1
|
Moe J, Koh J, Ma JA, Pei LX, MacLean E, Keech J, Maguire K, Ronsley C, Doyle-Waters MM, Brubacher JR. Screening for harmful substance use in emergency departments: a systematic review. Int J Emerg Med 2024; 17:52. [PMID: 38584266 PMCID: PMC11000386 DOI: 10.1186/s12245-024-00616-2] [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: 09/24/2023] [Accepted: 03/15/2024] [Indexed: 04/09/2024] Open
Abstract
BACKGROUND Substance use-related emergency department (ED) visits have increased substantially in North America. Screening for substance use in EDs is recommended; best approaches are unclear. This systematic review synthesizes evidence on diagnostic accuracy of ED screening tools to detect harmful substance use. METHODS We included derivation or validation studies, with or without comparator, that included adult (≥ 18 years) ED patients and evaluated screening tools to identify general or specific substance use disorders or harmful use. Our search strategy combined concepts Emergency Department AND Screening AND Substance Use. Trained reviewers assessed title/abstracts and full-text articles for inclusion, extracted data, and assessed risk of bias (QUADAS-2) independently and in duplicate. Reviewers resolved disagreements by discussion. Primary investigators adjudicated if necessary. Heterogeneity precluded meta-analysis. We descriptively summarized results. RESULTS Our search strategy yielded 2696 studies; we included 33. Twenty-one (64%) evaluated a North American population. Fourteen (42%) applied screening among general ED patients. Screening tools were administered by research staff (n = 21), self-administered by patients (n = 10), or non-research healthcare providers (n = 1). Most studies evaluated alcohol use screens (n = 26), most commonly the Alcohol Use Disorders Identification Test (AUDIT; n = 14), Cut down/Annoyed/Guilty/Eye-opener (CAGE; n = 13), and Rapid Alcohol Problems Screen (RAPS/RAPS4/RAPS4-QF; n = 12). Four studies assessing six tools and screening thresholds for alcohol abuse/dependence in North American patients (AUDIT ≥ 8; CAGE ≥ 2; Diagnostic and Statistical Manual of Mental Disorders, 4th Edition [DSM-IV-2] ≥ 1; RAPS ≥ 1; National Institute on Alcohol Abuse and Alcoholism [NIAAA]; Tolerance/Worry/Eye-opener/Amnesia/K-Cut down [TWEAK] ≥ 3) reported both sensitivities and specificities ≥ 83%. Two studies evaluating a single alcohol screening question (SASQ) (When was the last time you had more than X drinks in 1 day?, X = 4 for women; X = 5 for men) reported sensitivities 82-85% and specificities 70-77%. Five evaluated screening tools for general substance abuse/dependence (Relax/Alone/Friends/Family/Trouble [RAFFT] ≥ 3, Drug Abuse Screening Test [DAST] ≥ 4, single drug screening question, Alcohol, Smoking and Substance Involvement Screening Test [ASSIST] ≥ 42/18), reporting sensitivities 64%-90% and specificities 61%-100%. Studies' risk of bias were mostly high or uncertain. CONCLUSIONS Six screening tools demonstrated both sensitivities and specificities ≥ 83% for detecting alcohol abuse/dependence in EDs. Tools with the highest sensitivities (AUDIT ≥ 8; RAPS ≥ 1) and that prioritize simplicity and efficiency (SASQ) should be prioritized.
Collapse
Affiliation(s)
- Jessica Moe
- Department of Emergency Medicine, University of British Columbia, Diamond Health Care Centre, 11 Floor - 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada.
| | - Justin Koh
- Department of Emergency Medicine, Queen's University, Kingston Health Sciences Centre, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada
| | - Jennifer A Ma
- Department of Emergency Medicine, University of Manitoba, S203 Medical Sciences Building, 750 Bannatyne Avenue, Winnipeg, MB, R3E 0W2, Canada
| | - Lulu X Pei
- Department of Emergency Medicine, University of British Columbia, Diamond Health Care Centre, 11 Floor - 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
| | - Eleanor MacLean
- Department of Emergency Medicine, University of British Columbia, Diamond Health Care Centre, 11 Floor - 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
| | - James Keech
- School of Medicine, Queen's University, 15 Arch Street, Kingston, ON, K7L 3N6, Canada
| | - Kaitlyn Maguire
- Department of Emergency Medicine, University of British Columbia, Diamond Health Care Centre, 11 Floor - 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
| | - Claire Ronsley
- Department of Emergency Medicine, University of British Columbia, Diamond Health Care Centre, 11 Floor - 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
| | - Mary M Doyle-Waters
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, 7th Floor, 828 West 10th Avenue, Research Pavilion, Vancouver, BC, V5Z 1M9, Canada
| | - Jeffrey R Brubacher
- Department of Emergency Medicine, University of British Columbia, Diamond Health Care Centre, 11 Floor - 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
| |
Collapse
|
2
|
Holkenborg J, Frenken BA, Bon BVDKV, Vroegop MP, Van Meggelen MGM, Kramers C, Schellekens AFA, Kraaijvanger N. The prevalence of prescription opioid use and misuse among emergency department patients in The Netherlands. J Eval Clin Pract 2024; 30:473-480. [PMID: 38251860 DOI: 10.1111/jep.13965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 12/06/2023] [Accepted: 12/31/2023] [Indexed: 01/23/2024]
Abstract
RATIONALE Prescription opioid use and misuse have increased rapidly in many Western countries in the past decade. Patients (mis)using opioids are at risk of presenting to the emergency department (ED) with opioid-related problems. European data concerning prescription opioid (mis)use among the ED population is lacking. AIMS AND OBJECTIVES This study aims to determine prevalence of prescription opioid use, misuse, and opioid use disorder (OUD) among Dutch ED patients. Secondary objectives were to explore factors associated with prescription opioid misuse and the number of patients discharged with a new opioid prescription. METHODS In a cross-sectional multicenter study at three hospitals in the Netherlands, adult ED patients were screened for current prescription opioid use. Opioid users filled out questionnaires regarding opioid (mis)use, and underwent a structured interview to assess OUD criteria. The primary outcomes were prevalence rates of (1) current prescription opioid use, (2) prescription opioid misuse (based on a Current Opioid Misuse Measure [COMM] score > 8), (3) OUD, based on DSM-5 criteria. Independent T-tests, Pearson χ2 and Fisher's Exact tests were used to analyse differences in characteristics between groups. RESULTS A total of 997 patients were screened, of which 15% (n = 150) used prescription opioids. Out of 93 patients assessed, 22.6% (n = 21) showed signs of prescription opioid misuse, and 9.8% (n = 9, 95% CI: 4.5-17.8) fulfilled criteria for OUD. A medical history of psychiatric disorder was significantly more common in patients with prescription opioid misuse and OUD. CONCLUSION This study shows that prescription opioid use is relatively common in ED patients in the Netherlands, compared to the overall population. Over one fifth of these patients shows signs of opioid misuse or OUD. Awareness among ED personnel about the high prevalence of prescription opioid (mis)use in their population is critical for signalling opioid-related problems.
Collapse
Affiliation(s)
- Joris Holkenborg
- Emergency Department, Rijnstate Hospital, Arnhem, The Netherlands
| | | | | | - Maurice P Vroegop
- Emergency Department, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Cees Kramers
- Department of Pharmacology-Toxicology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Arnt F A Schellekens
- Nijmegen Institute for Science Practitioners in Addiction (NISPA), Nijmegen, The Netherlands
- Department of Psychiatry, Radboud University Medical Center, Nijmegen, The Netherlands
| | | |
Collapse
|
3
|
Yusufov M, Pirl WF, Braun I, Sannes T, McHugh RK. Toward a Psychological Model of Chemical Coping with Opioids in Cancer Care. Harv Rev Psychiatry 2023; 31:259-266. [PMID: 37948154 PMCID: PMC11060627 DOI: 10.1097/hrp.0000000000000384] [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] [Indexed: 11/12/2023]
Abstract
LEARNING OBJECTIVES AFTER PARTICIPATING IN THIS CME ACTIVITY, THE PSYCHIATRIST SHOULD BE BETTER ABLE TO • Outline the risk factors involved with opioid accessibility in patients receiving treatment for cancer.• Identify factors to address in order to mitigate risk for opioid misuse during cancer care. ABSTRACT Most patients with advanced cancer receive treatment for related pain. Opioid accessibility, however, is a risk factor for misuse, which can present care challenges and quality-of-life concerns. There is a lack of consistent universal screening prior to initiation of opioid prescribing. One crucial issue in treating this population is adequately identifying and mitigating risk factors driving opioid misuse. Drawing on theory and research from addiction science, psychology, palliative care, and oncology, the presented conceptual framework suggests that risk factors for opioid misuse during cancer care can be stratified into historical, current, malleable, and unmalleable factors. The framework identifies necessary factors to address in order to mitigate risk for opioid misuse during cancer care, and offers key directions for future research.
Collapse
Affiliation(s)
- Miryam Yusufov
- Dana-Farber Cancer Institute, Department of Psychosocial Oncology & Palliative Care, 450 Brookline Avenue, Boston, MA 02215
- Harvard Medical School, Boston, MA 02115
| | - William F. Pirl
- Dana-Farber Cancer Institute, Department of Psychosocial Oncology & Palliative Care, 450 Brookline Avenue, Boston, MA 02215
- Harvard Medical School, Boston, MA 02115
| | - Ilana Braun
- Dana-Farber Cancer Institute, Department of Psychosocial Oncology & Palliative Care, 450 Brookline Avenue, Boston, MA 02215
- Harvard Medical School, Boston, MA 02115
| | - Timothy Sannes
- Dana-Farber Cancer Institute, Department of Psychosocial Oncology & Palliative Care, 450 Brookline Avenue, Boston, MA 02215
- Harvard Medical School, Boston, MA 02115
| | - R. Kathryn McHugh
- McLean Hospital, Center of Excellence in Alcohol, Drugs, and Addiction, 115 Mill Street, Belmont, MA 02478
- Harvard Medical School, Boston, MA 02115
| |
Collapse
|
4
|
Caplan M, Friedman BW, Siebert J, Takematsu M, Adewunmi V, Gupta C, White DJ, Irizarry E. Use of clinical phenotypes to characterize emergency department patients administered intravenous opioids for acute pain. Clin Exp Emerg Med 2023; 10:327-332. [PMID: 37092185 PMCID: PMC10579725 DOI: 10.15441/ceem.23.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/30/2023] [Accepted: 03/31/2023] [Indexed: 04/25/2023] Open
Abstract
OBJECTIVE Individual experience with opioids is highly variable. Some patients with acute pain do not experience pain relief with opioids, and many report no euphoria or dysphoric reactions. In this study, we describe the clinical phenotypes of patients who receive intravenous opioids. METHODS This was an emergency department-based study in which we enrolled patients who received an intravenous opioid. We collected 0 to 10 pain scores prior to opioid administration and 15 minutes after. We also used 0 to 10 instruments to determine how high and how much euphoria the patient felt after receipt of the opioid. Using a cutoff point of ≥50% improvement in pain and the median score on the high and euphoria scales, we assigned each participant to one of the following clinical phenotypes: pain relief with feeling high or euphoria, pain relief without feeling high or euphoria, inadequate relief with feeling high or euphoria, and inadequate relief without feeling high or euphoria. RESULTS A total of 713 patients were enrolled, 409 (57%) of whom reported not feeling high, and 465 (65%) reported no feeling of euphoria. Median percent improvement in pain was 37.5% (interquartile range, 12.5%-60.0%). One hundred seventy-eight participants (25%) were classified as experiencing pain relief with euphoria or feeling high, 190 (27%) experienced inadequate relief with euphoria or feeling high, 101 (14%) experienced pain relief without euphoria or feeling high, and 244 (34%) reported inadequate relief without euphoria or feeling high. CONCLUSION Among patients who receive intravenous opioids in the emergency department, the experiences of pain relief and euphoria are highly variable. For many, pain relief is independent of feeling high.
Collapse
Affiliation(s)
- Mordechai Caplan
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Benjamin W. Friedman
- Department of Emergency Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jason Siebert
- Department of Emergency Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Mai Takematsu
- Department of Emergency Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Victoria Adewunmi
- Department of Emergency Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Chiraag Gupta
- Department of Emergency Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Deborah J. White
- Department of Emergency Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Eddie Irizarry
- Department of Emergency Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| |
Collapse
|
5
|
Abstract
Efforts to minimize the impact of prescribed opioids on future adverse outcomes are reliant on emergency care providers' ability to screen and detect opioid use disorder (OUD). Many prescriptions are initiated in the emergency department (ED) for acute pain; thus, validated measures are especially needed. Our systematic review describes the available opioid-related screening measures identified through search of the available literature. Measures were categorized by intent and applied clinical setting. We found 44 articles, identifying 15 screening measures. Of these, nine were developed to screen for current opioid misuse and five to screen for risk of future opioid misuse. None were created for use outside of a chronic pain setting. Many measures were applied differently from intended purpose. Although several measures are available, screening for adverse opioid outcomes in the ED is hampered by lack of validated instruments. Development of clarified conceptual models and ED-specific research is necessary to limit OUD.
Collapse
|
6
|
Bailey J, Nafees S, Jones L, Poole R. Rationalisation of long-term high-dose opioids for chronic pain: development of an intervention and conceptual framework. Br J Pain 2021; 15:326-334. [PMID: 34381614 PMCID: PMC8339941 DOI: 10.1177/2049463720958731] [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] [Indexed: 11/17/2022] Open
Abstract
There has been a large increase in the number of prescriptions for opioid drugs in the United Kingdom over the last 20 years or more and the prescribing of opioids in high doses continues to increase. Much opioid prescribing is for chronic non-cancer pain (CNCP) despite serious doubts about the long-term effectiveness of opioids for this indication. Clinical experience is that there are increasing numbers of patients who are on high dosages of opioid drugs over sustained periods which provide limited or no pain relief while having significant negative effects on functioning and quality of life. The aim of this article is to bring readers' attention to some clinical observations of the CNCP population with high doses and to describe an intervention to reduce these doses. Many of these patients have no clinical features of addiction; we suggest that those who show little or no substance misuse behaviours are best understood as a distinct clinical population who have different treatment needs. In order to understand and treat these patients, a model is required which, rather than seeing the problem as lying solely with the patient, focuses on the interaction between the individual and his or her environment and seeks a change in what the patient does every day, rather than a simple, and largely unattainable, goal of symptom elimination. The clinician authors worked together to develop an intervention based upon approaches taken from both pain management and psychiatric practice. A detailed description of this rapid opioid reduction intervention (RORI) is provided along with some preliminary outcome data.
Collapse
Affiliation(s)
- John Bailey
- Centre for Mental Health and
Society, Bangor University, Wrexham, UK
| | - Sadia Nafees
- Centre for Mental Health and
Society, Bangor University, Wrexham, UK
| | - Lucy Jones
- Betsi Cadwaladr University Health
Board, Wrexham, UK
| | - Rob Poole
- Centre for Mental Health and
Society, Bangor University, Wrexham, UK
- Betsi Cadwaladr University Health
Board, Wrexham, UK
| |
Collapse
|
7
|
Levy N, Quinlan J, El-Boghdadly K, Fawcett WJ, Agarwal V, Bastable RB, Cox FJ, de Boer HD, Dowdy SC, Hattingh K, Knaggs RD, Mariano ER, Pelosi P, Scott MJ, Lobo DN, Macintyre PE. An international multidisciplinary consensus statement on the prevention of opioid-related harm in adult surgical patients. Anaesthesia 2021; 76:520-536. [PMID: 33027841 DOI: 10.1111/anae.15262] [Citation(s) in RCA: 87] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2020] [Indexed: 01/01/2023]
Abstract
This international multidisciplinary consensus statement was developed to provide balanced guidance on the safe peri-operative use of opioids in adults. An international panel of healthcare professionals evaluated the literature relating to postoperative opioid-related harm, including persistent postoperative opioid use; opioid-induced ventilatory impairment; non-medical opioid use; opioid diversion and dependence; and driving under the influence of prescription opioids. Recommended strategies to reduce harm include pre-operative assessment of the risk of persistent postoperative opioid use; use of an assessment of patient function rather than unidimensional pain scores alone to guide adequacy of analgesia; avoidance of long-acting (modified-release and transdermal patches) opioid formulations and combination analgesics; limiting the number of tablets prescribed at discharge; providing deprescribing advice; avoidance of automatic prescription refills; safe disposal of unused medicines; reducing the risk of opioid diversion; and better education of healthcare professionals, patients and carers. This consensus statement provides a framework for better prescribing practices that could help reduce the risk of postoperative opioid-related harm in adults.
Collapse
Affiliation(s)
- N Levy
- Department of Anaesthesia and Peri-operative Medicine, West Suffolk Hospital, Bury St. Edmunds, UK
| | - J Quinlan
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - K El-Boghdadly
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK
- King's College London, London, UK
| | - W J Fawcett
- Department of Anaesthesia and Pain Medicine, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - V Agarwal
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | | | - F J Cox
- Pain Management Service, Critical Care and Anaesthesia, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - H D de Boer
- Department of Anaesthesiology, Pain Medicine and Procedural Sedation and Analgesia, Martini General Hospital Groningen, Groningen, The Netherlands
| | - S C Dowdy
- Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN, USA
| | - K Hattingh
- Bendigo Health, Bendigo, Victoria, Australia
| | - R D Knaggs
- School of Pharmacy, Pain Centre Versus Arthritis, University of Nottingham, Nottingham, UK
| | - E R Mariano
- Department of Anesthesiology, Peri-operative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Anesthesiology and Peri-operative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - P Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
- IRCCS for Oncology and Neurosciences, San Martino Policlinico Hospital, Genoa, Italy
| | - M J Scott
- Anesthesiology and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - D N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
- David Greenfield Metabolic Physiology Unit, MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - P E Macintyre
- Department of Anaesthesia, Pain Medicine and Hyperbaric Medicine, Royal Adelaide Hospital and University of Adelaide, Adelaide, South Australia, Australia
| |
Collapse
|
8
|
Emergency physician risk assessment practices prior to prescribing opioids. CAN J EMERG MED 2021; 23:351-355. [PMID: 33523388 DOI: 10.1007/s43678-020-00066-8] [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: 07/29/2020] [Accepted: 12/11/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Safer opioid prescribing remains a crucial issue for emergency physicians. Policy statements and guidelines recommend deliberate risk assessment for likelihood of current or future opioid use disorder prior to prescribing opioids. However, the practice patterns of emergency physicians remain underreported. METHODS We surveyed emergency physicians across Canada about their local opioid prescribing policies, their practice patterns of risk assessment prior to prescribing opioids, and which clinical risk factors they find most important. RESULTS The response rate was 20.4% (n = 312/1532). 59.8% of respondents report usually or always assessing for risk. Physicians rely on gestalt (80.3%), targeted histories based on risk factors in the literature (55.6%) or their experience (57.6%), and reviewing medical (83.1%) and medication records (75.6%). Contacting primary prescribers is uncommon (16.3%). A minority routinely use opioid prescribing risk assessment tools (6.4%), have local opioid prescribing policies (27%), or make use of electronic medical record functions to assist risk stratifying (2.4%). CONCLUSION Many Canadian emergency physicians make risk assessments based on gestalt rather than identifying literature-based risk factors. This conflicts with guidelines calling for routine comprehensive assessment. Further efforts should be directed towards education in optimizing risk assessment; and towards system-level initiatives such as clear local prescribing policies, electronic-systems functionality, and developing assessment tools for use in the ED.
Collapse
|
9
|
Jonassaint CR. If you Can't Assess It, How Can you Treat It? Improving Pain Management in Sickle Cell Disease. J Emerg Nurs 2021; 47:10-15. [PMID: 33390216 DOI: 10.1016/j.jen.2020.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 10/28/2020] [Indexed: 02/06/2023]
|
10
|
Delcher C, Pauly N, Moyo P. Advances in prescription drug monitoring program research: a literature synthesis (June 2018 to December 2019). Curr Opin Psychiatry 2020; 33:326-333. [PMID: 32250984 PMCID: PMC7409839 DOI: 10.1097/yco.0000000000000608] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW Nearly every U.S. state operates a prescription drug monitoring program (PDMP) to monitor dispensing of controlled substances. These programs are often considered key policy levers in the ongoing polydrug epidemic. Recent years have seen rapid growth of peer-reviewed literature examining PDMP consultation and the impacts of these programs on diverse patient populations and health outcomes. This literature synthesis presents a review of studies published from June 2018 to December 2019 and provides relevant updates from the perspective of three researchers in this field. RECENT FINDINGS The analyzed studies were primarily distributed across three overarching research focus areas: outcome evaluations (n = 29 studies), user surveys (n = 23), and surveillance (n = 22). Identified themes included growing awareness of the unintended consequences of PDMPs on access to opioids, effects on benzodiazepines and stimulant prescribing, challenges with workflow integration across multiple specialties, and new opportunities for applied data science. SUMMARY There is a critical gap in existing PDMP literature assessing how these programs have impacted psychiatrists, their prescribing behaviors, and their patients. Although PDMPs have improved population-level monitoring of controlled substances from medical sources, their role in responding to a drug epidemic shifting to illicitly manufactured drugs is under scrutiny.
Collapse
Affiliation(s)
- Chris Delcher
- Institute for Pharmaceutical Outcomes and Policy, University of Kentucky College of Pharmacy, Lexington, Kentucky
| | - Nathan Pauly
- Department of Health Policy Management and Leadership, West Virginia University School of Public Health, Morgantown, West Virginia
| | - Patience Moyo
- Department of Health Services, Policy, and Practice, Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| |
Collapse
|
11
|
Friedman BW, Ochoa LA, Naeem F, Perez HR, Starrels JL, Irizarry E, Chertoff A, Bijur PE, Gallagher EJ. Opioid Use During the Six Months After an Emergency Department Visit for Acute Pain: A Prospective Cohort Study. Ann Emerg Med 2020; 75:578-586. [PMID: 31685253 PMCID: PMC7188578 DOI: 10.1016/j.annemergmed.2019.08.446] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 08/16/2019] [Accepted: 08/22/2019] [Indexed: 10/25/2022]
Abstract
STUDY OBJECTIVE Despite the frequent use of opioids to treat acute pain, the long-term risks and analgesic benefits of an opioid prescription for an individual emergency department (ED) patient with acute pain are still poorly understood and inadequately quantified. Our objective was to determine the frequency of recurrent or persistent opioid use during the 6 months after the ED visit METHODS: This was a prospective, observational cohort study of opioid-naive patients presenting to 2 EDs for acute pain who were prescribed an opioid at discharge. Patients were followed by telephone 6 months after the ED visit. Additionally, we reviewed the statewide prescription monitoring program database. Outcomes included frequency of recurrent and persistent opioid use and frequency of persistent moderate or severe pain 6 months after the ED visit. Persistent opioid use was defined as filling greater than or equal to 6 prescriptions during the 6-month study period. RESULTS During 9 months beginning in November 2017, 733 patients were approached for participation. Four hundred eighty-four met inclusion criteria and consented to participate. Four hundred ten patients (85%) provided 6-month telephone data. The prescription monitoring database was reviewed for all 484 patients (100%). Most patients (317/484, 66%; 95% confidence interval 61% to 70%) filled only the initial prescription they received in the ED. One in 5 patients (102/484, 21%; 95% confidence interval 18% to 25%) filled at least 2 prescriptions within the 6-month period. Five patients (1%; 95% confidence interval 0% to 2%) met criteria for persistent opioid use. Of these 5 patients, all but 1 reported moderate or severe pain in the affected body part 6 months later. CONCLUSION Although 1 in 5 opioid-naive ED patients who received an opioid prescription for acute pain on ED discharge filled at least 2 opioid prescriptions in 6 months, only 1% had persistent opioid use. These patients with persistent opioid use were likely to report moderate or severe pain 6 months after the ED visit.
Collapse
Affiliation(s)
- Benjamin W Friedman
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY.
| | - Lorena Abril Ochoa
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
| | - Farnia Naeem
- Medical College, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
| | - Hector R Perez
- Division of General Internal Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
| | - Joanna L Starrels
- Division of General Internal Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
| | - Eddie Irizarry
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
| | - Andrew Chertoff
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
| | - Polly E Bijur
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
| | - E John Gallagher
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
| |
Collapse
|
12
|
Strayer RJ, Hawk K, Hayes BD, Herring AA, Ketcham E, LaPietra AM, Lynch JJ, Motov S, Repanshek Z, Weiner SG, Nelson LS. Management of Opioid Use Disorder in the Emergency Department: A White Paper Prepared for the American Academy of Emergency Medicine. J Emerg Med 2020; 58:522-546. [DOI: 10.1016/j.jemermed.2019.12.034] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 12/19/2019] [Accepted: 12/24/2019] [Indexed: 11/28/2022]
|
13
|
Macintyre PE, Roberts LJ, Huxtable CA. Management of Opioid-Tolerant Patients with Acute Pain: Approaching the Challenges. Drugs 2019; 80:9-21. [DOI: 10.1007/s40265-019-01236-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
|
14
|
Wilson MP, Cucciare MA, Porter A, Chalmers CE, Mullinax S, Mancino M, Oliveto AH. The utility of a statewide prescription drug-monitoring database vs the Current Opioid Misuse Measure for identifying drug-aberrant behaviors in emergency department patients already on opioids. Am J Emerg Med 2019; 38:503-507. [PMID: 31221474 DOI: 10.1016/j.ajem.2019.05.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 05/07/2019] [Accepted: 05/16/2019] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The most recent guidelines on prescribing opioids from the United States Centers for Disease Control recommend that clinicians not prescribe opioids as first-line therapy for chronic non-cancer pain. If an opioid prescription is considered for a patient already on opioids, prescribers are encouraged to check the statewide prescription drug monitoring database (PDMP). Some additional guidelines recommend screening tools such as the Current Opioid Misuse Measure (COMM) which may also help identify drug-aberrant behaviors. OBJECTIVE To compare the PDMP and the Current Opioid Misuse Measure (COMM), a commonly-recommended screening tool for patients on opioids, in detecting drug-aberrant behaviors in patients already taking opioids at the time of ED presentation. METHODS Patients on opioids were enrolled prospectively in a mixed urban-suburban ED seeing approximately 65,000 patients per year. The sensitivity, specificity, likelihood ratios, and diagnostic odds ratios of the PDMP and COMM were compared against objective criteria of drug-aberrant behaviors as documented in the electronic medical record (EMR) and medical examiner databases. RESULTS Compared to the COMM, the PDMP had similar sensitivity (36% vs 45%) and similar specificity (79% vs 55%), but better positive predictive value, better negative predictive value, and better diagnostic odds ratio. The combination of the PDMP and the COMM did not improve the detection of drug-aberrant behaviors. CONCLUSIONS The PDMP alone is a more useful as a screening instrument than either the COMM or the combination of the PDMP plus COMM in patients already taking opioids at time of ED presentation. However, the PDMP misses a majority of patients with documented drug-aberrant behaviors in the EMR, and should not be used in isolation to justify whether a particular opioid prescription is appropriate.
Collapse
Affiliation(s)
- Michael P Wilson
- Division of Research and Evidence-Based Medicine, Department of Emergency Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America; Department of Emergency Medicine Behavioral Emergencies Research (DEMBER) lab, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America; Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America.
| | - Michael A Cucciare
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America; VA South Central Mental Illness Research, Education, and Clinical Center, Central Arkansas Veterans Healthcare System, North Little Rock, AR 72205 USA; Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Affairs Healthcare System, North Little Rock, AR 72205 USA
| | - Austin Porter
- College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America; Arkansas Department of Health, Little Rock, AR, United States of America
| | - Christen E Chalmers
- School of Medicine, University of California, Irvine, United States of America
| | - Samuel Mullinax
- Department of Emergency Medicine Behavioral Emergencies Research (DEMBER) lab, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Michael Mancino
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Alison H Oliveto
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| |
Collapse
|