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Black E, Monds LA, Chan B, Brett J, Hutton JE, Acheson L, Penm J, Harding S, Strumpman D, Demirkol A, Lintzeris N. Overdose and take-home naloxone in emergency settings: A pilot study examining feasibility of delivering brief interventions addressing overdose prevention with 'take-home naloxone' in emergency departments. Emerg Med Australas 2022; 34:509-518. [PMID: 35021268 DOI: 10.1111/1742-6723.13925] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 11/16/2021] [Accepted: 12/02/2021] [Indexed: 01/26/2023]
Abstract
OBJECTIVE Although most unintentional opioid deaths in Australia are attributed to pharmaceutical opioids, take-home naloxone (THN) programmes have to date predominantly targeted people using illicit opioids in drug treatment and harm reduction settings. We sought to examine the feasibility of delivering THN brief interventions (THN-BIs) with intranasal naloxone in EDs. METHODS This pilot feasibility study was conducted across three major metropolitan EDs in Sydney and Melbourne. ED staff were surveyed about their perspectives regarding THN before completing a 30-min training programme in THN-BI delivery. Patients presenting with opioid overdose or considered high risk for future overdose were eligible to receive the THN-BI. Staff survey responses were compared between hospitals and provider types using one-way analysis of variances. Patient demographic and clinical characteristics were extracted from medical records and compared between hospitals and overdose type using Fisher's exact test and one-way analysis of variances. RESULTS One hundred and twenty-two ED staff completed the survey. One hundred and ten (90.2%) agreed that EDs should provide THN-BIs, whereas 23 (19.2%) identified time constraints and 17 (12.9%) felt uncomfortable discussing overdose with patients. Fifty-seven patients received the THN-BI, with the majority (n = 50, 87.7%) having presented following opioid overdose. The median age was 44 years and 40 (71.4%) were men. Two-thirds of the overdoses (n = 31, 66.0%) were attributed to heroin with one-third (n = 16, 34%) being attributed to pharmaceutical opioids. CONCLUSIONS ED-based delivery of THN-BIs can reach a wide range of individuals at-risk of overdose. The present study supports the feasibility of THN interventions in EDs and underscores the importance of addressing implementation barriers including staff training.
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Affiliation(s)
- Eleanor Black
- Drug and Alcohol Services, South Eastern Sydney Local Health District, Sydney, New South Wales, Australia.,School of Population Health, The University of New South Wales, Sydney, New South Wales, Australia.,New South Wales Drug and Alcohol Clinical Research and Improvement Network (DACRIN), Sydney, New South Wales, Australia
| | - Lauren A Monds
- Drug and Alcohol Services, South Eastern Sydney Local Health District, Sydney, New South Wales, Australia.,New South Wales Drug and Alcohol Clinical Research and Improvement Network (DACRIN), Sydney, New South Wales, Australia.,Faculty of Medicine and Health, Specialty of Addiction Medicine, The University of Sydney, Sydney, New South Wales, Australia
| | - Betty Chan
- Emergency Department, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Jonathan Brett
- New South Wales Drug and Alcohol Clinical Research and Improvement Network (DACRIN), Sydney, New South Wales, Australia.,Alcohol and Drug Service, St Vincent's Hospital Sydney, Sydney, New South Wales, Australia
| | - Jennie E Hutton
- Emergency Department, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Liam Acheson
- Alcohol and Drug Service, St Vincent's Hospital Sydney, Sydney, New South Wales, Australia.,National Drug and Alcohol Research Centre, The University of New South Wales, Sydney, New South Wales, Australia
| | - Jonathan Penm
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, New South Wales, Australia.,Pharmacy Department, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Sally Harding
- Emergency Department, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Dana Strumpman
- Pharmacy Department, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Apo Demirkol
- Drug and Alcohol Services, South Eastern Sydney Local Health District, Sydney, New South Wales, Australia.,School of Population Health, The University of New South Wales, Sydney, New South Wales, Australia.,New South Wales Drug and Alcohol Clinical Research and Improvement Network (DACRIN), Sydney, New South Wales, Australia
| | - Nicholas Lintzeris
- Drug and Alcohol Services, South Eastern Sydney Local Health District, Sydney, New South Wales, Australia.,New South Wales Drug and Alcohol Clinical Research and Improvement Network (DACRIN), Sydney, New South Wales, Australia.,Faculty of Medicine and Health, Specialty of Addiction Medicine, The University of Sydney, Sydney, New South Wales, Australia
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2
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Armoon B, Mohammadi R, Fattah Moghaddam L, Gonabadi-Nezhad L. Type of drug use and risky determinants associated with fatal overdose among people who use drugs: a meta-analysis. JOURNAL OF SUBSTANCE USE 2021. [DOI: 10.1080/14659891.2021.2019329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Bahram Armoon
- Douglas Hospital Research Centre, Douglas Mental Health University Institute, Montreal, QC, Canada
- Department of Psychiatry, McGill University, Montreal, QC, Canada
| | - Rasool Mohammadi
- Department of Biostatistics and Epidemiology, School of Public Health and Nutrition, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Ladan Fattah Moghaddam
- Department of Nursing, Faculty of Nursing and Midwifery, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
| | - Leila Gonabadi-Nezhad
- Department of Psychiatry, Faculty of Medicine, Aja University of Medical Sciences, Tehran, Iran
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3
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CAEP Position Statement: Emergency department management of people with opioid use disorder. CAN J EMERG MED 2021; 22:768-771. [PMID: 33028446 DOI: 10.1017/cem.2020.459] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Deaths due to opioid overdose have reached unprecedented levels in Canada; over 12,800 opioid-related deaths occurred between January 2016 and March 2019, and overdose death rates increased by approximately 50% from 2016 to 2018.1 In 2016, Health Canada declared the opioid epidemic a national public health crisis,2 and life expectancy increases have halted in Canada for the first time in decades.3 Children are not exempt from this crisis, and the Chief Public Health Officer of Canada has recently prioritized the prevention of problematic substance use among Canadian youth.4.
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Hawk K, Grau LE, Fiellin DA, Chawarski M, O’Connor PG, Cirillo N, Breen C, D’Onofrio G. A qualitative study of emergency department patients who survived an opioid overdose: Perspectives on treatment and unmet needs. Acad Emerg Med 2021; 28:542-552. [PMID: 33346926 DOI: 10.1111/acem.14197] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 12/05/2020] [Accepted: 12/17/2020] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Emergency medicine clinicians are uniquely positioned to deliver interventions to enhance linkage to evidence-based treatment for opioid use disorder (OUD) in the acute overdose period, yet little is known about patient perspectives to effectively engage patients immediately following opioid overdose. Our objective was to explore patients' perspectives on substance use treatment, perceived needs, and contextual factors that shape the choice of patients seen in the emergency department (ED) to engage with treatment and other patient support services in the acute post-opioid overdose period. METHODS We administered a brief quantitative survey and conducted semistructured interviews with 24 adult ED patients receiving care after an acute opioid overdose between June 2016 and August 2017 in an urban, academic ED. We used constant comparison method and thematic analysis to identify themes across four levels of a modified social ecologic model (individual, interpersonal, organizational, and structural). RESULTS The mean (±SD) age of the sample was 33.5 (±9.33) years; 83% were White and 12% were Black; 67% were male; and 83% were diagnosed with OUD, with a mean (±SD) of 3.25 (±2.64) self-reported lifetime opioid overdoses. Eight themes were identified as influencing participants' consideration of OUD treatment and other services: (1) perceptions about control of drug use, (2) personal experience with substance use treatment, (3) role of interpersonal relationships, (4) provider communication skills, (5) stigma, (6) availability of ED resources, (7) impact of treatment policies, and (8) support for unmet basic needs. CONCLUSIONS Patients receiving ED care following overdose in our ED are willing to discuss their opioid use and its treatment in the ED and report a variety of unmet needs. This work supports a role for ED-based research evaluating a patient-oriented approach to engage patients after opioid overdose.
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Affiliation(s)
- Kathryn Hawk
- Department of Emergency Medicine Yale University New Haven Connecticut USA
| | - Lauretta E. Grau
- School of Public Health Yale University New Haven Connecticut USA
| | - David A. Fiellin
- Department of Emergency Medicine Yale University New Haven Connecticut USA
- Department of Internal Medicine Yale University New Haven Connecticut USA
| | - Marek Chawarski
- Department of Psychiatry Yale University New Haven Connecticut USA
| | | | - Nikolas Cirillo
- Department of Emergency Medicine Yale University New Haven Connecticut USA
- Department of Psychology Nova Southeastern University Fort Lauderdale Florida USA
| | - Chris Breen
- Department of Emergency Medicine Yale University New Haven Connecticut USA
- School of Medicine Yale University New Haven Connecticut USA
| | - Gail D’Onofrio
- Department of Emergency Medicine Yale University New Haven Connecticut USA
- School of Public Health Yale University New Haven Connecticut USA
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5
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Bongiovanni T, Hernandez S, Ledesma Y, Menza R, Wick E, Steinman M, Mackersie R, Stein DM, Coffin PO. Surviving traumatic injury, only to die of acute drug poisoning: Should trauma centers be a path for intervention? Surgery 2021; 170:1249-1254. [PMID: 33867166 DOI: 10.1016/j.surg.2021.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 02/21/2021] [Accepted: 03/01/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Although death from drug overdose is a leading cause of injury-related death in the United States, its incidence after traumatic incident is unknown. Moreover, little is known about related risk factors. We sought to determine the incidence and characteristics of and risk factors for trauma patients suffering death by acute drug poisoning ("overdose") after hospitalization for a traumatic incident. METHODS We conducted a retrospective chart review of all admitted trauma patients ≥18 y of age at the only level-1 trauma center in our region from 2012 to 2019, matched with unintentional overdose decedents from the California death registry. We assessed associations between demographic and clinical characteristics with risk of overdose death, using cumulative incidence functions and Fine-Gray subdistribution hazard models. RESULTS Of 9,860 patients residing in San Francisco, CA, USA, at the time of their trauma activation or admission during the study period, 1,418 died (4.3 per 100 person-years), 107 from unintentional overdose (0.3 per 100 person-years). Overdose decedents were 84% male, 50% white, with a mean age of 48 years at the time of presentation; 20% of deaths occurred within 3 months of hospitalization, and 40% were attributed to a prescription opioid. In multivariate analysis, younger age, male sex, white race, and having undergone a urine drug screening were all associated with subsequent death from overdose. CONCLUSION During a mean 3.4-year follow-up, the mortality rate from overdose among adult patients with traumatic incidents was 0.3/100 person-years. Trauma hospitalization may serve as an opportunity to screen and initiate prevention, harm reduction, and treatment interventions.
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Affiliation(s)
- Tasce Bongiovanni
- University of California San Francisco School of Medicine, Department of Surgery, San Francisco, CA; San Francisco General Hospital, Trauma and Acute Care Surgery, San Francisco, CA.
| | - Sophia Hernandez
- University of California San Francisco School of Medicine, San Francisco, CA. https://twitter.com/SEHernandezz
| | - Yeranui Ledesma
- University of California San Francisco School of Medicine, Department of Surgery, San Francisco, CA
| | - Rebecca Menza
- San Francisco General Hospital, Trauma and Acute Care Surgery, San Francisco, CA. https://twitter.com/MenzaNP
| | - Elizabeth Wick
- University of California San Francisco School of Medicine, Department of Surgery, San Francisco, CA
| | - Michael Steinman
- University of California San Francisco School of Medicine, San Francisco, CA; San Francisco VA Medical Center, Division of Geriatrics, San Francisco, CA. https://twitter.com/MikeSteinman
| | - Robert Mackersie
- University of California San Francisco School of Medicine, Department of Surgery, San Francisco, CA; San Francisco General Hospital, Trauma and Acute Care Surgery, San Francisco, CA
| | - Deborah M Stein
- University of California San Francisco School of Medicine, Department of Surgery, San Francisco, CA; San Francisco General Hospital, Trauma and Acute Care Surgery, San Francisco, CA
| | - Phillip O Coffin
- University of California San Francisco School of Medicine, San Francisco, CA; San Francisco Department of Public Health, San Francisco, CA
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Naloxone provision to emergency department patients recognized as high-risk for opioid use disorder. Am J Emerg Med 2020; 40:173-176. [PMID: 33243535 DOI: 10.1016/j.ajem.2020.10.061] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 10/19/2020] [Accepted: 10/29/2020] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Patients with opioid use disorder (OUD) are at increased risk for overdose and death. Clinical practice guidelines and professional organization policy statements recommend providing naloxone to patients at risk for overdose. We sought to characterize fidelity to naloxone practice recommendations in a cohort of Emergency Department (ED) patients in whom opioid use disorder was suspected by the treating physician. METHODS This single-center cross-sectional study evaluated electronic health records from an urban academic ED with 73,000 annual encounters in a region with a high prevalence of OUD. Patients ≥18 years old with encounters from January 1, 2018 to November 30, 2019 were included if discharged from the ED and either administered buprenorphine in the ED or referred to outpatient substance use treatment. The primary outcome measure was the percentage of included patients provided naloxone (take-home or prescription). We used random effects multivariable logistic regression (accounting for multiple patient encounters) to estimate the odds ratio (OR) for receiving naloxone. RESULTS Of 1036 eligible patient encounters, 320 resulted in naloxone provision (30.9%, 95% CI: 28.1-33.8). Naloxone provision occurred for 33.6% (95% CI 30.5-36.7) of 900 patients referred to outpatient substance use treatment without ED buprenorphine administration, 10.6% (95% CI 5.0-19.2) of 85 patients administered buprenorphine and not referred to outpatient substance use treatment, and 17.6% (95% CI 8.4-30.9) of 51 patients administered buprenorphine and referred to outpatient treatment. After controlling for age, sex, race, and prior provision of naloxone, the administration of buprenorphine was associated with a 94% lower odds (aOR = 0.06 [95% CI 0.011-0.33]) for naloxone provision compared to those only referred to outpatient treatment. CONCLUSION A majority of ED patients who received an intervention targeted at OUD, in an ED where take-home naloxone is freely available, did not receive either take-home naloxone or a prescription for naloxone at discharge. Patients receiving buprenorphine were less likely to receive naloxone than patients only referred to outpatient treatment. These data suggest barriers other than recognition of potential OUD and naloxone availability impact provision of naloxone and argue for a treatment "bundle" as a conceptual model for care of ED patients with suspected OUD.
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7
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Skoy E, Werremeyer A, Steig J, Eukel H, Frenzel O, Strand M. Patient acceptance of naloxone resulting from targeted intervention from community pharmacists to prevent opioid misuse and accidental overdose. Subst Abus 2020; 42:672-677. [PMID: 33044896 DOI: 10.1080/08897077.2020.1827126] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background: Community pharmacists are in a unique position to prevent opioid-related deaths through the provision of naloxone. However, for those identified as candidates for take-home naloxone, the acceptance rate remains low. Value would be gained from knowing what patient demographics and pharmacist actions are associated with increased patient acceptance of naloxone. Methods: Through a state-wide program, community pharmacists screened all patients receiving an opioid prescription for risk of opioid misuse and/or accidental overdose. Pharmacists prescribed and/or dispensed take-home naloxone to patients at elevated risk. Naloxone acceptance rates were stratified based on risk factors for misuse and overdose to determine which patients are most likely to accept naloxone. Patient acceptance of naloxone and risks were captured electronically. Results: Pharmacist-initiated naloxone recommendations based on risk screening resulted in a 5.81% take-home naloxone acceptance rate. Individuals that were taking multiple opioid medications were most likely to accept the naloxone (20.45%). Concurrent disease states or medications (COPD, concurrent anxiety/depression medication, concurrent sleep aid) were associated with a statistically significant increase in the rate of naloxone acceptance. Acceptance of take-home naloxone increased as a patient risk for opioid misuse and/or accidental overdose increased. Conclusion: Patient acceptance of naloxone at the community pharmacy level was notably higher compared to national naloxone dispensing rates when pharmacists implemented a patient screening and systematic risk-based approach to identify candidates in need of take-home naloxone.
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Affiliation(s)
- Elizabeth Skoy
- Pharmacy Practice Department, North Dakota State University, Fargo, North Dakota, USA
| | - Amy Werremeyer
- Pharmacy Practice Department, North Dakota State University, Fargo, North Dakota, USA
| | - Jayme Steig
- Quality Health Associates of North Dakota, Minot, North Dakota, USA
| | - Heidi Eukel
- Pharmacy Practice Department, North Dakota State University, Fargo, North Dakota, USA
| | - Oliver Frenzel
- Pharmacy Practice Department, North Dakota State University, Fargo, North Dakota, USA
| | - Mark Strand
- Pharmacy Practice Department, North Dakota State University, Fargo, North Dakota, USA
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8
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Beauchamp GA, Grim SM, Minnich ED, Cannon RD, Land SD. Missed Opportunities Preceding Overdose Death. Am J Forensic Med Pathol 2020; 41:342-343. [DOI: 10.1097/paf.0000000000000624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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9
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Mortality Following Nonfatal Opioid and Sedative/Hypnotic Drug Overdose. Am J Prev Med 2020; 59:59-67. [PMID: 32389530 PMCID: PMC7311279 DOI: 10.1016/j.amepre.2020.02.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 02/19/2020] [Accepted: 02/20/2020] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Opioid and sedative/hypnotic drug overdoses are major causes of morbidity in the U.S. This study compares 12-month incidence of fatal unintentional drug overdose, suicide, and other mortality among emergency department patients presenting with nonfatal opioid or sedative/hypnotic overdose. METHODS This is a retrospective cohort study using statewide, longitudinally linked emergency department patient record and mortality data from California. Participants comprised all residents presenting to a licensed emergency department at least once in 2009-2011 with nonfatal unintentional opioid overdose, sedative/hypnotic overdose, or neither (a 5% random sample). Participants were followed for 1 year after index emergency department presentation to assess death from unintentional overdose, suicide, or other causes, ascertained using ICD-10 codes. Absolute death rates per 100,000 person years and standardized mortality ratios relative to the general population were calculated. Data were analyzed February-August 2019. RESULTS Following the index emergency department visit, unintentional overdose death rates per 100,000 person years were 1,863 following opioid overdose, 342 following sedative/hypnotic overdose, and 31 for reference patients without an index overdose (respective standardized mortality ratios of 106.1, 95% CI=95.2, 116.9; 24.5, 95% CI=21.3, 27.6; and 2.6, 95% CI=2.2, 3.0). Suicide mortality rates per 100,000 were 319, 174, and 32 following opioid overdose, sedative/hypnotic overdose, and reference visits, respectively. Natural causes mortality rates per 100,000 were 8,058 (opioid overdose patients), 17,301 (sedative/hypnotic overdose patients), and 3,097 (reference patients). CONCLUSIONS Emergency department patients with nonfatal opioid or sedative/hypnotic drug overdose have exceptionally high risks of death from unintentional overdose, suicide, and other causes. Emergency department-based interventions offer potential for reducing these patients' overdose and other mortality risks.
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10
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Krawczyk N, Eisenberg M, Schneider KE, Richards TM, Lyons BC, Jackson K, Ferris L, Weiner JP, Saloner B. Predictors of Overdose Death Among High-Risk Emergency Department Patients With Substance-Related Encounters: A Data Linkage Cohort Study. Ann Emerg Med 2020; 75:1-12. [PMID: 31515181 PMCID: PMC6928412 DOI: 10.1016/j.annemergmed.2019.07.014] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 05/22/2019] [Accepted: 07/05/2019] [Indexed: 10/26/2022]
Abstract
STUDY OBJECTIVE Persons with substance use disorders frequently utilize emergency department (ED) services, creating an opportunity for intervention and referral to addiction treatment and harm-reduction services. However, EDs may not have the appropriate tools to distinguish which patients are at greatest risk for negative outcomes. We link hospital ED and medical examiner mortality databases in one state to identify individual-level risk factors associated with overdose death among ED patients with substance-related encounters. METHODS This retrospective cohort study linked Maryland statewide ED hospital claims records for adults with nonfatal overdose or substance use disorder encounters in 2014 to 2015 with medical examiner mortality records in 2015 to 2016. Logistic regression was used to identify factors in hospital records associated with risk of opioid overdose death. Predicted probabilities for overdose death were calculated for hypothetical patients with different combinations of overdose and substance use diagnostic histories. RESULTS A total of 139,252 patients had substance-related ED encounters in 2014 to 2015. Of these patients, 963 later experienced an opioid overdose death, indicating a case fatality rate of 69.2 per 10,000 patients, 6 times higher than that of patients who used the ED for any cause. Factors most strongly associated with death included having both an opioid and another substance use disorder (adjusted odds ratio 2.88; 95% confidence interval 2.04 to 4.07), having greater than or equal to 3 previous nonfatal overdoses (adjusted odds ratio 2.89; 95% confidence interval 1.54 to 5.43), and having a previous nonfatal overdose involving heroin (adjusted odds ratio 2.24; 95% confidence interval 1.64 to 3.05). CONCLUSION These results highlight important differences in overdose risk among patients receiving care in EDs for substance-related conditions. The findings demonstrate the potential utility of incorporating routine data from patient records to assess risk of future negative outcomes and identify primary targets for initiation and linkage to lifesaving care.
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Affiliation(s)
- Noa Krawczyk
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
| | - Matthew Eisenberg
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Kristin E Schneider
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Tom M Richards
- Johns Hopkins Center for Population and Health and Information Technology, Baltimore, MD
| | - B Casey Lyons
- Behavioral Health Administration, Maryland Department of Health, Columbia, MD
| | - Kate Jackson
- Behavioral Health Administration, Maryland Department of Health, Columbia, MD
| | - Lindsey Ferris
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Chesapeake Regional Information System for Our Patients, Columbia, MD
| | - Jonathan P Weiner
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Johns Hopkins Center for Population and Health and Information Technology, Baltimore, MD
| | - Brendan Saloner
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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Goedel WC, Marshall BDL, Samuels EA, Brinkman MG, Dettor D, Langdon KJ, Mahoney LA, Merchant RC, Nizami T, O'Toole GA, Ramsey SE, Yedinak JL, Beaudoin FL. Randomised clinical trial of an emergency department-based peer recovery support intervention to increase treatment uptake and reduce recurrent overdose among individuals at high risk for opioid overdose: study protocol for the navigator trial. BMJ Open 2019; 9:e032052. [PMID: 31719087 PMCID: PMC6858243 DOI: 10.1136/bmjopen-2019-032052] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 10/15/2019] [Accepted: 10/16/2019] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Effective approaches to increase engagement in treatment for opioid use disorder (OUD) and reduce the risk of recurrent overdose and death following emergency department (ED) presentation for opioid overdose remain unknown. As such, we aim to compare the effectiveness of behavioural interventions delivered in the ED by certified peer recovery support specialists relative to those delivered by licensed clinical social workers (LCSWs) in promoting OUD treatment uptake and reducing recurrent ED visits for opioid overdose. METHODS AND ANALYSIS Adult ED patients who are at high risk for opioid overdose (ie, are being treated for an opioid overdose or identified by the treating physician as having OUD) (n=650) will be recruited from two EDs in a single healthcare system in Providence, Rhode Island into a two-arm randomised trial with 18 months of follow-up postrandomisation. Eligible participants will be randomly assigned (1:1) in the ED to receive a behavioural intervention from a certified peer recovery support specialist or a behavioural intervention from an LCSW. The primary outcomes are engagement in formal OUD treatment within 30 days of the initial ED visit and recurrent ED visits for opioid overdose within 18 months of the initial ED visit, as measured through statewide administrative records. ETHICS AND DISSEMINATION This protocol was approved by the Rhode Island Hospital institutional review board (Approval Number: 212418). Data will be presented at national and international conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT03684681.
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Affiliation(s)
- William C Goedel
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Brandon D L Marshall
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Elizabeth A Samuels
- Department of Emergency Medicine, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
| | - Mark G Brinkman
- Department of Emergency Medicine, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Debra Dettor
- Anchor Recovery Community Center, Pawtucket, Rhode Island, USA
| | - Kirsten J Langdon
- Department of Psychiatry and Human Behavior, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
| | - Linda A Mahoney
- Rhode Island Department of Behavioral Healthcare Developmental Disabilities and Hospitals, Cranston, Rhode Island, USA
| | - Roland C Merchant
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
- Department of Emergency Medicine, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
| | - Tarek Nizami
- Department of Emergency Medicine, Rhode Island Hospital, Providence, Rhode Island, USA
| | | | - Susan E Ramsey
- Department of Psychiatry and Human Behavior, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
- Department of Medicine, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
| | - Jesse L Yedinak
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Francesca L Beaudoin
- Department of Emergency Medicine, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
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12
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Larochelle MR, Bernstein R, Bernson D, Land T, Stopka TJ, Rose AJ, Bharel M, Liebschutz JM, Walley AY. Touchpoints - Opportunities to predict and prevent opioid overdose: A cohort study. Drug Alcohol Depend 2019; 204:107537. [PMID: 31521956 PMCID: PMC7020606 DOI: 10.1016/j.drugalcdep.2019.06.039] [Citation(s) in RCA: 105] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 06/21/2019] [Accepted: 06/27/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Medical care, public health, and criminal justice systems encounters could serve as touchpoints to identify and intervene with individuals at high-risk of opioid overdose death. The relative risk of opioid overdose death and proportion of deaths that could be averted at such touchpoints are unknown. METHODS We used 8 individually linked data sets from Massachusetts government agencies to perform a retrospective cohort study of Massachusetts residents ages 11 and older. For each month in 2014, we identified past 12-month exposure to 4 opioid prescription touchpoints (high dosage, benzodiazepine co-prescribing, multiple prescribers, or multiple pharmacies) and 4 critical encounter touchpoints (opioid detoxification, nonfatal opioid overdose, injection-related infection, and release from incarceration). The outcome was opioid overdose death. We calculated Standardized Mortality Ratios (SMRs) and Population Attributable Fractions (PAFs) associated with touchpoint exposure. RESULTS The cohort consisted of 6,717,390 person-years of follow-up with 1315 opioid overdose deaths. We identified past 12-month exposure to any touchpoint in 2.7% of person-months and for 51.8% of opioid overdose deaths. Opioid overdose SMRs were 12.6 (95% CI: 11.1, 14.1) for opioid prescription and 68.4 (95% CI: 62.4, 74.5) for critical encounter touchpoints. Fatal opioid overdose PAFs were 0.19 (95% CI: 0.17, 0.21) for opioid prescription and 0.37 (95% CI: 0.34, 0.39) for critical encounter touchpoints. CONCLUSIONS Using public health data, we found eight candidate touchpoints were associated with increased risk of fatal opioid overdose, and collectively identified more than half of opioid overdose decedents. These touchpoints are potential targets for development of overdose prevention interventions.
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Affiliation(s)
- Marc R. Larochelle
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, 801 Massachusetts Avenue, 2nd Floor, Boston, MA 02218, USA,Corresponding author at: Boston Medical Center, 801 Massachusetts Avenue, 2nd Floor, Boston, MA 02118, USA. (M.R. Larochelle)
| | - Ryan Bernstein
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, 801 Massachusetts Avenue, 2nd Floor, Boston, MA 02218, USA
| | - Dana Bernson
- Massachusetts Department of Public Health, 250 Washington Street, Boston, MA 02108, USA
| | - Thomas Land
- Department of Medicine, University of Massachusetts Medical School, 55 North Lake Avenue, Worcester, MA 01655, USA
| | - Thomas J. Stopka
- Department of Public Health and Community Medicine, Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA 02111, USA
| | - Adam J. Rose
- RAND Corporation, 20 Park Plaza #920, Boston, MA 02116, USA
| | - Monica Bharel
- Massachusetts Department of Public Health, 250 Washington Street, Boston, MA 02108, USA
| | - Jane M. Liebschutz
- Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh School of Medicine, 200 Lothrop Street, Suite 933 West MUH, Pittsburgh, PA 15213, USA
| | - Alexander Y. Walley
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, 801 Massachusetts Avenue, 2nd Floor, Boston, MA 02218, USA,Massachusetts Department of Public Health, 250 Washington Street, Boston, MA 02108, USA
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13
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Laniado N, Brow AR, Tranby E, Badner VM. Trends in non‐traumatic dental emergency department use in New York and New Jersey: a look at Medicaid expansion from both sides of the Hudson River. J Public Health Dent 2019; 80:9-13. [DOI: 10.1111/jphd.12343] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Revised: 07/27/2019] [Accepted: 08/18/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Nadia Laniado
- Department of DentistryAlbert Einstein College of Medicine Bronx NY USA
- Department of Epidemiology & Population HealthAlbert Einstein College of Medicine Bronx NY USA
| | - Avery R. Brow
- DentaQuest Partnership for Oral Health Advancement Boston MA USA
| | - Eric Tranby
- DentaQuest Partnership for Oral Health Advancement Boston MA USA
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14
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O'Brien DC, Dabbs D, Dong K, Veugelers PJ, Hyshka E. Patient characteristics associated with being offered take home naloxone in a busy, urban emergency department: a retrospective chart review. BMC Health Serv Res 2019; 19:632. [PMID: 31488142 PMCID: PMC6727417 DOI: 10.1186/s12913-019-4469-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 08/27/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Overdose deaths can be prevented by distributing take home naloxone (THN) kits. The emergency department (ED) is an opportune setting for overdose prevention, as people who use opioids frequently present for emergency care, and those who have overdosed are at high risk for future overdose death. We evaluated the implementation of an ED-based THN program by measuring the extent to which THN was offered to patients presenting with opioid overdose. We analyzed whether some patients were less likely to be offered THN than others, to identify areas for program improvement. METHODS We retrospectively reviewed medical records from all ED visits between April 2016 and May 2017 with a primary diagnosis of opioid overdose at a large, urban tertiary hospital located in Alberta, Canada. A wide array of patient data was collected, including demographics, opioid intoxicants, prescription history, overdose severity, and whether a naloxone kit was offered and accepted. Multivariable analyses were used to identify patient characteristics and situational variables associated with being offered THN. RESULTS Among the 342 ED visits for opioid overdose, THN was offered in 49% (n = 168) of cases. Patients were more likely to be offered THN if they had been found unconscious (Adjusted Odds Ratio 3.70; 95% Confidence Interval [1.63, 8.37]), or if they had smoked or injected an illegal opioid (AOR 6.05 [2.15,17.0] and AOR 3.78 [1.32,10.9], respectively). In contrast, patients were less likely to be offered THN if they had a current prescription for opioids (AOR 0.41 [0.19, 0.88]), if they were admitted to the hospital (AOR 0.46 [0.22,0.97], or if they unexpectedly left the ED without treatment or before completing treatment (AOR 0.16 [0.22, 0.97). CONCLUSIONS In this real-world evaluation of an ED-based THN program, we observed that only half of patients with opioid overdose were offered THN. ED staff readily identify patients who use illegal opioids or experience a severe overdose as potentially benefitting from THN, but may miss others at high risk for future overdose. We recommend that hospital EDs provide additional guidance to staff to ensure that all eligible patients at risk of overdose have access to THN.
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Affiliation(s)
- Daniel C O'Brien
- University of Alberta, School of Public Health, 3-300 Edmonton Clinic Health Academy, 11405 - 87 Ave, Edmonton, Alberta, T6G 1C9, Canada
| | - Daniel Dabbs
- University of Alberta, Faculty of Medicine and Dentistry, 2J2.00 WC Mackenzie Health Sciences Centre, 8440 112 St. NW, Edmonton, Alberta, T6G 2R7, Canada
| | - Kathryn Dong
- University of Alberta, Faculty of Medicine and Dentistry, 790 University Terrace Building, 8303 112 St. NW, Edmonton, Alberta, T6G 2T4, Canada
| | - Paul J Veugelers
- University of Alberta, School of Public Health, 33-50 University Terrace, 8303 - 112 Ave, Edmonton, Alberta, T6G 2T4, Canada
| | - Elaine Hyshka
- University of Alberta, School of Public Health, 3-300 Edmonton Clinic Health Academy, 11405 - 87 Ave, Edmonton, Alberta, T6G 1C9, Canada.
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15
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Frequent emergency department use and mortality in patients with substance and opioid use in Alberta: A population-based retrospective cohort study. CAN J EMERG MED 2019; 21:482-491. [PMID: 30983561 DOI: 10.1017/cem.2019.15] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES In the current opioid epidemic, identifying high-risk patients among those with substance and opioid use may prevent deaths. The objective of this study was to determine whether frequent emergency department (ED) use and degree of frequent use are associated with mortality among ED patients with substance and opioid use. METHODS This cohort study used linked population-based ED (National Ambulatory Care Reporting System) and mortality data from Alberta. All adults ≥ 18 years with substance or opioid use-related visits based on diagnostic codes from April 1, 2012, to March 31, 2013, were included (n = 16,389). Frequent use was defined by ≥ 5 visits in the previous year. Outcomes were unadjusted and adjusted (for age, sex, income) mortality within 90 days (primary), and 30 days, 365 days, and 2 years (secondary). To examine degree, frequent use was subcategorized into 5-10, 11-15, 16-20, and > 20 visits. RESULTS Frequent users were older, lower income, and made lower acuity visits than non-frequent users. Frequent users with substance use had higher mortality at 365 days (hazard ratio [HR] 1.36 [1.04, 1.77]) and 2 years (HR 1.32 [1.04, 1.67]), but not at 90 or 30 days. Mortality did not differ for frequent users with opioid use overall. By degree, patients with substance use and > 20 visits/year and with opioid use and 16-20 visits/year demonstrated a higher 365-day and 2-year mortality. CONCLUSIONS Among patients with substance use, frequent ED use and extremely frequent use (> 20 visits/year) were associated with long-term but not short-term mortality. These findings suggest a role for targeted screening and preventive intervention.
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Conner KR, Wiegand TJ, Kaukeinen K, Gorodetsky R, Schult R, Heavey SC. Prescription-, Illicit-, and Self-Harm Opioid Overdose Cases Treated in Hospital. J Stud Alcohol Drugs 2018; 79:893-898. [PMID: 30573020 PMCID: PMC10017273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2023] Open
Abstract
OBJECTIVE Research suggests unintentional overdose on prescription drugs and intentional self-harm cases differ fundamentally from unintentional illicit drug overdoses, but there are few data on opioid overdose per se. METHOD We analyzed consecutive opioid overdose patients age 13 and over (N = 435) treated by a toxicology consult service to compare three poisoning groups: unintentional illicit drug (illicit, n = 128), unintentional prescription drug (prescription, n = 217), and intentional self-harm (self-harm, n = 90). The groups were compared on key characteristics of the poisoning events (severity, co-ingestion of non-opioid) and the hospital-based treatments required to manage the poisonings (use of antidote, provision of pharmacological support). Logistic regressions yielded incident rate ratios (IRRs) and 95% confidence intervals (CI) adjusted for age and sex. RESULTS Compared to the illicit group, the prescription group was more likely to co-ingest a non-opioid drug (IRR [95% CI] = 1.594 [1.077, 2.358], p = .020. Compared to illicit cases, self-harm cases were more likely to co-ingest a non-opioid drug (IRR = 3.181 [1.620, 6.245], p = .001) and had a lower poisoning severity score (IRR = 0.750 [0.564, 0.997], p = .048). There were no statistically significant differences between the self-harm and prescription groups. CONCLUSIONS The similarities between the self-harm and prescription poisoning groups suggest that they may benefit from common interventions including appropriate restriction on prescription of opioids and other medications that may be misused (e.g., sedative-hypnotic/muscle relaxants). The characteristics of the illicit poisoning group (use of heroin; more severe overdose events) suggest the need for initiation of intensive substance use treatment interventions during hospitalization.
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Affiliation(s)
- Kenneth R Conner
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York.,Department of Psychiatry, University of Rochester Medical Center, Rochester, New York
| | - Timothy J Wiegand
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York
| | - Kimberly Kaukeinen
- Department of Biostatistics, University of Rochester Medical Center, Rochester, New York
| | - Rachel Gorodetsky
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York.,D'Youville College School of Pharmacy, Buffalo, New York
| | - Rachel Schult
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York
| | - Sarah Cercone Heavey
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York
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Conner KR, Wiegand TJ, Kaukeinen K, Gorodetsky R, Schult R, Heavey SC. Prescription-, Illicit-, and Self-Harm Opioid Overdose Cases Treated in Hospital. J Stud Alcohol Drugs 2018; 79:893-898. [PMID: 30573020 PMCID: PMC10017273 DOI: 10.15288/jsad.2018.79.893] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 07/23/2018] [Indexed: 04/25/2024] Open
Abstract
OBJECTIVE Research suggests unintentional overdose on prescription drugs and intentional self-harm cases differ fundamentally from unintentional illicit drug overdoses, but there are few data on opioid overdose per se. METHOD We analyzed consecutive opioid overdose patients age 13 and over (N = 435) treated by a toxicology consult service to compare three poisoning groups: unintentional illicit drug (illicit, n = 128), unintentional prescription drug (prescription, n = 217), and intentional self-harm (self-harm, n = 90). The groups were compared on key characteristics of the poisoning events (severity, co-ingestion of non-opioid) and the hospital-based treatments required to manage the poisonings (use of antidote, provision of pharmacological support). Logistic regressions yielded incident rate ratios (IRRs) and 95% confidence intervals (CI) adjusted for age and sex. RESULTS Compared to the illicit group, the prescription group was more likely to co-ingest a non-opioid drug (IRR [95% CI] = 1.594 [1.077, 2.358], p = .020. Compared to illicit cases, self-harm cases were more likely to co-ingest a non-opioid drug (IRR = 3.181 [1.620, 6.245], p = .001) and had a lower poisoning severity score (IRR = 0.750 [0.564, 0.997], p = .048). There were no statistically significant differences between the self-harm and prescription groups. CONCLUSIONS The similarities between the self-harm and prescription poisoning groups suggest that they may benefit from common interventions including appropriate restriction on prescription of opioids and other medications that may be misused (e.g., sedative-hypnotic/muscle relaxants). The characteristics of the illicit poisoning group (use of heroin; more severe overdose events) suggest the need for initiation of intensive substance use treatment interventions during hospitalization.
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Affiliation(s)
- Kenneth R. Conner
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York
| | - Timothy J. Wiegand
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York
| | - Kimberly Kaukeinen
- Department of Biostatistics, University of Rochester Medical Center, Rochester, New York
| | - Rachel Gorodetsky
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York
- D’Youville College School of Pharmacy, Buffalo, New York
| | - Rachel Schult
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York
| | - Sarah Cercone Heavey
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York
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Sahota PK, Shastry S, Mukamel DB, Murphy L, Yang N, Lotfipour S, Chakravarthy B. Screening emergency department patients for opioid drug use: A qualitative systematic review. Addict Behav 2018; 85:139-146. [PMID: 29909354 DOI: 10.1016/j.addbeh.2018.05.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 05/13/2018] [Accepted: 05/23/2018] [Indexed: 10/16/2022]
Abstract
INTRODUCTION The opioid drug epidemic is a major public health concern and an economic burden in the United States. The purpose of this systematic review is to assess the reliability and validity of screening instruments used in emergency medicine settings to detect opioid use in patients and to assess psychometric data for each screening instrument. METHODS PubMed/MEDLINE, PsycINFO, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Web of Science, Cumulative Index to Nursing and Allied Health Literature and ClinicalTrials.gov were searched for articles published up to May 2018. The extracted articles were independently screened for eligibility by two reviewers. We extracted 1555 articles for initial screening and 95 articles were assessed for full-text eligibility. Six articles were extracted from the full-text assessment. RESULTS Six instruments were identified from the final article list: Screener and Opioid Assessment for Patients with Pain - Revised; Drug Abuse Screening Test; Opioid Risk Tool; Current Opioid Misuse Measure; an Emergency Medicine Providers Clinician Assessment Questionnaire; and an Emergency Provider Impression Data Collection Form. Screening instrument characteristics, and reliability and validity data were extracted from the six studies. A meta-analysis was not conducted due to heterogeneity between the studies. CONCLUSIONS There is a lack of validity and reliability evidence in all six articles; and sensitivity, specificity and predictive values varied between the different instruments. These instruments cannot be validated for use in emergency medicine settings. There is no clear evidence to state which screening instruments are appropriate for use in detecting opioid use disorders in emergency medicine patients. There is a need for brief, reliable, valid and feasible opioid use screening instruments in the emergency medicine setting.
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Yes, not now, or never: an analysis of reasons for refusing or accepting emergency department-based take-home naloxone. CAN J EMERG MED 2018; 21:226-234. [PMID: 29789030 DOI: 10.1017/cem.2018.368] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Take-home naloxone (THN) reduces deaths from opioid overdose. To increase THN distribution to at-risk emergency department (ED) patients, we explored reasons for patients' refusing or accepting THN. METHODS In an urban teaching hospital ED, we identified high opioid overdose risk patients according to pre-specified criteria. We offered eligible patients THN and participation in researcher-administered surveys, which inquired about reasons to refuse or accept THN and about THN dispensing location preferences. We analyzed refusal and acceptance reasons in open-ended responses, grouped reasons into categories (absolute versus conditional refusals,) then searched for associations between patient characteristics and reasons. RESULTS Of 247 patients offered THN, 193 (78.1%) provided reasons for their decision. Of those included, 69 (35.2%) were female, 91 (47.2%) were under age 40, 61 (31.6%) were homeless, 144 (74.6%) reported injection drug use (IDU), and 131 (67.9%) accepted THN. Of 62 patients refusing THN, 19 (30.7%) felt "not at risk" for overdose, while 28 (45.2%) gave conditional refusal reasons: "too sick," "in a rush," or preference to get THN elsewhere. Non-IDU was associated with stating "not at risk," while IDU, homelessness, and age under 40 were associated with conditional refusals. Among acceptances, 86 (65.7%) mentioned saving others as a reason. Most respondents preferred other dispensing locations beside the ED, whether or not they accepted ED THN. CONCLUSION ED patients refusing THN felt "not at risk" for overdose or felt their ED visit was not the right time or place for THN. Most accepting THN wanted to save others.
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Abstract
To provide an update on prescription of naloxone as a harm-reduction strategy, PubMed was searched to identify publications relevant to naloxone prescribing for reversal of opioid overdose. Opportunities now exist to expand naloxone use, although evidence suggests these are often missed or underexploited. The US FDA has approved an intranasal naloxone spray and an autoinjector naloxone formulation for community use. Effective use of naloxone in community settings requires screening to identify patients at risk of opioid overdose, discussing naloxone use with patients and their relatives, and providing appropriate training. The tools exist to expand the use of naloxone more widely into the community, thereby creating an opportunity to reduce opioid overdose fatalities.
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Affiliation(s)
- Robert B Dunne
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, MI 48202, USA
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21
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Rate of patients at elevated risk of opioid overdose visiting the emergency department. Am J Emerg Med 2018; 36:2161-2165. [PMID: 29602664 DOI: 10.1016/j.ajem.2018.03.055] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 03/19/2018] [Accepted: 03/20/2018] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To determine the rate of patients visiting the emergency department who are at risk of opioid overdose. METHODS The electronic records of a 412 bed tertiary care county teaching hospital were searched for emergency department (ED) visits from January 1, 2013 to October 31, 2016 to find patients on at least 100mg morphine equivalents (MME) of oral opioid therapy, or an opioid in combination with a benzodiazepine. Records were also searched for patients with a positive urinalysis for opioids when no opioid was present on their home medication list. Medication reconciliations were searched for patients at risk of opioid overdose who were subsequently discharged on naloxone. RESULTS An analysis of 2521 patients visiting the ED was performed, and the overall rate of risk of opioid overdose increased from 25.84% to 47.41% (p<0.0001) in patients meeting inclusion criteria from 2013 to 2016. For patients on opioids, the rate of patients on 100 MME daily or greater increased from 9.72% to 28.24% (p<0.0001) from 2013 to 2016. The rate of patients on opioid therapy in combination with benzodiazepine therapy did not change significantly from 2013 to 2016. When comparing patients at risk of opioid overdose to total emergency department visits, we found the rate of at risk patients increased significantly from 0.12% to 0.56% (p<0.0001) from 2013 to 2016. CONCLUSIONS The rate of patients visiting the emergency department at risk of opioid overdose increased significantly from 2013 to 2016. Naloxone was not routinely prescribed to this patient cohort.
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Brady JE, Giglio R, Keyes KM, DiMaggio C, Li G. Risk markers for fatal and non-fatal prescription drug overdose: a meta-analysis. Inj Epidemiol 2017; 4:24. [PMID: 28762157 PMCID: PMC5545182 DOI: 10.1186/s40621-017-0118-7] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Accepted: 06/20/2017] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Drug overdose is a public health crisis in the United States, due in part to the unintended consequences of increases in prescribing of opioid analgesics. Many clinicians evaluate risk markers for opioid-related harms when prescribing opioids for chronic pain; however, more data on predictive risk markers are needed. Risk markers are attributes (modifiable and non-modifiable) that are associated with increased probability of an outcome. This review aims to identify risk markers associated with fatal and non-fatal prescription drug overdose by synthesizing findings in the existing peer-reviewed and grey literature. Eligible cohort, case-control, cross-sectional, and case-cohort studies were reviewed and data were extracted for qualitative and quantitative synthesis. FINDINGS Summary odds ratios (SOR) were estimated from 29 studies for six risk markers: sex, age, race, psychiatric disorders, substance use disorder (SUD), and urban/rural residence. Heterogeneity was assessed and effect estimates were stratified by study characteristics. Of the six risk markers identified, SUD had the strongest association with drug overdose death (SOR = 5.24, 95% confidence interval (CI) = 3.53 - 7.76), followed by psychiatric disorders (SOR = 3.94, 95% CI = 3.09 - 5.01), white race (SOR = 2.28, 95% CI = 1.93 - 2.70), the 35-44 year age group relative to the 25-34 year reference group (SOR = 1.52, 95% CI = 1.31 - 1.76), and male sex (SOR = 1.33, 95% CI = 1.17 - 1.51). CONCLUSIONS This review highlights fatal and non-fatal prescription drug risk markers most frequently assessed in peer-reviewed and grey literature. There is a need to better understand modifiable risk markers and underlying reasons for drug misuse in order to inform interventions that may prevent future drug overdoses.
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Affiliation(s)
- Joanne E. Brady
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY USA
| | - Rebecca Giglio
- Center for Injury Epidemiology and Prevention, Columbia University, New York, NY USA
| | - Katherine M. Keyes
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY USA
- Center for Injury Epidemiology and Prevention, Columbia University, New York, NY USA
| | - Charles DiMaggio
- Department of Surgery, Division of Trauma, New York University, New York, NY USA
| | - Guohua Li
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY USA
- Center for Injury Epidemiology and Prevention, Columbia University, New York, NY USA
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, NY USA
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Kestler A, Buxton J, Meckling G, Giesler A, Lee M, Fuller K, Quian H, Marks D, Scheuermeyer F. Factors Associated With Participation in an Emergency Department–Based Take-Home Naloxone Program for At-Risk Opioid Users. Ann Emerg Med 2017; 69:340-346. [DOI: 10.1016/j.annemergmed.2016.07.027] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 07/07/2016] [Accepted: 07/15/2016] [Indexed: 11/25/2022]
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Strayer RJ, Motov SM, Nelson LS. Something for pain: Responsible opioid use in emergency medicine. Am J Emerg Med 2016; 35:337-341. [PMID: 27802876 DOI: 10.1016/j.ajem.2016.10.043] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 10/18/2016] [Accepted: 10/20/2016] [Indexed: 10/20/2022] Open
Abstract
The United States is currently experiencing a public health crisis of opioid addiction, which has its genesis in an industry marketing effort that successfully encouraged clinicians to prescribe opioids liberally, and asserted the safety of prescribing opioids for chronic non-cancer pain, despite a preponderance of evidence demonstrating the risks of dependence and misuse. The resulting rise in opioid use has pushed drug overdose deaths in front of motor vehicle collisions to become the leading cause of accidental death in the country. Emergency providers frequently treat patients for complications of opioid abuse, and also manage patients with acute and chronic pain, for which opioids are routinely prescribed. Emergency providers are therefore well positioned to both prevent new cases of opioid misuse and initiate appropriate treatment of existing opioid addicts. In opioid-naive patients, this is accomplished by a careful consideration of the likelihood of benefit and harm of an opioid prescription for acute pain. If opioids are prescribed, the chance of harm is reduced by matching the number of pills prescribed to the expected duration of pain and selecting an opioid preparation with low abuse liability. Patients who present to acute care with exacerbations of chronic pain or painful conditions associated with opioid misuse are best managed by treating symptoms with opioid alternatives and encouraging treatment for opioid addiction.
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Affiliation(s)
- Reuben J Strayer
- 79-01 Broadway, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, Elmhurst, NY 11373, United States.
| | - Sergey M Motov
- 4802 Tenth Ave, Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY 11219, United States
| | - Lewis S Nelson
- 185 South Orange Avenue, Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, United States
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25
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Ruan X, Kaye AD. Emergency department utilization and subsequent prescription drug overdose death. Ann Epidemiol 2015; 25:879-80. [DOI: 10.1016/j.annepidem.2015.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 07/02/2015] [Indexed: 10/23/2022]
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Brady JE, DiMaggio CJ, Keyes KM, Li G. Response to Letter to the Editor. Ann Epidemiol 2015; 25:881. [PMID: 26350001 DOI: 10.1016/j.annepidem.2015.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 07/25/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Joanne E Brady
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY; Center for Injury Epidemiology and Prevention, Departments of Anesthesiology and Epidemiology, Columbia University Medical Center, New York, NY
| | - Charles J DiMaggio
- Department of Surgery, New York University School of Medicine, New York, NY
| | - Katherine M Keyes
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY; Center for Injury Epidemiology and Prevention, Departments of Anesthesiology and Epidemiology, Columbia University Medical Center, New York, NY
| | - Guohua Li
- Department of Anesthesiology, College of Physicians and Surgeons, Columbia University, New York, NY; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY; Center for Injury Epidemiology and Prevention, Departments of Anesthesiology and Epidemiology, Columbia University Medical Center, New York, NY
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