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January 15, 2020

Access to lethal means looked at to lower veterinary suicide rate

Researchers say changes needed to prevent diversion of euthanasia drug
Published on January 02, 2020

Veterinarians have a higher rate of suicide than does the general population, research says. But according to the most recent study, if suicides associated with pentobarbital, a drug commonly used for euthanasia of animals, were not counted, veterinarians would mirror the general population in terms of suicide rates. 

Researchers and veterinarians are calling for change, but there’s a lack of consensus as to the best steps to take. Some within the profession have advocated for controlling access to the means—that is, changing how pentobarbital is stored. Others say better policies need to be in place to avoid the risk of the drug leaving the clinic for potential use at home.

Jen Brandt, PhD, lectures on QPR training
Jen Brandt, PhD, director of well-being and diversity initiatives at the AVMA, lectures on QPR training, which helps in identifying and aiding individuals who may be at risk for suicide. QPR stands for question, persuade, and refer. (Photos by R. Scott Nolen)

Means to an end

Researchers from the Centers for Disease Control and Prevention’s National Institute for Occupational Safety and Health looked at mortality rates from suicide among 11,620 veterinarians who died from 1979-2015. They concluded that male veterinarians were 2.1 times as likely and female veterinarians were 3.5 times as likely to die from suicide as were members of the U.S. general population, and these higher suicide mortality rates extended the entire 36-year period (J Am Vet Med Assoc 2019;254:104-112).

When looking at methods of suicide, the researchers found notable differences.

Fifty-one percent of male veterinarians who died by suicide used firearms, and 33% overdosed, compared with 18% of female veterinarians who used firearms and 64% who overdosed.

For both male and female veterinarians, those in clinical positions more often used pharmaceuticals than did those in nonclinical positions.

Tracy Witte, PhD, a professor in the Auburn University psychology department, then built on the CDC’s work by looking more specifically at methods of suicide.

Dr. Witte’s research, published in September, showed not only that overdoses were the most common suicide means for veterinarians, but also that pentobarbital was the most common substance used, which is different from what’s seen in the general population (J Am Vet Med Assoc 2019;255:595-608).

“In some ways, this isn’t a shocking finding because people have speculated for a while, and there was indirect evidence that veterinarians are more likely to overdose. And reading between the lines, people assumed they overdosed on pento,” Dr. Witte said.

Further, 89% of the pentobarbital-caused deaths did not occur at work—most of the time they were at home (72%).

Taking it one step further, the researchers reanalyzed their data after excluding those veterinarians who used pentobarbital, and they found that suicide rates for male and female veterinarians were no different from those for the general population. 

“So, the idea is the people who used pentobarbital, theoretically, if that had been prevented, we would have a similar suicide rate in vets as we do in the general population,” Dr. Witte said. “This gives credence to the idea that if we made it a little more difficult for veterinarians to die by suicide, we could prevent suicide, not just make them switch to something else.

“Moreover, our finding that most of the suicides involving pentobarbital occurred outside the workplace suggests any new policies should consider guidelines for when and how pento can be removed from a clinical setting.”

One day at a time

On average, 129 Americans died by suicide each day in 2017, and upwards of 90% of those individuals had a diagnosable mental health condition at the time of their death, according to the American Foundation for Suicide Prevention.

There is no single cause of suicide, but a convergence of biological, psychological, social, and environmental factors contribute, and all of these factors interact with external life events every day. Suicide most often occurs when stressors exceed the current coping abilities of someone suffering from a mental health condition, the AFSP states.

Christine Yu Moutier, MD, chief medical officer for the AFSP, gave a talk during the 2019 Veterinary Wellbeing Summit, held Nov. 17-19 in Rosemont, Illinois, on preventing suicide and building resilience.

People experience negative life events all the time, she said, from bullying to crises, and the rule is resilience, not suicide. The latter happens when “those natural ways of resilience and protective factors are temporarily dismantled. In those moments, you don’t have access to a sense of connectivity, for example. That cognitive constriction lasts for a short period of time, but if you can allow a person to get through moments to hours of that high acute period and keep them away from lethal means, you don’t just save their life for a moment” but possibly for a lifetime, Dr. Moutier said.

Limiting access to lethal means is effective, as the data show that most people don’t opt for another method. Dr. Moutier cited a 2010 study that examined rates of suicide after a policy change in the Israeli Defense Forces that reduced adolescents’ access to firearms. Following the policy change, suicide rates decreased by 40%.

Further, a 2017 study in the online journal BMC Psychiatry found that people in jobs with access to firearms, medicines or drugs, or carbon monoxide more frequently used these methods to end their lives than those without access to lethal means.

Women in jobs with access to lethal means had suicide rates that were 3.02 times the rates for those without access at their work. Men in jobs with access had suicide rates that were 1.24 times the rates for those without access.

“The findings of this study suggest the importance of controlling access to lethal methods in occupations where these are readily available,” the authors concluded.

Keeping tabs

All health professionals licensed to dispense, administer, or prescribe controlled drugs, such as pentobarbital, must register with the Drug Enforcement Administration. Registrants must comply with regulatory requirements relating to drug security and record keeping. Prescription drugs should be stored separately from over-the-counter drugs and in a secure manner, with access limited to key personnel. But that’s not always the case, said Dr. Suzanne E. Tomasi, an epidemiologist at NIOSH and lead researcher on the CDC study.

“Once staff gets in for the day, they’re constantly in and out of the drug box,” said Dr. Tomasi, a former practicing veterinarian. “You have the morning appointments while the surgery technician is prepping for surgery and hope to get one done in time for lunch. As the vet, you unlock the controlled box so the tech can start dosing meds and calculating surgery meds. Usually, I would double-check doses before giving to patients, but you’re running around and doing your stuff, and the box is basically open.”

She says the profession needs to come up with ways to look at better administrative controls in various situations, from a small rural clinic to a big multidoctor practice to an ambulatory clinic.

“That’s where the paper in September was driving that point home. We’re working on the mental health part—changing stigma, looking at the business model, improving work-life balance, and educating the public when they say these things that are a form of bullying and hurting the profession—but that’s going to take time,” Dr. Tomasi said. “Changing administrative controls that change how clinics view and access the drug box could be an immediate lifesaving change for a certain percentage of the profession.”

Finding what works

Of course, the devil lies in the details.

There are the quick and easy solutions, such as putting a sticker on drug boxes with the phone number of a suicide prevention lifeline. But other solutions will take greater effort to thwart veterinarians from diverting pentobarbital.

Dr. Andy Roark, a practicing veterinarian at Cleveland Park Animal Hospital in Greenville, South Carolina, and an author and speaker, started the Four Eyes campaign last year. He’s advocating that accessing controlled drugs should require two people in every clinic possible.

But the campaign has seen pushback. For example, solo mobile practitioners have said they wouldn’t have a second person around to sign off.

“And my response is, if you have something great for 90-95% of the profession, and 5-10% percent can’t do it, it doesn’t mean 90-95% can’t,” he said.

Other criticisms include that a two-person system wouldn’t work as quickly as veterinarians would need access to drugs in some cases or that implementing a new system would be expensive. Dr. Roark says he doesn’t buy the quickness argument because human emergency rooms have been able to make the same system work. And drug management systems range in cost, from those that require thumbprint recognition from two approved people before allowing access to just having two locks on a drug box, which the DEA already requires, and committing to a key management system.

Regarding the latter, Dr. Roark said, “It has to come from leadership. You can’t have doctors hiding keys. I think a lot of people think it (suicide) can’t happen in their practice. The truth is you don’t know what’s going on in the mind of colleagues.”

Summit attendees
The theme of the 2019 Veterinary Wellbeing Summit was "Putting the 'We' in Wellbeing." The event brings together veterinarians, veterinary students, educators, and mental health professionals each year.

He thinks the hesitation he’s seen about his idea is that veterinarians worry they will lose access to important drugs they need to do their job. 

“That’s why us choosing to do this (voluntarily) and do it well is important to get people on board,” he said.

Meanwhile, Dr. Witte’s research group is planning to get feedback from practitioners on a variety of ideas on how to implement better controls and seeing whether they work.

“We shouldn’t have one solution for everybody,” she said. “What needs to be done is a bottom-up approach to identify things that might work and be viewed as acceptable by people who would need to use them.”

 

The National Suicide Prevention Lifeline website provides a number of useful resources, including how to find a therapist or support group.

The Suicide Prevention Resource Center has a webpage dedicated to reducing access to means of suicide.