September 2026

Suicide presents a major public health challenge in the U.S. Although the suicide rate slightly declined between 2022 and 2024, it remains the tenth leading cause of death in the nation. 

Racism, historical trauma, and long-lasting inequities such as disproportionate exposure to poverty have contributed to higher suicide rates among non-Hispanic American Indian/Alaskan Native (AI/AN) youth and other groups who have been marginalized.

Many individual risk factors contribute to this, such as:

• history of depression and other mental illnesses,
• chronic pain,
• criminal/legal problems,
• job/financial problems or loss,
• substance misuse,
• history of adverse childhood experiences,
• violence victimization and/or perpetration

The best way to help your patients is to assess for Depression/Suicidal Ideation by utilizing validated screening tools. We’re here to help!

Please visit: Behavioral Health in Primary Care | Independent Health for additional resources and to view the Behavioral Health Toolkit.

For access to BH Policies, view the Document Manager in the secure portal.

 Check out the CDC's resources: Suicide Prevention | Suicide Prevention | CDC

For those experiencing a suicidal crisis, call the National Suicide Prevention Lifeline at 988.

This article is the first in a four-part SCOPE series on pain management. Future installments will discuss setting meaningful goals in chronic pain management, recognizing progress beyond pain scores, and understanding the role of opioids in chronic pain treatment. Together, these articles aim to support a patient-centered approach that balances safety, function, quality of life, and appropriate medication use.

Pain is one of the most common reasons patients seek medical care. While opioids remain an important treatment option for selected patients, certain populations are more vulnerable to opioid-related adverse events and require additional clinical consideration.

Pregnant individuals, older adults, patients with sleep-disordered breathing or chronic respiratory disease, those receiving multiple central nervous system (CNS) depressant medications, and patients with renal or hepatic impairment represent populations in whom careful risk-benefit assessment is especially important. Identifying risk factors before initiating opioid therapy can help clinicians improve safety while maintaining access to appropriate pain management.

Pregnancy: Treat Pain, Prescribe Thoughtfully

Opioid use during pregnancy can have significant effects on the developing fetus. Because opioids  cross the placenta, fetal exposure may lead to physiologic dependence before birth. Prenatal opioid exposure has been associated with adverse outcomes including preterm birth, fetal growth restriction, low birth weight, and stillbirth in some populations.

After delivery, infants exposed to opioids in utero may develop neonatal opioid withdrawal syndrome (NOWS).

These maternal and neonatal risks underscore the importance of careful risk-benefit assessment and close monitoring whenever patients are already on an opioid, as well as when prescribed during pregnancy. When opioids are necessary, clinicians should prescribe the lowest effective dose for the shortest clinically appropriate duration. For chronic pain, nonpharmacologic therapies and non-opioid options should be prioritized whenever possible.

Methadone and buprenorphine remain first-line treatments for OUD during pregnancy. Abrupt opioid discontinuation is generally discouraged because it may increase the risk of fetal distress, miscarriage, preterm labor, relapse, and other adverse outcomes.

Older Adults: A Population at Heightened Risk

Older adults experience physiologic changes that increase sensitivity to opioids and other CNS-active medications. Polypharmacy, frailty, cognitive impairment, and chronic medical conditions further increase the likelihood of adverse outcomes. At the same time, many older adults have hepatic, renal, or cardiovascular disease that limits the use of common non-opioid analgesics, making pain management particularly complex.

Potential opioid-related complications include, but not limited to:

• Excessive sedation
• Cognitive impairment
• Delirium
• Falls
• Fractures
• Constipation
• Urinary retention
• Respiratory depression

Pain management in older adults is often further complicated by comorbid medical conditions that restrict non-opioid treatment options. Acetaminophen may need to be avoided or dose-restricted in patients with significant liver disease, while nonsteroidal anti-inflammatory drugs (NSAIDs) may be inappropriate in patients with heart failure, chronic kidney disease, uncontrolled hypertension, or other cardiovascular conditions. As a result, clinicians are frequently faced with managing pain in patients who are simultaneously at increased risk from opioids and have fewer safe alternatives available. This underscores the importance of individualized treatment plans, careful medication selection, and realistic discussions regarding the benefits and limitations of available therapies.

Practical strategies may include:

• Start with lower opioid doses.
• Titrate slowly.
• Reassess frequently.
• Monitor cognition and fall risk.
• Proactively address constipation.
• Regularly review the complete medication regimen.

Sleep-Disordered Breathing and Chronic Respiratory Disease

Patients with obstructive sleep apnea, chronic obstructive pulmonary disease (COPD), obesity hypoventilation syndrome, and other chronic respiratory conditions may be particularly vulnerable to opioid-induced respiratory depression. Opioids can reduce respiratory drive and impair protective airway reflexes, increasing the risk of hypoventilation, hypoxemia, hospitalization, and overdose in patients with underlying respiratory compromise.

Before initiating long-term opioid therapy, clinicians should consider:

• History of obstructive sleep apnea
• COPD or other chronic lung disease
• Excessive daytime sleepiness
• Obesity
• Witnessed apneas
• Supplemental oxygen use
• CPAP adherence when applicable

When possible, opioids should be avoided or minimized in patients with moderate-to-severe sleep-disordered breathing or significant respiratory disease. If opioid therapy is necessary, enhanced monitoring should be considered.

CNS Depressant Polypharmacy: Looking Beyond Benzodiazepines

While opioid-benzodiazepine combinations are well recognized, many patients accumulate CNS depressant effects from multiple medications prescribed by different clinicians.

Potential contributors include:

• Benzodiazepines
• Gabapentinoids
• Skeletal muscle relaxants
• Z-drugs (e.g., zolpidem, eszopiclone, zaleplon)
• Sedating antidepressants
• Sedating antipsychotics
• First-generation antihistamines
• Alcohol

The danger often stems from cumulative sedative burden rather than any single medication in isolation. Additive effects may increase risks of sedation, respiratory depression, impaired driving, falls, overdose, and death.

Anticholinergic Burden: The Overlooked Amplifier

Opioid safety discussions frequently focus on CNS depression while overlooking anticholinergic burden. Medications with anticholinergic properties can amplify many of the same adverse outcomes associated with opioids.

This concern is particularly important in older adults and patients receiving multiple centrally acting medications. When evaluating opioid safety, clinicians should consider both cumulative sedative burden and cumulative anticholinergic burden.

Renal and Hepatic Impairment

Patients with impaired kidney or liver function may experience increased opioid exposure, delayed clearance, and accumulation of active metabolites. The CDC recommends additional caution and monitoring in these populations.

Clinical considerations may include:

• Evaluating renal and hepatic function before initiating long-term therapy
• Using lower starting doses when appropriate
• Monitoring closely during dose adjustments
• Watching for signs of excessive sedation or toxicity
• Reviewing medications that may further affect opioid metabolism or clearance

Naloxone: A Critical Safety Tool

New York State law requires most prescribers to provide an opioid antagonist prescription, typically naloxone, with a patient's first opioid prescription each year when specific risk factors are present, including a history of substance use disorder, opioid dosages of 90 morphine milligram equivalents (MME) per day or greater, or concurrent use of opioids with benzodiazepines or non-benzodiazepine sedative-hypnotics.

Beyond regulatory compliance, prescribing naloxone makes good clinical sense for many of the high-risk populations discussed in this article. However, simply prescribing naloxone is not enough. Patients should be encouraged to ensure that family members, caregivers, and other supporters know where naloxone is stored, how to recognize the signs of an opioid overdose, and how to administer naloxone in an emergency. A naloxone kit sitting unused in a medicine cabinet provides little benefit if the people most likely to witness an overdose have not been trained to recognize when and how to use it.

Bottom Line

Opioid prescribing requires particular caution in populations at increased risk for medication-related harm. For these patients, safe and effective pain management depends on thoughtful risk-benefit assessment, careful medication selection, ongoing monitoring, and patient-centered decision-making. Clinicians should also view naloxone as a routine safety intervention for many high-risk patients and ensure that family members and caregivers are prepared to recognize and respond to an opioid overdose. By understanding these unique risk factors and proactively addressing them, healthcare providers can improve pain management while reducing the likelihood of preventable harm.

Looking Ahead: Part 2

Next month, Setting Meaningful Goals in Chronic Pain Management, will explore how clinicians and patients can shift the focus from pain elimination to meaningful outcomes such as mobility, independence, participation in valued activities, and quality of life.

Independent Health regularly evaluates medical services to understand utilization patterns in order to promote clinically appropriate, evidence-based care, and mitigate variability in quality and usage. 

Independent Health develops outreach campaigns to members in need of certain preventive services and to help make them aware of our programs and resources to help them maintain or improve their health. Here is a summary of the current outreach campaigns underway. 

Independent Health is required by state and federal agencies to ensure our participating providers complete this annual compliance training. 

Independent Health is required to conduct medical record chart quality reviews to meet New York State (NYS) regulatory requirements and standards for coding accuracy. The purpose of these review is to support supplemental data submission to NYS’s All Payer Data to help ensure members are assigned the correct clinical risk score by New York State. The scope of this review is for Independent Health’s Essential Plan, Child Health Plus, MediSource, and MediSource Connect benefit plans. 

Remember to view our up-to-date policies online. 

Drug Formulary Changes

View the formulary changes for the Third Quarter of 2026.

View the formulary deletions, effective September 1, 2026:

• Medicare Advantage formulary deletions for the Individual Standard formulary
• Medicare Advantage formulary deletions for the Individual Enhanced & Group formularies
• Pharmacy Benefit Dimensions 3-Tier formulary deletions
• Pharmacy Benefit Dimensions 5-Tier formulary deletions

Access Independent Health's drug formularies here.

Drug Policy Changes

The policy changes for the Third Quarter of 2026 are now available online. Log in to the provider portal to view the changes. Click on ‘Monthly Policy Updates’ under the News tab once you are logged in.

Search for and view the most current versions of all Independent Health’s drug policies when logged in to our provider portal.

Prime Therapeutics reviews prior authorizations for select oncology and specialty drugs on Independent Health’s behalf. Log in to view Prime Therapeutics policies for the drugs it reviews.

To obtain a hard copy, please contact Independent Health Provider Relations by calling (716) 631-3282 or 1-800-736-5771, Monday through Friday from 8 a.m. to 5 p.m.