For the roughly 300,000 Americans living with a spinal cord injury (SCI), chronic pain is often a part of daily life and, for many, opioids are prescribed to combat it. In addition to the serious physical considerations, mental health concerns are prevalent in this population. Depression is common among individuals with SCIs, whose risk is three times higher than that of the general population.
In a recent study published in Spinal Cord, a team of researchers at MUSC and elsewhere sought to untangle the complex relationship between prescription opioid use and misuse and suicidal ideation in SCI patients. The team was led by James S. Krause, Ph.D., Distinguished University Professor and the associate dean for Research in the College of Health Professions , and Clara E. Dismuke-Greer, Ph.D., a research health scientist with the Palo Alto VA Health Care System in California. Their work brings to light patterns for opioid use that may serve as warning signs for increased suicide risk and provide clinicians and caregivers with new opportunities for intervention and prevention.
Opioids are a class of drugs that have been at the center of national debate for years, due to their powerful and broad-use pain-relieving effects and high potential for addiction and overdose. For people living with daily pain, opioids can lend significant relief by blocking pain messages being perceived by the brain and releasing dopamine, a "reward chemical" that can make users feel euphoric. For physicians, especially those who do not specialize in treating SCIs and are less familiar with providing nuanced or alternative treatments, these drugs represent the first line of defense when a patient presents with chronic, unmanaged pain.
Krause and Dismuke-Greer's study also noted the emotional toll that living with an SCI can have on patients.
"It takes great vigilance to survive day to day with a serious spinal cord injury," explained Krause, who has himself been living with an SCI for 54 years. "Even a single misstep can result in pressure ulcers and start a cycle of after-effects that unfold."
Between the physical impairments and the secondary mental and emotional conditions experienced by those with SCIs, it is unsurprising that this population is more likely to exhibit symptoms of depression, as well as substance misuse, which is defined as taking a medication in any way other than how it was originally prescribed.
Despite these general observations about depression, opioid misuse and possible suicidal ideation in spinal cord injury survivors, the formal relationship was surprisingly understudied. "The work we're doing with opioids and SCI is pretty unique. There's not much literature," said Krause. "Unlike in a lot of other fields, when you deal with spinal cord injury, there's still a lot of room for breaking new ground."
Krause and Dismuke-Greer wanted to do just that. So, between September 2021 and December 2023, their team surveyed over 1,200 participants with SCIs to understand more fully their experiences with opioids and depression in their day-to-day lives. Participants were not only asked whether they used opioids, but which ones, how often and whether they were being used in combination with any others. By collecting detailed information on prescribing and the use of these medications, investigators were able to explore relationships between SCI, opioid use and mental health more closely.
Their key finding was highly specific: simply taking prescribed opioids was not statistically associated with suicidal ideation. Instead, elevated risk occurred when patients were misusing opioids or when taking three or more simultaneously, known as polyopioid use. Depression and experiencing 15 or more painful days a month also emerged as strong predictors of suicidal ideation in the SCI population.
Having determined the relationship between opioid misuse, overprescribing and suicidal ideation, the researchers said this information can now be put into practice. Healthcare providers treating people with SCIs should now be on high alert for suicidal ideation when patients are prescribed multiple opioids, show signs of misuse or report persistent severe pain. "Polyopioid use should be a flashing light for providers to screen for suicidal ideation," said Dismuke-Greer.
These findings are relevant to caregivers and family members as well. Heightened awareness of multiple opioid prescriptions, signs of misuse and behavioral changes could help loved ones to advocate for mental health screening and intervention.
The team's next focus is on identifying protective factors, ways to reduce suicidal ideation, such as improving job opportunity satisfaction and social engagement. While identifying risk factors is important, Krause emphasized that the ultimate goal is understanding what helps people with an SCI thrive.
"People have a good bit of control," he said. "They have to be responsible for their own lives, and this gives them some information. If we understand what predicts something, we have the opportunity to change it."
About MUSC
