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Ezell JM, Pho MT, Ajayi BP, Simek E, Shetty N, Goddard-Eckrich DA, Bluthenthal RN. Opioid use, prescribing and fatal overdose patterns among racial/ethnic minorities in the United States: A scoping review and conceptual risk environment model. Drug Alcohol Rev 2024. [PMID: 38646735 DOI: 10.1111/dar.13832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 02/11/2024] [Accepted: 02/19/2024] [Indexed: 04/23/2024]
Abstract
ISSUES To date, there has been no synthesis of research addressing the scale and nuances of the opioid epidemic in racial/ethnic minority populations in the United States that considers the independent and joint impacts of dynamics such as structural disadvantage, provider bias, health literacy, cultural norms and various other risk factors. APPROACH Using the "risk environment" framework, we conducted a scoping review on PubMed, Embase and Google Scholar of peer-reviewed literature and governmental reports published between January 2000 and February 2024 on the nature and scale of opioid use, opioid prescribing patterns, and fatal overdoses among racial/ethnic minorities in the United States, while also examining macro, meso and individual-level risk factors. KEY FINDINGS Results from this review illuminate a growing, but fragmented, literature lacking standardisation in racial/ethnic classification and case reporting, specifically in regards to Indigenous and Asian subpopulations. This literature broadly illustrates racial/ethnic minorities' increasing nonmedical use of opioids, heightened burdens of fatal overdoses, specifically in relation to polydrug use and synthetic opioids, with notable elevations among Black/Latino subgroups, in addition uneven opioid prescribing patterns. Moreover, the literature implicates a variety of unique risk environments corresponding to dynamics such as residential segregation, provider bias, overpolicing, acculturative stress, patient distrust, and limited access to mental health care services and drug treatment resources, including medications for opioid use disorder. IMPLICATIONS There has been a lack of rigorous, targeted study on racial/ethnic minorities who use opioids, but evidence highlights burgeoning increases in usage, especially polydrug/synthetic opioid use, and disparities in prescriptions and fatal overdose risk-phenomena tied to multi-level forms of entrenched disenfranchisement. CONCLUSION There is a need for further research on the complex, overlapping risk environments of racial/ethnic minorities who use opioids, including deeper inclusion of Indigenous and Asian individuals, and efforts to generate greater methodological synergies in population classification and reporting guidelines.
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Affiliation(s)
- Jerel M Ezell
- Community Health Sciences, School of Public Health, University of California Berkeley, Berkeley, USA
- Berkeley Center for Cultural Humility, University of California Berkeley, Berkeley, USA
| | - Mai T Pho
- Department of Medicine, Section of Infectious Diseases and Global Health, University of Chicago Medicine, Chicago, USA
| | - Babatunde P Ajayi
- Community Health Sciences, School of Public Health, University of California Berkeley, Berkeley, USA
| | - Elinor Simek
- Community Health Sciences, School of Public Health, University of California Berkeley, Berkeley, USA
- Berkeley Center for Cultural Humility, University of California Berkeley, Berkeley, USA
| | - Netra Shetty
- University of California Berkeley, Berkeley, USA
| | | | - Ricky N Bluthenthal
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, USA
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Hawk KF, Weiner SG, Rothenberg C, Bernstein E, D'Onofrio G, Herring A, Hoppe J, Ketcham E, LaPietra A, Nelson L, Perrone J, Ranney M, Samuels EA, Strayer R, Sharma D, Goyal P, Schuur J, Venkatesh AK. Leveraging a Learning Collaborative Model to Develop and Pilot Quality Measures to Improve Opioid Prescribing in the Emergency Department. Ann Emerg Med 2024; 83:225-234. [PMID: 37831040 DOI: 10.1016/j.annemergmed.2023.08.490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/28/2023] [Accepted: 08/29/2023] [Indexed: 10/14/2023]
Abstract
The American College of Emergency Physicians (ACEP) Emergency Medicine Quality Network (E-QUAL) Opioid Initiative was launched in 2018 to advance the dissemination of evidence-based resources to promote the care of emergency department (ED) patients with opioid use disorder. This virtual platform-based national learning collaborative includes a low-burden, structured quality improvement project, data benchmarking, tailored educational content, and resources designed to support a nationwide network of EDs with limited administrative and research infrastructure. As a part of this collaboration, we convened a group of experts to identify and design a set of measures to improve opioid prescribing practices to provide safe analgesia while reducing opioid-related harms. We present those measures here, alongside initial performance data on those measures from a sample of 370 nationwide community EDs participating in the 2019 E-QUAL collaborative. Measures include proportion of opioid administration in the ED, proportion of alternatives to opioids as first-line treatment, proportion of opioid prescription, opioid pill count per prescription, and patient medication safety education among ED visits for atraumatic back pain, dental pain, or headache. The proportion of benzodiazepine and opioid coprescribing for ED visits for atraumatic back pain was also evaluated. This project developed and effectively implemented a collection of 6 potential measures to evaluate opioid analgesic prescribing across a national sample of community EDs, representing the first feasibility assessment of opioid prescribing-related measures from rural and community EDs.
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Affiliation(s)
- Kathryn F Hawk
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT.
| | | | - Craig Rothenberg
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Edward Bernstein
- Boston Medical Center Department of Emergency Medicine, Boston, MA
| | - Gail D'Onofrio
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Andrew Herring
- Department of Emergency Medicine, Highland Hospital-Alameda Health System, University of California, San Francisco
| | - Jason Hoppe
- Department of Emergency Medicine, University of Colorado School of Medicine, Denver
| | - Eric Ketcham
- Presbyterian Healthcare, Espanola & Santa Fe, NM
| | - Alexis LaPietra
- Division of Emergency Medicine, RWJBarnabus Health, West Orange, NJ
| | - Lewis Nelson
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark
| | - Jeanmarie Perrone
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Megan Ranney
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT
| | | | - Reuben Strayer
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY
| | - Dhruv Sharma
- American College of Emergency Physicians, Dallas, TX
| | - Pawan Goyal
- American College of Emergency Physicians, Dallas, TX
| | - Jeremiah Schuur
- Department of Emergency Medicine, Brown School of Medicine, Providence, RI
| | - Arjun K Venkatesh
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
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Daoust R, Paquet J, Chauny JM, Williamson D, Huard V, Arbour C, Emond M, Rouleau D, Cournoyer A. Impact of vitamin C on the reduction of opioid consumption after an emergency department visit for acute musculoskeletal pain: a double-blind randomised control trial protocol. BMJ Open 2023; 13:e069230. [PMID: 37225265 PMCID: PMC10230879 DOI: 10.1136/bmjopen-2022-069230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 04/28/2023] [Indexed: 05/26/2023] Open
Abstract
INTRODUCTION Recent evidence has shown that vitamin C has some analgesic properties in addition to its antioxidant effect and can, therefore, reduce opioid use during recovery time. Vitamin C analgesic effect has been explored mostly during short-term postoperative context or in disease-specific chronic pain prevention, but never after acute musculoskeletal injuries, which are often seen in the emergency department (ED). The protocol's primary aim is to compare the total morphine 5 mg pills consumed during a 2-week follow-up between patients receiving vitamin C or a placebo after ED discharge for an acute musculoskeletal pain complaint. METHODS AND ANALYSIS We will conduct a two-centre double-blind randomised placebo-controlled trial with 464 participants distributed in two arms, one group receiving 1000 mg of vitamin C two times a day for 14 days and another one receiving a placebo. Participants will be ≥18 years of age, treated in ED for acute musculoskeletal pain present for less than 2 weeks and discharged with an opioid prescription for home pain management. Total morphine 5 mg pills consumed during the 2-week follow-up will be assessed via an electronic (or paper) diary. In addition, patients will report their daily pain intensity, pain relief, side effects and other types of pain medication or other non-pharmacological approach used. Three months after the injury, participants will also be contacted to evaluate chronic pain development. We hypothesised that vitamin C, compared with a placebo, will reduce opioid consumption during a 14-day follow-up for ED discharged patients treated for acute musculoskeletal pain. ETHICS AND DISSEMINATION This study has received approval from the Ethics Review Committee from the 'Comité d'éthique de la recherche du CIUSSS du Nord-de-l'Île-de-Montréal (No 2023-2442)'. Findings will be disseminated through scientific conferences and peer-reviewed journal publication. The data sets generated during the study will be available from the corresponding author on reasonable request. TRIAL REGISTRATION NUMBER NCT05555576 ClinicalTrials.Gov PRS.
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Affiliation(s)
- Raoul Daoust
- Département de Médecine Familiale et de Médecine d'Urgence, Université de Montréal, Montreal, Quebec, Canada
- Study Center in Emergency Medicine, Hopital du Sacre-Coeur de Montreal Centre de Recherche, Montreal, Quebec, Canada
- Centre de Recherche, Hopital du Sacre-Coeur de Montreal, Montreal, Quebec, Canada
| | - Jean Paquet
- Study Center in Emergency Medicine, Hopital du Sacre-Coeur de Montreal Centre de Recherche, Montreal, Quebec, Canada
| | - Jean-Marc Chauny
- Département de Médecine Familiale et de Médecine d'Urgence, Université de Montréal, Montreal, Quebec, Canada
- Study Center in Emergency Medicine, Hopital du Sacre-Coeur de Montreal Centre de Recherche, Montreal, Quebec, Canada
| | - David Williamson
- Centre de Recherche, Hopital du Sacre-Coeur de Montreal, Montreal, Quebec, Canada
- Faculté de Pharmacie, Université de Montréal, Montreal, Quebec, Canada
| | - Vérilibe Huard
- Département de Médecine Familiale et de Médecine d'Urgence, Université de Montréal, Montreal, Quebec, Canada
- Study Center in Emergency Medicine, Hopital du Sacre-Coeur de Montreal Centre de Recherche, Montreal, Quebec, Canada
- Centre de Recherche, Hopital du Sacre-Coeur de Montreal, Montreal, Quebec, Canada
| | - Caroline Arbour
- Centre de Recherche, Hopital du Sacre-Coeur de Montreal, Montreal, Quebec, Canada
- Faculté des sciences infirmières, Université de Montréal, Montréal, Québec, Canada
| | - Marcel Emond
- Department of Family and Emergency Medicine, Universite Laval, Quebec, Quebec, Canada
| | - Dominique Rouleau
- Centre de Recherche, Hopital du Sacre-Coeur de Montreal, Montreal, Quebec, Canada
| | - Alexis Cournoyer
- Département de Médecine Familiale et de Médecine d'Urgence, Université de Montréal, Montreal, Quebec, Canada
- Study Center in Emergency Medicine, Hopital du Sacre-Coeur de Montreal Centre de Recherche, Montreal, Quebec, Canada
- Centre de Recherche, Hopital du Sacre-Coeur de Montreal, Montreal, Quebec, Canada
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Emergency department opioid discharge instructions: a multidisciplinary national Delphi study. CAN J EMERG MED 2022; 24:641-649. [PMID: 35969328 DOI: 10.1007/s43678-022-00352-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 06/21/2022] [Indexed: 11/02/2022]
Abstract
OBJECTIVES Currently, there are no Canadian guidelines for discharge instruction to be given to patients receiving an opioid prescription in the ED. This likely contributes to inadequate discharge instructions for these potentially dangerous medications. The principal goal of this study was to develop an interdisciplinary Canadian consensus regarding important concepts to be included in written opioid discharge instructions within the ED setting. METHODS We conducted a modified Delphi study between May and August 2021. The national multidisciplinary panel consisted of 23 healthcare professionals and one patient partner. The survey consisted of 19 initial concepts developed after a review of the literature and a meeting with local experts. The panel added four new concepts after the first survey round. Three rounds of online surveys were distributed in total. Panel consensus was defined a priori as a disagreement index score less than 1, in accordance with the RAND/UCLA Appropriateness Method. RESULTS We achieved a 100% response rate in round one and a 96% response rate in rounds two and three of our Delphi study. There was group consensus (disagreement index = 0.66, median importance = 9) that all patients receiving opioid prescriptions from the ED should receive written discharge instructions. The interdisciplinary panel arrived at a consensus on 21/23 concepts for ED opioid discharge instructions. The concepts with the highest level of agreement were related to minimizing the use of the prescribed opioid medication and opioid use safety (mixing with drugs/alcohol, storage, and impairment). CONCLUSION This Delphi study with a national, multidisciplinary panel achieved consensus on 21 concepts that should be included in written discharge instructions to patients receiving an opioid prescription upon discharge from the ED.
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Valdes IL, Possinger MC, Hincapie-Castillo JM, Goodin AJ, Dewar MA, Sumfest JM, Vouri SM. Changes in Prescribing by Provider Type Following a State Prescription Opioid Restriction Law. J Gen Intern Med 2022; 37:1838-1844. [PMID: 34236602 PMCID: PMC9198141 DOI: 10.1007/s11606-021-06966-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 06/04/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Many states have implemented opioid days' supply restriction policies, leading to reductions in opioid prescribing. Although research within certain provider types exist, no study has evaluated a restriction policy by various provider types. OBJECTIVE To evaluate changes in opioid utilization following a days' supply restriction policy stratified by provider type: surgery, emergency medicine, primary care, specialty care, and dentistry. DESIGN Interrupted time series (ITS) PARTICIPANTS: Opioid prescription claims of patients in a private health plan serving a large Florida employer from 1/1/2015 to 3/31/2019. Provider types were determined using the Healthcare Provider Taxonomy Code associated with the national provider identifier (NPI). INTERVENTIONS Florida's opioid restriction policy implemented on July 1, 2018. MAIN MEASURES Changes in mean morphine milligram equivalent (MMEs), mean days' supply, and mean number of units dispensed per opioid prescription before and after policy implementation. KEY RESULTS There were 10,583 opioid initial prescriptions dispensed. Treating providers were classified as surgery (16.4%; n = 1732), emergency care (14.3%; n = 1516), primary care (21.2%; n = 2241), specialty care (11.4%; n = 1207), and dentistry providers (23.7%; n = 2511). Significant reductions in mean days' supply were observed across most provider types ranging from 14% reduction for dentistry providers to 41% reduction for specialty care providers. Significant changes were observed for emergency care and specialty care providers with a 30% (p = 0.001)and 29% (p < 0.001) reduction in mean MME, respectively, and a 27% (p = 0.040) reduction in mean number of units dispensed in emergency care providers, after implementation. Pre-implementation trends in opioid prescribing varied by provider type impacting the effects of the opioid days' supply restriction policy. CONCLUSIONS Pre-policy opioid prescribing varied by provider type with a differential impact on mean MMEs, mean days' supply, and mean number of units dispensed per prescription following implementation.
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Affiliation(s)
- Ivelisse L Valdes
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
- Center for Drug Evaluation and Safety, University of Florida, Gainesville, FL, USA
| | - Marie-Christin Possinger
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Juan M Hincapie-Castillo
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
- Center for Drug Evaluation and Safety, University of Florida, Gainesville, FL, USA
- Pain Research and Intervention Center of Excellence, University of Florida, Gainesville, USA
| | - Amie J Goodin
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
- Center for Drug Evaluation and Safety, University of Florida, Gainesville, FL, USA
| | - Marvin A Dewar
- University of Florida Health Physicians, Gainesville, FL, USA
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Jill M Sumfest
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Scott M Vouri
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA.
- Center for Drug Evaluation and Safety, University of Florida, Gainesville, FL, USA.
- University of Florida Health Physicians, Gainesville, FL, USA.
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Oskvarek JJ, Aldeen A, Shawbell J, Venkat A, Zocchi MS, Pines JM. Opioid Prescription Reduction After Implementation of a Feedback Program in a National Emergency Department Group. Ann Emerg Med 2022; 79:420-432. [DOI: 10.1016/j.annemergmed.2021.12.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 12/10/2021] [Accepted: 12/15/2021] [Indexed: 02/07/2023]
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Takakuwa KM, Schears RM. Emergency Medicine Physicians Would Prefer Using Cannabis Over Opioids for First-Line Treatment of a Medical Condition if Provided With Medical Evidence: A National Survey. Cureus 2021; 13:e19641. [PMID: 34926086 PMCID: PMC8673685 DOI: 10.7759/cureus.19641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2021] [Indexed: 11/21/2022] Open
Abstract
Objective: To determine emergency medicine (EM) physicians’ preferences for using medical cannabis versus opioids if medical cannabis was legalized. Methods: We surveyed US physicians at the largest national EM conference (American College of Emergency Physicians’ Annual Conference) held in San Diego, CA from October 1 to 4, 2018. Of the thousands of conference participants approached, 539 US physicians completed the anonymous written survey, which represented 15.2% of the US physicians attending the conference. Results: The mean age of the participants was 39.6 ± 10.9 years, men composed 57.5% of the participants, and whites made up 72.8% of the respondents. Participants practicing in medically legal (54.8%) and medically plus adult-use legal cannabis states (23.1%) totaled 77.9%. A majority (70.7%) of the participants believed that cannabis has medical value. EM physicians preferred cannabis over opioids as a first-line treatment addressing a medical condition provided that medical studies found that cannabis was equally effective (p < 0.001, X2 = 36.8 [95% CI 2, 415]), and overwhelmingly preferred cannabis over opioids if it were more effective (p < 0.001, X2 = 90.8 [95% CI 2, 415]). Physicians appeared to prefer opioids over cannabis if medical studies found that cannabis was less effective though it was not significant (p > 0.05). Subgroup analyses showed that belief in the medical value of cannabis significantly increased the odds ratio of choosing cannabis over opioids if cannabis was equally or more effective than opioids. Conclusion: Our study shows that EM physicians believe cannabis has medical value and would prefer using cannabis over opioids if provided with equivalent findings. We believe our findings reflect EM physicians’ experience of the opioid epidemic and suggest the need for further study of this potential therapeutic.
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Affiliation(s)
- Kevin M Takakuwa
- Emergency Medicine, Society of Cannabis Clinicians, Sebastopol, USA
| | - Raquel M Schears
- College of Medicine, University of Central Florida, Orlando, USA
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Bauer MR, Larson MJ, Moresco N, Huntington N, Walker R, Richard P. Association between 1-year patient outcomes and opioid-prescribing group of emergency department clinicians: A cohort study with Army active-duty soldiers. Acad Emerg Med 2021; 28:1251-1261. [PMID: 34245641 PMCID: PMC10393064 DOI: 10.1111/acem.14331] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 06/07/2021] [Accepted: 06/23/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective was to examine the association between clinicians' opioid prescribing group and patients' outcomes among patients treated in the emergency department (ED). METHODS This was a retrospective cohort study. The setting was the EDs of the U.S. Military Health System (MHS). Patients were 181,557 Army active-duty opioid-naïve (no fill in past 180 days) patients with an index encounter to the ED between October 2010 and September 2016. Exposure was patients classified by opioid prescribing tier of the treating ED clinician: top, middle, or bottom third relative to the clinician's peers in the same ED. Follow-up measurement was from 31 to 365 days after the index encounter. The primary outcome was long-term opioid prescriptions (LTOPs) defined as 180 (or more) days' supply within the follow-up window. We also computed the total morphine milligram equivalents (MME) and total opioid days' supply. Secondary measures were any repeat ED encounter, any hospitalization, any sick leave, and any military-duty restriction. RESULTS We found a 2.5-fold variation in opioid prescribing rates among clinicians in the same MHS ED. Controlling for sample demographics, reason for encounter, and military background, in multivariate analyses the odds of receiving a 180-day opioid supply during follow-up were 1.19 (95% confidence interval [CI] = 1.01 to 1.40, p < 0.05) for the top opioid exposure group and 1.37 (95% CI = 1.19 to 1.57, p < 0.001) for the middle opioid exposure group compared to the bottom exposure group, and there were significant increases in total opioid days' supply and total MME. There were no differences in secondary outcome measures. CONCLUSION In a relatively healthy sample of Army soldiers, variation in opioid exposure defined by clinician's prescribing history was associated with increased odds of LTOP and increase in opioid volume, but not in functional outcomes.
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Affiliation(s)
- Mark R. Bauer
- Institute for Behavioral Health The Heller School for Social Policy and Management Brandeis University Waltham MA USA
| | - Mary Jo Larson
- Institute for Behavioral Health The Heller School for Social Policy and Management Brandeis University Waltham MA USA
| | - Natalie Moresco
- Institute for Behavioral Health The Heller School for Social Policy and Management Brandeis University Waltham MA USA
| | - Nick Huntington
- Institute for Behavioral Health The Heller School for Social Policy and Management Brandeis University Waltham MA USA
| | - Regine Walker
- Uniformed Services University of the Health Sciences Bethesda MD USA
| | - Patrick Richard
- Uniformed Services University of the Health Sciences Bethesda MD USA
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Lvovschi VE, Hermann K, Lapostolle F, Joly LM, Tavolacci MP. Bedside Evaluation of Early VAS/NRS Based Protocols for Intravenous Morphine in the Emergency Department: Reasons for Poor Follow-Up and Targeted Practices. J Clin Med 2021; 10:jcm10215089. [PMID: 34768612 PMCID: PMC8584399 DOI: 10.3390/jcm10215089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/24/2021] [Accepted: 10/25/2021] [Indexed: 11/16/2022] Open
Abstract
Intravenous (IV) morphine protocols based on patient-reported scores, immediately at triage, are recommended for severe pain in Emergency Departments. However, a low follow-up is observed. Scarce data are available regarding bedside organization and pain etiologies to explain this phenomenon. The objective was the real-time observation of motivations and operational barriers leading to morphine avoidance. In a single French hospital, 164 adults with severe pain at triage were included in a cross-sectional study of the prevalence of IV morphine titration; caregivers were interviewed by real-time questionnaires on “real” reasons for protocol avoidance or failure. IV morphine prevalence was 6.1%, prescription avoidance was mainly linked to “Pain reassessment” (61.0%) and/or “alternative treatment prioritization” (49.3%). To further evaluate the organizational impact on prescription decisions, a parallel assessment of “simulated” prescription conditions was simultaneously performed for 98/164 patients; there were 18 titration decisions (18.3%). Treatment prioritization was a decision driver in the same proportion, while non-eligibility for morphine was more frequently cited (40.6% p = 0.001), with higher concerns about pain etiologies. Anticipation of organizational constraints cannot be excluded. In conclusion, IV morphine prescription is rarely based on first pain scores. Triage assessment is used for screening by bedside physicians, who prefer targeted practices to automatic protocols.
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Affiliation(s)
- Virginie Eve Lvovschi
- Emergency Department, UNIROUEN, INSERM U 1073, Rouen University Hospital, INSERM CIC-CRB 1404, F-76031 Rouen, France
- Correspondence:
| | - Karl Hermann
- Rouen University Hospital, INSERM CIC-CRB 1404, F-76000 Rouen, France;
| | - Frédéric Lapostolle
- SAMU 93-UF Recherche-Enseignement-Qualité, Université Paris 13, Sorbonne Paris Cité, INSERM U 942, Hôpital Avicenne, F-93009 Bobigny, France;
| | - Luc-Marie Joly
- Emergency Department, Rouen University Hospital, F-76031 Rouen, France;
| | - Marie-Pierre Tavolacci
- Normandie University, UNIROUEN, INSERM U 1073, Rouen University Hospital, INSERM CIC-CRB 1404, F-76031 Rouen, France;
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Heron MJ, Nwokorie NA, O'Connor B, Brown RS, Fugh-Berman A. Survey of opioid prescribing among dentists indicates need for more effective education regarding pain management. J Am Dent Assoc 2021; 153:110-119. [PMID: 34689958 DOI: 10.1016/j.adaj.2021.07.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 06/11/2021] [Accepted: 07/21/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Dentists commonly prescribe opioids and are the highest prescribers of opioids to patients 18 years and younger. Little is known about dentists' beliefs regarding opioids and other analgesics. METHODS The authors conducted a national survey of dentists about their opioid prescribing habits, perceptions regarding opioid effectiveness, beliefs about patient behaviors, and relationships with drug and equipment manufacturers. RESULTS The authors received 291 responses from 30 states and 2 territories and analyzed 269 completed surveys. Although 84% of respondents reported believing that nonsteroidal anti-inflammatory drug (NSAID)-acetaminophen combinations are equally as effective or more effective than opioids, 43% of respondents also reported regularly prescribing opioid medications. Of those who reported prescribing opioids, 9 of 10 reported they were less likely to prescribe opioids to adolescents aged 11 through 18 years, but only 48% reported they were less likely to prescribe opioids to young adults aged 19 through 25 years. One-half of those who reported prescribing opioids reported prescribing in amounts that would result in unused medication, and 69% reported having had patients divert or misuse opioids. Few dentists reported industry interactions. CONCLUSIONS The continued prescription of opioids contradicts mounting evidence about the superiority of NSAIDs over opioids in dentistry. Continuing dental education, increased use of prescription drug monitoring programs, and the development of national guidelines are necessary to align clinical practice with current evidence. PRACTICAL IMPLICATIONS Dentists should seek to minimize opioid prescribing and pill counts and instead opt for safer, more effective NSAID-acetaminophen combinations. Dentists also should refrain from prescribing opioids to patients younger than 25 years because of the high risk of experiencing addiction in this population.
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Sheikh S, Booth-Norse A, Holden D, Henson M, Dodd C, Edgerton E, James D, Kalynych C, Smotherman C, Hendry P. Opioid Overdose Risk in Patients Returning to the Emergency Department for Pain. PAIN MEDICINE 2021; 22:2100-2105. [PMID: 33560418 DOI: 10.1093/pm/pnab047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Using the Risk Index for Overdose or Serious Opioid-induced Respiratory Depression (CIP-RIOSORD) in patients returning to the emergency department (ED) for pain and discharged with an opioid prescription, we assessed overall opioid overdose risk and compared risk in opioid naive patients to those who are non-opioid naive. DESIGN This was a secondary analysis from a prospective observational study of patients ≥ 18 years old returning to the ED within 30 days. Data were collected from patient interviews and chart reviews. Patients were categorized as Group 1 (not using prescription opioids) or Group 2 (consuming prescription opioids). Statistical analyses were performed using Fisher's exact and Wilcoxon's rank sum tests. Risk class and probability of overdose was determined using Risk Index for Overdose or Serious Opioid-induced Respiratory Depression (CIP-RIOSORD). RESULTS Of the 389 enrollees who returned to the ED due to pain within 30 days of an initial visit, 67 (17%) were prescribed opioids. The majority of these patients were in Group 1 (60%). Both Group 1 (n = 40) and Group 2 (n = 27) held an average CIP-RIOSORD risk class of 3. Race significantly differed between groups; the majority of Group 1 self-identified as African American (80%) (P = .0267). There were no differences in age, gender, or CIP-RIOSORD risk class between groups. However, Group 2 had nearly double the number of predictive factors (median = 1.93) as Group 1 (median = 1.18) (P = .0267). CONCLUSIONS A substantial proportion of patients (25%) were high risk for opioid overdose. CIP-RIOSORD may prove beneficial in risk stratification of patients discharged with prescription opioids from the ED.
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Affiliation(s)
- Sophia Sheikh
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Ashley Booth-Norse
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - David Holden
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Morgan Henson
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Caroline Dodd
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Eric Edgerton
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Divya James
- University of Florida College of Medicine, Gainesville, Florida
| | - Colleen Kalynych
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Carmen Smotherman
- Center for Health Equity and Quality Research, University of Florida College of Medicine-Jacksonville, Florida, USA
| | - Phyllis Hendry
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
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12
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Pickard JG, van den Berk-Clark C, Matthieu MM. Association of Medication-Assisted Treatment and Age With Treatment Completion Among Veterans Seeking Non-VA Treatment for Opioid use Disorder at Non-Veterans Health Administration Facilities. Mil Med 2021; 187:504-512. [PMID: 34173832 DOI: 10.1093/milmed/usab242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 04/19/2021] [Accepted: 06/10/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Medication-assisted treatment has been shown to be effective in treating opioid use disorder among both older adults and veterans of U.S. Armed Forces. However, limited evidence exists on MAT's differential effect on treatment completion across age groups. This study aims to ascertain the role of MAT and age in treatment completion among veterans seeking treatment in non-Department of Veterans Affairs healthcare facilities for opioid use disorder. METHODS We used the Treatment Episode Data Set-Discharges (TEDS-D; 2006-2017) to examine trends in treatment and MAT usage over time and TEDS-2017 to determine the role of age and MAT in treatment completion. We examined a subset of those who self-identified as veterans and who sought treatment for an opioid use disorder. RESULTS Veterans presented in treatment more often as heroin users than prescription opioid users, and older veterans were more likely to get MAT than younger veterans. We found that before propensity score matching, MAT initially appeared to be associated with a lower likelihood of treatment completion in inpatient ($\beta $ = -1.47, 95% CI -1.56 to -1.39) and outpatient ($\beta $ = -1.40, 95% CI -2.21 to -0.58) settings, and age (50+ years) appeared to mediate the effect of MAT on treatment completion ($\beta $ = -0.54, 95% CI -0.87 to -0.21). After matching, older veterans were more likely to complete substance use disorder treatment ($\beta $ = 0.21, 95% CI 0.01-0.42), while age no longer mediated the effect of MAT, and MAT had a significant positive impact on treatment completion in detox settings ($\beta $ = 1.36, 95% CI 1.15-1.50) and inpatient settings ($\beta $ = 1.54, 95% CI 1.37 -1.71). CONCLUSION The results show that age plays an important role in outpatient treatment completion, while MAT plays an important role in inpatient treatment completion. Implications for veterans are discussed.
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Affiliation(s)
- Joseph G Pickard
- School of Social Work, University of Missouri-Saint Louis, 63121, USA
| | | | - Monica M Matthieu
- College for Public Health and Social Justice, Saint Louis University, 63103, USA
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13
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Lovett S, Reed T, Riggs R, Lew G, Koch E, Durazo‐Arvizu RA, Rech MA. A randomized, noninferiority, controlled trial of two doses of intravenous subdissociative ketamine for analgesia in the emergency department. Acad Emerg Med 2021; 28:647-654. [PMID: 33354815 DOI: 10.1111/acem.14200] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 12/14/2020] [Accepted: 12/17/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE This study aimed to determine if 0.15 mg/kg intravenous (IV) subdissociative ketamine is noninferior to 0.3 mg/kg in emergency department (ED) patients with acute pain. METHODS This randomized, prospective, double-blinded, noninferiority trial included patients' age 18 to 59 years presenting to the ED with acute moderate to severe pain. Subjects were randomized to IV subdissociative ketamine, 0.15 mg/kg ("low" dose) or 0.30 mg/kg ("high" dose), over 15 minutes. The primary endpoint was the 11-point numeric rating scale (NRS) pain score between groups at 30 minutes. Secondary endpoints included NRS pain scores at 15 and 60 minutes; change in NRS at 15, 30, and 60 minutes; rescue analgesia; and adverse effects. The noninferiority limit, δ0 , was set to 1.3. RESULTS Forty-nine patients were included in each group. After the differences in the baseline NRS score were adjusted for, the mean NRS score at 30 minutes was 4.7 (95% confidence interval [CI] = 3.8 to 5.5) in the low-dose group and 5.0 (95% CI = 4.2 to 5.8) in the high-dose group (mean difference = 0.4, 95% CI = -0.8 to 1.5), indicating that the low-dose subdissociative ketamine was noninferior to the high dose (lower limit of 95% CI = -0.8 to ≥1.3 = -δ0 ). Adverse effects were similar at 30 minutes. At 15 minutes, the high-dose group experienced greater change in NRS; however, more adverse effects occurred. CONCLUSION Our data did not detect a large difference in analgesia or adverse effect profile between 0.15 mg/kg IV ketamine and 0.30 mg/kg in the short-term treatment of acute pain in the ED.
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Affiliation(s)
- Shannon Lovett
- Department of Emergency Medicine Loyola University ChicagoStritch School of Medicine Maywood Illinois USA
| | - Trent Reed
- Department of Emergency Medicine Loyola University ChicagoStritch School of Medicine Maywood Illinois USA
- Department of Medical Education Loyola University ChicagoStritch School of Medicine Maywood Illinois USA
| | - Robert Riggs
- Department of Emergency Medicine Loyola University ChicagoStritch School of Medicine Maywood Illinois USA
| | - George Lew
- Department of Emergency Medicine Loyola University ChicagoStritch School of Medicine Maywood Illinois USA
| | - Erica Koch
- Department of Emergency Medicine Vanderbilt University Medical Center Nashville Tennessee USA
| | - Ramon A. Durazo‐Arvizu
- School of Health Sciences and Public Health Loyola University Chicago Maywood Illinois USA
| | - Megan A. Rech
- Department of Emergency Medicine Loyola University ChicagoStritch School of Medicine Maywood Illinois USA
- Department of Pharmacy Loyola University Medical Center Maywood Illinois USA
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14
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Gupta R, Boehmer S, Giampetro D, Gupta A, DeFlitch CJ. Effect of a Prescription Drug Monitoring Program on Emergency Department Opioid Prescribing. West J Emerg Med 2021; 22:756-762. [PMID: 34125057 PMCID: PMC8202985 DOI: 10.5811/westjem.2021.1.49652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 01/30/2021] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Our goal was to determine whether implementation of a prescription drug monitoring program (PDMP) altered emergency department (ED) opioid prescription rates overall and in patients of different pain severities. METHODS We conducted this single-center, retrospective review at an academic ED. The study examined patients discharged from the ED who received opioid prescriptions, before and after the state's implementation of a PDMP (August 25, 2016). The monthly rate was a ratio of the patients given ≥ 1 opioid prescription to the ED patients with a numeric pain rating scale (NPRS) > 0. We performed an interrupted time series analysis on each demographic. RESULTS The overall ED opioid prescription rate decreased from 51.3% (95% confidence interval [Cl], 50.4%-52.2%) to 47.9% (95% Cl, 47.0%-48.7%). For males, this decreased from 51.1% to 46.7% (P < 0.0001), while in females it did not significantly change (51.6% to 49.7% [P = 0.0529]). For those with mild pain, the rate increased from 27.5% to 34.3% (P < 0.0001), while for those with moderate pain, it did not significantly change (42.8% to 43.5% [P = 0.5924]). For those with severe pain, the rate decreased from 66.1% to 59.6% (P < 0.0001). CONCLUSION We found that PDMP implementation was associated with an overall decrease in opioid prescription rates, and that patients with mild pain were prescribed opioids more often while severe pain patients were prescribed opioids less often.
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Affiliation(s)
- Rahul Gupta
- Penn State College of Medicine, Hershey, Pennsylvania
| | - Sue Boehmer
- Penn State Hershey Medical Center, Department of Public Health Services, Division of Biostatistics, Hershey, Pennsylvania
| | - David Giampetro
- Penn State Hershey Medical Center, Department of Anesthesiology and Perioperative Medicine
| | - Anuj Gupta
- University of Texas at Dallas, Richardson, Texas
| | - Christopher J DeFlitch
- Penn State Hershey Medical Center, Department of Emergency Medicine, Hershey, Pennsylvania
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15
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Piper BJ, McCall KL, Kogan LR, Hellyer P. Assessment of Controlled Substance Distribution to U.S. Veterinary Teaching Institutions From 2006 to 2019. Front Vet Sci 2020; 7:615646. [PMID: 33392300 PMCID: PMC7775551 DOI: 10.3389/fvets.2020.615646] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 11/24/2020] [Indexed: 11/13/2022] Open
Abstract
Objective: To evaluate the changing pattern of distribution of Schedule II and III opioids, barbiturates, and stimulants to veterinary educational institutions in the United States. Design: Longitudinal study. Sample: Veterinary teaching institutions that use Schedule II and III drugs. Procedures: Distribution of controlled substances to veterinary teaching institutions was obtained from the Drug Enforcement Administration's Automated Reports and Consolidated Orders System (ARCOS) for opioids (e.g., methadone, fentanyl, codeine), barbiturates (pentobarbital, butalbital), and stimulants (amphetamine, methylphenidate, lisdexamfetamine) from 2006–2019. Opioids were converted to their morphine milligram equivalents (MME) for evaluation over time. Results: Controlled substance distribution to veterinary schools exhibited dynamic, and agent specific, changes. The total MME for 11 opioids peaked in 2013 and decreased by 17.3% in 2019. Methadone accounted for two-fifths (42.3%) and fentanyl over one-third (35.4%) of the total MME in 2019. Pentobarbital distribution was greatest by weight of all substances studied and peaked in 2011 at 69.4 kg. Stimulants underwent a pronounced decline and were very modest by 2014. Conclusions and Clinical Relevance: Opioids by total MME in veterinary teaching practice have undergone more modest changes than opioids used with humans. Hydrocodone, codeine and recently fentanyl use have declined while methadone increased. Stimulant distribution decreased to become negligible. Together, this pattern of findings warrant continued monitoring.
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Affiliation(s)
- Brian J Piper
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, PA, United States.,Center for Pharmacy Innovation and Outcomes, Geisinger Precision Health Center, Forty Fort, PA, United States
| | - Kenneth L McCall
- Department of Pharmacy Practice, University of New England, Portland, ME, United States
| | - Lori R Kogan
- Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, CO, United States
| | - Peter Hellyer
- Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, CO, United States
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16
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Kominsky HD, Rose J, Lehman A, Palettas M, Posid T, Caterino JM, Knudsen BE, Sourial MW. Trends in Acute Pain Management for Renal Colic in the Emergency Department at a Tertiary Care Academic Medical Center. J Endourol 2020; 34:1195-1202. [PMID: 32668985 DOI: 10.1089/end.2020.0402] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Introduction: Renal colic secondary to kidney stone disease is a common reason for emergency department (ED) visits and often leads to patients receiving narcotic medications. The objective of this study was to describe longitudinal analgesia prescribing patterns for kidney stone patients acutely managed in the ED. Methods: This was a retrospective chart review of patients who presented to the ED between 2013 and 2018 and were subsequently diagnosed with a kidney stone. Encounters during which opioids and nonopioids were administered in the ED and prescribed at discharge were stratified by year, race, ethnicity, insurance status, gender, and location of ED (main academic campus and community-based campus). Patients were excluded if they required hospital admission or a stone-related procedure related to the ED encounter. Results: We reviewed 1620 total encounters for 1376 unique patients. Frequency of patients receiving opioids in the ED decreased from 81% in 2013 to 57% in 2018 (p < 0.001). During the same time period, nonopioid administration in the ED remained relatively unchanged (64% vs 67%). The proportion of patients prescribed opioids at discharge decreased from 77% to 59% (p < 0.001), while nonopioid prescriptions at discharge increased from 32% to 41% (p = 0.010). Frequency of administering both a narcotic and non-narcotic during the same ED encounter decreased over the 5-year period from 27% to 8% (p < 0.001). Conclusion: Opioids are being given less both during the ED encounter and at discharge for acute renal colic, while nonopioid prescribing is increasing. These trends may be due to increasing physician awareness to opioid addiction, or as a result of stricter legislation prohibiting opioid prescribing.
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Affiliation(s)
- Hal D Kominsky
- Department of Urology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Justin Rose
- Department of Urology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Amy Lehman
- Department of Biomedical Informatics, Center for Biostatistics, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Marilly Palettas
- Department of Biomedical Informatics, Center for Biostatistics, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Tasha Posid
- Department of Urology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Jeffrey M Caterino
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Bodo E Knudsen
- Department of Urology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Michael W Sourial
- Department of Urology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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