Development of the Pharm-SAVES educational module for gatekeeper suicide prevention training for community pharmacy staff.

INTRODUCTION: Pharmacists are one of the most accessible health professionals in the United States, who, with training, may serve as gatekeepers who recognize suicide warning signs and refer at-risk individuals to care. Our objective was to codesign a 30-min online gatekeeper training module (Pharm-SAVES) specifically for community pharmacy staff. METHODS: Over a period of 8 months, a nine-member pharmacy staff stakeholder panel and the Finger Lakes (New York) Veterans Research Engagement Review Board each worked with the study team to codesign Pharm-SAVES. Formative data from previous interviews with community pharmacists were presented to the panels and guided website development. RESULTS: Four key topics were identified for brief skills-based modules that could be delivered asynchronously online. To help pharmacy staff understand their opportunities as gatekeepers in suicide prevention, statistics and statements from the Joint Commission and pharmacy professional organizations were highlighted in Module 1 ('Why Me?'). Module 2 ('What can I do?') presents the five gatekeeping steps (SAVES): (1) Recognize suicide warning Signs, (2) Ask if someone is considering suicide, (3) Validate feelings, (4) Expedite referral, and (5) Set a reminder to follow-up. Module 3 ('How does it work?') provides three video scenarios modeling SAVES steps and two interactive video cases for participant practice. Module 3 demonstrates use of the 24/7 National Suicide Prevention Lifeline, including the DOD/VA Crisis Line. Module 4 (Resources) includes links to national resources and a searchable zip code-based provider directory. Pharm-SAVES was codesigned with pharmacy and veteran stakeholders to deliver brief, skills-focused, video-based interactive training that is feasible to implement in busy community pharmacy settings. CONCLUSION: Pharm-SAVES is a brief, online suicide prevention gatekeeper training program codesigned by researchers, community pharmacy and veteran stakeholders. By actively engaging stakeholders at each stage of the design process, we were able to create training content that was not only realistic but more relevant to the needs of pharmacy staff. Currently, Pharm-SAVES is being evaluated in a pilot randomized controlled trial for changes in pharmacy staff suicide prevention communication behaviors. PATIENT OR PUBLIC CONTRIBUTION: Stakeholder engagement was purposefully structured to engage pharmacy staff and pharmacy consumers, with multiple opportunities for study contribution. Likewise, the involvement of patient/public contribution was paramount in study design and overall development of our study team.

Escalating costs of self-injury mortality in the 21st century United States: an interstate observational study.

BACKGROUND: Estimating the economic costs of self-injury mortality (SIM) can inform health planning and clinical and public health interventions, serve as a basis for their evaluation, and provide the foundation for broadly disseminating evidence-based policies and practices. SIM is operationalized as a composite of all registered suicides at any age, and 80% of drug overdose (intoxication) deaths medicolegally classified as 'accidents,' and 90% of corresponding undetermined (intent) deaths in the age group 15 years and older. It is the long-term practice of the United States (US) Centers for Disease Control and Prevention (CDC) to subsume poisoning (drug and nondrug) deaths under the injury rubric. This study aimed to estimate magnitude and change in SIM and suicide costs in 2019 dollars for the United States (US), including the 50 states and the District of Columbia. METHODS: Cost estimates were generated from underlying cause-of-death data for 1999/2000 and 2018/2019 from the US Centers for Disease Control and Prevention's (CDC's) Wide-ranging ONline Data for Epidemiologic Research (WONDER). Estimation utilized the updated version of Medical and Work Loss Cost Estimation Methods for CDC's Web-based Injury Statistics Query and Reporting System (WISQARS). Exposures were medical expenditures, lost work productivity, and future quality of life loss. Main outcome measures were disaggregated, annual-averaged total and per capita costs of SIM and suicide for the nation and states in 1999/2000 and 2018/2019. RESULTS: 40,834 annual-averaged self-injury deaths in 1999/2000 and 101,325 in 2018/2019 were identified. Estimated national costs of SIM rose by 143% from $0.46 trillion to $1.12 trillion. Ratios of quality of life and work losses to medical spending in 2019 US dollars in 2018/2019 were 1,476 and 526, respectively, versus 1,419 and 526 in 1999/2000. Total national suicide costs increased 58%-from $318.6 billion to $502.7 billion. National per capita costs of SIM doubled from $1,638 to $3,413 over the observation period; costs of the suicide component rose from $1,137 to $1,534. States in the top quintile for per capita SIM, those whose cost increases exceeded 152%, concentrated in the Great Lakes, Southeast, Mideast and New England. States in the bottom quintile, those with per capita cost increases below 70%, were located in the Far West, Southwest, Plains, and Rocky Mountain regions. West Virginia exhibited the largest increase at 263% and Nevada the smallest at 22%. Percentage per capita cost increases for suicide were smaller than for SIM. Only the Far West, Southwest and Mideast were not represented in the top quintile, which comprised states with increases of 50% or greater. The bottom quintile comprised states with per capita suicide cost increases below 24%. Regions represented were the Far West, Southeast, Mideast and New England. North Dakota and Nevada occupied the extremes on the cost change continuum at 75% and - 1%, respectively. CONCLUSION: The scale and surge in the economic costs of SIM to society are large. Federal and state prevention and intervention programs should be financed with a clear understanding of the total costs-fiscal, social, and personal-incurred by deaths due to self-injurious behaviors.

Opioid Overdose Knowledge among College Students in a High Overdose Death State.

PURPOSE: The goal of this study was to investigate university students' knowledge about identification of opioid overdose and actions to take in an overdose emergency. METHODS: A cross-sectional, anonymous, 36-item survey was developed and administered to West Virginia University (WVU) students. Overdose knowledge was assessed using the Opioid Overdose Knowledge Scale (OOKS). Demographic information, health insurance coverage status, previously receiving an opioid prescription, and knowledge about West Virginia Good Samaritan laws were also collected. Online survey responses were collected via REDCap. RESULTS: The study sample (n=214) was 90% white, 72.5% female, had a mean age of 24.8 years, and over half previously received a prescription opioid (51.9%). Additionally, 6.5% reported witnessing an overdose in the past year, and 15.9% previously received naloxone training. Overall, our participants had an average score of 30.9 out of 45 on the OOKS. Participants who previously received naloxone training scored higher overall on the OOKS than participants who did not (p<0.001). Similarly, participants who previously received a prescription for an opioid also scored higher than participants who had never had a previous prescription for an opioid (p<0.001). CONCLUSIONS: University students' knowledge suggests that previous exposure to opioid prescriptions and naloxone training increase a student's knowledge about opioid overdose. This information is not surprising; however, this does make the case that students may benefit from brief overdose education programs that could be implemented across university health education curricula. However, a larger effort may need to be implemented to encourage students to participate in such programs.

Enhanced neural activation with blueberry supplementation in mild cognitive impairment.

OBJECTIVES: Preclinical studies have shown that blueberry supplementation can improve cognitive performance and neural function in aged animals and have identified associations between anthocyanins and such benefits. Preliminary human trials also suggest cognitive improvement in older adults, although direct evidence of enhancement of brain function has not been demonstrated. In this study, we investigated the effect of blueberry supplementation on regional brain activation in older adults at risk for dementia. METHODS: In a randomized, double-blind, placebo-controlled trial we performed pre- and post-intervention functional magnetic resonance imaging during a working memory (WM) task to assess the effect of blueberry supplementation on blood oxygen level-dependent (BOLD) signal in older adults with mild cognitive impairment, a risk condition for dementia. RESULTS: Following daily supplementation for 16 weeks, blueberry-treated participants exhibited increased BOLD activation in the left pre-central gyrus, left middle frontal gyrus, and left inferior parietal lobe during WM load conditions (corrected P < 0.01). There was no clear indication of WM enhancement associated with blueberry supplementation. Diet records indicated no between-group difference in anthocyanin consumption external to the intervention. DISCUSSION: These data demonstrate, for the first time, enhanced neural response during WM challenge in blueberry-treated older adults with cognitive decline and are consistent with prior trials showing neurocognitive benefit with blueberry supplementation in this at-risk population.

fMRI brain activation changes following treatment of a first bipolar manic episode.

OBJECTIVES: We tested the hypothesis that, with treatment, functional magnetic resonance imaging (fMRI) regional brain activation in first-episode mania would normalize - i.e., that differences from healthy subjects would diminish over time, and would be associated with clinical remission status, potentially identifying neuroanatomic treatment response markers. METHODS: Forty-two participants with bipolar I disorder were recruited during their first manic episode, pseudo-randomized to open-label lithium or quetiapine, and followed for 8 weeks. fMRI scans were obtained at baseline and then after 1 and 8 weeks of treatment, while participants performed a continuous performance task with emotional distracters. Healthy participants received fMRI scans at these same intervals. Specific region-of-interest (ROI) activations within prefrontal emotional networks were assessed as potential measures of treatment response. RESULTS: ROI data were reduced using exploratory factor analysis, which identified five factors that were organizationally consistent with functional anatomic models of human emotion modulation. Half of the participants with bipolar disorder achieved remission by Week 8 and were contrasted with the other half that did not. Analyses demonstrated that, in the bipolar disorder group in general, treatment led to decreases in activation across brain regions toward healthy subject values. However, differences in activation changes were observed between subjects with bipolar disorder who did or did not achieve remission in subcortical and amygdala factors. CONCLUSIONS: These findings provide evidence for potential neuroanatomic treatment response markers in first-episode bipolar disorder.

Detecting mild cognitive impairment remotely with the modified memory impairment screen by telephone.

The original Memory Impairment Screen by Telephone (MIST) was designed to identify individuals with dementia but was relatively ineffective for identification of less severe impairment observed in mild cognitive impairment (MCI). We expanded the original MIST to create a modified instrument (mMIST) with greater sensitivity to less severe memory impairment. Older men and women with subjective cognitive decline were assessed by phone with the mMIST and subsequently classified independently with MCI or non-pathological cognitive decline. Participants with MCI produced lower scores on the mMIST than did participants without MCI, 10.8 ± 2.7 vs 13.3 ± 1.3, t = 5.68, p < 0.001, and performance on the mMIST predicted performances on the California Verbal Learning Test (CVLT), Verbal Paired Associate Learning Test (VPAL), Montreal Cognitive Assessment (MoCA) total score, and MoCA memory index score, p < 0.001. Receiver operating characteristic (ROC) analyses identified the optimal cut score on the mMIST to distinguish participants with and without MCI with Sensitivity = 73.1%, Specificity = 79.1%, and AUC = 0.79. Predictive values for distinguishing the amnestic form of MCI (aMCI) from non-amnestic MCI were Sensitivity = 81.8%, Specificity = 30%, and AUC = 0.82. These findings indicate that the mMIST is a valid screening instrument for identifying MCI. It can be administered remotely at low cost and low participant burden. Also, the mMIST has potential utility for remote cross-sectional and longitudinal evaluation in research and clinical contexts. Further investigation is indicated to corroborate its utility for assessment of aging patients and research participants.

A randomized controlled trial protocol for a virtual, scalable suicide prevention gatekeeper training program for community pharmacy staff (Pharm-SAVES).

Background: Suicide prevention gatekeeping is a skill that may support community (retail) pharmacists in managing patients who present with suicide warning signs. A brief, virtual, case-based training intervention was tailored to the retail setting (Pharm-SAVES). To test training effectiveness, a randomized controlled trial (RCT) protocol was developed for use in pharmacies across four states. Objective: To introduce the trial protocol for assessing the effectiveness for increasing the proportion of staff who recognize patients displaying warning signs and self-report engaging in gatekeeping, including asking if the patient is considering suicide. Methods: This study uses a parallel cluster-randomized controlled trial to recruit 150 pharmacy staff in community pharmacies in four states with two groups (intervention and control). The control group completes Pharm-SAVES online suicide prevention gatekeeper training and all assessment surveys at baseline after training and at 1-month follow-up. The experimental group completes all control group training and assessments plus interactive video role-play patient cases. Conclusion: We hypothesize that compared to those in the control group, experimental group trainees exposed to the interactive video role play patient cases will be more likely to recognize warning signs in patient cases and self-report engaging in gatekeeping.

A Scoping Review of Suicide Prevention Training Programs for Pharmacists and Student Pharmacists.

Objective. This scoping review updates a 2018 review of suicide prevention training programs for community and student pharmacists. Five scholarly databases were searched for articles published between January 2018 and December 2020. Articles were excluded if they did not describe an educational or training program for pharmacists or student pharmacists, did not explicitly include suicide, focused solely on attitudes, or did not provide sufficient detail to evaluate program content. The quality of each study was examined using a quality assessment tool.Findings. Seven studies met inclusion criteria. Most trainings (86%) were delivered live with interactive or role play scenarios to promote verbal and behavioral skill practice. About half (57%) assessed changes in knowledge, and fewer programs (29%) assessed changes in communication. All assessed participants' ability to identify suicide warning signs and included referral resources. Six studies were assessed for quality, of which 67% had a rating of good and 33% were rated as fair.Summary. Given the increase in suicide rates nationally, it is likely that pharmacists will encounter a patient in need of suicide prevention services. Since 2018, seven new suicide prevention training programs for community and student pharmacists have been reported, which demonstrates growing interest in suicide prevention training in the pharmacy profession. When integrated in Doctor of Pharmacy (PharmD) curricula, trainings may help prepare the pharmacy workforce for encounters with patients in crisis. The impact of training on self-efficacy and communication skills warrants additional attention. Variation between programs should be evaluated to understand which instructional methods best prepare pharmacy professionals to engage in suicide prevention.

Exploring the impact of brief training on student pharmacists' naloxone communication skills.

Objective: To explore: a) whether videos that model naloxone communication skills improve student pharmacists' naloxone knowledge, self-efficacy and communication skills and b) whether outcomes differ between video versus written materials. Methods: Student pharmacists (N = 31) were randomized to either video or written materials training. Changes in naloxone dispensing barriers, self-efficacy, and naloxone knowledge were assessed via survey, while changes in naloxone communication were measured with a standardized patient assessment. Results: For the entire sample, knowledge and self-efficacy significantly increased and barriers to dispensing decreased. Communication improved significantly in both groups. In unadjusted analyses, students with video resources reported higher self-efficacy post-training. However, analyses that controlled for demographic characteristics and baseline measures found that training type did not significantly predict any outcome. Conclusion: Brief written or video-based naloxone training improved students' knowledge, self-efficacy, and communication. Given the small sample, results are inconclusive regarding impact of training material type on outcomes. Innovation: Teaching student pharmacists how to communicate about naloxone is important given increasing opioid overdose death rates. This study was innovative because it examined the impact of two training material types that can be delivered asynchronously and that pharmacy programs could incorporate into their curricula to improve students' naloxone communication skills.

Impact of a Brief Suicide Prevention Training with an Interactive Video Case Assessment on Student Pharmacist Outcomes.

OBJECTIVE: To determine whether a brief suicide prevention training with an interactive video case (Pharm-SAVES) improves student pharmacists' suicide prevention knowledge and self-efficacy. METHODS: Student pharmacists (N = 146) from 2 United States universities completed the 75-minute Pharm-SAVES training in September 2021. Suicide prevention knowledge and self-efficacy were measured via an online pre-test and post-test, and a post-test interactive video case assessed self-efficacy to engage in SAVES steps (recognize Signs, Ask about suicide, Validate feelings, Expedite a National Suicide Prevention Lifeline [NSPL] referral, and Set a follow-up reminder). Paired samples t tests compared pre-test and post-test scores (alpha = 0.05). Three months later, students indicated if they had used Pharm-SAVES in practice. RESULTS: Mean knowledge and self-efficacy significantly improved from pre-test to post-test. The interactive video case assessment revealed that students were least confident asking about suicide, moderately confident referring to or calling the NSPL on behalf of patients, and most confident following up with patients. Three months later, 17 (11.6%) students reported that they had recognized someone with suicide warning signs (S in SAVES). Among them, 9 (52.9%) reported asking the person with warning signs if they were considering suicide (A in SAVES), 13 (76.5%) validated feelings (V in SAVES), 3 (9.4%) called the NSPL for the patient, and 6 (35.3%) referred to the NSPL (E in SAVES). CONCLUSION: Pharm-SAVES increased student pharmacists' suicide prevention knowledge and self-efficacy. Within 3 months, more than 10% had used Pharm-SAVES skills with at-risk individuals. All Pharm-SAVES content is now online and available for asynchronous or synchronous instruction.

Distinguishing clinical factors associated with unintentional overdose, suicidal ideation, and attempted suicide among opioid use disorder in-patients.

Opioid and other drug-related overdoses and suicides are leading causes of injury death and represent a significant public health threat in the United States (U.S.). This study examined clinical factors of three patient groups from two inpatient addiction treatment facilities in Appalachian West Virginia (n = 66). Patients were classified as having: 1) unintentional overdose(s) (OD), 2) suicidal ideation or suicide attempt(s) (SI/SA), and 3) suicidal ideation or suicide attempt, and unintentional overdose (SI/SA/OD). Multinomial logistic regression models were used to determine whether adverse childhood experiences, self-injurious behaviors, substance use history, overdose history, and past year stressful life events were differentially associated with history of SI/SA/OD. Participants in the OD group were more likely to have used heroin in the 24-h preceding their most recent overdose compared to either the SI/SA or SI/SA/OD groups. The multivariable model found participants with history of SI/SA had higher adverse childhood experience scores and more participants with history of SI/SA endorsed childhood physical abuse and teen dating violence. Overall, there are characteristics that distinguish unintentional overdose from suicidal ideation and attempt. Patients with SI/SA/OD appear to have greater clinical severity. More thorough evaluation of drugs involved in overdose and history of self-injury may help distinguish future risk and inform treatment planning.

Establishing Peer Recovery Support Services to Address the Central Appalachian Opioid Epidemic: The West Virginia Peers Enhancing Education, Recovery, and Survival (WV PEERS) Pilot Program.

Introduction: Central Appalachia has been disproportionately affected by the opioid epidemic and overdose fatalities. We developed West Virginia Peers Enhancing Education, Recovery, and Survival (WV PEERS), a program based on peer recovery support, to engage individuals using opioids and link them with a range of services. Methods: Community partners providing services to individuals with opioid use disorder (OUD) were identified and collaborations were formalized using a standardized memorandum of understanding. The program was structured to offer ongoing peer recovery support specialist (PRSS) services, not just a one-time referral. A website and cards describing the WV PEERS program were developed and disseminated via community partners and community education sessions. Results: Overall, 1456 encounters with individuals with OUD (mean= 2 encounters per individual) occurred in a variety of community settings over 8 months. The majority of referrals were from harm reduction programs. Overall, 63.9% (n=931) of individuals served by WV PEERS accessed services for substance use disorders and/or mental health problems. Over half (52.3%; n = 487) of individuals entered substance use and/or mental health treatment, and nearly a third (30.4%; n = 283) remained in treatment over six months. Implications: Using the WV PEERS model, PRSSs effectively engaged and linked individuals with OUD to mental health and substance use treatment in rural central Appalachia. Future research is needed to determine whether these services reduce the risk of overdose mortality.

Concurrent Alcohol and Opioid Use Among Harm Reduction Clients.

BACKGROUND: Harm reduction services infrequently address alcohol use among clients using opioids, despite the evaluated risk of overdose or medical consequences for clients with viral infections. The purpose of this study is to assess concurrent alcohol and opioid use among syringe services and overdose prevention program participants predominately in southern Ohio and northern Kentucky. METHODS: This is a cross-sectional study using self-report data (n = 1,142) pooled across regional overdose prevention programs and a mobile syringe services program. The outcome variable was concurrent use categorized as no concurrent alcohol, prescription opioid or heroin use; alcohol and heroin or prescription opioid use; and alcohol, prescription opioid and heroin use in the past three months. RESULTS: The sample was predominantly white (95%), 56% were male and the mean age was 33 years old. Forty-seven percent of the clients had no concurrent use of alcohol and opioids; 20.1% reported concurrent use of alcohol and either heroin or prescription opioids; and 33.4% reported concurrent use of alcohol, heroin and prescription opioids in the past 3 months. Lifetime suicidal ideation and non-opioid drug use were associated with concurrent alcohol and opioid use in the multivariable model. CONCLUSION: Harm reduction clients with concurrent alcohol and opioid use may warrant enhanced overdose prevention services. Syringe services and overdose prevention program participants may benefit from education or a brief intervention on alcohol consumption.

Feasibility and acceptability of safety screening among patients receiving addiction treatment.

INTRODUCTION: Premature mortality associated with opioid-related overdose and suicide is a significant public health problem in the United States. Approximately 20-30% of individuals with opioid use disorder (OUD) have a history of both suicide attempt and unintentional opioid overdose. The objective of this study is to evaluate the feasibility of a standardized screen for suicide and overdose among patients receiving addiction treatment. METHODS: We conducted a cross-sectional study using a convenience sample of patients (n = 113) recruited from two inpatient treatment programs. We used a modified version of the Patient Safety Screener (mPSS) to screen for suicidal ideation, suicide attempt, and overdose. Study staff administered the screen in-person during treatment, and we linked results to administrative clinical data. Subjects (n = 108) and members of their clinical care team (n = 20) completed a screening acceptability survey. We recorded a positive mPSS if a patient reported suicidal ideation in the past two weeks, a suicide attempt, and/or an overdose in the past six months. RESULTS: Fifty-eight percent of subjects had a positive mPSS screen, and 30.3% reported suicidal ideation, suicide attempt, and overdose. Subjects and clinical staff reported that it was acceptable to screen for suicide attempt(s) and overdose(s). About a third of the clinical staff reported concerns about administration time (n = 7) and impact on workflow (n = 6). CONCLUSIONS: Both suicide and overdose are important patient safety factors that should be incorporated into addiction treatment and discharge planning. This study's findings support simultaneously screening for suicide and overdose in OUD inpatient treatment settings. Future research needs to determine whether screening improves provision of services and reduces self-injurious behavior.

The Impact of the Opioid Epidemic on Children and Adolescents.

Although an epidemic of opioid-related overdose deaths has continued to increase in the United States for 2 decades, the impact of opioid use disorders (OUDs) on children and families receives minimal attention. The purpose of this commentary was to provide an overview of the impact of the opioid epidemic on children and adolescents, as well as to summarize challenges to improving outcomes for children. Children and adolescents who grow up in households with opioid misuse and OUDs may experience a myriad of adverse consequences, including: increased risk of mental health problems and drug use; accidental opioid poisoning; increased risk of developing a substance use disorder; and family dissolution that results from parents' incarceration, foster care placement, or loss of parent to an opioid overdose. Parental drug use may result in child neglect or deficits in parent-child attachment, and parents with an OUD may be less likely to be reunified with their children. OUD treatment is effective at reducing parental opioid use and improving child outcomes; however, stigma and cross-system collaboration may limit access to treatment and timely reunification of families. Children are the most vulnerable witnesses of the opioid epidemic, and further research is urgently needed to expand prevention interventions.

Cognitive response to fish oil, blueberry, and combined supplementation in older adults with subjective cognitive impairment.

Given evidence that eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), and anthocyanin-rich blueberries provide neurocognitive benefit, we investigated long-term supplementation in older adults with cognitive complaints. In a 24-week randomized, double-blind, placebo-controlled trial, elderly men and women received daily fish oil (FO) or blueberry (BB) or both. Diet records confirmed that participants reduced background consumption of EPA, DHA, and anthocyanins as prescribed. Erythrocyte EPA + DHA composition increased in the FO groups (p = 0.0001). Total urinary anthocyanins did not differ between the groups after supplementation but glycoside and native (food) forms increased only in the BB-supplemented groups. The FO (p = 0.03) and BB (p = 0.05) groups reported fewer cognitive symptoms, and the BB group showed improved memory discrimination (p = 0.04), indicating that supplementation improved cognition. Cognitive benefit in the BB group was associated with the presence of urinary anthocyanins reflecting recent BB intake but not with anthocyanin metabolites. However, combined FO + BB treatment was not associated with cognitive enhancement as expected.