What Do We Do About Suicide? It’s Time to Limit Access to Means

ANDY ROARK, DVM MS

Want to do something about suicide in veterinary medicine? Make it so no one in your clinic can access lethal drugs alone. Do it now.

Yesterday, one of my friends reached out because she was devastated after a doctor she worked with took his own life. The clinic had been short-staffed for months and hiring efforts hadn’t worked out yet.

The day before, the technicians in my clinic talked about how a veterinarian down the road took her own life while her staff was out to lunch.

Every day it seems we lose another veterinary professional to suicide. I’ve had nightmares about suicide in my staff, friends, and colleagues, and I am certain I’m not alone in my anxiety. It’s past time for us to commit to addressing suicide in our profession.

According to a study¹ released this year by the Centers for Disease Control and Prevention (CDC), male veterinarians are 2.1 times as likely as the general population to die by suicide, while female veterinarians (who are 60% of the profession and growing) are 3.5 times as likely. This trend is in stark contrast to the general population, where women have lower rates of suicide than men. A 2015 CDC study² found that 1 in 6 veterinarians has considered suicide.

Anecdotally, suicide in veterinary technicians and support staff is both common and tragically under-researched. Veterinarians are not the only people in our practices who are affected, and we are being dangerously naive if we act like they are. Our support staff is unquestionably at risk.

For years, many of us have fought against the presumed causes of suicide. These include low pay, high debt, compassion fatigue, long working hours, work overload and poor work-life balance. Both wellness and communication programs have been initiated across our profession (including Wellbeing Gatekeeper Training³, which I personally recommend for everyone). Unfortunately, these initiatives alone have not yet been effective in reducing our losses. While we continue our efforts in these areas, it’s time to consider new approaches to the problem as well.

So what comes next?

I believe it is time to restrict access to the means by which so many of our colleagues attempt suicide: the lethal medications readily available within our very own clinics.

Consider that many suicide attempts are not carried out after thoughtful consideration or detailed planning. According to a 2016 study⁴, a large percentage are made impulsively. Interviews with suicide attempt survivors have shown that two-thirds of suicide attempts are contemplated for less than an hour beforehand, and almost half of attempts for no more than 10 minutes.⁵ Also, contrary to popular belief, people who attempt suicide and survive are very unlikely to die by suicide at a later date⁷. Therefore, if periods of high suicide risk are relatively short (as these figures suggest), and if repeated suicide attempts are rare, then restricting access to the method by which a person intends to end his or her life may disrupt the suicidal process and increase the likelihood of survival. This should give us hope, and is the reason we must act.

I was once presenting at a veterinary conference when a veterinarian approached me. She told me that one evening, after her clinic closed, she decided to take her own life. She sat down at her desk computer to write a note, and when the screen flickered on, an article about mental health was open on the desktop. She said she had no idea why it was there or how it got there, but she decided to skim through it. When she was done, she decided that maybe she would give her decision some more consideration. She went home that night and later began therapy. She said that article is the reason she is still with us today. I believe this is an example of what can happen if we disrupt the suicidal process.

So, what is our best chance of accomplishing this disruption in the veterinary world? At present, I believe it is restricting access to the medications that veterinarians and veterinary technicians so often use to take their own lives. It seems obvious that one of the reasons our profession has such a problem with suicide is our access to, knowledge of, and comfort with drugs that are both lethal and painless.

The numbers seem to support this theory. According to the CDC two-thirds of female veterinarians who died by suicide and one-third of male veterinarians used “poison.” The CDC could not report how much “poison” was made up of euthanasia drugs, but did indicate it was “a substantial part.⁶”

When I imagine how suicide in our profession happens, it isn’t difficult to picture a veterinarian or technician alone in the clinic after everyone else has gone home. Perhaps it has been a terrible day, with no end to the grind in sight; maybe mental and emotional fatigue has set in or things aren’t going so well at home. Compounding it all, a person at the end of such an exhausting day may not have eaten since morning. That’s the kind of temporary moment in which everything seems permanently bleak, and hopelessness can wrap around somebody like the lab coat or scrubs they’ve been wearing for twelve hours straight. It’s so common.

I suspect that, often, it’s during this moment that the suicide decision is made. And the drug safe is right there.

To investigate this theory, I recently conducted a short online survey of veterinary professionals. With over 8,000 individuals responding, 42.3% indicated that, if they felt depressed or deeply sad over the previous 12 months, these feelings were most likely to occur at the end of work before going home (8%) or at home in the evening (34.3%). One might assume that these would also be the times of greatest opportunity to privately access lethal medications since other employees are leaving or have gone home for the day.

Participants were also asked: “If you were alone in your veterinary clinic and needed to access the controlled drugs, could you do so?” Seventy-one percent of respondents said that they could access the controlled drugs in their clinic alone. This includes: 92% of veterinarians, 74% of managers, 64% of technicians/assistants, 38% of front desk staff, and 25% of kennel staff. (Yes. You read that correctly.)

Now, think about your own clinic for a moment. If one of your doctors or technicians wanted to linger and access the clinic’s supply of euthanasia drugs after the business closed, could she? I’m sure your drugs are secured under lock and key… but who has that key? How many “just in case” copies are stashed around the clinic? How many “secret” keys are there? How secret do you really think they are?

I suspect that in most clinics, if a doctor, manager, or licensed technician wanted to privately access euthanasia or other controlled drugs during lunch or after hours, they could do it in under 10 minutes. That’s been true (at least for me) at every clinic I’ve ever worked in. This reality needs to change. And when we change it, we will save lives.

It is time for veterinary medicine to take up a “4-eyes” system to control drugs that are commonly used in suicide attempts. This means that, in every clinic possible, it should require two people to access these drugs. No one should be able to get to them alone.

Imagine a lockbox that would pop right open for easy access… As long as two people were present to open it. This could be two doctors, a doctor and a technician, two technicians, etc. This would provide quick access during business hours when the clinic is in full swing, and zero access when someone wants to remove drugs privately.

This “4-eyes” system is standard in human hospitals today. In fact, a second person is generally not only required to access controlled drugs, but also to witness those drugs being given. There is no doubt that our profession lags behind in controlled drug security.

There are a number of ways to create a 4-eyes system, and some practices already have it in place. For example, I know of a clinic in Washington that has two locks on their controlled substance safe. The doctors have keys that fit one and the technicians and manager have keys that fit the other. This simple system was put in place as a safeguard against opioid abuse. It’s now doing double duty as a suicide prevention strategy.

A new system I’m excited about is based on Radio Frequency Identification (RFID) technology. RFID uses electromagnetic fields to identify and track tags attached to cards, wristbands, keyrings, etc. If you’ve ever used a key fob, you’ve used RFID.

RFID is not uncommon in veterinary medicine right now. Dr. Tracy Sands uses RFID in her clinic in Carlisle, Pa., not only to track and control who opens the drug safe and when, but also to control who enters and leaves through the back of the clinic. Many other clinics take the same approach. As someone who has found clients wandering in our storage area after entering the rear of the building, this seems like a nice safety feature.

Now, imagine an RFID lock on your drug safe that requires two different fobs (or wristbands or cards or whatever) to open. Any two people with fobs could quickly swipe the lock and open it, but no single person could access the box. A company called Senseon Secure Access will be releasing an electronic lock with this functionality in the coming months. [Let me say here that I have no relationship with this company at all. Also, other RFID companies may have the same or similar technology, I just haven’t found them.] The standalone system pricing has yet to be announced but is expected to be around $700-$900 (including nine key cards). Additional cards/fobs/wristbands will be approximately $7 each.

Alternatively, all drug management systems from Cubex (a company that provides automated medication and supply management to the veterinary, dental and healthcare industries) come equipped with their Witness feature. This system requires thumbprint recognition from two approved people before allowing access to controlled drugs. The company focuses on DEA-compliance and operates on a subscription basis. Their most popular product for veterinary clinics is the Cubex Mini.

Regardless of how it is done, I implore every veterinary clinic to begin restricting easy access to lethal medications. I know there are clinics (including equine, mobile and hospice practices) where doctors must be able to access these drugs alone, but that doesn’t mean we shouldn’t implement these practices in every clinic where they can work.

We need to install 4-eyes systems across our profession, and we need to educate our staff about why we are doing so. If our employees believe these systems are a mandate from the DEA or OSHA, or a program brought down “from corporate,” they’ll bypass them. They will leave keys at the clinic instead of taking them home, and they will share fobs for easy access. If, however, they know that this system exists to prevent one of their teammates from taking his or her own life, and that sharing fobs or leaving keys at work will result in losing access, then I believe they will step up to keep their friends and co-workers safe. They have to understand the reason, and every drug box should have the National Suicide Prevention phone number posted on it to serve as a reminder.

Preventing suicide seems difficult, but with this approach, I think we can make important headway. We can take the most available, accessible and common method of suicide in our profession and lock it up — so that no one can get to it alone in a matter of moments.

We’re talking about our friends, colleagues and employees. If we can save even 1% of those we are currently losing to suicide, isn’t it worth it?

(For more information on the Senseon Dual Authentication Lock system, contact Lisa Summers, Sr. Business Development Manager, Senseon by Accuride International.

(Dr. Andy Roark has no financial or business relationships with any companies mentioned in this article. He does not endorse any products here, and encourages everyone to do their due diligence and find a solution that will work best in their own practices. Practices should confirm DEA-compliance in any system they choose to use).

1. https://avmajournals.avma.org/doi/full/10.2460/javma.254.1.104?rel=0&
2. https://avmajournals.avma.org/doi/10.2460/javma.247.8.945
3. https://www.avma.org/ProfessionalDevelopment/PeerAndWellness/Pages/Wellness-Gatekeeper-Training-for-Veterinarians.aspx
4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4965648/
5. Suicide prevention by limiting access to methods: A review of theory and practice – Julia Buus Florentine, Catherine Crane – Social Science & Medicine 70 (2010) 1626–1632
6. https://www.avma.org/News/JAVMANews/Pages/180615c.aspx
7. https://www.hsph.harvard.edu/means-matter/means-matter/survival/