Managing suicide risk among people who inject drugs

What’s the issue?

People who inject drugs die by suicide at a higher rate than the general population.¹ Although the evidence highlights the increased risk of suicide, there is limited evidence informing clinical practice to identify and manage suicide risk in people who inject drugs.

Supervised injecting facilities are harm reduction spaces where people can legally inject substances under the supervision of health professionals. These types of services provide an opportunity for health professionals to conduct brief crisis intervention, determine suicide risk and provide clients with options to access further support.

A 2016 survey of clients of the Medically Supervised Injecting Centre (MSIC) in Sydney found more than half the respondents reported a lifetime suicide attempt and 30% had a history of self-harm.²

Although clinical guidelines exist to support staff working in alcohol and other drug services, the guidelines do not incorporate strong guidance on the identification and management of suicide risk for people who inject drugs.

There are currently no suicide risk assessment and management guidelines appropriately tailored for use within harm reduction services.

What was done?

Using the setting of the MSIC in Sydney, Australia the researchers of this study aimed to:

1. Assess experience and confidence among staff at the MSIC in managing suicide risk among clients.
2. Identify suitable methods to assess and respond to suicide risk among clients attending the service; and
3. Develop updated clinical practice guidelines and safety planning tools for assessing and responding to suicide risk.

Researchers used a mixed methods (quantitative and qualitative) and co-design approach to inform the guideline development.

Staff survey

Researchers surveyed staff at MSIC (nurses, health education officers) to understand their knowledge skills and experience in identifying and managing suicide risk.

Focus groups

Black Dog Institute clinician-researchers facilitated mental health and alcohol and other drugs (AOD) focus groups with MSIC clients who had a lived experience of suicidal thoughts or self-harm to identify barriers and enablers to supporting clients at risk of suicide.

A second focus group included MSIC clients and health staff employed at local health and AOD services, and built upon themes identified in the first focus group.

What was found?

Staff survey

Results from the staff survey found that staff were able to:

• Identify subtle signs of distress and nonverbal cues
• Identify that many clients who attend MSIC did not have the health literacy and communication skills to verbalise their distress, and so nonverbal cues were important.

Focus groups

The client focus groups highlighted:

• The importance of client autonomy in deciding on the type and level of care and support a person receives
• A lack of autonomy in support can prevent clients from sharing suicidal thoughts with MSIC staff
• Clients reported feeling ‘conned’ when disclosure of suicidal thoughts resulted in involuntary hospital admission
• Trust was weakened when health professionals were simply ‘going through a checklist’ rather than listening to what was going on for the client
• System barriers such as the service not being helpful, were expressed as negative experiences with hospital (and associated) services during suicidal crises.

Mixed focus group

Key themes identified in the discussion were:

• Autonomy was considered important for clients during suicidal crises
• Providing options to clients, and being discreet was important
• Trust, validation, and transparency was seen as integral to staff–client interactions
• Service models do not always prioritise the needs of clients and can devalue their perspectives and experience
• Stigma is a barrier to accessing healthcare services for people who use drugs.

Guideline development

The survey and focus group findings informed the updates to existing clinical practice guidelines for staff supporting people who inject drugs.

The updated guidelines encourage:

• Transparency in assessment of suicide risk
• Transparency in referrals and involvement of emergency service or other health supports
• Collaboration between staff and client to manage perceived risk
• Compassionate care that validates the person’s experience and resources.

Why are the findings important?

These findings highlight the importance of moving away from risk stratification approaches to identify suicide risk, and use a collaborative and strength-based approach instead.

Using risk assessment tools or frameworks that categorise risk level is not supportive of a person’s safety. Risk assessment tools may not provide opportunity to understand the whole experience of a person if they are modelled on set questions.

The researchers note that people who use drugs often have limited social supports and experience high levels of stigma, making them less likely to disclose their suicidality for fear of trust being broken or experiencing judgement.

Trust and transparency between staff and clients are vital to build rapport, positive experiences and encourage future help-seeking behaviours.