN 8.

Figure 2 shows the annual rates (per 100,000 individuals) of suicide for NF/SGVHS, VISN 8, and VHA national. The suicide pattern for VISN 8 shows a cyclical acceleration and deceleration trend across the study period. From 2012 to 2014, the VHA national data show a steady increase of about 1 per 100,000 from year to year. On the contrary, NF/SGVHS shows a low suicide rate from year to year within the same period with a rate of 10 per 100,000 in 2013 compared with the previous year. Although the NF/SGVHS suicide rate increased in 2016 (10.4 per 100,000), it remained lower than that of VISN 8 (10.7 per 100,00) and VHA national (38.2 per 100,000).

Discussion

This study described and compared the distribution pattern of overdose (nonopioid and opioid) and suicide rates at different levels of the VHA system. Although VHA implemented systemwide opioid tapering in 2013, little is known about the association between opioid tapering and overdose and suicide. We believe a retrospective examination regarding overdose and suicide among VHA users at 3 different levels of the system from 2012 to 2016 could contribute to the discussion regarding the potential risks and benefits of discontinuing opioids.

First, the average annual rate of overdose diagnosis for NF/SGVHS during the study period was slightly higher (16.8 per 1,000) compared with those of VISN 8 (16.0 per 1,000) and VHA national (15.3 per 1,000) with a general pattern of increase and minimum variations in the rates observed during the study period among the 3 levels of the system. These increased overdose patterns are consistent with other reports in the literature.¹⁴ By the end of the study period, the NF/SGVHS rate (18.6 per 1,000) nearly matched the national rate (18.2 per 1,000) and was lower than VISN 8 (20.4 per 1,000). During the last year of the study period (2016), there was a dramatic increase in overdose diagnosis for all health care systems ranging from 2.2 per 1,000 for NF/SGVHS to 3.3 per 1,000 for VISN 8, which might be because of the VHA systemwide change of diagnosis code from ICD-9 to ICD-10, which includes more detailed diagnosis codes.

Second, our results showed that NF/SGVHS had the lowest average annual suicide rate (9.1 per 100,000) during the study period, which is one-fourth the VHA national rate and 2.6 per 100,000 lower than the VISN 8 rate. According to Bohnert and Ilgen,programs that improve the quality of pain care, expand access to psychotherapy, and increase access to medication-assisted treatment for OUDs could reduce suicide by drug overdose.⁷ We suggest that the low suicide rate at NF/SGVHS and the difference in the suicide rates between the NF/SGVHS and VISN 8 and VHA national data might be associated with the practice-based biopsychosocial interventions implemented at NF/SGVHS.

Our data showed a rise in the incidence of suicide at the NF/SGVHS in 2016. We are not aware of a local change in conditions, policy, and practice that would account for this increase. Suicide is variable, and data are likely to show spikes and valleys. Based on the available data, although the incidence of suicides at the NF/SGVHS in 2016 was higher, it remained below the VISN 8 and national VHA rate. This study seems to support the practice of tapering or stopping opioids within the context of a multidisciplinary approach that offers frequent follow-up, nonopioid options, and treatment of opioid addiction/dependence.

Limitations

The research findings of this study are limited by the retrospective and descriptive nature of its design. However, the findings might provide important information for understanding variations of overdose and suicide among VHA enrollees. Studies that use more robust methodologies are warranted to clinically investigate the impact of a multispecialty opioid risk reduction program targeting chronic pain and addiction management and identify best practices of opioid reduction and any unintended consequences that might arise from opioid tapering.²⁶ Further, we did not have access to the VA national overdose and suicide data after 2016. Similar to most retrospective data studies, ours might be limited by availability of national overdose and suicide data after 2016. It is important for future studies to cross-validate our study findings.

Conclusions

The NF/SGVHS developed and implemented a biopsychosocial model of pain treatment that includes multicomponent primary care integrated with mental health and addiction services as well as the interventional pain and physical medicine and rehabilitation services. The presence of this program, during a period when the facility was tapering opioids is likely to account for at least part of the relative reduction in suicide.

Suicide is the 10th leading cause of death in the US. In 2017, there were 47,173 deaths by suicide (14 deaths per 100,000 people), representing a 33% increase from 1999.¹ In 2017 veterans accounted for 13.5% of all suicide deaths among US adults, although veterans comprised only 7.9% of the adult population; the age- and sex-adjusted suicide rate was 1.5 times higher for veterans than that of nonveteran adults.^2,3

Among veteran users of Veterans Health Administration (VHA) services, mental health and substance use disorders, chronic medical conditions, and chronic pain are associated with an increased risk for suicide.³ About one-half of VHA veterans have been diagnosed with chronic pain.⁴ A chronic pain diagnosis (eg, back pain, migraine, and psychogenic pain) increased the risk of death by suicide even after adjusting for comorbid psychiatric diagnoses, according to a study on pain and suicide among US veterans.⁵

One-quarter of veterans received an opioid prescription during VHA outpatient care in 2012.⁴ Increased prescribing of opioid medications has been associated with opioid overdose and suicides.^6-10 Opioids are the most common drugs found in suicide by overdose.¹¹ The rate of opioid-related suicide deaths is 13 times higher among individuals with opioid use disorder (OUD) than it is for those without OUD.¹² The rate of OUD diagnosis among VHA users was 7 times higher than that for non-VHA users.¹³

In the US the age-adjusted rate of drug overdose deaths increased from 6 per 100,000 persons in 1999 to 22 per 100,000 in 2017.¹⁴ Drug overdoses accounted for 52,404 US deaths in 2015; 33,091 (63.1%) were from opioids.¹⁵ In 2017, there were 70,237 drug overdose deaths; 67.8% involved opioids (ie, 5 per 100,000 population represent prescription opioids).¹⁶

The VHA is committed to reducing opioid use and veteran suicide prevention. In 2013 the VHA launched the Opioid Safety Initiative employing 4 strategies: education, pain management, risk management, and addiction treatment.¹⁷ To address the opioid epidemic, the North Florida/South Georgia Veteran Health System (NF/SGVHS) developed and implemented a multispecialty Opioid Risk Reduction Program that is fully integrated with mental health and addiction services. The purpose of the NF/SGVHS one-stop pain addiction clinic is to provide a treatment program for chronic pain and addiction. The program includes elements of a whole health approach to pain care, including battlefield and traditional acupuncture. The focus went beyond replacing pharmacologic treatments with a complementary integrative health approach to helping veterans regain control of their lives through empowerment, skill building, shared goal setting, and reinforcing self-management.

The self-management programs include a pain school for patient education, a pain psychology program, and a yoga program, all stressing self-management offered onsite and via telehealth. Special effort was directed to identify patients with OUD and opioid dependence. Many of these patients were transitioned to buprenorphine, a potent analgesic that suppresses opioid cravings and withdrawal symptoms associated with stopping opioids. The clinic was structured so that patients could be seen often for follow-up and support. In addition, open lines of communication and referral were set up between this clinic, the interventional pain clinic, and the physical medicine and rehabilitation service. A detailed description of this program has been published elsewhere.¹⁸

The number of veterans receiving opioid prescription across the VHA system decreased by 172,000 prescriptions quarterly between 2012 and 2016.¹⁹ Fewer veterans were prescribed high doses of opioids or concomitant interacting medicines and more veterans were receiving nonopioid therapies.¹⁹ The prescription reduction across the VHA has varied. For example, from 2012 to 2017 the NF/SGVHS reported an 87% reduction of opioid prescriptions (≥ 100 mg morphine equivalents/d), compared with the VHA national average reduction of 49%.¹⁸

Vigorous opioid reduction is controversial. In a systematic review on opioid reduction, Frank and colleagues reported some beneficial effects of opioid reduction, such as increased health-related quality of life.²⁰ However, another study suggested a risk of increased pain with opioid tapering.²¹ The literature findings on the association between prescription opioid use and suicide are mixed. The VHA Office of Mental Health and Suicide Prevention literature review reported that veterans were at increased risk of committing suicide within the first 6 months of discontinuing opioid therapy.²² Another study reported that veterans who discontinued long-term opioid treatment had an increased risk for suicidal ideation.²³ However, higher doses of opioids were associated with an increased risk for suicide among individuals with chronic pain.¹⁰ The link between opioid tapering and the risk of suicide or overdose is uncertain.

Bohnert and Ilgen suggested that discontinuing prescription opioids leads to suicide without examining the risk factors that influenced discontinuation is ill-informed.⁷ Strong evidence about the association or relationship among opioid use, overdose, and suicide is needed. To increase our understanding of that association, Bohnert and Ilgen argued for multifaceted interventions that simultaneously address the shared causes and risk factors for OUD,⁷ such as the multispecialty Opioid Risk Reduction Program at NF/SGVHS.

Because of the reported association between robust integrated mental health and addiction, primary care pain clinic intervention, and the higher rate of opioid tapering in NF/SGVHS,¹⁸ this study aims to describe the pattern of overdose diagnosis (opioid overdose and nonopioid overdose) and pattern of suicide rates among veterans enrolled in NF/SGVHS, Veterans Integrated Service Network (VISN) 8, and the entire VA health care system during 2012 to 2016.The study reviewed and compared overdose diagnosis and suicide rates among veterans across NF/SGVHS and 2 other levels of the VA health care system to determine whether there were variances in the pattern of overdose/suicide rates and to explore these differences.

Methods

In this retrospective study, aggregate data were obtained from several sources. First, the drug overdose data were extracted from the VA Support Service Center (VSSC) medical diagnosis cube. We reviewed the literature for opioid codes reported in the literature and compared these reported opioid International Classification of Diseases, Ninth Revision (ICD-9) and International Classification of Diseases, 10th Revision (ICD-10) codes with the local facility patient-level comprehensive overdose diagnosis codes. Based on the comparison, we found 98 ICD-9 and ICD-10 overdose diagnosis codes and ran the modified codes against the VSSC national database. Overdose data were aggregated by facility and fiscal year, and the overdose rates (per 1,000) were calculated for unique veteran users at the 3 levels (NF/SGVHS, VISN 8, and VA national) as the denominator.

Each of the 18 VISNs comprise multiple VAMCs and clinics within a geographic region. VISN 8 encompasses most of Florida and portions of southern Georgia and the Caribbean (Puerto Rico, US Virgin Islands), including NF/SGVHS.

In this study, drug overdose refers to the overdose or poisoning from all drugs (ie, opioids, cocaine, amphetamines, sedatives, etc) and defined as any unintentional (accidental), deliberate, or intent undetermined drug poisoning.²⁴ The suicide data for this study were drawn from the VA Suicide Prevention Program at 3 different levels: NF/SGVHS, VISN 8, and VHA national. Suicide is death caused by an intentional act of injuring oneself with the intent to die.²⁵

This descriptive study compared the rate of annual drug overdoses (per 1,000 enrollees) between NF/SGVHS, VISN 8, and VHA national from 2012 to 2016. It also compared the annual rate of suicide per 100,000 enrollees across these 3 levels of the VHA. The overdose and suicide rates and numbers are mutually exclusive, meaning the VISN 8 data do not include the NF/SGVHS information, and the national data excluded data from VISN 8 and NF/SGVHS. This approach helped improve the quality of multiple level comparisons for different levels of the VHA system.

Results

Figure 1 shows the pattern of overdose diagnosis by rates (per 1,000) across the study period (2012 to 2016) and compares patterns at 3 levels of VHA (NF/SGVHS, VISN 8, and VHA national). The average annual rate of overdose diagnoses for NF/SGVHS during the study was slightly higher (16.8 per 1,000) than that of VISN 8 (16 per 1,000) and VHA national (15.3 per 1,000), but by the end of the study period the NF/SGVHS rate (18.6 per 1,000) nearly matched the national rate (18.2 per 1,000) and was lower than the VISN 8 rate (20.4 per 1,000). Additionally, NF/SGVHS had less variability (SD, 1.34) in yearly average overdose rates compared with VISN 8 (SD, 2.96), and VHA national (SD, 1.69).

From 2013 to 2014 the overdose diagnosis rate for NF/SGVHS remained the same (17.1 per 1,000). A similar pattern was observed for the VHA national data, whereas the VISN 8 data showed a steady increase during the same period. In 2015, the NF/SGVHS had 0.7 per 1,000 decrease in overdose diagnosis rate, whereas VISN 8 and VHA national data showed 1.7 per 1,000 and 0.9 per 1,000 increases, respectively. During the last year of the study (2016), there was a dramatic increase in overdose diagnosis for all the health care systems, ranging from 2.2 per 1,000 for NF/SGVHS to 3.3 per 1,000 for VISN 8.

Figure 2 shows the annual rates (per 100,000 individuals) of suicide for NF/SGVHS, VISN 8, and VHA national. The suicide pattern for VISN 8 shows a cyclical acceleration and deceleration trend across the study period. From 2012 to 2014, the VHA national data show a steady increase of about 1 per 100,000 from year to year. On the contrary, NF/SGVHS shows a low suicide rate from year to year within the same period with a rate of 10 per 100,000 in 2013 compared with the previous year. Although the NF/SGVHS suicide rate increased in 2016 (10.4 per 100,000), it remained lower than that of VISN 8 (10.7 per 100,00) and VHA national (38.2 per 100,000).

Discussion

This study described and compared the distribution pattern of overdose (nonopioid and opioid) and suicide rates at different levels of the VHA system. Although VHA implemented systemwide opioid tapering in 2013, little is known about the association between opioid tapering and overdose and suicide. We believe a retrospective examination regarding overdose and suicide among VHA users at 3 different levels of the system from 2012 to 2016 could contribute to the discussion regarding the potential risks and benefits of discontinuing opioids.

First, the average annual rate of overdose diagnosis for NF/SGVHS during the study period was slightly higher (16.8 per 1,000) compared with those of VISN 8 (16.0 per 1,000) and VHA national (15.3 per 1,000) with a general pattern of increase and minimum variations in the rates observed during the study period among the 3 levels of the system. These increased overdose patterns are consistent with other reports in the literature.¹⁴ By the end of the study period, the NF/SGVHS rate (18.6 per 1,000) nearly matched the national rate (18.2 per 1,000) and was lower than VISN 8 (20.4 per 1,000). During the last year of the study period (2016), there was a dramatic increase in overdose diagnosis for all health care systems ranging from 2.2 per 1,000 for NF/SGVHS to 3.3 per 1,000 for VISN 8, which might be because of the VHA systemwide change of diagnosis code from ICD-9 to ICD-10, which includes more detailed diagnosis codes.

Second, our results showed that NF/SGVHS had the lowest average annual suicide rate (9.1 per 100,000) during the study period, which is one-fourth the VHA national rate and 2.6 per 100,000 lower than the VISN 8 rate. According to Bohnert and Ilgen,programs that improve the quality of pain care, expand access to psychotherapy, and increase access to medication-assisted treatment for OUDs could reduce suicide by drug overdose.⁷ We suggest that the low suicide rate at NF/SGVHS and the difference in the suicide rates between the NF/SGVHS and VISN 8 and VHA national data might be associated with the practice-based biopsychosocial interventions implemented at NF/SGVHS.

Our data showed a rise in the incidence of suicide at the NF/SGVHS in 2016. We are not aware of a local change in conditions, policy, and practice that would account for this increase. Suicide is variable, and data are likely to show spikes and valleys. Based on the available data, although the incidence of suicides at the NF/SGVHS in 2016 was higher, it remained below the VISN 8 and national VHA rate. This study seems to support the practice of tapering or stopping opioids within the context of a multidisciplinary approach that offers frequent follow-up, nonopioid options, and treatment of opioid addiction/dependence.

Limitations

The research findings of this study are limited by the retrospective and descriptive nature of its design. However, the findings might provide important information for understanding variations of overdose and suicide among VHA enrollees. Studies that use more robust methodologies are warranted to clinically investigate the impact of a multispecialty opioid risk reduction program targeting chronic pain and addiction management and identify best practices of opioid reduction and any unintended consequences that might arise from opioid tapering.²⁶ Further, we did not have access to the VA national overdose and suicide data after 2016. Similar to most retrospective data studies, ours might be limited by availability of national overdose and suicide data after 2016. It is important for future studies to cross-validate our study findings.

Conclusions

The NF/SGVHS developed and implemented a biopsychosocial model of pain treatment that includes multicomponent primary care integrated with mental health and addiction services as well as the interventional pain and physical medicine and rehabilitation services. The presence of this program, during a period when the facility was tapering opioids is likely to account for at least part of the relative reduction in suicide.

US veterans die by suicide at a higher rate than that of the civilian population, and are more likely to use a firearm as their lethal means.¹ In 2017, 6,139 veterans died by suicide, about 17 per day.¹ Nearly as many veterans die by suicide yearly as the total aggregate number of service members killed in action during the decades-long Iraq and Afghanistan operations.² Veterans are more likely to own firearms than are civilians.³ Until June 2020, however, systemic efforts to address the use of firearms in suicide had been largely evaded, entangled in gun advocates’ assertion that veterans’ constitutional right to bear arms would be infringed.

That impasse changed with the President’s Roadmap to Empower Veterans and End the National Tragedy of Suicide (PREVENTS) task force report, released June 17, 2020.⁴ Although the US Department of Veterans Affairs (VA) has pioneered initiatives to encourage safe firearm storage for at-risk veterans, and major public health organizations have endorsed the utility of lethal means safety strategies, the policy language of the Roadmap released by the White House is unprecedented. Lethal means safety refers to efforts aimed at increasing the time and distance needed to access suicide methods.

Among the report’s 10 recommendations, the Roadmap verified the link between, and the need to address, at-risk veterans and their access to firearms (the author was a minor consultant to a PREVENTS workgroup). The document states, “The science supporting lethal means safety is robust and compelling: enhancing safety measures specific to the availability and accessibility of potential lethal means saves lives. A key component of effective suicide prevention is voluntary reduction in the ability to access lethal means with respect to time, distance, and convenience, particularly during acute suicidal crises.”⁴ The report recommends widespread distribution of safety education materials that encourage at-risk individuals to temporarily transfer or store their guns safely, and the expansion of free or affordable options for storing weapons, among other recommendations.

This paper reviews the literature on the intersection of veterans, firearms, and suicide, then explores existing VA prevention initiatives aimed at reducing at-risk veterans’ access to lethal means and offers policy recommendations to expand efforts in the context of the PREVENTS Roadmap.

Veteran Suicide and Firearms

Firearms are, by far, the most common lethal means used by veterans who die by suicide. About 71% of male veteran suicide deaths and 43% of female veteran suicide deaths are with firearms, rates that far exceed those of nonveterans (Table).For all age groups, veterans are more likely to complete suicide by firearm than are nonveterans.⁵

Veteran suicide and gun ownership rates are highest in rural areas.^6,7 When compared with veterans living in urban areas, veterans in rural areas are 20% more likely to die by suicide, with the excessive risk largely attributed to suicide by firearm.⁸

Access to firearms at home increases the risk of suicide. Individuals with any firearm at home are 3 times more likely to die by suicide than is a person with no firearms at home. The elevated suicide risk applies to other household members as well as the firearm owner.^9-18 Survivors of suicide attempts using firearms report that the availability of guns at home is the primary reason for their method choice.^19,20

There is a common misperception that people who are intent on suicide and are thwarted or survive an attempt using one method will try again with another.²¹ Suicidal crises often represent a conflicting wish to live or die,²² and approximately two-thirds of those who survive an attempt will never try again. About 23% reattempt nonfatally, and only 10% die by suicide.^23-25 However, people who attempt suicide with a firearm usually won’t get a chance at a new start, because 90% of such acts are fatal.²⁶

Although some suicide attempts might be contemplated or planned over an extended period, the decision is impulsive for most individuals. Surveys have found that many people who survive suicide attempts began the act only minutes or hours after making the decision to end their life.^27-30 The high-risk, acute phase of many suicidal crises arise quickly and is fleeting.

Limiting the ease by which at-risk individuals can access firearms has been shown to prevent suicide. In 2006, the overall suicide rate in Israel dropped 40% when the Israeli Defense Forces began requiring soldiers to store their firearms on base before going on weekend leave.Since then, the suicide rate has declined even further.^31,32

Delaying Access to Firearms for At-Risk Veterans

Among veterans, 45% own ≥ 1 firearms (47% male and 24% female veterans vs 30% male and 12% female nonveterans).³ Many veteran firearm owners (34% male and 13% female) store ≥ 1 gun loaded and unlocked; 44% store a firearm either loaded or unlocked. Only 23% safely store their firearms unloaded and locked at home. Storing ≥ 1 firearm loaded and unlocked is more likely among veterans who reside in rural areas, separated from service before 2002, and report personal protection as the primary reason for ownership.³³

Because evidence shows that delaying access to firearms—especially by transferring them out of the home—saves lives, many US health organizations have advocated for strategies that promote evaluation of firearm access and counseling safe storage for individuals at risk for suicide. These organizations include the US Office of the Surgeon General, National Action Alliance for Suicide Prevention, Centers for Disease Control and Prevention, and American Public Health Association.^34-36

Some health care systems—notably Kaiser Permanente and Henry Ford Health Systems—implemented protocols for lethal means assessment and counseling for behavioral health patients.^37,38 Washington state requires specific health professionals to enroll in suicide prevention training that includes content on the risk of imminent harm by lethal means.³⁹ California is designing a curriculum on counseling patients to reduce firearm injury for physicians and other health care practitioners (HCPs).⁴⁰

The scope of these efforts, however, pale in comparison with the VA’s comprehensive, innovative lethal means safety approach. Since 2012, VA’s Suicide Prevention Program has distributed free firearm cable locks to veterans who request them. The VA has created lethal means public service announcements, social media messages, and websites.^41-44 The VA distributes firearm and medication safe storage practice resource kits to its primary care, mental health and women’s health clinics, and Vet Centers, that include brochures, large poster cards, stickers, exam room posters, and provider pocket cards. VA developed an online lethal means safety counseling training that 20,000 VA HCPs have taken, and is moving toward a revamped mandatory training for VA’s mental health, pain, primary care, and emergency department (ED) providers and Veterans Crisis Line responders. VA offers free, individualized lethal means risk management consultation to all clinicians who work with veterans.⁴⁵ VA includes lethal means safety procedures in its National Strategy for Preventing Veteran Suicide,VA/DoD Clinical Practice Guideline,and VA Suicide Risk Evaluation and Suicide Prevention Safety Planrequired of clinicians.^46-48

The VA also added public health strategies that promote safe storage practices for veterans through a partnership with the National Shooting Sports Foundation (NSSF; the firearm industry trade association) and the American Foundation for Suicide Prevention (AFSP).⁴⁹ Collectively, these organizations cobranded an educational, training, and resource toolkit to foster community coalitions and gun retailer projects that encourage veterans to securely store firearms.⁵⁰ The VA partnered with NSSF to post billboards in 8 states, encouraging storing firearms responsibly to prevent suicide. VA invited states and cities in the Governor/Mayoral Challenge to Prevent Suicide (joint VA and Substance Abuse and Mental Health Services Administration endeavors) to develop plans for messaging regarding enhanced lethal means safety processes. The VA collaborated with local firearm advocates in community prevention pilot projects and in a “Together with Veterans” dissemination of material and outreach to rural veterans.⁵¹ Along with AFSP, VA hosted conferences for HCPs, policy makers, and stakeholders about innovations related to lethal means safety.⁵² In May 2020, the VA cosponsored a COVID-19 suicide prevention video with the United States Concealed Carry Association, NSSF, and AFSP, including ways that the firearm industry, gun owners, and their families can help.⁵³

These programs are promising, and the Roadmap’s emphatic endorsement of lethal means safety approaches will accelerate advances. However, the Roadmap’s omissions are consequential. By focusing on population interventions, the document is silent about VA-specific or veteran-specific firearm access strategies. The means safety work of VA’s Suicide Prevention Program Office is scarcely recognized. Further, it stops short of specific legislative initiatives, making aspirational recommendations instead.

This paper will list proposed policy actions to bolster the acceptability and practice of lethal means safety with veterans. They cover an entire range of possibilities, from putting more teeth into the Roadmap’s population-wide interventions to initiatives tailored to veterans. Responsibility for leading and funding the changes would reside in a mix of Congress and state legislatures, the VA, and health system accreditation bodies. Although there is solid evidence that lethal means safety prevents suicide, it is unknown how these approaches affect firearm storage behaviors or suicide rates;therefore, the policy actions should come with federal and state funds for rigorous evaluation.⁵⁴

Recommended Actions to Further Promote Safe Storage

Develop Campaigns to Shift Cultural Norms for Firearm Storage During Crises

National campaigns have been shown to be highly effective in changing injurious behaviors. Alliances and resources with regard to lethal means safety could be assembled, including federal funds for a campaign to shift social norms for firearm storage conversations and behaviors during crises. This campaign should be modeled after the “friends don’t let friends drive drunk” and “designated driver” campaigns that empower family and friends to protect one another. Since those campaigns’ inception in 1982, two-thirds of Americans have tried to prevent someone from driving after drinking,and traffic deaths involving alcohol-impaired crashes have decreased 65%.^55,56

The comparable lethal means safety enterprise would encourage friends and family to talk with those in crisis about storing firearms safely. The campaign must use spokespersons who have strong respect and credibility among firearm owners, such as the NSSF and the United States Concealed Carry Association who have developed firearm suicide prevention websites and videos.^57,58

The emphasis is that it’s a personal strength—not a failing—to talk to friends, loved ones, or counselors about storing guns until a crisis passes. Some of the current phrasing includes: “Hey, let me hold your guns for a while,” “People who love guns, love you,” and “Have a brave conversation.” ^59-61

The national campaign should attempt to correct the inaccurate beliefs that suicide death always is the result of mental illness and is inevitable once seriously contemplated. In fact, more than half of the individuals who die by suicide have no diagnosed mental health condition.⁶² Other crises, such as with finances, relationships, or physical health, might be more contributory. These myths about suicide and mental illness weaken public and policy maker interest in solutions aimed toward accessing lethal means.

Facilitate Temporary Storage Out of the Home

The PREVENTS Roadmap Supplemental Materials concluded, “Moving firearms out of the home is generally cited as the safest, most desirable option; this can include storage with another person or at a location like a firearm range, armory, pawn shop, self-storage unit, or law enforcement agency, although state laws for firearm transfers may affect what options are legal.”⁶³ This goal could be achieved by establishing grants to gun shops and ranges to offer free lockers for voluntary safe harbor.

The creation of free community lockers was a top PREVENTS recommendation. Likewise, the congressionally chartered COVER (Creating Options for Veterans' Expedited Recovery) Commission recommended grants “to further support the development of voluntary firearm safe storage options across the country.”⁶⁴ Federal and state grants might resolve hesitations cited by retailers by covering all expenses for lockers, labor, and insurance for theft/damage/liability.^65,66 Locker use would be free to the user, eliminating all financial barriers, although it is unknown whether monetary incentives change storage behaviors. Many firearm owners report that private gun shops or ranges are more acceptable than police stations for storage. If retailers come on board, changes in cultural storage norms might be expedited. An additional benefit could be reduction of accidental firearm fatalities in the home. States that have legal impediments to returning firearms to their owners could modify laws to achieve popular acceptance.

Congress could consider funding a national, easily accessible, public online directory of locations for out-of-home firearm storage, with staff to update the site. Colorado, Maryland, and Washington have developed online maps showing locations of firearm outlets and law enforcement agencies willing to consider temporary storage.⁶⁷ A site directory for every state would simplify the process for individuals and family members seeking to temporarily and voluntarily store guns offsite during a crisis. Online directories have been backed by firearm groups,although their effect on storage behavior is not known.⁶⁸State governments should strive to make it easier to quickly transfer firearms temporarily to trusted individuals in situations of imminent suicide risk. Rapid transfer of firearms to friends or family could effectively separate lethal means from individuals during a crisis. However, some state laws that require background checks whenever a gun is transferred might delay such transfers.⁶⁹ Only a few states have legal exemptions that could expedite temporary transfers when it’s potentially lifesaving.

Improve In-Home Safe Storage Options

Out-of-home transfer of firearms might not be acceptable or feasible for some veterans. Accordingly, there is need for improved options for safer in-home storage, especially because of frequent unsafe storage practices among veterans. The VA could consider sponsoring another open-innovation Gun Safety Matters Challenge like the one it held in 2018 for in-home firearm storage technology that could prevent suicide.⁷⁰ Further innovation and bringing winning entries to market has great potential.

Require Enhanced Lethal Means Safety Standards and Training

Broader lethal means safety competence is needed, both in the VA where modest levels of training has been implemented and in the community among Veterans Community Care Program (VCCP) HCPs where it hasn’t. Oversight for enhanced standards and training—as well as of all lethal means initiatives and their program evaluations—might best be accomplished by establishing a separate VA Suicide Prevention Program lethal means safety team. Veteran firearm suicide is a significant problem that warrants its own discrete, permanent VA team (although joining with the US Department of Defense might be advantageous). The VA Suicide Prevention Program has been the industry leader and innovator in this field and should be conferred continued stewardship going forward.

The VA is moving toward requiring lethal means safety counseling training for mental health, pain, primary care, women’s health, ED providers, and Veterans Crisis Line responders.

VCCP HCPs, however, have no required training in lethal means safety counseling or even in basic suicide risk identification and intervention, and the Roadmap did not stipulate that this deficiency should be remedied. Surveys have revealed that community HCPs rarely screen or counsel their patients—even those at high risk—about firearm safety.⁷¹ A bill was introduced in Congress August 21, 2020, to expand VA suicide prevention training with firearms community input on cultural competency components and mandate that VA and VCCP providers, and some others with frequent contact with veterans, receive this training.⁷²

Training should be obligatory for VA and VCCP HCPs and trainees most likely to interface with at-risk veterans, including those working in mental health, primary care, pain, women’s health, and ED. Training also should include geriatrics, extended care, and oncology providers because most older adults who die by firearm suicide have physical health problems but no known mental illness.^73-75 Lethal means safety counseling training has been shown to improve HCPs’ knowledge about the relationship between access to lethal means and suicide, and confidence in and frequency of having lethal means safety counseling conversations.⁷⁶ Likewise, training should include peer counselors; veterans are receptive to fellow veterans raising the topic of safe storage.^56,77 If feasible, the training should include time to rehearse skills shown to motivate behavior change among patients.

The VA should aim to improve semiyearly clinical pertinence reviews and safety plans for VA and VCCP mental health providers. VA could conduct clinical pertinence reviews that ascertain whether a suicide assessment is recorded in the health record, and when a patient is at elevated risk, whether a lethal means safety assessment and plan is documented.

VA’s safety plan template, although best practice, covers only the initial steps to take when suicide potential is identified. A standard for follow-up is needed. If an at-risk patient agrees to take a safe storage action, subsequent contact HCPs need to ask and document what action was performed. This action will help ensure that at-risk patients with ready access do not fall through the cracks. This suggestion lends itself to studying changes in veterans’ storage habits after intervention.

I also recommend that health care accrediting bodies include lethal means safety assessment, counseling, and follow up as a suicide prevention standard. This recommendation applies to more than just the VA health care system and recognizes that modifying accrediting body standards is an expeditious way to drive change in health care. The accreditation standards of the Commission on Accreditation of Rehabilitation Facilities for behavioral health and opioid treatment programs, and of the Joint Commission for medical centers do not require lethal means safety assessment and intervention.^78,79

Conclusions

Suicide prevention requires a multimodal approach, and attention to firearms access must become a more salient component. The high rate of veteran suicides involving firearms requires far-reaching interventions at societal, institutional, community, family, and individual levels. With the link between ready access to firearms and suicide supported by research and now firmly recognized by the PREVENTS Roadmap, we have a fresh opportunity to reduce suicide among veterans. Efforts must move vigorously forward until it is commonplace for veterans—and anyone—at risk of suicide to voluntarily reduce immediate access to firearms.

US veterans die by suicide at a higher rate than that of the civilian population, and are more likely to use a firearm as their lethal means.¹ In 2017, 6,139 veterans died by suicide, about 17 per day.¹ Nearly as many veterans die by suicide yearly as the total aggregate number of service members killed in action during the decades-long Iraq and Afghanistan operations.² Veterans are more likely to own firearms than are civilians.³ Until June 2020, however, systemic efforts to address the use of firearms in suicide had been largely evaded, entangled in gun advocates’ assertion that veterans’ constitutional right to bear arms would be infringed.

That impasse changed with the President’s Roadmap to Empower Veterans and End the National Tragedy of Suicide (PREVENTS) task force report, released June 17, 2020.⁴ Although the US Department of Veterans Affairs (VA) has pioneered initiatives to encourage safe firearm storage for at-risk veterans, and major public health organizations have endorsed the utility of lethal means safety strategies, the policy language of the Roadmap released by the White House is unprecedented. Lethal means safety refers to efforts aimed at increasing the time and distance needed to access suicide methods.

Among the report’s 10 recommendations, the Roadmap verified the link between, and the need to address, at-risk veterans and their access to firearms (the author was a minor consultant to a PREVENTS workgroup). The document states, “The science supporting lethal means safety is robust and compelling: enhancing safety measures specific to the availability and accessibility of potential lethal means saves lives. A key component of effective suicide prevention is voluntary reduction in the ability to access lethal means with respect to time, distance, and convenience, particularly during acute suicidal crises.”⁴ The report recommends widespread distribution of safety education materials that encourage at-risk individuals to temporarily transfer or store their guns safely, and the expansion of free or affordable options for storing weapons, among other recommendations.

This paper reviews the literature on the intersection of veterans, firearms, and suicide, then explores existing VA prevention initiatives aimed at reducing at-risk veterans’ access to lethal means and offers policy recommendations to expand efforts in the context of the PREVENTS Roadmap.

Veteran Suicide and Firearms

Firearms are, by far, the most common lethal means used by veterans who die by suicide. About 71% of male veteran suicide deaths and 43% of female veteran suicide deaths are with firearms, rates that far exceed those of nonveterans (Table).For all age groups, veterans are more likely to complete suicide by firearm than are nonveterans.⁵

Veteran suicide and gun ownership rates are highest in rural areas.^6,7 When compared with veterans living in urban areas, veterans in rural areas are 20% more likely to die by suicide, with the excessive risk largely attributed to suicide by firearm.⁸

Access to firearms at home increases the risk of suicide. Individuals with any firearm at home are 3 times more likely to die by suicide than is a person with no firearms at home. The elevated suicide risk applies to other household members as well as the firearm owner.^9-18 Survivors of suicide attempts using firearms report that the availability of guns at home is the primary reason for their method choice.^19,20

There is a common misperception that people who are intent on suicide and are thwarted or survive an attempt using one method will try again with another.²¹ Suicidal crises often represent a conflicting wish to live or die,²² and approximately two-thirds of those who survive an attempt will never try again. About 23% reattempt nonfatally, and only 10% die by suicide.^23-25 However, people who attempt suicide with a firearm usually won’t get a chance at a new start, because 90% of such acts are fatal.²⁶

Although some suicide attempts might be contemplated or planned over an extended period, the decision is impulsive for most individuals. Surveys have found that many people who survive suicide attempts began the act only minutes or hours after making the decision to end their life.^27-30 The high-risk, acute phase of many suicidal crises arise quickly and is fleeting.

Limiting the ease by which at-risk individuals can access firearms has been shown to prevent suicide. In 2006, the overall suicide rate in Israel dropped 40% when the Israeli Defense Forces began requiring soldiers to store their firearms on base before going on weekend leave.Since then, the suicide rate has declined even further.^31,32

Delaying Access to Firearms for At-Risk Veterans

Among veterans, 45% own ≥ 1 firearms (47% male and 24% female veterans vs 30% male and 12% female nonveterans).³ Many veteran firearm owners (34% male and 13% female) store ≥ 1 gun loaded and unlocked; 44% store a firearm either loaded or unlocked. Only 23% safely store their firearms unloaded and locked at home. Storing ≥ 1 firearm loaded and unlocked is more likely among veterans who reside in rural areas, separated from service before 2002, and report personal protection as the primary reason for ownership.³³

Because evidence shows that delaying access to firearms—especially by transferring them out of the home—saves lives, many US health organizations have advocated for strategies that promote evaluation of firearm access and counseling safe storage for individuals at risk for suicide. These organizations include the US Office of the Surgeon General, National Action Alliance for Suicide Prevention, Centers for Disease Control and Prevention, and American Public Health Association.^34-36

Some health care systems—notably Kaiser Permanente and Henry Ford Health Systems—implemented protocols for lethal means assessment and counseling for behavioral health patients.^37,38 Washington state requires specific health professionals to enroll in suicide prevention training that includes content on the risk of imminent harm by lethal means.³⁹ California is designing a curriculum on counseling patients to reduce firearm injury for physicians and other health care practitioners (HCPs).⁴⁰

The scope of these efforts, however, pale in comparison with the VA’s comprehensive, innovative lethal means safety approach. Since 2012, VA’s Suicide Prevention Program has distributed free firearm cable locks to veterans who request them. The VA has created lethal means public service announcements, social media messages, and websites.^41-44 The VA distributes firearm and medication safe storage practice resource kits to its primary care, mental health and women’s health clinics, and Vet Centers, that include brochures, large poster cards, stickers, exam room posters, and provider pocket cards. VA developed an online lethal means safety counseling training that 20,000 VA HCPs have taken, and is moving toward a revamped mandatory training for VA’s mental health, pain, primary care, and emergency department (ED) providers and Veterans Crisis Line responders. VA offers free, individualized lethal means risk management consultation to all clinicians who work with veterans.⁴⁵ VA includes lethal means safety procedures in its National Strategy for Preventing Veteran Suicide,VA/DoD Clinical Practice Guideline,and VA Suicide Risk Evaluation and Suicide Prevention Safety Planrequired of clinicians.^46-48

The VA also added public health strategies that promote safe storage practices for veterans through a partnership with the National Shooting Sports Foundation (NSSF; the firearm industry trade association) and the American Foundation for Suicide Prevention (AFSP).⁴⁹ Collectively, these organizations cobranded an educational, training, and resource toolkit to foster community coalitions and gun retailer projects that encourage veterans to securely store firearms.⁵⁰ The VA partnered with NSSF to post billboards in 8 states, encouraging storing firearms responsibly to prevent suicide. VA invited states and cities in the Governor/Mayoral Challenge to Prevent Suicide (joint VA and Substance Abuse and Mental Health Services Administration endeavors) to develop plans for messaging regarding enhanced lethal means safety processes. The VA collaborated with local firearm advocates in community prevention pilot projects and in a “Together with Veterans” dissemination of material and outreach to rural veterans.⁵¹ Along with AFSP, VA hosted conferences for HCPs, policy makers, and stakeholders about innovations related to lethal means safety.⁵² In May 2020, the VA cosponsored a COVID-19 suicide prevention video with the United States Concealed Carry Association, NSSF, and AFSP, including ways that the firearm industry, gun owners, and their families can help.⁵³

These programs are promising, and the Roadmap’s emphatic endorsement of lethal means safety approaches will accelerate advances. However, the Roadmap’s omissions are consequential. By focusing on population interventions, the document is silent about VA-specific or veteran-specific firearm access strategies. The means safety work of VA’s Suicide Prevention Program Office is scarcely recognized. Further, it stops short of specific legislative initiatives, making aspirational recommendations instead.

This paper will list proposed policy actions to bolster the acceptability and practice of lethal means safety with veterans. They cover an entire range of possibilities, from putting more teeth into the Roadmap’s population-wide interventions to initiatives tailored to veterans. Responsibility for leading and funding the changes would reside in a mix of Congress and state legislatures, the VA, and health system accreditation bodies. Although there is solid evidence that lethal means safety prevents suicide, it is unknown how these approaches affect firearm storage behaviors or suicide rates;therefore, the policy actions should come with federal and state funds for rigorous evaluation.⁵⁴

Recommended Actions to Further Promote Safe Storage

Develop Campaigns to Shift Cultural Norms for Firearm Storage During Crises

National campaigns have been shown to be highly effective in changing injurious behaviors. Alliances and resources with regard to lethal means safety could be assembled, including federal funds for a campaign to shift social norms for firearm storage conversations and behaviors during crises. This campaign should be modeled after the “friends don’t let friends drive drunk” and “designated driver” campaigns that empower family and friends to protect one another. Since those campaigns’ inception in 1982, two-thirds of Americans have tried to prevent someone from driving after drinking,and traffic deaths involving alcohol-impaired crashes have decreased 65%.^55,56

The comparable lethal means safety enterprise would encourage friends and family to talk with those in crisis about storing firearms safely. The campaign must use spokespersons who have strong respect and credibility among firearm owners, such as the NSSF and the United States Concealed Carry Association who have developed firearm suicide prevention websites and videos.^57,58

The emphasis is that it’s a personal strength—not a failing—to talk to friends, loved ones, or counselors about storing guns until a crisis passes. Some of the current phrasing includes: “Hey, let me hold your guns for a while,” “People who love guns, love you,” and “Have a brave conversation.” ^59-61

The national campaign should attempt to correct the inaccurate beliefs that suicide death always is the result of mental illness and is inevitable once seriously contemplated. In fact, more than half of the individuals who die by suicide have no diagnosed mental health condition.⁶² Other crises, such as with finances, relationships, or physical health, might be more contributory. These myths about suicide and mental illness weaken public and policy maker interest in solutions aimed toward accessing lethal means.

Facilitate Temporary Storage Out of the Home

The PREVENTS Roadmap Supplemental Materials concluded, “Moving firearms out of the home is generally cited as the safest, most desirable option; this can include storage with another person or at a location like a firearm range, armory, pawn shop, self-storage unit, or law enforcement agency, although state laws for firearm transfers may affect what options are legal.”⁶³ This goal could be achieved by establishing grants to gun shops and ranges to offer free lockers for voluntary safe harbor.

The creation of free community lockers was a top PREVENTS recommendation. Likewise, the congressionally chartered COVER (Creating Options for Veterans' Expedited Recovery) Commission recommended grants “to further support the development of voluntary firearm safe storage options across the country.”⁶⁴ Federal and state grants might resolve hesitations cited by retailers by covering all expenses for lockers, labor, and insurance for theft/damage/liability.^65,66 Locker use would be free to the user, eliminating all financial barriers, although it is unknown whether monetary incentives change storage behaviors. Many firearm owners report that private gun shops or ranges are more acceptable than police stations for storage. If retailers come on board, changes in cultural storage norms might be expedited. An additional benefit could be reduction of accidental firearm fatalities in the home. States that have legal impediments to returning firearms to their owners could modify laws to achieve popular acceptance.

Congress could consider funding a national, easily accessible, public online directory of locations for out-of-home firearm storage, with staff to update the site. Colorado, Maryland, and Washington have developed online maps showing locations of firearm outlets and law enforcement agencies willing to consider temporary storage.⁶⁷ A site directory for every state would simplify the process for individuals and family members seeking to temporarily and voluntarily store guns offsite during a crisis. Online directories have been backed by firearm groups,although their effect on storage behavior is not known.⁶⁸State governments should strive to make it easier to quickly transfer firearms temporarily to trusted individuals in situations of imminent suicide risk. Rapid transfer of firearms to friends or family could effectively separate lethal means from individuals during a crisis. However, some state laws that require background checks whenever a gun is transferred might delay such transfers.⁶⁹ Only a few states have legal exemptions that could expedite temporary transfers when it’s potentially lifesaving.

Improve In-Home Safe Storage Options

Out-of-home transfer of firearms might not be acceptable or feasible for some veterans. Accordingly, there is need for improved options for safer in-home storage, especially because of frequent unsafe storage practices among veterans. The VA could consider sponsoring another open-innovation Gun Safety Matters Challenge like the one it held in 2018 for in-home firearm storage technology that could prevent suicide.⁷⁰ Further innovation and bringing winning entries to market has great potential.

Require Enhanced Lethal Means Safety Standards and Training

Broader lethal means safety competence is needed, both in the VA where modest levels of training has been implemented and in the community among Veterans Community Care Program (VCCP) HCPs where it hasn’t. Oversight for enhanced standards and training—as well as of all lethal means initiatives and their program evaluations—might best be accomplished by establishing a separate VA Suicide Prevention Program lethal means safety team. Veteran firearm suicide is a significant problem that warrants its own discrete, permanent VA team (although joining with the US Department of Defense might be advantageous). The VA Suicide Prevention Program has been the industry leader and innovator in this field and should be conferred continued stewardship going forward.

The VA is moving toward requiring lethal means safety counseling training for mental health, pain, primary care, women’s health, ED providers, and Veterans Crisis Line responders.

VCCP HCPs, however, have no required training in lethal means safety counseling or even in basic suicide risk identification and intervention, and the Roadmap did not stipulate that this deficiency should be remedied. Surveys have revealed that community HCPs rarely screen or counsel their patients—even those at high risk—about firearm safety.⁷¹ A bill was introduced in Congress August 21, 2020, to expand VA suicide prevention training with firearms community input on cultural competency components and mandate that VA and VCCP providers, and some others with frequent contact with veterans, receive this training.⁷²

Training should be obligatory for VA and VCCP HCPs and trainees most likely to interface with at-risk veterans, including those working in mental health, primary care, pain, women’s health, and ED. Training also should include geriatrics, extended care, and oncology providers because most older adults who die by firearm suicide have physical health problems but no known mental illness.^73-75 Lethal means safety counseling training has been shown to improve HCPs’ knowledge about the relationship between access to lethal means and suicide, and confidence in and frequency of having lethal means safety counseling conversations.⁷⁶ Likewise, training should include peer counselors; veterans are receptive to fellow veterans raising the topic of safe storage.^56,77 If feasible, the training should include time to rehearse skills shown to motivate behavior change among patients.

The VA should aim to improve semiyearly clinical pertinence reviews and safety plans for VA and VCCP mental health providers. VA could conduct clinical pertinence reviews that ascertain whether a suicide assessment is recorded in the health record, and when a patient is at elevated risk, whether a lethal means safety assessment and plan is documented.

VA’s safety plan template, although best practice, covers only the initial steps to take when suicide potential is identified. A standard for follow-up is needed. If an at-risk patient agrees to take a safe storage action, subsequent contact HCPs need to ask and document what action was performed. This action will help ensure that at-risk patients with ready access do not fall through the cracks. This suggestion lends itself to studying changes in veterans’ storage habits after intervention.

I also recommend that health care accrediting bodies include lethal means safety assessment, counseling, and follow up as a suicide prevention standard. This recommendation applies to more than just the VA health care system and recognizes that modifying accrediting body standards is an expeditious way to drive change in health care. The accreditation standards of the Commission on Accreditation of Rehabilitation Facilities for behavioral health and opioid treatment programs, and of the Joint Commission for medical centers do not require lethal means safety assessment and intervention.^78,79

Conclusions

Suicide prevention requires a multimodal approach, and attention to firearms access must become a more salient component. The high rate of veteran suicides involving firearms requires far-reaching interventions at societal, institutional, community, family, and individual levels. With the link between ready access to firearms and suicide supported by research and now firmly recognized by the PREVENTS Roadmap, we have a fresh opportunity to reduce suicide among veterans. Efforts must move vigorously forward until it is commonplace for veterans—and anyone—at risk of suicide to voluntarily reduce immediate access to firearms.

US veterans die by suicide at a higher rate than that of the civilian population, and are more likely to use a firearm as their lethal means.¹ In 2017, 6,139 veterans died by suicide, about 17 per day.¹ Nearly as many veterans die by suicide yearly as the total aggregate number of service members killed in action during the decades-long Iraq and Afghanistan operations.² Veterans are more likely to own firearms than are civilians.³ Until June 2020, however, systemic efforts to address the use of firearms in suicide had been largely evaded, entangled in gun advocates’ assertion that veterans’ constitutional right to bear arms would be infringed.

That impasse changed with the President’s Roadmap to Empower Veterans and End the National Tragedy of Suicide (PREVENTS) task force report, released June 17, 2020.⁴ Although the US Department of Veterans Affairs (VA) has pioneered initiatives to encourage safe firearm storage for at-risk veterans, and major public health organizations have endorsed the utility of lethal means safety strategies, the policy language of the Roadmap released by the White House is unprecedented. Lethal means safety refers to efforts aimed at increasing the time and distance needed to access suicide methods.

Among the report’s 10 recommendations, the Roadmap verified the link between, and the need to address, at-risk veterans and their access to firearms (the author was a minor consultant to a PREVENTS workgroup). The document states, “The science supporting lethal means safety is robust and compelling: enhancing safety measures specific to the availability and accessibility of potential lethal means saves lives. A key component of effective suicide prevention is voluntary reduction in the ability to access lethal means with respect to time, distance, and convenience, particularly during acute suicidal crises.”⁴ The report recommends widespread distribution of safety education materials that encourage at-risk individuals to temporarily transfer or store their guns safely, and the expansion of free or affordable options for storing weapons, among other recommendations.

This paper reviews the literature on the intersection of veterans, firearms, and suicide, then explores existing VA prevention initiatives aimed at reducing at-risk veterans’ access to lethal means and offers policy recommendations to expand efforts in the context of the PREVENTS Roadmap.

Veteran Suicide and Firearms

Firearms are, by far, the most common lethal means used by veterans who die by suicide. About 71% of male veteran suicide deaths and 43% of female veteran suicide deaths are with firearms, rates that far exceed those of nonveterans (Table).For all age groups, veterans are more likely to complete suicide by firearm than are nonveterans.⁵

Veteran suicide and gun ownership rates are highest in rural areas.^6,7 When compared with veterans living in urban areas, veterans in rural areas are 20% more likely to die by suicide, with the excessive risk largely attributed to suicide by firearm.⁸

Access to firearms at home increases the risk of suicide. Individuals with any firearm at home are 3 times more likely to die by suicide than is a person with no firearms at home. The elevated suicide risk applies to other household members as well as the firearm owner.^9-18 Survivors of suicide attempts using firearms report that the availability of guns at home is the primary reason for their method choice.^19,20

There is a common misperception that people who are intent on suicide and are thwarted or survive an attempt using one method will try again with another.²¹ Suicidal crises often represent a conflicting wish to live or die,²² and approximately two-thirds of those who survive an attempt will never try again. About 23% reattempt nonfatally, and only 10% die by suicide.^23-25 However, people who attempt suicide with a firearm usually won’t get a chance at a new start, because 90% of such acts are fatal.²⁶

Although some suicide attempts might be contemplated or planned over an extended period, the decision is impulsive for most individuals. Surveys have found that many people who survive suicide attempts began the act only minutes or hours after making the decision to end their life.^27-30 The high-risk, acute phase of many suicidal crises arise quickly and is fleeting.

Limiting the ease by which at-risk individuals can access firearms has been shown to prevent suicide. In 2006, the overall suicide rate in Israel dropped 40% when the Israeli Defense Forces began requiring soldiers to store their firearms on base before going on weekend leave.Since then, the suicide rate has declined even further.^31,32

Delaying Access to Firearms for At-Risk Veterans

Among veterans, 45% own ≥ 1 firearms (47% male and 24% female veterans vs 30% male and 12% female nonveterans).³ Many veteran firearm owners (34% male and 13% female) store ≥ 1 gun loaded and unlocked; 44% store a firearm either loaded or unlocked. Only 23% safely store their firearms unloaded and locked at home. Storing ≥ 1 firearm loaded and unlocked is more likely among veterans who reside in rural areas, separated from service before 2002, and report personal protection as the primary reason for ownership.³³

Because evidence shows that delaying access to firearms—especially by transferring them out of the home—saves lives, many US health organizations have advocated for strategies that promote evaluation of firearm access and counseling safe storage for individuals at risk for suicide. These organizations include the US Office of the Surgeon General, National Action Alliance for Suicide Prevention, Centers for Disease Control and Prevention, and American Public Health Association.^34-36

Some health care systems—notably Kaiser Permanente and Henry Ford Health Systems—implemented protocols for lethal means assessment and counseling for behavioral health patients.^37,38 Washington state requires specific health professionals to enroll in suicide prevention training that includes content on the risk of imminent harm by lethal means.³⁹ California is designing a curriculum on counseling patients to reduce firearm injury for physicians and other health care practitioners (HCPs).⁴⁰

The scope of these efforts, however, pale in comparison with the VA’s comprehensive, innovative lethal means safety approach. Since 2012, VA’s Suicide Prevention Program has distributed free firearm cable locks to veterans who request them. The VA has created lethal means public service announcements, social media messages, and websites.^41-44 The VA distributes firearm and medication safe storage practice resource kits to its primary care, mental health and women’s health clinics, and Vet Centers, that include brochures, large poster cards, stickers, exam room posters, and provider pocket cards. VA developed an online lethal means safety counseling training that 20,000 VA HCPs have taken, and is moving toward a revamped mandatory training for VA’s mental health, pain, primary care, and emergency department (ED) providers and Veterans Crisis Line responders. VA offers free, individualized lethal means risk management consultation to all clinicians who work with veterans.⁴⁵ VA includes lethal means safety procedures in its National Strategy for Preventing Veteran Suicide,VA/DoD Clinical Practice Guideline,and VA Suicide Risk Evaluation and Suicide Prevention Safety Planrequired of clinicians.^46-48

The VA also added public health strategies that promote safe storage practices for veterans through a partnership with the National Shooting Sports Foundation (NSSF; the firearm industry trade association) and the American Foundation for Suicide Prevention (AFSP).⁴⁹ Collectively, these organizations cobranded an educational, training, and resource toolkit to foster community coalitions and gun retailer projects that encourage veterans to securely store firearms.⁵⁰ The VA partnered with NSSF to post billboards in 8 states, encouraging storing firearms responsibly to prevent suicide. VA invited states and cities in the Governor/Mayoral Challenge to Prevent Suicide (joint VA and Substance Abuse and Mental Health Services Administration endeavors) to develop plans for messaging regarding enhanced lethal means safety processes. The VA collaborated with local firearm advocates in community prevention pilot projects and in a “Together with Veterans” dissemination of material and outreach to rural veterans.⁵¹ Along with AFSP, VA hosted conferences for HCPs, policy makers, and stakeholders about innovations related to lethal means safety.⁵² In May 2020, the VA cosponsored a COVID-19 suicide prevention video with the United States Concealed Carry Association, NSSF, and AFSP, including ways that the firearm industry, gun owners, and their families can help.⁵³

These programs are promising, and the Roadmap’s emphatic endorsement of lethal means safety approaches will accelerate advances. However, the Roadmap’s omissions are consequential. By focusing on population interventions, the document is silent about VA-specific or veteran-specific firearm access strategies. The means safety work of VA’s Suicide Prevention Program Office is scarcely recognized. Further, it stops short of specific legislative initiatives, making aspirational recommendations instead.

This paper will list proposed policy actions to bolster the acceptability and practice of lethal means safety with veterans. They cover an entire range of possibilities, from putting more teeth into the Roadmap’s population-wide interventions to initiatives tailored to veterans. Responsibility for leading and funding the changes would reside in a mix of Congress and state legislatures, the VA, and health system accreditation bodies. Although there is solid evidence that lethal means safety prevents suicide, it is unknown how these approaches affect firearm storage behaviors or suicide rates;therefore, the policy actions should come with federal and state funds for rigorous evaluation.⁵⁴

Recommended Actions to Further Promote Safe Storage

Develop Campaigns to Shift Cultural Norms for Firearm Storage During Crises

National campaigns have been shown to be highly effective in changing injurious behaviors. Alliances and resources with regard to lethal means safety could be assembled, including federal funds for a campaign to shift social norms for firearm storage conversations and behaviors during crises. This campaign should be modeled after the “friends don’t let friends drive drunk” and “designated driver” campaigns that empower family and friends to protect one another. Since those campaigns’ inception in 1982, two-thirds of Americans have tried to prevent someone from driving after drinking,and traffic deaths involving alcohol-impaired crashes have decreased 65%.^55,56

The comparable lethal means safety enterprise would encourage friends and family to talk with those in crisis about storing firearms safely. The campaign must use spokespersons who have strong respect and credibility among firearm owners, such as the NSSF and the United States Concealed Carry Association who have developed firearm suicide prevention websites and videos.^57,58

The emphasis is that it’s a personal strength—not a failing—to talk to friends, loved ones, or counselors about storing guns until a crisis passes. Some of the current phrasing includes: “Hey, let me hold your guns for a while,” “People who love guns, love you,” and “Have a brave conversation.” ^59-61

The national campaign should attempt to correct the inaccurate beliefs that suicide death always is the result of mental illness and is inevitable once seriously contemplated. In fact, more than half of the individuals who die by suicide have no diagnosed mental health condition.⁶² Other crises, such as with finances, relationships, or physical health, might be more contributory. These myths about suicide and mental illness weaken public and policy maker interest in solutions aimed toward accessing lethal means.

Facilitate Temporary Storage Out of the Home

The PREVENTS Roadmap Supplemental Materials concluded, “Moving firearms out of the home is generally cited as the safest, most desirable option; this can include storage with another person or at a location like a firearm range, armory, pawn shop, self-storage unit, or law enforcement agency, although state laws for firearm transfers may affect what options are legal.”⁶³ This goal could be achieved by establishing grants to gun shops and ranges to offer free lockers for voluntary safe harbor.

The creation of free community lockers was a top PREVENTS recommendation. Likewise, the congressionally chartered COVER (Creating Options for Veterans' Expedited Recovery) Commission recommended grants “to further support the development of voluntary firearm safe storage options across the country.”⁶⁴ Federal and state grants might resolve hesitations cited by retailers by covering all expenses for lockers, labor, and insurance for theft/damage/liability.^65,66 Locker use would be free to the user, eliminating all financial barriers, although it is unknown whether monetary incentives change storage behaviors. Many firearm owners report that private gun shops or ranges are more acceptable than police stations for storage. If retailers come on board, changes in cultural storage norms might be expedited. An additional benefit could be reduction of accidental firearm fatalities in the home. States that have legal impediments to returning firearms to their owners could modify laws to achieve popular acceptance.

Congress could consider funding a national, easily accessible, public online directory of locations for out-of-home firearm storage, with staff to update the site. Colorado, Maryland, and Washington have developed online maps showing locations of firearm outlets and law enforcement agencies willing to consider temporary storage.⁶⁷ A site directory for every state would simplify the process for individuals and family members seeking to temporarily and voluntarily store guns offsite during a crisis. Online directories have been backed by firearm groups,although their effect on storage behavior is not known.⁶⁸State governments should strive to make it easier to quickly transfer firearms temporarily to trusted individuals in situations of imminent suicide risk. Rapid transfer of firearms to friends or family could effectively separate lethal means from individuals during a crisis. However, some state laws that require background checks whenever a gun is transferred might delay such transfers.⁶⁹ Only a few states have legal exemptions that could expedite temporary transfers when it’s potentially lifesaving.

Improve In-Home Safe Storage Options

Out-of-home transfer of firearms might not be acceptable or feasible for some veterans. Accordingly, there is need for improved options for safer in-home storage, especially because of frequent unsafe storage practices among veterans. The VA could consider sponsoring another open-innovation Gun Safety Matters Challenge like the one it held in 2018 for in-home firearm storage technology that could prevent suicide.⁷⁰ Further innovation and bringing winning entries to market has great potential.

Require Enhanced Lethal Means Safety Standards and Training

Broader lethal means safety competence is needed, both in the VA where modest levels of training has been implemented and in the community among Veterans Community Care Program (VCCP) HCPs where it hasn’t. Oversight for enhanced standards and training—as well as of all lethal means initiatives and their program evaluations—might best be accomplished by establishing a separate VA Suicide Prevention Program lethal means safety team. Veteran firearm suicide is a significant problem that warrants its own discrete, permanent VA team (although joining with the US Department of Defense might be advantageous). The VA Suicide Prevention Program has been the industry leader and innovator in this field and should be conferred continued stewardship going forward.

The VA is moving toward requiring lethal means safety counseling training for mental health, pain, primary care, women’s health, ED providers, and Veterans Crisis Line responders.

VCCP HCPs, however, have no required training in lethal means safety counseling or even in basic suicide risk identification and intervention, and the Roadmap did not stipulate that this deficiency should be remedied. Surveys have revealed that community HCPs rarely screen or counsel their patients—even those at high risk—about firearm safety.⁷¹ A bill was introduced in Congress August 21, 2020, to expand VA suicide prevention training with firearms community input on cultural competency components and mandate that VA and VCCP providers, and some others with frequent contact with veterans, receive this training.⁷²

Training should be obligatory for VA and VCCP HCPs and trainees most likely to interface with at-risk veterans, including those working in mental health, primary care, pain, women’s health, and ED. Training also should include geriatrics, extended care, and oncology providers because most older adults who die by firearm suicide have physical health problems but no known mental illness.^73-75 Lethal means safety counseling training has been shown to improve HCPs’ knowledge about the relationship between access to lethal means and suicide, and confidence in and frequency of having lethal means safety counseling conversations.⁷⁶ Likewise, training should include peer counselors; veterans are receptive to fellow veterans raising the topic of safe storage.^56,77 If feasible, the training should include time to rehearse skills shown to motivate behavior change among patients.

The VA should aim to improve semiyearly clinical pertinence reviews and safety plans for VA and VCCP mental health providers. VA could conduct clinical pertinence reviews that ascertain whether a suicide assessment is recorded in the health record, and when a patient is at elevated risk, whether a lethal means safety assessment and plan is documented.

VA’s safety plan template, although best practice, covers only the initial steps to take when suicide potential is identified. A standard for follow-up is needed. If an at-risk patient agrees to take a safe storage action, subsequent contact HCPs need to ask and document what action was performed. This action will help ensure that at-risk patients with ready access do not fall through the cracks. This suggestion lends itself to studying changes in veterans’ storage habits after intervention.

I also recommend that health care accrediting bodies include lethal means safety assessment, counseling, and follow up as a suicide prevention standard. This recommendation applies to more than just the VA health care system and recognizes that modifying accrediting body standards is an expeditious way to drive change in health care. The accreditation standards of the Commission on Accreditation of Rehabilitation Facilities for behavioral health and opioid treatment programs, and of the Joint Commission for medical centers do not require lethal means safety assessment and intervention.^78,79

Conclusions

Suicide prevention requires a multimodal approach, and attention to firearms access must become a more salient component. The high rate of veteran suicides involving firearms requires far-reaching interventions at societal, institutional, community, family, and individual levels. With the link between ready access to firearms and suicide supported by research and now firmly recognized by the PREVENTS Roadmap, we have a fresh opportunity to reduce suicide among veterans. Efforts must move vigorously forward until it is commonplace for veterans—and anyone—at risk of suicide to voluntarily reduce immediate access to firearms.

Factors including older age and certain comorbidities have been linked to more serious COVID-19 outcomes in previous research, and now a large dataset collected from hundreds of hospitals nationwide provides more detailed data regarding risk for mechanical ventilation and death.

Comorbidities such as cardiovascular disease, chronic kidney disease, and obesity also were associated with more severe COVID-19 outcomes in this observational study of 11,721 adults. History of pulmonary disease or smoking, interestingly, were not.

One expert urges caution when interpreting the results, however. Although the study found a number of risk factors for ventilation and mortality, she says the dataset lacks information on race and disease severity, and the sample may not be nationally representative. 

The investigators hope their level of granularity will further assist researchers searching for effective treatments and clinicians seeking to triage patients during the COVID-19 pandemic.

The study was published online August 28 in Clinical Infectious Diseases.
 

COVID-19 and comorbidities

“What I found most illuminating was this whole concept of comorbid conditions. This provides suggestive data about who we need to worry about most and who we may need to worry about less,” study author Robert S. Brown Jr, MD, MPH, told Medscape Medical News.

Comorbid conditions included hypertension in 47% of patients, diabetes in 28%, and cardiovascular disease in 19%. Another 16% were obese and 12% had chronic kidney disease. People with comorbid obesity, chronic kidney disease, and cardiovascular disease were more likely to receive mechanical ventilation compared to those without a history of these conditions in an adjusted, multivariable logistic analysis.

With the exception of obesity, the same factors were associated with risk for death during hospitalization.

In contrast, hypertension, history of smoking, and history of pulmonary disease were associated with a lower risk of needing mechanical ventilation and/or lower risk for mortality.

Furthermore, people with liver disease, gastrointestinal diseases, and even autoimmune diseases – which are likely associated with immunosuppression – “are not at that much of an increased risk that we noticed it in our data,” Brown said.

“As I tell many of my patients who have mild liver disease, for example, I would rather have mild liver disease and be on immunosuppressant therapy than be an older, obese male,” he added.

Assessing data for people in 38 U.S. states, and not limiting outcomes to patients in a particular COVID-19 hot spot, was a unique aspect of the research, said Brown, clinical chief of the Division of Gastroenterology and Hepatology at Weill Cornell Medicine in New York City.

Brown, lead author Michael W. Fried, MD, from TARGET PharmaSolutions in Durham, North Carolina, and colleagues studied adults from a commercially available Target Real-World Evidence (RWE) dataset of nearly 70,000 patients. They examined hospital chargemaster data and ICD-10 codes for COVID-19 inpatients between February 15 and April 20.

This population tended to be older, with 60% older than 60 years. A little more than half of participants, 53%, were men.
 

Key findings

A total of 21% of patients died after a median hospital length of stay of 8 days.

Older patients were significantly more likely to die, particularly those older than 60 years (P < .0001).

“This confirms some of the things we know about age and its impact on outcome,” Brown said.

The risk for mortality among patients older than 60 years was 7.2 times that of patients between 18 and 40 years in an adjusted multivariate analysis. The risk for death for those between 41 and 60 years of age was lower (odds ratio [OR], 2.6), compared with the youngest cohort.  

Men were more likely to die than women (OR, 1.5).

When asked if he was surprised by the high mortality rates, Brown said, “Having worked here in New York? No, I was not.”
 

Mechanical ventilation and mortality

Male sex, age older than 40 years, obesity, and presence of cardiovascular or chronic kidney disease were risk factors for mechanical ventilation.

Among the nearly 2,000 hospitalized adults requiring mechanical ventilation in the current report, only 27% were discharged alive. “The outcomes of people who are mechanically ventilated are really quite sobering,” Brown said.

People who ever required mechanical ventilation were 32 times more likely to die compared with others whose highest level of oxygenation was low-flow, high-flow, or no-oxygen therapy in an analysis that controlled for demographics and comorbidities.

Furthermore, patients placed on mechanical ventilation earlier – within 24 hours of admission – tended to experience better outcomes.
 

COVID-19 therapies?

Brown and colleagues also evaluated outcomes in patients who were taking either remdesivir or hydroxychloroquine. A total of 48 people were treated with remdesivir.

The four individuals receiving remdesivir who died were among 11 who were taking remdesivir and also on mechanical ventilation.

“The data for remdesivir is very encouraging,” Brown said.

Many more participants were treated with hydroxychloroquine, more than 4,200 or 36% of the total study population.

A higher proportion of people treated with hydroxychloroquine received mechanical ventilation, at 25%, versus 12% not treated with hydroxychloroquine.

The unadjusted mortality rate was also higher among those treated with the agent, at 25%, compared to 20% not receiving hydroxychloroquine.

The data with hydroxychloroquine can lead to two conclusions, Brown said: “One, it doesn’t work. Or two, it doesn’t work in the way that we use it.”

The researchers cautioned that their hydroxychloroquine findings must be interpreted carefully because those treated with the agent were also more likely to have comorbidities and greater COVID-19 disease severity.

“This study greatly contributes to understanding the natural course of COVID-19 infection by describing characteristics and outcomes of patients with COVID-19 hospitalized throughout the US,” the investigators note. “It identified categories of patients at greatest risk for poor outcomes, which should be used to prioritize prevention and treatment strategies in the future.”
 

Some limitations

“The findings that patients with hypertension and who were smokers had lower ventilation rates, and patients with hypertension, pulmonary disease, who were smokers had lower mortality risks was very surprising,” Ninez A. Ponce, PhD, MPP, told Medscape Medical News when asked to comment on the study.

Although the study identified multiple risk factors for ventilation and mortality, “unfortunately the dataset did not have race available or disease severity,” said Ponce, director of the UCLA Center for Health Policy Research and professor in the Department of Health Policy and Management at the UCLA Fielding School of Public Health.

“These omitted variables could have a considerable effect on the significance, magnitude, and direction of point estimates provided, so I would be cautious in interpreting the results as a picture of a nationally representative sample,” she said.

On a positive note, the study and dataset could illuminate the utility of medications used to treat COVID-19, Ponce said. In addition, as the authors note, “the data will expand over time.” 

Brown has reported receiving grants and consulting for Gilead. Ponce has disclosed no relevant financial relationships.
 

This article first appeared on Medscape.com.

Factors including older age and certain comorbidities have been linked to more serious COVID-19 outcomes in previous research, and now a large dataset collected from hundreds of hospitals nationwide provides more detailed data regarding risk for mechanical ventilation and death.

Comorbidities such as cardiovascular disease, chronic kidney disease, and obesity also were associated with more severe COVID-19 outcomes in this observational study of 11,721 adults. History of pulmonary disease or smoking, interestingly, were not.

One expert urges caution when interpreting the results, however. Although the study found a number of risk factors for ventilation and mortality, she says the dataset lacks information on race and disease severity, and the sample may not be nationally representative. 

The investigators hope their level of granularity will further assist researchers searching for effective treatments and clinicians seeking to triage patients during the COVID-19 pandemic.

The study was published online August 28 in Clinical Infectious Diseases.
 

COVID-19 and comorbidities

“What I found most illuminating was this whole concept of comorbid conditions. This provides suggestive data about who we need to worry about most and who we may need to worry about less,” study author Robert S. Brown Jr, MD, MPH, told Medscape Medical News.

Comorbid conditions included hypertension in 47% of patients, diabetes in 28%, and cardiovascular disease in 19%. Another 16% were obese and 12% had chronic kidney disease. People with comorbid obesity, chronic kidney disease, and cardiovascular disease were more likely to receive mechanical ventilation compared to those without a history of these conditions in an adjusted, multivariable logistic analysis.

With the exception of obesity, the same factors were associated with risk for death during hospitalization.

In contrast, hypertension, history of smoking, and history of pulmonary disease were associated with a lower risk of needing mechanical ventilation and/or lower risk for mortality.

Furthermore, people with liver disease, gastrointestinal diseases, and even autoimmune diseases – which are likely associated with immunosuppression – “are not at that much of an increased risk that we noticed it in our data,” Brown said.

“As I tell many of my patients who have mild liver disease, for example, I would rather have mild liver disease and be on immunosuppressant therapy than be an older, obese male,” he added.

Assessing data for people in 38 U.S. states, and not limiting outcomes to patients in a particular COVID-19 hot spot, was a unique aspect of the research, said Brown, clinical chief of the Division of Gastroenterology and Hepatology at Weill Cornell Medicine in New York City.

Brown, lead author Michael W. Fried, MD, from TARGET PharmaSolutions in Durham, North Carolina, and colleagues studied adults from a commercially available Target Real-World Evidence (RWE) dataset of nearly 70,000 patients. They examined hospital chargemaster data and ICD-10 codes for COVID-19 inpatients between February 15 and April 20.

This population tended to be older, with 60% older than 60 years. A little more than half of participants, 53%, were men.
 

Key findings

A total of 21% of patients died after a median hospital length of stay of 8 days.

Older patients were significantly more likely to die, particularly those older than 60 years (P < .0001).

“This confirms some of the things we know about age and its impact on outcome,” Brown said.

The risk for mortality among patients older than 60 years was 7.2 times that of patients between 18 and 40 years in an adjusted multivariate analysis. The risk for death for those between 41 and 60 years of age was lower (odds ratio [OR], 2.6), compared with the youngest cohort.  

Men were more likely to die than women (OR, 1.5).

When asked if he was surprised by the high mortality rates, Brown said, “Having worked here in New York? No, I was not.”
 

Mechanical ventilation and mortality

Male sex, age older than 40 years, obesity, and presence of cardiovascular or chronic kidney disease were risk factors for mechanical ventilation.

Among the nearly 2,000 hospitalized adults requiring mechanical ventilation in the current report, only 27% were discharged alive. “The outcomes of people who are mechanically ventilated are really quite sobering,” Brown said.

People who ever required mechanical ventilation were 32 times more likely to die compared with others whose highest level of oxygenation was low-flow, high-flow, or no-oxygen therapy in an analysis that controlled for demographics and comorbidities.

Furthermore, patients placed on mechanical ventilation earlier – within 24 hours of admission – tended to experience better outcomes.
 

COVID-19 therapies?

Brown and colleagues also evaluated outcomes in patients who were taking either remdesivir or hydroxychloroquine. A total of 48 people were treated with remdesivir.

The four individuals receiving remdesivir who died were among 11 who were taking remdesivir and also on mechanical ventilation.

“The data for remdesivir is very encouraging,” Brown said.

Many more participants were treated with hydroxychloroquine, more than 4,200 or 36% of the total study population.

A higher proportion of people treated with hydroxychloroquine received mechanical ventilation, at 25%, versus 12% not treated with hydroxychloroquine.

The unadjusted mortality rate was also higher among those treated with the agent, at 25%, compared to 20% not receiving hydroxychloroquine.

The data with hydroxychloroquine can lead to two conclusions, Brown said: “One, it doesn’t work. Or two, it doesn’t work in the way that we use it.”

The researchers cautioned that their hydroxychloroquine findings must be interpreted carefully because those treated with the agent were also more likely to have comorbidities and greater COVID-19 disease severity.

“This study greatly contributes to understanding the natural course of COVID-19 infection by describing characteristics and outcomes of patients with COVID-19 hospitalized throughout the US,” the investigators note. “It identified categories of patients at greatest risk for poor outcomes, which should be used to prioritize prevention and treatment strategies in the future.”
 

Some limitations

“The findings that patients with hypertension and who were smokers had lower ventilation rates, and patients with hypertension, pulmonary disease, who were smokers had lower mortality risks was very surprising,” Ninez A. Ponce, PhD, MPP, told Medscape Medical News when asked to comment on the study.

Although the study identified multiple risk factors for ventilation and mortality, “unfortunately the dataset did not have race available or disease severity,” said Ponce, director of the UCLA Center for Health Policy Research and professor in the Department of Health Policy and Management at the UCLA Fielding School of Public Health.

“These omitted variables could have a considerable effect on the significance, magnitude, and direction of point estimates provided, so I would be cautious in interpreting the results as a picture of a nationally representative sample,” she said.

On a positive note, the study and dataset could illuminate the utility of medications used to treat COVID-19, Ponce said. In addition, as the authors note, “the data will expand over time.” 

Brown has reported receiving grants and consulting for Gilead. Ponce has disclosed no relevant financial relationships.
 

This article first appeared on Medscape.com.

Factors including older age and certain comorbidities have been linked to more serious COVID-19 outcomes in previous research, and now a large dataset collected from hundreds of hospitals nationwide provides more detailed data regarding risk for mechanical ventilation and death.

Comorbidities such as cardiovascular disease, chronic kidney disease, and obesity also were associated with more severe COVID-19 outcomes in this observational study of 11,721 adults. History of pulmonary disease or smoking, interestingly, were not.

One expert urges caution when interpreting the results, however. Although the study found a number of risk factors for ventilation and mortality, she says the dataset lacks information on race and disease severity, and the sample may not be nationally representative. 

The investigators hope their level of granularity will further assist researchers searching for effective treatments and clinicians seeking to triage patients during the COVID-19 pandemic.

The study was published online August 28 in Clinical Infectious Diseases.
 

COVID-19 and comorbidities

“What I found most illuminating was this whole concept of comorbid conditions. This provides suggestive data about who we need to worry about most and who we may need to worry about less,” study author Robert S. Brown Jr, MD, MPH, told Medscape Medical News.

Comorbid conditions included hypertension in 47% of patients, diabetes in 28%, and cardiovascular disease in 19%. Another 16% were obese and 12% had chronic kidney disease. People with comorbid obesity, chronic kidney disease, and cardiovascular disease were more likely to receive mechanical ventilation compared to those without a history of these conditions in an adjusted, multivariable logistic analysis.

With the exception of obesity, the same factors were associated with risk for death during hospitalization.

In contrast, hypertension, history of smoking, and history of pulmonary disease were associated with a lower risk of needing mechanical ventilation and/or lower risk for mortality.

Furthermore, people with liver disease, gastrointestinal diseases, and even autoimmune diseases – which are likely associated with immunosuppression – “are not at that much of an increased risk that we noticed it in our data,” Brown said.

“As I tell many of my patients who have mild liver disease, for example, I would rather have mild liver disease and be on immunosuppressant therapy than be an older, obese male,” he added.

Assessing data for people in 38 U.S. states, and not limiting outcomes to patients in a particular COVID-19 hot spot, was a unique aspect of the research, said Brown, clinical chief of the Division of Gastroenterology and Hepatology at Weill Cornell Medicine in New York City.

Brown, lead author Michael W. Fried, MD, from TARGET PharmaSolutions in Durham, North Carolina, and colleagues studied adults from a commercially available Target Real-World Evidence (RWE) dataset of nearly 70,000 patients. They examined hospital chargemaster data and ICD-10 codes for COVID-19 inpatients between February 15 and April 20.

This population tended to be older, with 60% older than 60 years. A little more than half of participants, 53%, were men.
 

Key findings

A total of 21% of patients died after a median hospital length of stay of 8 days.

Older patients were significantly more likely to die, particularly those older than 60 years (P < .0001).

“This confirms some of the things we know about age and its impact on outcome,” Brown said.

The risk for mortality among patients older than 60 years was 7.2 times that of patients between 18 and 40 years in an adjusted multivariate analysis. The risk for death for those between 41 and 60 years of age was lower (odds ratio [OR], 2.6), compared with the youngest cohort.  

Men were more likely to die than women (OR, 1.5).

When asked if he was surprised by the high mortality rates, Brown said, “Having worked here in New York? No, I was not.”
 

Mechanical ventilation and mortality

Male sex, age older than 40 years, obesity, and presence of cardiovascular or chronic kidney disease were risk factors for mechanical ventilation.

Among the nearly 2,000 hospitalized adults requiring mechanical ventilation in the current report, only 27% were discharged alive. “The outcomes of people who are mechanically ventilated are really quite sobering,” Brown said.

People who ever required mechanical ventilation were 32 times more likely to die compared with others whose highest level of oxygenation was low-flow, high-flow, or no-oxygen therapy in an analysis that controlled for demographics and comorbidities.

Furthermore, patients placed on mechanical ventilation earlier – within 24 hours of admission – tended to experience better outcomes.
 

COVID-19 therapies?

Brown and colleagues also evaluated outcomes in patients who were taking either remdesivir or hydroxychloroquine. A total of 48 people were treated with remdesivir.

The four individuals receiving remdesivir who died were among 11 who were taking remdesivir and also on mechanical ventilation.

“The data for remdesivir is very encouraging,” Brown said.

Many more participants were treated with hydroxychloroquine, more than 4,200 or 36% of the total study population.

A higher proportion of people treated with hydroxychloroquine received mechanical ventilation, at 25%, versus 12% not treated with hydroxychloroquine.

The unadjusted mortality rate was also higher among those treated with the agent, at 25%, compared to 20% not receiving hydroxychloroquine.

The data with hydroxychloroquine can lead to two conclusions, Brown said: “One, it doesn’t work. Or two, it doesn’t work in the way that we use it.”

The researchers cautioned that their hydroxychloroquine findings must be interpreted carefully because those treated with the agent were also more likely to have comorbidities and greater COVID-19 disease severity.

“This study greatly contributes to understanding the natural course of COVID-19 infection by describing characteristics and outcomes of patients with COVID-19 hospitalized throughout the US,” the investigators note. “It identified categories of patients at greatest risk for poor outcomes, which should be used to prioritize prevention and treatment strategies in the future.”
 

Some limitations

“The findings that patients with hypertension and who were smokers had lower ventilation rates, and patients with hypertension, pulmonary disease, who were smokers had lower mortality risks was very surprising,” Ninez A. Ponce, PhD, MPP, told Medscape Medical News when asked to comment on the study.

Although the study identified multiple risk factors for ventilation and mortality, “unfortunately the dataset did not have race available or disease severity,” said Ponce, director of the UCLA Center for Health Policy Research and professor in the Department of Health Policy and Management at the UCLA Fielding School of Public Health.

“These omitted variables could have a considerable effect on the significance, magnitude, and direction of point estimates provided, so I would be cautious in interpreting the results as a picture of a nationally representative sample,” she said.

On a positive note, the study and dataset could illuminate the utility of medications used to treat COVID-19, Ponce said. In addition, as the authors note, “the data will expand over time.” 

Brown has reported receiving grants and consulting for Gilead. Ponce has disclosed no relevant financial relationships.
 

This article first appeared on Medscape.com.