Hello April, tell us about yourself!

I’m the project coordinator for CSI:OPIOIDs – this means that I oversee all aspects of the study ranging from administrative tasks like ethical review with the Institutional Review Board (IRB) and contracting to data and analytical tasks like conducting interviews and taking part in qualitative analyses.

What is your professional background or personal connection to this work. Why are you interested in this study?

I’ve worked in Research at the VA for 7 years. The studies I’ve worked on have focused on several different topic areas such as homelessness, quality care experiences among Veterans with homeless experience, and care changes due to the COVID-19 pandemic. I’ve always loved working with Veterans, in college I worked with a local nonprofit called Three Hots and a Cot.

I would go to my nearest Three Hots and a Cot house each week to talk to the folks there and update their resource guide which provided contact information on local organizations that can assist with medical needs, job skills, and general resource connectors. Since that experience, I’ve known that I would like to build a career focused on supporting those who have served our country through military service.

There are 2 special things about CSI:OPIOIDs that drew me to it: 1. The opportunity to collect completely new data on a serious problem facing our country and 2. The opportunity to potentially inform change both within and outside of the VA. Though the purpose of the study is not to inform policy, I do believe collecting these narratives of individual’s pain and care journeys and noting the personal and systems-level factors present in these stories will finally elucidate the trends we’re seeing in quantitative research.

What has been the most interesting/surprising/meaningful thing about doing this work, so far?

Right off the bat, the most meaningful part of this work has been lending an ear to participants telling us about their loss.

Obviously the goal of the study is to build a narrative structure for pre-existing statistical work in this field and identify themes that surround these deaths, but I am proud to offer even a small amount of comfort to individuals who have lost loved ones this way.

This is a difficult topic to talk about – much less to complete a full interview on – and I have been so grateful to have the opportunity to talk with our participants and let them know that we care about these stories.

What do you think people in our society might need to learn at this time about pain and its care?

I am not a clinician, but my number one takeaway is that healthcare and medicine are truly individual and often times governmental oversight of medication and broad-strokes policies can be very harmful.

Doctors need to feel safe and secure in their provision of treatment and patients need to have shared decision making in regards to their personal care. Chronic pain is an incredibly complex issue and even at the individual-level a perfect answer probably won’t exist, but sweeping guidelines that fully restrict access to different lines of care are less likely to help patients find effective treatment.

Meet CSI:OPIOIDs team member, Dr. Adam Gordon at VA Salt Lake City and University of Utah!

Hello Adam, tell us about yourself!

I’m Adam Gordon. I’m a physician in internal medicine and addiction medicine.  I’m also a health services investigator: I seek to improve the access and quality of care for patients who are vulnerable, including those with pain and/or addiction. I am also a gardener!  I have worked with Dr. Kertesz for over 2 decades and we are passionate about reducing the harms associated with involuntary opioid tapering and tapering in general. Indeed, we have published many articles about this. I am passionate about the CSI:OPIOIDs study. I offer advice and my expertise to the research team, but more importantly I want to learn from patients, families, and significant others about lives lost.

What has been the most interesting/surprising/meaningful thing about doing this work, so far?

We have known from prior studies that health care providers have had difficulty in addressing pain and opioid prescribing for pain. Often times, the care may not be patient-centric. Many providers follow guidelines strictly, often not listening to patients or individualizing patient care. The work of CSI-OPIOIDS validates these thoughts. The narratives we have heard indicate that patients with chronic pain are very vulnerable. Rapport, patient-collaboration, and patient-driven health care choices are important. My hope is that CSI:OPIOIDS will change how health care providers perceive patients with chronic and acute pain and change how they address pain and opioid prescribing among these patients.

What ideas do you have that might help us think about suicide and how to prevent it?

Suicide is obviously not the most optimum outcome. Preventing suicide is incredibly important. CSI:OPIOIDS may be the critical research that can prevent suicide among patients with chronic pain. Changing health care provider perceptions and stigma regarding patients with chronic pain may be the first step to improve their interaction with these patients.

What do you think people in our society might need to learn at this time about pain and its care?

It is unfortunate that our health care training has not included more patient-centric approaches for acute and chronic pain. Thus, existing health care providers are often unclear how to address pain among their patients. With guidelines and health insurers may give a false mandate to “do this or that” with every patient, health care providers often cannot individualize care. I am concerned about patient abandonment and patient distrust in the health care system. Patients with pain need to trust their providers and not feel that they have to justify their pain or existing treatment to every provider. Health care providers need to trust their patients too. Patient and provider rapport is important in addressing acute and chronic pain. CSI:OPIOIDS will help build this rapport.

The CSI:OPIOIDs team includes many of us who are moved to this work by a strong sense of passion to prevent suicide and to improve the care of people with pain.

Dr. Kertesz began to speak out against harm to patients with pain in 2016. By 2019, he had published opinion pieces in journals across the country. While many people welcomed his voice, some were angry that he spoke out. Some even called his supervisors to complain about him, or spoke to the press.

Dr. Kertesz recently wrote about his experience as an advocate, where he had to confront some of his own fears. He described being “rattled” by criticism, but also finding the strength to persevere, based on a mission of fundamental fairness for everyone, regardless of disability or power.

In his latest article for the blog “Sensible Medicine” he writes: “there is something in me that has always recoiled against making the short end of the stick even shorter for whoever is already on that end.” The full story (and a recording of it by Dr. Kertesz) is online here

Read the full story at Sensible Medicine here

Dr. Thomas Joiner is a leading national expert on suicide. He is also a chaired professor at Florida State University. He has written several books and hundreds of scientific articles on suicide, and he is a key advisor to the CSI:OPIOIDs study. He also has developed an important theory that helps us begin to think about why people take their lives. Our principal investigator, Dr. Stefan Kertesz, recently spoke with Dr. Thomas Joiner. Read more below.

Q: Dr. Joiner, can you tell us where you grew up and why you became a psychologist?

A: I was born and raised in Atlanta. I was initially drawn to philosophy but grew frustrated with the abundance of questions and the lack of answers. I noticed the psychologists were asking the same kinds of questions and then empirically arbitrating them. I thought that was very appealing. As for why a clinical psychologist, I just thought and still think that psychopathology is inherently fascinating. It is also a major source of human suffering and so trying to contribute to the reduction of suffering is also appealing to me.

Q: What has led you to put your effort into suicide prevention?

A: Initially it was the intellectual interest in philosophical questions having to do with existence, the lack of it, meaning, and the lack of it as well. Then, it became deeply personal and urgent when my dad took his own life when I was in graduate school.

Q: Our team sought for advice when we were just getting started. Why did you decide to advise the CSI:OPIOIDs project?

A: I’m interested in virtually any effort that has suicide prevention potential as this effort plainly does.

Q: There’s a theory about why people sometimes take their own lives. It’s credited to you. In simple terms, the theory says that people are more likely die by suicide when a few different things happen together. Two of those things have to do with how they feel in relationship to others. One has to do with feeling alone, and the other with felling like a burden. Can you tell us more about what those mean?

A: I believe the two main pillars of human nature are autonomy/agency and inter-dependence/connection. These also account for things like meaning. If those are undermined–as they are when people feel that they do not belong and that they burden others–reasons for living, meaning, and purpose are reduced.

Q: People talk about a theories in different ways. Sometimes they mean “it’s proven reality” like Einstein’s “Theory of Relativity”. Sometimes they mean, “this is an idea we are still developing and trying to document”. Which kind of theory is this?

A: I’m with the philosopher of science Karl Popper that there generally is no “proven” category. The only categories are “false” and “not false…yet”.  But a problem with Popper’s philosophy, one that he recognized, is that falsifications can be spurious, and so the judgment is difficult. As for my theory, I would use terms like “useful, including clinically “and “explanatory, at least partially.” There is a considerable empirical basis behind it, though it is unsurprisingly imperfect.

Q: Our study looks at a difficult event that happens in US health care where a person with pain loses access to pain medication. Some people do wind up taking their own lives and others don’t. What do you think are important questions for us to ask as we go forward?

A: I think an important point is that people can adapt to all sorts of things if they’re just given time and support. Exploring ways to disseminate that view seems like a potentially significant contribution to me.

Q: Many of us who work with the study know people who have lost someone to suicide, and we don’t always know what to say when we aren’t wearing our research hats. How can we be helpful to families and friends who have lost someone?

A: People can lose sight of the fact that the word “death” is of course an important part of the term “death by suicide.” It is a death, like a cardiac death or a car accident, and people should be guided in their reactions by remembering that.

Our CSI:OPIOIDs research team was honored to present and learn from United Survivors (United Suicide Survivors International) and its chair Sally Spencer-Thomas, PsD, a leader and advocate in the prevention of suicide.

This evening was made unique by powerful observations from both Mark Flower and Jim Elliott. Mark is an advocate and Veteran who is in recovery and has lost friends suicide. Jim lost his brother Danny to suicide in November, 2022, after a physician’s office was closed down.

This presentation introduces why it’s so important to collect the stories of these losses. Powerful reflection from Jim and Mark begin at 13:50. View the discussion on Facebook here.

Members of our study team shared the CSI:OPIOIDs study design and “early insights” at the renowned “Rx and Illicit Drug Summit“ in Atlanta on April 1, 2024. The Summit draws on policymakers, patients, and clinicians. Competition to present is steep. Our presentation will focus primarily on insights learned through recruitment and outreach to the community of people living with pain and survival after suicide loss. 

Dr. Stefan Kertesz and April Hoge discuss the CSI:OPIOIDs study with Dr. Jay Joshi on the Daily Remedy podcast in an episode titled, Discussing patient suicides following forced tapering with the investigators of CSI:OPIOIDs.

Listen here or by clicking below!

Can we try to understand a suicide the way investigators look at a plane crash? In this video snippet from a recent talk, Dr. Kertesz introduces psychological autopsy, and shows how it might be applied to the death of former Nirvana lead, Kurt Cobain.

New article by Dr. Stefan Kertesz and University of Michigan’s Dr. Pooja Lagisetty. Please write our team at csiopioids@uabmc.edu if you would like a copy.

Today, the well-read Pain News Network website published “Why We Need to Study Suicides After Opioid Tapering”, a column by study investigator Dr. Stefan G. Kertesz. “Prescription opioid reductions are not always good, and not always bad,” writes Dr. Kertesz, but he then lays out why it’s important to study the suicides that have happened, and how people can spread the word. Check it out online here.