CSI:OPIOIDs (Clinical Context of Suicide Following Opioid Transitions) is a rigorous scientific research study that systematically examines suicides occurring after prescription opioid dose reductions or discontinuations in patients with long-term (chronic) pain. Using psychological autopsy methods using detailed interviews with bereaved survivors combined with medical record review where obtainable, it seeks to characterize the multifactorial demographic, societal, clinical, and health-system factors involved. The study began as a pilot supported by the University of Alabama at Birmingham (UAB) Heersink School of Medicine’s Department of Medicine and is now primarily funded by a Veterans Affairs Health Services Research & Development grant under the title CSI:OPIOIDs-V. Led by Stefan G. Kertesz, MD, MSc (professor of medicine at UAB and investigator at the Birmingham VA Health Care System), its core purpose is to generate actionable knowledge that can improve care and help prevent future tragedies.
The CSI:OPIOIDs team is working to understand the factors that play key roles in American suicides. As recognized at NCP3.org (the National Campaign to Protect People in Pain), chronic severe pain is among those factors.
(Independent commentary from NCP3 perspective: Beyond the study’s findings, it appears that misdirection and misinformation from certain U.S. national health care agencies have also contributed to thousands of patient deaths by suicide and the departure of hundreds of clinicians from pain management practice each year. This pattern of institutional response requires urgent correction.) In the meantime, efforts such as CSI:OPIOIDs represent important work to understand and help reduce suicide.
Reflections on suicide prevention (September was Suicide Prevention Month)
Dr. Kertesz has offered the following commentary, drawing on both clinical experience with patients who have been suicidal and direct observation of the challenging overlap between suicide and pain:
This is a sensitive topic. If you or someone you know is in distress, help is available. The U.S. and Canadian 988 Suicide & Crisis Lifeline is accessible by phone or text.
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In 2024, approximately 48,824 Americans died by suicide; of these, 27,593 died by self-inflicted gunshot. A long list of factors is associated with elevated risk of suicide, including mental illness, serious pain, presence of a firearm in the home, family history of suicide, unsecured debt, and others. Each exerts some effect on risk. Yet statistics alone cannot reliably predict who will die by suicide. Many people carry multiple risk factors and never attempt to take their own lives, while others with few apparent risk factors still do. Consequently, interventions driven primarily by statistical models face inherent limits in effectiveness.
An alternative and complementary framework is the Interpersonal Theory of Suicide developed by Dr. Thomas Joiner. It proposes that three factors commonly converge:
- Perceived burdensomeness: The belief that “Others are better off without me.” Clinicians can usefully ask patients who report suicidal thoughts whether they hold this belief and how they reached that conclusion.
- Lack of belongingness: A sense of not belonging or not being part of any valued group or relationship.
- Acquired capability for self-harm: The capacity to overcome the natural barriers of fear and pain. This may involve access to means, but also develops through prior exposure to significant suffering, which can lower the psychological threshold for lethal action. Most people remain protected by an intact fear response.
While no single theory fully “explains” every suicide, Joiner’s framework supplies useful clinical anchors: Can a person experiencing suicidal thoughts reconnect with a group that matters to them? Can they be helped to re-examine the conviction that they are a burden?
In acute crisis, the priority is connection to immediate help like an emergency department. However, far more people exist in an intermediate state of risk: thoughts such as “I don’t like being alive,” “I wish I weren’t alive,” or “Could I act on these feelings?” For these individuals, the most effective response is often not a crisis protocol but genuine human listening: asking questions, demonstrating that the person is not alone. Even those who have never felt suicidal have usually experienced moments of despair or fear; that shared humanity creates a basis for connection.
September was a month of remembrance for those who are lost. But remember we can still do good for one another every month. For further information, see the American Foundation for Suicide Prevention or the CSI:OPIOIDs resources on pain-related suicide research.
In summary, CSI:OPIOIDs remains the only study of its kind dedicated to in-depth examination of the real-world clinical and human contexts in which opioid transitions have been followed by suicide among patients living with long-term pain. Its findings, together with frameworks such as Joiner’s Interpersonal Theory and broader public-health efforts, aim to move beyond aggregate statistics toward practical, individualized approaches that can reduce preventable loss of life.
Kayvan Haddadan is a physiatrist and pain management physician, and president and medical director of Advanced Pain Diagnostic & Solutions, a multidisciplinary pain management practice in California that he founded in 2012. A physician and surgeon licensed by the Medical Board of California, he is double board-certified in pain medicine and physical medicine and rehabilitation. He is also certified in controlled substance registration through the DEA and serves as a qualified medical examiner through California’s Department of Industrial Relations Division of Workers’ Compensation.
Dr. Haddadan earned his Bachelor of Science degree from the College of Alborz in Tehran, Iran, and his medical degree from Shahid Beheshti University of Medical Sciences. He later received his Educational Commission for Foreign Medical Graduates certification in Philadelphia, completed an internship in medical surgery at Loyola University Medical Center’s Stritch School of Medicine in Illinois, and finished his residency in physical medicine and rehabilitation at the same institution. He completed his fellowship in pain medicine at California Pacific Medical Center’s Pacific Pain Treatment Center and also trained in medical acupuncture for physicians at the University of California, Los Angeles David Geffen School of Medicine.
Dr. Haddadan has contributed to 29 research publications across multiple specialties, including pain management, cardiology, pulmonology, endocrinology, gastroenterology, and infectious disease. His work has examined topics such as hyperlipidemia in high cardiovascular risk patients, hyperuricemia and gout management, type 2 diabetes and hypertension, chronic obstructive pulmonary disease and asthma therapies, influenza treatment, irritable bowel syndrome, and opioid related complications in chronic pain care. His research has also included clinical outcome studies in spinal cord stimulation and award-winning presentations on neuropathic pain management and neuromuscular disorders.
