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Ajumobi O, Friedman S, Westhoff J, Granner M, Lucero J, Koch B, Wagner KD. Age and racial and ethnic disparities in filled buprenorphine prescriptions post-emergency department visit in Nevada. J Am Coll Emerg Physicians Open 2024; 5:e13272. [PMID: 39247155 PMCID: PMC11377888 DOI: 10.1002/emp2.13272] [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: 02/03/2024] [Revised: 07/16/2024] [Accepted: 08/02/2024] [Indexed: 09/10/2024] Open
Abstract
Objectives We described age, gender, race, and ethnicity associations with filling buprenorphine prescriptions post-emergency department (post-ED) visits. Methods We analyzed 1.5 years (July 1, 2020-December 31, 2021) of encounter-level Medicaid ED and retail pharmacy claims data obtained from the Nevada Department of Health and Human Services. We studied ED patients with an opioid use disorder (OUD) diagnosis who did not fill a prescription for OUD medications within 6 months before the ED encounter. Using logistic regression, we modeled the associations between the patient's demographic characteristics and the outcome, filling a buprenorphine prescription at a community pharmacy within 14 or 30 days of the ED encounter. Results Among 2781 ED visits, representing 2094 patients, the median age was 39 years, 54% were male, 18.5% were Black, 11.7% were Hispanic, and 62.3% were White. Only 4% of the ED visits were followed by a filled buprenorphine prescription. Increasing age (14-day window: adjusted odds ratio (aOR) = 0.965, 95% confidence interval [CI]: 0.948-0.983) and being a Black patient (14-day window: aOR: 0.114, 95% CI 0.036-0.361) were both associated with lower odds of filled buprenorphine prescriptions. These results were similar within 30 days of an ED visit. Conclusions Initiation of buprenorphine following an ED visit remains low among Nevadan Medicaid patients and is less likely with increasing age and among Black patients, despite strong evidence supporting its use. Overburdened EDs, lack of attention from managers, and substance use stigma are among possible explanations. When ED clinicians do write buprenorphine prescriptions, peer recovery support could increase the fill rates.
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Affiliation(s)
- Olufemi Ajumobi
- School of Public Health University of Nevada Reno Nevada USA
- North Carolina Department of Health and Human Services Raleigh North Carolina USA
- Present address: Oak Ridge Institute for Science and Education United States Department of Energy Oak Ridge Tennessee USA
| | - Sarah Friedman
- School of Public Health University of Nevada Reno Nevada USA
| | - John Westhoff
- Department of Internal Medicine University of Nevada Reno School of Medicine Reno Nevada USA
| | | | - Julie Lucero
- College of Health University of Utah Salt Lake City Utah USA
| | - Brandon Koch
- College of Public Health The Ohio State University Columbus Ohio USA
| | - Karla D Wagner
- School of Public Health University of Nevada Reno Nevada USA
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Lambert J, Petrovitch D, Himes KP, Freiermuth CE, Braun RS, Brown JL, Bischof JJ, Lyons MS, Punches BE, Littlefield AK, Kisor DF, Sprague JE. Association of genetic variants in CYP3A5, DRD2 and NK1R with opioid overdose. Chem Biol Interact 2024; 403:111242. [PMID: 39265714 DOI: 10.1016/j.cbi.2024.111242] [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: 05/22/2024] [Revised: 08/29/2024] [Accepted: 09/10/2024] [Indexed: 09/14/2024]
Abstract
In 2023, 3651 Ohioans died because of an opioid overdose. Of those opioid overdoses, 3579 (98%) of which were attributed to fentanyl. We evaluated the association between 180 candidate single nucleotide polymorphisms (SNPs) and self-reported, nonfatal opioid overdose history from a prospective sample of 1301 adult patients (≥18 years of age) seen in three urban emergency departments in Ohio. Candidate SNPs included 120 related to the dopamine reward pathway and 60 related to pharmacokinetics. Of the 821 patients who reported having been exposed to opioids in their lifetime, 95 (11.6%) also reported having experienced an opioid-related overdose. Logistic regression, adjusting for age and biologic sex, was used to characterize the association between each SNP and opioid overdose, correcting for multiple comparisons. Three SNPs, located in three different genes were associated with opioid overdose: increased odds with CYP3A5 (rs776746) and DRD2 (rs4436578), and decreased odds with NKIR (rs6715729). Homozygotic CYP3A5 (rs776746) had the highest adjusted odds ratio (OR) of 6.96 (95% CI [2.45, 29.23]) and homozygotic NK1R (rs6715729) had the lowest OR of 0.28 (95% CI [0.14, 0.54). Given that CYP3A5 (rs776746) has been associated with increased plasma concentrations of fentanyl, rs776746 could potentially be utilized as a prognostic risk indicator for the potential of an opioid overdose. NK1R regulates the expression of the neurokinin-1 receptor, a regulator of respiration and NK1R (rs6715729) represents a novel genetic marker for a decreased risk of opioid overdose risk.
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Affiliation(s)
- Joshua Lambert
- College of Nursing, University of Cincinnati, Cincinnati, OH, USA
| | - Dan Petrovitch
- Department of Psychological Sciences, Texas Tech University, Lubbock, TX, USA
| | - Katie P Himes
- Department of Psychological Sciences, Texas Tech University, Lubbock, TX, USA
| | - Caroline E Freiermuth
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH, USA; Center for Addiction Research, University of Cincinnati, Cincinnati, OH, USA
| | - Robert S Braun
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Jennifer L Brown
- Department of Psychological Sciences, Purdue University, West Lafayette, IN, USA
| | - Jason J Bischof
- Department of Emergency Medicine, The Ohio State University, Columbus, OH, USA
| | - Michael S Lyons
- Department of Emergency Medicine, The Ohio State University, Columbus, OH, USA
| | - Brittany E Punches
- Department of Emergency Medicine, The Ohio State University, Columbus, OH, USA; College of Nursing, The Ohio State University, Columbus, OH, USA
| | | | - David F Kisor
- Department of Pharmaceutical Sciences and Pharmacogenomics, College of Pharmacy, Natural and Health Sciences, Manchester University, Fort Wayne, Indiana, USA
| | - Jon E Sprague
- The Ohio Attorney General's Center for the Future of Forensic Science, Bowling Green State University, Bowling Green, OH, USA.
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Levine M, Culbreth R, Amaducci A, Calello DP, Shulman J, Judge B, Love J, Hughes A, Schwarz ES, Carpenter J, Wax P, Aldy K, Krotulski AJ, Logan BK, Buchanan J, Brent J, Meaden CW, Hendrickson RG, Abston S, Li S, Campleman S, Manini AF. Prevalence and predictors of HIV among patients presenting to US emergency departments with opioid overdose. Drug Alcohol Depend 2024; 264:112423. [PMID: 39270332 DOI: 10.1016/j.drugalcdep.2024.112423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 08/19/2024] [Accepted: 08/20/2024] [Indexed: 09/15/2024]
Abstract
INTRODUCTION Opioid overdose deaths in the U.S. have risen dramatically in the past decade, largely due to the surge in illicitly manufactured fentanyl. Injection drug use is a known risk factor for HIV, further complicating the long-term consequences of opioid use. The baseline prevalence of HIV among adults in the US is 0.46 %. The primary purpose of this study was to determine the prevalence and risk factors of HIV among patients presenting to the emergency departments (ED) with an acute opioid overdose. METHODS This study is a prospective observational cohort study from the ToxIC Fentalog Study group. Patients age 18 years of age or older are included if they present to one of 10 participating U.S. hospitals in 9 states between September 2020 and May 2023 with a suspected opioid overdose and had waste serum available after routine laboratory testing. Clinical data is collected from the medical record and patient serum is sent for comprehensive toxicologic analysis via liquid chromatography quadrupole time-of-flight mass spectroscopy to detect the presence of over 1200 substances including illicit opioids, novel synthetic opioids, medications, and adulterants. Logistic multivariable regression was performed to examine the association between demographic, behavioral, and serum toxicology data with risk factors and HIV status. RESULTS Among the total cohort (n=1690), 1062 cases had known HIV status (62.8 % of total sample). Among patients with a known HIV status, 60 (5.6 % [95 % CI: 4.2 %, 7.0 %]) were HIV positive. Patients with HIV reported stimulant use more frequently (13.3 %) than those without HIV (6.8 %; p=0.003). After controlling for confounding, bipolar psychiatric history was a significant independent predictor of HIV positivity (aOR: 1.08; 95 % CI: 1.02, 1.13) in this population. CONCLUSIONS In this large multicenter cohort, the prevalence of HIV for ED patients with illicit opioid overdose was 9 times higher than that expected by the general population. Bipolar disorder appears to be a novel risk factor for HIV positivity in this patient population.
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Affiliation(s)
- Michael Levine
- Department of Emergency Medicine, Division of Medical Toxicology, University of California, Los Angeles, Los Angeles, CA, United States.
| | - Rachel Culbreth
- American College of Medical Toxicology, Phoenix, AZ, United States
| | - Alexandra Amaducci
- Department of Emergency Medicine, Lehigh Valley Health Network/USF Morsani College of Medicine, Allentown, PA, United States
| | - Diane P Calello
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ, United States
| | - Joshua Shulman
- Department of Emergency Medicine, Division of Medical Toxicology, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Bryan Judge
- Department of Emergency Medicine, Division of Medical Toxicology, Corewell Health, Michigan State University, Grand Rapids, MI, United States
| | - Jennifer Love
- Department of Emergency Medicine, Division of Medical Toxicology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Adrienne Hughes
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR, United States
| | - Evan S Schwarz
- Department of Emergency Medicine, Division of Medical Toxicology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Joseph Carpenter
- Division of Medical Toxicology, Emory University School of Medicine, Atlanta, GA, United States
| | - Paul Wax
- American College of Medical Toxicology, Phoenix, AZ, United States
| | - Kim Aldy
- American College of Medical Toxicology, Phoenix, AZ, United States; Department of Emergency Medicine, Baylor University Medical Center, Dallas, TX, United States
| | - Alex J Krotulski
- Center for Forensic Science Research and Education, Fredric Rieders Family Foundation, Horsham, PA, United States
| | - Barry K Logan
- Center for Forensic Science Research and Education, Fredric Rieders Family Foundation, Horsham, PA, United States; NMS Labs, Horsham, PA, United States
| | - Jennie Buchanan
- Denver Health and Hospital Authority Department of Emergency Medicine, Denver, CO, United States
| | - Jeffrey Brent
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Colorado School of Medicine, Aurora, CO, United States
| | - Christopher W Meaden
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ, United States
| | - Robert G Hendrickson
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR, United States
| | - Stephanie Abston
- American College of Medical Toxicology, Phoenix, AZ, United States
| | - Shao Li
- American College of Medical Toxicology, Phoenix, AZ, United States
| | - Sharan Campleman
- American College of Medical Toxicology, Phoenix, AZ, United States
| | - Alex F Manini
- Mount Sinai Center for Research on Emerging Substances, Poisoning, Overdose, and New Discoveries (RESPOND), Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, NYC Health + Hospitals/Elmhurst, New York, NY, United States
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Kurzhals S, Schäfer M, Bonnet U, Isbruch K, Kühnhold S, Timm J, Specka M, Scherbaum N. SARS-CoV-2-Infection in People Addicted to Illegal Drugs - Is There a Protective Effect of Opioid Maintenance Treatment? PHARMACOPSYCHIATRY 2024; 57:255-260. [PMID: 39089318 DOI: 10.1055/a-2345-7448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/03/2024]
Abstract
INTRODUCTION People addicted to illegal drugs were discussed as a risk group for SARS-CoV-2 infections, with increased susceptibility and a severe course of infection. METHODS In this study, the frequency of SARS-CoV-2 infections of drug-dependent persons admitted to inpatient detoxification treatment in five psychiatric hospitals was determined by implementing routine polymerase chain reaction (PCR)-testing at admission (9/2020) up to one year. Main substance-related diagnosis, comorbid respiratory disease, housing situation, and current opioid maintenance treatment (OMT) were documented. An age-matched control group of psychiatric inpatients without dependence from illegal drugs was established. RESULTS Data from 1675 patients (male 79.5%; mean age 39.5 years; opioid dependence 81.5% homelessness; 2.4%; chronic respiratory disease 6.3%) were included. Out of 1365 patients dependent on opioids, 50.2% were currently in OMT. Six (3 female; mean age 40.3 years) patients tested positive for SARS-CoV-2 by PCR (0.36%), and none showed symptoms of COVID-19. All six were opioid dependent, 5 currently not in OMT. In the control group, 11 out of 1811 inpatients tested positive (0.61%). DISCUSSION The rate of SARS-CoV-2-infections in persons with dependence on illegal drugs was not increased compared to a control group of psychiatric patients. OMT is presumably a protective factor, e. g. in the participating cities, OMT facilities offered an easy access to vaccination programs. In contrast, drug addicts in the USA were severely affected by the pandemic. Differences between countries might partially be explained by social factors such as the higher availability of OMT in Germany and a much lower frequency of homelessness.
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Affiliation(s)
- Simon Kurzhals
- Klinik für Psychiatrie, Psychotherapie, Suchtmedizin und Psychosomatik, Kliniken Essen Mitte, Germany
| | - Martin Schäfer
- Klinik für Psychiatrie, Psychotherapie, Suchtmedizin und Psychosomatik, Kliniken Essen Mitte, Germany
| | - Udo Bonnet
- Klinik für Psychiatrie, Psychotherapie und Psychosomatik, Ev. Krankenhaus Castrop-Rauxel, Germany
| | - Katrin Isbruch
- Klinik für Psychiatrie, Psychotherapie und Psychosomatik, Ev. Krankenhaus Castrop-Rauxel, Germany
| | - Stefan Kühnhold
- Zentrum für Suchtmedizin, LWL-Kliniken Warstein und Lippstadt, Germany
| | - Jörg Timm
- Institute of Virology, University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Germany
| | - Michael Specka
- Department of Psychiatry and Psychotherapy, LVR-University Hospital Essen, Medical Faculty, University of Duisburg Essen, Essen, Germany
| | - Norbert Scherbaum
- Department of Psychiatry and Psychotherapy, LVR-University Hospital Essen, Medical Faculty, University of Duisburg Essen, Essen, Germany
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Guyon-Harris KL, Krans EE, Gill A, Karnosh C, Shaw DS. Supporting positive parenting among pregnant people in recovery from opioid use disorder: Introducing family check‐up–prenatal. Infant Ment Health J 2024. [PMID: 39118311 DOI: 10.1002/imhj.22132] [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: 11/08/2023] [Revised: 06/14/2024] [Accepted: 06/25/2024] [Indexed: 08/10/2024]
Abstract
Opioid use disorder (OUD) among pregnant people has increased dramatically during the opioid epidemic, affecting a significant number of families with young children. Parents with OUD commonly face significant challenges as they are often balancing the stress of caring for young children with maintaining recovery and co-occurring psychosocial challenges (e.g., mental health, low social support). Toward designing interventions to address parenting needs among parents with OUD, we conducted a mixed-methods study to understand the acceptability of receiving parenting support prenatally among pregnant people with OUD residing in the United States. Semi-structured interviews were conducted among 18 pregnant and early postpartum people recruited from a substance use treatment program specializing in the care of pregnant and parenting populations. Among all participants, a prenatal parenting program that comprehensively addresses recovery, parenting, and wellbeing was found to be widely acceptable. Regarding content most desirable within a parenting intervention, participants indicated an interest in breastfeeding, caring for newborns with in-utero opioid exposure, parent-infant bonding, infant soothing techniques, their own wellbeing/mental health, and parenting skills. We introduce a prenatal adaptation of the well-established Family Check-up parenting intervention as a novel, prenatal intervention to prevent negative outcomes for caregivers in recovery and their children.
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Affiliation(s)
- Katherine L Guyon-Harris
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Elizabeth E Krans
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-Womens Research Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Anne Gill
- Department of Psychology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Caroline Karnosh
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Daniel S Shaw
- Department of Psychology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Sprague JE, Freiermuth CE, Lambert J, Braun R, Frey JA, Bachmann DJ, Bischof JJ, Beaumont L, Lyons MS, Pantalon MV, Punches BE, Ancona R, Kisor DF. Opioid use disorder risk alleles in self-reported assigned African American/Afro-Caribbean and European biogeographical genetic ancestry groups and in males and females. THE PHARMACOGENOMICS JOURNAL 2024; 24:23. [PMID: 39090078 PMCID: PMC11294185 DOI: 10.1038/s41397-024-00337-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 05/02/2024] [Accepted: 05/15/2024] [Indexed: 08/04/2024]
Abstract
The influence of genetic variants related to opioid use disorder (OUD) was evaluated using multiple logistic regression analysis in self-reported assigned African American/Afro-Caribbean and European biogeographical ancestry groups (BGAGs) and by sex. From a sample size of 1301 adult patients (>18 years of age) seen in emergency departments of three medical centers in Ohio, six variants were found to be associated with OUD. Two of the variants, rs2740574 (CYP3A4) and rs324029 (DRD3), were included in the analysis having met criteria of at least five subjects for each BGAG, variant carrier status, and OUD status combinations. Variant carriers in the African/Afro-Caribbean BGAG had slightly lower predicted probabilities of OUD. Variant carriers in the European BGAG had slightly higher predicted probabilities of OUD. Relative to sex, all the six variants met evaluation criteria (five subjects for all sex, variant, and OUD status combinations). No statistically significant interactions were found between a given variant, BGAGs and sex. Findings suggest variant testing relative to OUD risk can be applied across BGAGs and sex, however, studies in larger populations are needed.
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Affiliation(s)
- Jon E Sprague
- Bowling Green State University, The Ohio Attorney General's Center for the Future of Forensic Science, Bowling Green, OH, USA.
| | - Caroline E Freiermuth
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH, USA
- Center for Addiction Research, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Joshua Lambert
- College of Nursing, University of Cincinnati, Cincinnati, OH, USA
| | - Robert Braun
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Jennifer A Frey
- Department of Emergency Medicine, The Ohio State University, Columbus, OH, USA
| | - Daniel J Bachmann
- Department of Emergency Medicine, The Ohio State University, Columbus, OH, USA
| | - Jason J Bischof
- Department of Emergency Medicine, The Ohio State University, Columbus, OH, USA
| | - Lauren Beaumont
- Department of Pharmaceutical Sciences and Pharmacogenomics, College of Pharmacy, Natural and Health Sciences, Manchester University, Fort Wayne, IN, USA
| | - Michael S Lyons
- Department of Emergency Medicine, The Ohio State University, Columbus, OH, USA
| | - Michael V Pantalon
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Brittany E Punches
- Department of Emergency Medicine, The Ohio State University, Columbus, OH, USA
- College of Nursing, The Ohio State University, Columbus, OH, USA
| | - Rachel Ancona
- Washington University School of Medicine, St. Louis, MO, USA
| | - David F Kisor
- Department of Pharmaceutical Sciences and Pharmacogenomics, College of Pharmacy, Natural and Health Sciences, Manchester University, Fort Wayne, IN, USA
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Marshall KD, Derse AR, Weiner SG, Joseph JW. Navigating Care Refusal and Noncompliance in Patients with Opioid Use Disorder. J Emerg Med 2024; 67:e233-e242. [PMID: 38849254 DOI: 10.1016/j.jemermed.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 01/09/2024] [Accepted: 03/06/2024] [Indexed: 06/09/2024]
Abstract
BACKGROUND For many emergency physicians (EPs), deciding whether or not to allow a patient suffering the ill effects of opioid use to refuse care is the most frequent and fraught situation in which they encounter issues of decision-making capacity, informed refusal, and autonomy. Despite the frequency of this issue and the well-known impacts of opioid use disorder on decision-making, the medical ethics community has offered little targeted analysis or guidance regarding these situations. DISCUSSION As a result, EPs demonstrate significant variability in how they evaluate and respond to them, with highly divergent understandings and application of concepts such as decision-making capacity, informed consent, autonomy, legal repercussions, and strategies to resolve the clinical dilemma. In this paper, we seek to provide more clarity to this issue for the EPs. CONCLUSIONS Successfully navigating this issue requires that EPs understand the specific effects that opioid use disorder has on decision-making, and how that in turn bears on the ethical concepts of autonomy, capacity, and informed refusal. Understanding these concepts can lead to helpful strategies to resolve these commonly-encountered dilemmas.
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Affiliation(s)
- Kenneth D Marshall
- Department of Emergency Medicine and History and Philosophy of Medicine, University of Kansas Medical Center, Kansas City, Kansas.
| | - Arthur R Derse
- Department of Emergency Medicine, Center for Bioethics and Medical Humanities, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Scott G Weiner
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Joshua W Joseph
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Hébert AH, Hill AL. Impact of opioid overdoses on US life expectancy and years of life lost, by demographic group and stimulant co-involvement: a mortality data analysis from 2019 to 2022. LANCET REGIONAL HEALTH. AMERICAS 2024; 36:100813. [PMID: 38978785 PMCID: PMC11228948 DOI: 10.1016/j.lana.2024.100813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 05/21/2024] [Accepted: 05/29/2024] [Indexed: 07/10/2024]
Abstract
Background The United States' opioid crisis is worsening, with the number of deaths reaching 81,806 in 2022 after more than tripling over the past decade. This study aimed to comprehensively characterize changes in burden of opioid overdose mortality in terms of life expectancy reduction and years of life lost between 2019 and 2022, including differential burden across demographic groups and the contribution of polysubstance use. Methods Using life tables and counts for all-cause and opioid overdose deaths from the National Center for Health Statistics, we constructed cause-eliminated life tables to estimate mortality by age in the absence of opioid-related deaths. We calculated the loss in life expectancy at birth (LLE) and total years of life lost (YLL) due to opioid overdose deaths by state of residency, sex, racial/ethnic group, and co-involvement of cocaine and psychostimulants. Findings Opioid-related deaths in the US led to an estimated 3.1 million years of life lost in 2022 (38 years per death), compared to 2.0 million years lost in 2019. Relative to a scenario with no opioid mortality, we estimate that opioid-related deaths reduced life expectancy nationally by 0.67 years in 2022 vs 0.52 years in 2019. This LLE worsened in all racial/ethnic groups during the study period: 0.76 y-0.96 y for white men, 0.36 y-0.55 y for white women, 0.59 y-1.1 y for Black men, 0.27 y-0.53 y for Black women, 0.31 y-0.82 y for Hispanic men, 0.19 y-0.31 y for Hispanic women, 0.62 y-1.5 y for American Indian/Alaska Native (AI/AN) men, 0.43 y-1 y for AI/AN women, 0.09 y-0.2 y for Asian men, and 0.08 y-0.13 y for Asian women. Nearly all states experienced an increase in years of life lost (YLL) per capita from 2019 to 2022, with YLL more than doubling in 16 states. Cocaine or psychostimulants with abuse potential (incl. methamphetamines) were involved in half of all deaths and years of life lost in 2022, with substantial variation in the predominant drug class by state and racial/ethnic group. Interpretation The burden of opioid-related mortality increased dramatically in the US between 2019 and 2022, coinciding with the period of the COVID-19 pandemic and the associated disruptions to social, economic, and health systems. Opioid overdose deaths are an important contributor to decreasing US life expectancy, and Black, Hispanic, and Native Americans now experience mortality burdens approaching or exceeding white Americans. Funding None.
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Affiliation(s)
- Anne H. Hébert
- Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Alison L. Hill
- Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD, USA
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Bergman AA, Oberman RS, Taylor SL, Kranke B, Chang ET. Prescribing and Acceptance of Medications for Opioid Use Disorder in VA Primary Care: Veteran and Provider Perspectives. J Gen Intern Med 2024; 39:1690-1697. [PMID: 38587730 PMCID: PMC11254870 DOI: 10.1007/s11606-024-08703-z] [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: 10/17/2023] [Accepted: 02/23/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Medications to treat opioid use disorder (MOUD) such as buprenorphine/naloxone can effectively treat OUD and reduce opioid-related mortality, but they remain underutilized, especially in non-substance use disorder settings such as primary care (PC). OBJECTIVE To uncover the factors that can facilitate successful prescribing of MOUD and uptake/acceptance of MOUD by patients in PC settings in the Veterans Health Administration. DESIGN Semi-structured qualitative telephone interviews with 77 providers (e.g., primary care providers, hospitalists, nurses, addiction psychiatrists) and 22 Veteran patients with experience taking MOUD. Interviews were recorded, transcribed, and analyzed thematically using a combination a priori/inductive approach. KEY RESULTS Providers and patients shared their general perceptions and experiences with MOUD, including high satisfaction with buprenorphine/naloxone with few side effects and caveats, although some patients reported drawbacks to methadone. Both providers and patients supported the idea of prescribing MOUD in PC settings to prioritize patient comfort and convenience. Providers described individual-level barriers (e.g., time, stigma, perceptions of difficulty level), structural-level barriers (e.g., pharmacy not having medications ready, space for inductions), and organizational-level barriers (e.g., inadequate staff support, lack of nursing protocols) to PC providers prescribing MOUD. Facilitators centered on education and knowledge enhancement, workflow and practice support, patient engagement and patient-provider communication, and leadership and organizational support. The most common barrier faced by patients to starting MOUD was apprehensions about pain, while facilitators focused on personal motivation, encouragement from others, education about MOUD, and optimally timed provider communication strategies. CONCLUSIONS These findings can help improve provider-, clinic-, and system-level supports for MOUD prescribing across multiple settings, as well as foster communication strategies that can increase patient acceptance of MOUD. They also point to how interprofessional collaboration across service lines and leadership support can facilitate MOUD prescribing among non-addiction providers.
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Affiliation(s)
- Alicia A Bergman
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, 16111 Plummer Street, Los Angeles, CA, 91343, USA.
| | - Rebecca S Oberman
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, 16111 Plummer Street, Los Angeles, CA, 91343, USA
| | - Stephanie L Taylor
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, 16111 Plummer Street, Los Angeles, CA, 91343, USA
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
- Department of Health Policy and Management, University of California, Los Angeles Fielding School of Public Health, Los Angeles, CA, USA
| | - Bridget Kranke
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, 16111 Plummer Street, Los Angeles, CA, 91343, USA
| | - Evelyn T Chang
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, 16111 Plummer Street, Los Angeles, CA, 91343, USA
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
- Division of General Internal Medicine, Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
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Barkley A, Lander L, Dilcher B, Tuscano M. Initiation of Buprenorphine in the Emergency Department: A Survey of Emergency Clinicians. West J Emerg Med 2024; 25:470-476. [PMID: 39028232 PMCID: PMC11254164 DOI: 10.5811/westjem.18029] [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: 03/31/2023] [Revised: 02/05/2024] [Accepted: 02/16/2024] [Indexed: 07/20/2024] Open
Abstract
Introduction Initiation of buprenorphine for opioid use disorder (OUD) in the emergency department (ED) is supported by the American College of Emergency Physicians and is shown to be beneficial. This practice, however, is largely underutilized. Methods To assess emergency clinicians' attitudes and readiness to initiate buprenorphine in the ED we conducted a cross-sectional, electronic survey of clinicians (attendings, residents, and non-physician clinicians) in a single, academic ED of a tertiary-care hospital, which serves a rural population. Our survey aimed to assess emergency clinicians' attitudes toward and readiness to initiate buprenorphine in the ED and identify clinician-perceived facilitators and barriers. Our survey took place after the initiation of the IMPACT (Initiation of Medication, Peer Access, and Connection to Treatment) project. Results Our results demonstrated the level of agreement that buprenorphine prescribing is within the emergency clinician's scope of practice was inversely correlated to average years in practice (R2 = 0.93). X-waivered clinicians indicated feeling more prepared to administer buprenorphine in the ED R2 = 0.93. However, they were not more likely to report ordering buprenorphine or naloxone in the ED within the prior three months. Those who reported having a family member or close friend with substance use disorder (SUD) were not more likely to agree buprenorphine initiation is within the clinician's scope of practice (P = 0.91), nor were they more likely to obtain an X-waiver (P = 0.58) or report ordering buprenorphine or naloxone for patients in the ED within the prior three months (P = 0.65, P = 0.77). Clinicians identified availability of pharmacists, inpatient/outpatient referral resources, and support staff (peer recovery support specialists and care managers) as primary facilitators to buprenorphine initiation. Inability to ensure follow-up, lack of knowledge of available resources, and insufficient education/preparedness were primary barriers to ED buprenorphine initiation. Eighty-three percent of clinicians indicated they would be interested in additional education regarding OUD treatment. Conclusion Our data suggests that newer generations of emergency clinicians may have less hesitancy initiating buprenorphine in the ED. In time, this could mean increased access to treatment for patients with OUD. Understanding clinician-perceived facilitators and barriers to buprenorphine initiation allows for better resource allocation. Clinicians would likely further benefit from additional education regarding medications for opioid use disorder (MOUD), available resources, and follow-up statistics.
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Affiliation(s)
- Ariana Barkley
- West Virginia University, Department of Emergency Medicine, Morgantown, West Virginia
| | - Laura Lander
- West Virginia University, Department of Behavioral Medicine and Psychiatry, Morgantown, West Virginia
| | - Brian Dilcher
- West Virginia University, Department of Emergency Medicine, Morgantown, West Virginia
| | - Meghan Tuscano
- West Virginia University, Department of Behavioral Medicine and Psychiatry, Morgantown, West Virginia
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Iyer NS, Ferguson EB, Yan VZ, Hand DJ, Abatemarco DJ, Boelig RC. Standard Versus Rapid Inpatient Methadone Titration for Pregnant Patients With Opioid Use Disorder: A Retrospective Cohort Study. J Addict Med 2024:01271255-990000000-00337. [PMID: 38912695 DOI: 10.1097/adm.0000000000001339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/25/2024]
Abstract
ABSTRACT OBJECTIVES Our study evaluated if rapid inpatient titration of methadone for pregnant patients with opioid use disorder (OUD) improved outcomes without increasing the risk for overdose. METHODS This is a retrospective cohort study of pregnant patients admitted for inpatient methadone titration from January 2020 to June 2022. Outcomes were compared between standard versus rapid titration protocols. Standard titration involved an initial methadone dose with additional doses every 6 hours if clinical opiate withdrawal score (COWS) is >9. Rapid titration involved an initial methadone dose with additional doses every 4 hours if COWS is >9. The primary outcome was time required to achieve stable dose. Secondary outcomes included elopement prior to achieving stable dose, methadone-related readmission, opioid overdose, and final dose. RESULTS There were 97 patients in the standard titration (STP) and 97 patients in the rapid titration (RTP) groups. Demographic characteristics and substance use history did not differ between the 2 groups. Time to stable dose did not differ between the 2 groups (RTP, 5.0 days ±4.0; STP, 4.0 days ±3.0; P = 0.08). Patients in the rapid titration group were less likely to elope from the hospital prior to stabilization (RTP 23.0% vs STP 37.9%, P = 0.03) and had fewer methadone-related readmissions (P < 0.001). One patient (1.0%) in the RTP group required naloxone treatment while inpatient for concern for overdose, while none did in the STP group (P = 0.32). There was no difference in median final stable dose between the 2 groups (P = 0.07). CONCLUSIONS Rapid titration of methadone for pregnant patients with OUD was associated with decreased medical elopement and methadone-related readmission, without increasing the risk for overdose.
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Affiliation(s)
- Neel S Iyer
- From the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA (NSI, RCB); Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA (EBF, VZY); and Jefferson College of Nursing and Department of Psychiatry and Human Behavior, Thomas Jefferson University, Philadelphia, PA (DJH, DJA)
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12
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Steinhauser S, Haroz R, Jones I, Skelton W, Fuller BM, Roberts MB, Jones CW, Trzeciak S, Roberts BW. Emergency department staff compassion is associated with lower fear of enacted stigma among patients with opioid use disorder. Acad Emerg Med 2024. [PMID: 38881343 DOI: 10.1111/acem.14970] [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: 01/23/2024] [Revised: 04/15/2024] [Accepted: 04/21/2024] [Indexed: 06/18/2024]
Abstract
OBJECTIVES Fear of enacted stigma (fear of discrimination or being treated unfairly) is associated with decreased health care-seeking behaviors among patients with opioid use disorder (OUD). We sought to describe the prevalence of fear of enacted stigma among patients presenting to the emergency department (ED) with OUD and to test whether experiencing greater compassion from ED staff is associated with lower fear of enacted stigma. METHODS We conducted a cross-sectional study in the ED of an academic medical center between February and August 2023. We included adult patients with OUD presenting to the ED and assessed patient experience of compassion from ED staff using a previously validated 5-item compassion measure (score range 5-20). The primary outcome measure was fear of enacted stigma in the ED, measured using the validated 9-item subscale of the Substance Abuse Self-Stigma Scale (score range 9-45). RESULTS Of the 116 subjects enrolled, 97% (95% confidence interval [CI] 91%-99%) reported some degree of stigma, with a median (interquartile range) score of 23 (16-31). In a multivariable model adjusting for potential confounders, patient experience of greater ED compassion was independently associated with lower fear of enacted stigma, β = -0.66 (95% CI -1.03 to -0.29), suggesting that every 1-point increase in the 5-item compassion measure score is associated with a 0.66-point decrease in the fear of enacted stigma score. CONCLUSIONS Among ED patients with OUD, fear of enacted stigma is common. Patient experience of compassion from ED staff is associated with lower fear of enacted stigma. Future research is warranted to test if interventions aimed at increasing compassion from ED staff reduce patient fear of enacted stigma among patients with OUD.
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Affiliation(s)
- Savannah Steinhauser
- The Department of Emergency Medicine, Cooper University Health Care (CUHC), Cooper Medical School of Rowan University (CMSRU), Camden, New Jersey, USA
| | - Rachel Haroz
- The Department of Emergency Medicine, Cooper University Health Care (CUHC), Cooper Medical School of Rowan University (CMSRU), Camden, New Jersey, USA
- The Department of Emergency Medicine, Division of Toxicology and Addiction Medicine, CUHC/CMSRU, Camden, New Jersey, USA
- Cooper Center for Healing, CUHC/CMSRU, Camden, New Jersey, USA
| | - Iris Jones
- Cooper Center for Healing, CUHC/CMSRU, Camden, New Jersey, USA
| | - William Skelton
- The Department of Emergency Medicine, Cooper University Health Care (CUHC), Cooper Medical School of Rowan University (CMSRU), Camden, New Jersey, USA
- Department of Behavioral Medicine, CUHC/CMSRU, Camden, New Jersey, USA
| | - Brian M Fuller
- Division of Critical Care Medicine, Departments of Emergency Medicine and Anesthesia, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Michael B Roberts
- Institutional Research and Outcomes Assessment, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania, USA
| | - Christopher W Jones
- The Department of Emergency Medicine, Cooper University Health Care (CUHC), Cooper Medical School of Rowan University (CMSRU), Camden, New Jersey, USA
| | | | - Brian W Roberts
- The Department of Emergency Medicine, Cooper University Health Care (CUHC), Cooper Medical School of Rowan University (CMSRU), Camden, New Jersey, USA
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Sindhwani MK, Friedman A, O'Donnell M, Stader D, Weiner SG. Naloxone distribution programs in the emergency department: A scoping review of the literature. J Am Coll Emerg Physicians Open 2024; 5:e13180. [PMID: 38726467 PMCID: PMC11079430 DOI: 10.1002/emp2.13180] [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: 12/15/2023] [Revised: 03/28/2024] [Accepted: 04/12/2024] [Indexed: 05/12/2024] Open
Abstract
This scoping review summarized the literature regarding naloxone distribution from emergency departments (EDs) without a prescription. Our intention was to examine various naloxone distribution programs, their methodologies, and the level of effectiveness of each. Understanding these key aspects of naloxone distribution could lead to improved standardized protocols, saving countless additional lives from opioid overdose. This review evaluated studies reporting naloxone distribution from EDs in the United States. The included studies were written in English and published between January 1, 2017, and December 31, 2022. Searches were performed using PubMed and Embase. A total of 129 studies were reviewed, with only 12 meeting the necessary criteria for analysis. Heterogeneity was found across naloxone distribution programs, including how patients were identified, how naloxone was dispensed to patients, and the specific naloxone products made available. The protocols included various methods, such as patient screening, where information used for this screening was sometimes obtained from health records or patient interviews. Some programs detailed only the distribution of naloxone, while others included additional interventions such as behavior counseling, peer support, and education. In four studies, patients received buprenorphine with naloxone kits. The various programs differed in their implementation but were generally successful in improving naloxone distribution. However, among the studies reviewed, the percentage of ED patients receiving naloxone varied from ∼30% to 70%, suggesting that certain program elements may be more impactful. Further research is needed to identify key elements of the most impactful programs in order to improve naloxone distribution and improve patient odds of surviving an opioid overdose.
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Affiliation(s)
| | | | | | | | - Scott G. Weiner
- Department of Emergency MedicineBrigham and Women's HospitalBostonMassachusettsUSA
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Heil JM, Lassiter JM, Salzman MS, Herring A, Hoppe J, Lynch M, Weiner SG, Roberts B, Haroz R. A qualitative assessment of emergency physicians' experiences with robust emergency department buprenorphine bridge programs. Acad Emerg Med 2024; 31:576-583. [PMID: 38357749 DOI: 10.1111/acem.14880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 01/16/2024] [Accepted: 01/22/2024] [Indexed: 02/16/2024]
Abstract
OBJECTIVES Emergency departments (EDs) are a critical point of entry into treatment for patients struggling with opioid use disorder (OUD). When initiated in the ED, buprenorphine is associated with increased addiction treatment engagement at 30 days when initiated. Despite this association, it has had slow adoption. The barriers to ED buprenorphine utilization are well documented; however, the benefits of prescribing buprenorphine for emergency physicians (EPs) have not been explored. This study utilized semistructured interviews to explore and understand how EPs perceive their experiences working in EDs that have successfully implemented ED bridge programs (EDBPs) for patients with OUD. METHODS Semistructured interviews were conducted with EPs from four geographically diverse academic hospitals with established EDBPs. Interviews were recorded and transcribed, and emergent themes were identified using codebook thematic analysis. Analysis credibility and transparency were confirmed with peer debriefing. RESULTS Twenty-two interviews were conducted across the four sites. Three key themes were constructed during the analyses: (1) provided EPs agency; (2) transformed EPs' emotions, attitudes, and behaviors related to treating patients with OUD; and (3) improved EPs' professional quality of life. CONCLUSIONS Participants in this study reported several common themes related to participation in their hospital's BP. Overall our results suggest that physicians who participate in EDBPs may feel a renewed sense of fulfillment and purpose in their personal and professional lives. These positive changes may lead to increased job satisfaction in hospitals that have successfully launched EDBP.
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Affiliation(s)
- Jessica Marie Heil
- Center for Healing, Division of Addiction Medicine, Cooper University Health Care, Camden, New Jersey, USA
| | | | - Matthew S Salzman
- Center for Healing, Division of Addiction Medicine, Cooper University Health Care, Camden, New Jersey, USA
- Department of Emergency Medicine, Division of Addiction Medicine and Medical Toxicology, Cooper University Health Care, Camden, New Jersey, USA
- Cooper Medical School of Rowan University, Cooper University Healthcare, Camden, New Jersey, USA
| | - Andrew Herring
- Department of Emergency Medicine, Highland Hospital-Alameda Health System, University of California, San Francisco, California, USA
| | - Jason Hoppe
- Department of Emergency Medicine, University of Colorado School of Medicine, Colorado, Aurora, USA
| | - Michael Lynch
- University of Pittsburgh School of Medicine Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Scott G Weiner
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Brian Roberts
- Department of Emergency Medicine, Division of Addiction Medicine and Medical Toxicology, Cooper University Health Care, Camden, New Jersey, USA
- Cooper Medical School of Rowan University, Cooper University Healthcare, Camden, New Jersey, USA
| | - Rachel Haroz
- Center for Healing, Division of Addiction Medicine, Cooper University Health Care, Camden, New Jersey, USA
- Department of Emergency Medicine, Division of Addiction Medicine and Medical Toxicology, Cooper University Health Care, Camden, New Jersey, USA
- Cooper Medical School of Rowan University, Cooper University Healthcare, Camden, New Jersey, USA
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15
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Cherian T, Lim S, Katyal M, Goldfeld KS, McDonald R, Wiewel E, Khan M, Krawczyk N, Braunstein S, Murphy SM, Jalali A, Jeng PJ, Rosner Z, MacDonald R, Lee JD. Impact of jail-based methadone or buprenorphine treatment on non-fatal opioid overdose after incarceration. Drug Alcohol Depend 2024; 259:111274. [PMID: 38643529 PMCID: PMC11111329 DOI: 10.1016/j.drugalcdep.2024.111274] [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: 11/09/2023] [Revised: 02/13/2024] [Accepted: 03/18/2024] [Indexed: 04/23/2024]
Abstract
BACKGROUND Non-fatal overdose is a leading predictor of subsequent fatal overdose. For individuals who are incarcerated, the risk of experiencing an overdose is highest when transitioning from a correctional setting to the community. We assessed if enrollment in jail-based medications for opioid use disorder (MOUD) is associated with lower risk of non-fatal opioid overdoses after jail release among individuals with opioid use disorder (OUD). METHODS This was a retrospective, observational cohort study of adults with OUD who were incarcerated in New York City jails and received MOUD or did not receive any MOUD (out-of-treatment) within the last three days before release to the community in 2011-2017. The outcome was the first non-fatal opioid overdose emergency department (ED) visit within 1 year of jail release during 2011-2017. Covariates included demographic, clinical, incarceration-related, and other characteristics. We performed multivariable cause-specific Cox proportional hazards regression analysis to compare the risk of non-fatal opioid overdose ED visits within 1 year after jail release between groups. RESULTS MOUD group included 8660 individuals with 17,119 incarcerations; out-of-treatment group included 10,163 individuals with 14,263 incarcerations. Controlling for covariates and accounting for competing risks, in-jail MOUD was associated with lower non-fatal opioid overdose risk within 14 days after jail release (adjusted HR=0.49, 95% confidence interval=0.33-0.74). We found no significant differences 15-28, 29-56, or 57-365 days post-release. CONCLUSION MOUD group had lower risk of non-fatal opioid overdose immediately after jail release. Wider implementation of MOUD in US jails could potentially reduce post-release overdoses, ED utilization, and associated healthcare costs.
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Affiliation(s)
- Teena Cherian
- New York City Department of Health and Mental Hygiene, 42-09 28th Street, Queens, NY 11101, USA.
| | - Sungwoo Lim
- New York City Department of Health and Mental Hygiene, 42-09 28th Street, Queens, NY 11101, USA
| | - Monica Katyal
- New York City Health + Hospitals/Correctional Health Services, 55 Water Street, New York, NY 10041, USA
| | - Keith S Goldfeld
- New York University Grossman School of Medicine, 180 Madison Ave, New York, NY 10010, USA
| | - Ryan McDonald
- New York University Grossman School of Medicine, 180 Madison Ave, New York, NY 10010, USA
| | - Ellen Wiewel
- New York City Department of Health and Mental Hygiene, 42-09 28th Street, Queens, NY 11101, USA
| | - Maria Khan
- New York University Grossman School of Medicine, 180 Madison Ave, New York, NY 10010, USA
| | - Noa Krawczyk
- New York University Grossman School of Medicine, 180 Madison Ave, New York, NY 10010, USA
| | - Sarah Braunstein
- New York City Department of Health and Mental Hygiene, 42-09 28th Street, Queens, NY 11101, USA
| | - Sean M Murphy
- Weill Cornell Medical College, 425 East 61st Street, New York, NY 10065, USA
| | - Ali Jalali
- Weill Cornell Medical College, 425 East 61st Street, New York, NY 10065, USA
| | - Philip J Jeng
- Weill Cornell Medical College, 425 East 61st Street, New York, NY 10065, USA
| | - Zachary Rosner
- New York City Health + Hospitals/Correctional Health Services, 55 Water Street, New York, NY 10041, USA
| | - Ross MacDonald
- New York University Grossman School of Medicine, 180 Madison Ave, New York, NY 10010, USA
| | - Joshua D Lee
- New York University Grossman School of Medicine, 180 Madison Ave, New York, NY 10010, USA
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Collins AB, Macon EC, Levin S, Wunsch C, Wightman RS. "It gets you high as a kite but not unsick": Characterizations of and responses to a changing local drug supply by people who use drugs in Rhode Island. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 127:104391. [PMID: 38490014 PMCID: PMC11127783 DOI: 10.1016/j.drugpo.2024.104391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 02/28/2024] [Accepted: 03/06/2024] [Indexed: 03/17/2024]
Abstract
BACKGROUND The North American overdose crisis has continued at unprecedented rates with more than 100,000 overdose deaths occurring in the United States (US) in 2022. Overdose deaths have increasingly been polysubstance-involved, with novel substances (e.g., xylazine) complicating overdose risk and health outcomes. Understanding the effects of-and responses to-a changing drug supply among people who use drugs is critical to modifying harm reduction strategies to be more responsive to people's needs. METHODS This qualitative study draws on data collected from May to December 2022 in Rhode Island. Data include in-depth interviews with 50 people who use drugs and observational fieldwork in spaces frequented by participants (e.g., encampments, drop-in centers). Qualitative data were analyzed thematically drawing on concepts of situated rationality. RESULTS Participants described significant changes in the drug supply, with many attributing these transitions to COVID-19. Most participants characterized the local supply as "synthetic" with textures, color, and taste evolving. Notably, participants emphasized adverse outcomes related to available supplies, including during use (e.g., intense burning sensations) and post-consumption (e.g., heavy sedation, ongoing withdrawal, necrosis). Given the complex supply, participants highlighted the increased risk of overdose and shared how they altered their use practices to manage evolving health risks. CONCLUSION Our results underscore how people who use drugs characterized the local drug supply, including perceived changes to supply contents. Implementing and scaling up harm reduction interventions that reduce risk and reinforce the agency of people who use drugs are urgently needed to effectively address the overdose crisis.
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Affiliation(s)
- Alexandra B Collins
- Department of Epidemiology, Brown University School of Public Health, 121 S Main Street, Providence, RI, USA.
| | - E Claire Macon
- Department of Epidemiology, Brown University School of Public Health, 121 S Main Street, Providence, RI, USA
| | - Stacey Levin
- Parent Support Network of Rhode Island, Warwick, RI, USA
| | - Caroline Wunsch
- Lifespan Department of Psychiatry and Behavioral Health Services, Division of Addiction Medicine, Providence, RI, USA
| | - Rachel S Wightman
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
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Ledlie S, Tadrous M, Bayoumi AM, McCormack D, Cheng C, Besharah J, Munro C, Gomes T. Trends in opioid toxicities among people with and without opioid use disorder and the impact of the COVID-19 pandemic in Ontario, Canada: A population-based analysis. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 127:104392. [PMID: 38522177 DOI: 10.1016/j.drugpo.2024.104392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 03/03/2024] [Accepted: 03/06/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND Across Canada, the COVID-19 pandemic occurred amidst an ongoing drug toxicity crisis. Although elevated rates of substance-related harms have been observed nationally, it remains unknown if the pandemic state of emergency led to disproportionate increases in opioid toxicities among people with opioid use disorder (OUD) compared to those without. METHODS We conducted a population-based repeated cross-sectional time series analysis of fatal and non-fatal opioid toxicities between January 1, 2014, and December 31, 2021, in Ontario, Canada. We used interventional autoregressive integrated moving average models to examine the impact of the pandemic on monthly rates of opioid toxicities per 100,000 Ontario residents stratified by people with and without OUD. RESULTS We identified 80,296 opioid toxicities of which 53.5 % occurred among people with OUD. Among 52,052 unique individuals, 60.5 % were male and 46.2 % were 25-44 years old. Between January 2014 and December 2021, the rate of opioid toxicities increased from 2.6 to 10.5 per 100,000 (rate ratio [RR]=4.07). The magnitude of this increase differed among people with OUD (0.8 to 7.4 per 100,000; RR=9.35) and without OUD (1.8 to 3.1 per 100,000; RR=1.74). We observed a significant ramp increase in the overall rate of opioid toxicities following the declaration of the pandemic emergency in March 2020 (+0.19 per 100,000 monthly, 95 % CI: 0.029, 0.36, p = 0.021). In a stratified analysis, we found a similar ramp increase among people with OUD (+0.19 per 100,000 monthly, 95 % CI: 0.10, 0.28, p < 0.001); however, this was not observed among people without OUD (p = 0.95). CONCLUSIONS The rate of opioid toxicities accelerated across Ontario following the pandemic-related state of emergency, with the majority of this increase among people with OUD. The important differences observed among people with OUD compared with those without, highlights the critical need for improved access to harm reduction and treatment interventions among this population.
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Affiliation(s)
- Shaleesa Ledlie
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada; ICES, Toronto, ON, Canada.
| | - Mina Tadrous
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada; ICES, Toronto, ON, Canada; Women's College Research Institute, Toronto, ON, Canada
| | - Ahmed M Bayoumi
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, ON, Canada; Division of General Internal Medicine, St. Michael's Hospital, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada
| | | | - Clare Cheng
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Jes Besharah
- Ontario Drug Policy Research Network Lived Experience Advisory Group, Toronto, ON, Canada
| | - Charlotte Munro
- Ontario Drug Policy Research Network Lived Experience Advisory Group, Toronto, ON, Canada
| | - Tara Gomes
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada; ICES, Toronto, ON, Canada; MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
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18
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Page TF, Chen W, Sainfort F, Jacko JA. Opioid-Related Emergency Department Visits Before and During COVID-19: Association with Community-Level Factors. HCA HEALTHCARE JOURNAL OF MEDICINE 2024; 5:87-95. [PMID: 38984234 PMCID: PMC11229598 DOI: 10.36518/2689-0216.1608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/11/2024]
Abstract
Background The purpose of the study was to investigate the relationship between community-level variables and emergency department (ED) visit rates before and during COVID-19. The focus was on opioid-related ED visits. Despite large declines in overall ED visits during COVID-19, opioid-related visits increased. While visits for avoidable conditions decreased, the opposite was true for opioid-related visits. Methods We combined data from Florida EDs with community-level variables from the 2020 American Community Survey. The outcome measures of the study were quarterly ZIP code tabulation-area-level ED visit rates for opioid-related ED visits as well as visit rates for all other causes. Associations with opioid-related visit rates were estimated before and during COVID-19. Results The associations between community-level variables and opioid-related visit rates did not match those found when analyzing overall ED visit rates. The increase in opioid-related visits during COVID-19 was not unique to or more prevalent in areas with a larger percentage of racial/ethnic minority populations. However, socioeconomic status was important, as areas with higher unemployment, lower income, lower home ownership, and higher uninsured had higher overall ED visit rates and opioid visit rates during the pandemic. In addition, the negative association with income increased during the pandemic. Conclusion These results suggest socioeconomic status should be the focus of prevention and treatment efforts to reduce opioid-related visits in future pandemics. Healthcare organizations can use these results to target their prevention and treatment efforts during future pandemics.
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Affiliation(s)
- Timothy F Page
- H Wayne Huizenga College of Business and Entrepreneurship, Nova Southeastern University, Fort Lauderdale, FL
| | - Weiwei Chen
- Coles College of Business, Kennesaw State University, Kennesaw, GA
| | - François Sainfort
- H Wayne Huizenga College of Business and Entrepreneurship, Nova Southeastern University, Fort Lauderdale, FL
- Dr Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University Fort Lauderdale, FL
| | - Julie A Jacko
- Centre for Medical Informatics, The Usher Institute, College of Medicine and Veterinary Medicine, The University of Edinburgh, Edinburgh, Scotland,
UK
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Kessler R, Hall J, Chipman AK, Hall MK, Amick A. Nurse-focused ultrasound-guided IV program improves core emergency department process measures. J Vasc Access 2024:11297298241230109. [PMID: 38372249 DOI: 10.1177/11297298241230109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2024] Open
Abstract
INTRODUCTION Ultrasound-guided peripheral IV catheter (USGIV) insertion is as an effective procedure to establish access in patients with difficult intravenous access (DIVA), a condition frequently encountered in the Emergency Department (ED). This study describes a DIVA quality improvement program focusing on rapid identification of DIVA patients and emergency nurse USGIV training and evaluates its impact on overall frequency of USGIV use and process measures related to quality of patient care. METHODS This is a retrospective cohort study of patients over 18 years of age, presenting to a single, tertiary care hospital between September 1, 2018 and September 30, 2020. Difference-in-difference analysis was used to compare ED process measures pre- and post-implementation of the DIVA Program, and multivariate logistic regression was used to identify associations between patient characteristics and difficult IV access. RESULTS The frequency of ED encounters associated with USGIV placement more than doubled post-implementation of the DIVA Program, rising from 606 to 1323. There were improved covariate-adjusted time estimates of core ED process measures for encounters associated with USGIV placement post-implementation, including decreases in time to CT with contrast from 4.8 h (95% CI = 4.4-5.2) to 4.1 h (95% CI = 3.8-4.4), pain medications from 2.4 h (95% CI = 2.1-2.6) to 1.8 h (95% CI = 1.6-2.0), IV antibiotics from 3.0 h (95% CI = 2.4-3.7) to 2.1 h (95% CI = 1.5-2.6), and ED length of stay from 6.4 h (95% CI = 6.2-6.6) to 6.0 h (95% CI = 5.9-6.2). CONCLUSION A nurse-focused quality improvement program focused on teaching and promoting USGIV as a modality for managing difficult IV access was associated with increases in USGIV placement and improvements in core process measures related to quality of patient care.
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Affiliation(s)
- Ross Kessler
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA
| | - Jane Hall
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA
| | - Anne K Chipman
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA
| | | | - Ashley Amick
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA
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Cronin CE, Kubacki L, Donovan L, Puro N, Lavinder D, Schuller K, Franz B. Alignment of substance use community benefit prioritization and service lines in US hospitals: a cross-sectional study. Addict Sci Clin Pract 2024; 19:11. [PMID: 38351004 PMCID: PMC10865679 DOI: 10.1186/s13722-024-00442-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 02/05/2024] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND Non-profit hospitals in the U.S. are required by the 2010 Patient Protection and Affordable Care Act (ACA) to conduct a community health needs assessment (CHNA) every three years and to formulate an implementation strategy in response to those needs. Hospitals often identify substance use as a need relevant to their communities in their CHNAs and then must determine whether to create strategies to address such a need within their implementation strategies. The aim of this study is to assess the relationship between a hospital's prioritization of substance use within its community benefit documents and its substance use service offerings, while considering other hospital and community characteristics. METHODS This study of a national sample of U.S. hospitals utilizes data collected from publicly available CHNAs and implementation strategies produced by hospitals from 2018 to 2021. This cross-sectional study employs descriptive statistics and multivariable analysis to assess relationships between prioritization of substance use on hospital implementation strategies and the services offered by hospitals, with consideration of community and hospital characteristics. Hospital CHNA and strategy documents were collected and then coded to identify whether the substance use needs were prioritized by the hospital. The collected data were incorporated into a data set with secondary data sourced from the 2021 AHA Annual Survey. RESULTS Multivariable analysis found a significant and positive relationship between the prioritization of substance use as a community need on a hospital's implementation strategy and the number of the services included in this analysis offered by the hospital. Significant and positive relationships were also identified for five service categories and for hospital size. CONCLUSIONS The availability of service offerings is related both to a hospital's prioritization of substance use and to its size, indicating that these factors are likely inter-related regarding a hospital's sense of its ability to address substance use as a community need. Policymakers should consider why a hospital may not prioritize a need that is prevalent within their community; e.g., whether the organization believes it lacks resources to take such steps. This study also highlights the value of the assessment and implementation strategy process as a way for hospitals to engage with community needs.
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Affiliation(s)
- Cory E Cronin
- College of Health Sciences and Professions, Ohio University, Athens, OH, 45701, USA.
- Appalachian Institute to Advance Health Equity Science, Ohio University, Athens, OH, 45701, USA.
| | - Luke Kubacki
- Heritage College of Osteopathic Medicine, Ohio University, Athens, OH, 45701, USA
| | - Lauren Donovan
- Heritage College of Osteopathic Medicine, Ohio University, Athens, OH, 45701, USA
| | - Neeraj Puro
- College of Business, Florida Atlantic University, 777 Glades Rd, Boca Raton, FL, 33431, USA
| | - Dakota Lavinder
- College of Arts and Sciences, Ohio University, Athens, OH, 45701, USA
| | - Kristin Schuller
- College of Health Professions, Towson University, 8000 York Rd, Towson, MD, 21252, USA
| | - Berkeley Franz
- Appalachian Institute to Advance Health Equity Science, Ohio University, Athens, OH, 45701, USA
- Heritage College of Osteopathic Medicine, Ohio University, Athens, OH, 45701, USA
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21
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Abasilim C, Friedman LS, Karch L, Holloway-Beth A. Trends in non-fatal and fatal opioid overdoses during the first two years of the coronavirus disease-2019 pandemic. Ann Epidemiol 2024; 90:35-41. [PMID: 38501569 DOI: 10.1016/j.annepidem.2023.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 09/19/2023] [Accepted: 10/26/2023] [Indexed: 03/20/2024]
Abstract
PURPOSE This study assessed opioid-involved overdose rates by age, sex, and race-ethnicity across strict pandemic mitigation phases and how this varied across data systems. METHODS We examined opioid-involved overdoses using medical examiner and hospital data for Cook County, Illinois between 2016-2021. Multivariable segmented regression was used to assess weekly overdose rates across subgroups of age, sex and race/ethnicity and strict pandemic mitigation phases. RESULTS The overall rate of weekly opioid-involved overdoses increased when assessing the medical examiner (β = 0.01; 95% CI = 0.01,0.02; P ≤ .001) and emergency department visits data sources (β = 0.15; 95% CI = 0.09,0.20; P ≤ .001) but not for the hospital admissions data source. We found differences in overdose rates across subgroups and phases of pandemic mandates. Fatal overdoses increased during lockdown-1 while admissions and emergency department (ED) visits for opioid-involved overdoses generally decreased across all phases of pandemic mitigation mandates except for the period following lockdown-1. Across pandemic mitigation phases, Hispanics and individuals under 25 years did not demonstrate any change in admissions and ED visits for overdoses. CONCLUSIONS We underscore the importance of utilizing multiple sources of surveillance to better characterize opioid-involved overdoses and for public health planning.
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Affiliation(s)
- Chibuzor Abasilim
- Division of Environmental and Occupational Health Sciences, School of Public Health, University of Illinois Chicago, Chicago, IL
| | - Lee S Friedman
- Division of Environmental and Occupational Health Sciences, School of Public Health, University of Illinois Chicago, Chicago, IL
| | - Lydia Karch
- Epidemiology Unit, Cook County Department of Public Health, Bridgeview, IL
| | - Alfreda Holloway-Beth
- Division of Environmental and Occupational Health Sciences, School of Public Health, University of Illinois Chicago, Chicago, IL; Epidemiology Unit, Cook County Department of Public Health, Bridgeview, IL
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22
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Graham SS, Shifflet S, Amjad M, Claborn K. An interpretable machine learning framework for opioid overdose surveillance from emergency medical services records. PLoS One 2024; 19:e0292170. [PMID: 38289927 PMCID: PMC10826931 DOI: 10.1371/journal.pone.0292170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 09/14/2023] [Indexed: 02/01/2024] Open
Abstract
The goal of this study is to develop and validate a lightweight, interpretable machine learning (ML) classifier to identify opioid overdoses in emergency medical services (EMS) records. We conducted a comparative assessment of three feature engineering approaches designed for use with unstructured narrative data. Opioid overdose annotations were provided by two harm reduction paramedics and two supporting annotators trained to reliably match expert annotations. Candidate feature engineering techniques included term frequency-inverse document frequency (TF-IDF), a highly performant approach to concept vectorization, and a custom approach based on the count of empirically-identified keywords. Each feature set was trained using four model architectures: generalized linear model (GLM), Naïve Bayes, neural network, and Extreme Gradient Boost (XGBoost). Ensembles of trained models were also evaluated. The custom feature models were also assessed for variable importance to aid interpretation. Models trained using TF-IDF feature engineering ranged from AUROC = 0.59 (95% CI: 0.53-0.66) for the Naïve Bayes to AUROC = 0.76 (95% CI: 0.71-0.81) for the neural network. Models trained using concept vectorization features ranged from AUROC = 0.83 (95% 0.78-0.88)for the Naïve Bayes to AUROC = 0.89 (95% CI: 0.85-0.94) for the ensemble. Models trained using custom features were the most performant, with benchmarks ranging from AUROC = 0.92 (95% CI: 0.88-0.95) with the GLM to 0.93 (95% CI: 0.90-0.96) for the ensemble. The custom features model achieved positive predictive values (PPV) ranging for 80 to 100%, which represent substantial improvements over previously published EMS encounter opioid overdose classifiers. The application of this approach to county EMS data can productively inform local and targeted harm reduction initiatives.
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Affiliation(s)
- S. Scott Graham
- Department of Rhetoric & Writing, Center for Health Communication, University of Texas at Austin, Austin, TX, United States of Amedrica
- Addiction Research Institute, University of Texas at Austin, Austin, TX, United States of Amedrica
| | - Savannah Shifflet
- Addiction Research Institute, University of Texas at Austin, Austin, TX, United States of Amedrica
| | - Maaz Amjad
- Addiction Research Institute, University of Texas at Austin, Austin, TX, United States of Amedrica
| | - Kasey Claborn
- Addiction Research Institute, University of Texas at Austin, Austin, TX, United States of Amedrica
- Steve Hicks School of Social Work, University of Texas at Austin, Austin, TX, United States of Amedrica
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23
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V Carvalho AS, Broekema B, Brito Fernandes Ó, Klazinga N, Kringos D. Acute care pathway assessed through performance indicators during the COVID-19 pandemic in OECD countries (2020-2021): a scoping review. BMC Emerg Med 2024; 24:19. [PMID: 38273229 PMCID: PMC10811879 DOI: 10.1186/s12873-024-00938-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 01/18/2024] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND The COVID-19 pandemic severely impacted care for non-COVID patients. Performance indicators to monitor acute care, timely reported and internationally accepted, lacked during the pandemic in OECD countries. This study aims to summarize the performance indicators available in the literature to monitor changes in the quality of acute care in OECD countries during the first year and a half of the pandemic (2020-July 2021) and to assess their trends. METHODS Scoping review. Search in Embase and MEDLINE (07-07-2022). Acute care performance indicators and indicators related to acute general surgery were collected and collated following a care pathway approach. Indicators assessing identical clinical measures were grouped under a common indicator title. The trends from each group of indicators were collated (increase/decrease/stable). RESULTS A total of 152 studies were included. 2354 indicators regarding general acute care and 301 indicators related to acute general surgery were included. Indicators focusing on pre-hospital services reported a decreasing trend in the volume of patients: from 225 indicators, 110 (49%) reported a decrease. An increasing trend in pre-hospital treatment times was reported by most of the indicators (n = 41;70%) and a decreasing trend in survival rates of out-of-hospital cardiac arrest (n = 61;75%). Concerning care provided in the emergency department, most of the indicators (n = 752;71%) showed a decreasing trend in admissions across all levels of urgency. Concerning the mortality rate after admission, most of the indicators (n = 23;53%) reported an increasing trend. The subset of indicators assessing acute general surgery showed a decreasing trend in the volume of patients (n = 50;49%), stability in clinical severity at admission (n = 36;53%), and in the volume of surgeries (n = 14;47%). Most of the indicators (n = 28;65%) reported no change in treatment approach and stable mortality rate (n = 11,69%). CONCLUSION This review signals relevant disruptions across the acute care pathway. A subset of general surgery performance indicators showed stability in most of the phases of the care pathway. These results highlight the relevance of assessing this care pathway more regularly and systematically across different clinical entities to monitor disruptions and to improve the resilience of emergency services during a crisis.
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Affiliation(s)
- Ana Sofia V Carvalho
- Amsterdam UMC Location University of Amsterdam, Public and Occupational Health, Meibergdreef 9, Amsterdam, the Netherlands.
- Amsterdam Public Health Research Institute, Quality of Care, Amsterdam, the Netherlands.
| | - Bente Broekema
- Amsterdam UMC Location University of Amsterdam, Public and Occupational Health, Meibergdreef 9, Amsterdam, the Netherlands
- Department of Pediatrics, Dijklander Hospital, Location Hoorn, Maelsonstraat 3, Hoorn, 1624 NP, The Netherlands
| | - Óscar Brito Fernandes
- Amsterdam UMC Location University of Amsterdam, Public and Occupational Health, Meibergdreef 9, Amsterdam, the Netherlands
- Amsterdam Public Health Research Institute, Quality of Care, Amsterdam, the Netherlands
| | - Niek Klazinga
- Amsterdam UMC Location University of Amsterdam, Public and Occupational Health, Meibergdreef 9, Amsterdam, the Netherlands
- Amsterdam Public Health Research Institute, Quality of Care, Amsterdam, the Netherlands
| | - Dionne Kringos
- Amsterdam UMC Location University of Amsterdam, Public and Occupational Health, Meibergdreef 9, Amsterdam, the Netherlands
- Amsterdam Public Health Research Institute, Quality of Care, Amsterdam, the Netherlands
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24
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Serdarevic M, Cvitanovich M, MacDonald BR, d'Etienne J, DeMoss D, Ojha RP. Emergency Department Bridge Model and Health Services Use Among Patients With Opioid Use Disorder. Ann Emerg Med 2023; 82:694-704. [PMID: 37542490 DOI: 10.1016/j.annemergmed.2023.06.014] [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: 03/12/2023] [Revised: 06/06/2023] [Accepted: 06/15/2023] [Indexed: 08/07/2023]
Abstract
STUDY OBJECTIVES Little is known about the effectiveness of bridge clinics as transitional care programs for people with opioid use disorder in emergency departments (EDs). We assessed the effect of bridge clinic referral on health services use among patients with opioid use disorder identified in the ED. METHODS We used data for individuals aged 18 years and over with active opioid use disorder and no history of medication for opioid use disorder who were administered medication for opioid use disorder while in the ED between January 2013 and August 2022. Bridge clinic referrals started in January 2021. Eligible patients after this date comprised the intervention group. The usual care group included eligible patients before bridge clinic implementation, who were a 1:1 propensity score matched to intervention patients. We estimated risk differences and 95% confidence limits for linkage to long-term care, ED use, and inpatient admission within 120 days of the index ED visit. RESULTS Our study population comprised 928 observations after matching. Patients referred to the bridge clinic had a higher risk of linkage to long-term care (risk differences=25%; 95% confidence limits: 20%, 30%), higher risk of ED use (risk differences=7.5%, 95% confidence limits: 1.6%, 13%), and lower risk of inpatient admission (risk differences= -1.9%, 95% confidence limits: -5.9%, 2.1%). Inpatient admission increased among patients with serious mental illness but decreased among patients without serious mental illness. CONCLUSION Our overall results suggest that bridge clinic referral increases linkage to long-term care. Nevertheless, qualitatively different effects on inpatient admission between patients with and without serious mental illness warrant consideration of unmet needs among patients with serious mental illness.
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Affiliation(s)
- Mirsada Serdarevic
- Center for Epidemiology and Healthcare Delivery Research, JPS Health Network, Fort Worth, TX.
| | - Matthew Cvitanovich
- Center for Epidemiology and Healthcare Delivery Research, JPS Health Network, Fort Worth, TX
| | - Brooke R MacDonald
- Center for Epidemiology and Healthcare Delivery Research, JPS Health Network, Fort Worth, TX
| | - James d'Etienne
- Department of Emergency Medicine, Integrative Emergency Services, JPS Health Network, Fort Worth, TX
| | - Dustin DeMoss
- Acclaim Behavioral Health (DeMoss), JPS Health Network, Fort Worth, TX
| | - Rohit P Ojha
- Center for Epidemiology and Healthcare Delivery Research, JPS Health Network, Fort Worth, TX
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25
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Tatar M, Faraji MR, Keyes K, Wilson FA, Jalali MS. Social vulnerability predictors of drug poisoning mortality: A machine learning analysis in the United States. Am J Addict 2023; 32:539-546. [PMID: 37344967 DOI: 10.1111/ajad.13445] [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: 10/22/2022] [Revised: 04/16/2023] [Accepted: 06/05/2023] [Indexed: 06/23/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Drug poisoning is a leading cause of unintentional deaths in the United States. Despite the growing literature, there are a few recent analyses of a wide range of community-level social vulnerability features contributing to drug poisoning mortality. Current studies on this topic face three limitations: often studying a limited subset of vulnerability features, focusing on small sample sizes, or solely including local data. To address this gap, we conducted a national-level analysis to study the impacts of several social vulnerability features in predicting drug mortality rates in the United States. METHODS We used machine learning to investigate the role of 16 social vulnerability features in predicting drug mortality rates for US counties in 2014, 2016, and 2018-the most recent available data. We estimated each vulnerability feature's gain relative contribution in predicting drug poisoning mortality. RESULTS Among all social vulnerability features, the percentage of noninstitutionalized persons with a disability is the most influential predictor, with a gain relative contribution of 18.6%, followed by population density and the percentage of minority residents (13.3% and 13%, respectively). Percentages of households with no available vehicles, mobile homes, and persons without a high school diploma are the following features with gain relative contributions of 6.3%, 5.8%, and 5.1%, respectively. CONCLUSION AND SCIENTIFIC SIGNIFICANCE We identified social vulnerability features that are most predictive of drug poisoning mortality. Public health interventions and policies targeting vulnerable communities may increase the resilience of these communities and mitigate the overdose death and drug misuse crisis.
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Affiliation(s)
- Moosa Tatar
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mohammad R Faraji
- Department of Computer Science and Information Technology, Institute for Advanced Studies in Basic Sciences, Zanjan, Iran
| | - Katherine Keyes
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Fernando A Wilson
- Matheson Center for Health Care Studies, University of Utah, Salt Lake City, Utah, USA
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, USA
| | - Mohammad S Jalali
- MGH Institute for Technology Assessment, Harvard Medical School, Boston, Massachusetts, USA
- Sloan School of Management, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
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26
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Skains RM, Reynolds L, Carlisle N, Heath S, Covington W, Hornbuckle K, Walter L. Impact of Emergency Department-Initiated Buprenorphine on Repeat Emergency Department Utilization. West J Emerg Med 2023; 24:1010-1017. [PMID: 38165181 PMCID: PMC10754187 DOI: 10.5811/westjem.60511] [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: 03/30/2023] [Revised: 09/26/2023] [Accepted: 09/27/2023] [Indexed: 01/03/2024] Open
Abstract
Introduction Recent studies have demonstrated the promise of emergency department (ED)-initiated buprenorphine/naloxone (bup/nx) for improving 30-day retention in outpatient addiction care programs for patients with opioid use disorder (OUD). We investigated whether ED-initiated bup/nx for OUD also impacts repeat ED utilization. Methods We performed a retrospective chart review of ED patients discharged with a primary diagnosis of OUD from July 2019-December 2020. Characteristics considered included age, gender, race, insurance status, domicile status, presence of comorbid Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis, presenting chief complaint, and provision of a bup/nx prescription and/or naloxone kit. Primary outcomes included repeat ED visit (opioid or non-opioid related) within 30 days, 90 days, and one year. Statistical analyses included bivariate comparison and Poisson regression. Results Of 169 participants, the majority were male (67.5%), White (82.8%), uninsured (72.2%), and in opioid withdrawal and/or requesting "detox" (75.7%). Ninety-one (53.8%) received ED-initiated bup/nx, which was independent of age, gender, race, insurance status, presence of comorbid DSM-5 diagnosis, or domicile status. Naloxone was more likely to be provided to patients who received bup/nx (97.8% vs 26.9%; P < 0.001), and bup/nx was more likely to be given to patients who presented with opioid withdrawal and/or requested "detox" (63.3% vs 36.7%; P < 0.001). Bup/nx provision was associated with decreased ED utilization for opioid-related visits at 30 days (P = 0.04). Homelessness and lack of insurance were associated with increased ED utilization for non-opioid-related visits at 90 days (P = 0.008 and P = 0.005, respectively), and again at one year for homelessness (P < 0.001). When controlling for age and domicile status, the adjusted incidence rate ratio for overall ED visits was 0.56 (95% confidence interval [CI] 0.33-0.96) at 30 days, 0.43 (95% CI 0.27-0.69) at 90 days, and 0.60 (95% CI 0.39-0.92) at one year, favoring bup/nx provision. Conclusion Initiation of bup/nx in the ED setting was associated with decreased subsequent ED utilization. Socioeconomic factors, specifically health insurance and domicile status, significantly impacted non-opioid-related ED reuse. These findings demonstrate the ED's potential as an initiation point for bup/nx and highlight the importance of considering the social risk and social need for OUD patients.
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Affiliation(s)
- Rachel M Skains
- University of Alabama at Birmingham, Heersink School of Medicine, Department of Emergency Medicine, Birmingham, Alabama
- Birmingham VA Medical Center, Department of Emergency Medicine, Birmingham, Alabama
| | - Lindy Reynolds
- University of Alabama at Birmingham, Heersink School of Medicine, Department of Emergency Medicine, Birmingham, Alabama
| | - Nicholas Carlisle
- University of Alabama at Birmingham, School of Public Health, Department of Health Behavior, Birmingham, Alabama
| | - Sonya Heath
- University of Alabama at Birmingham, Heersink School of Medicine, Department of Internal Medicine, Birmingham, Alabama
| | - Whitney Covington
- University of Alabama at Birmingham, Heersink School of Medicine, Department of Emergency Medicine, Birmingham, Alabama
| | - Kyle Hornbuckle
- University of Alabama at Birmingham, Heersink School of Medicine, Birmingham, Alabama
| | - Lauren Walter
- University of Alabama at Birmingham, Heersink School of Medicine, Department of Emergency Medicine, Birmingham, Alabama
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Klemperer EM, Wreschnig L, Crocker A, King-Mohr J, Ramniceanu A, Brooklyn JR, Peck KR, Rawson RA, Evans EA. The impact of the implementation of medication for opioid use disorder and COVID-19 in a statewide correctional system on treatment engagement, postrelease continuation of care, and overdose. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2023; 152:209103. [PMID: 37311520 PMCID: PMC10257572 DOI: 10.1016/j.josat.2023.209103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 02/27/2023] [Accepted: 06/09/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND People with opioid use disorder (OUD) are overrepresented in US correctional facilities and experience disproportionately high risk for overdose after release. Medications for OUD (MOUD) are highly efficacious but not available to most incarcerated individuals. In 2018, Vermont began providing MOUD for all incarcerated individuals with OUD statewide. In 2020, the COVID-19 state of emergency began. We assessed the impact of both events on MOUD utilization and treatment outcomes. METHODOLOGY Analyses linked Vermont Department of Corrections administrative data and Medicaid claims data between 07/01/2017 and 03/31/2021. The study used logistic regression to analyze treatment engagement among all incarcerated individuals in Vermont. Multilevel modeling assessed change in clinical outcomes among release episodes that occurred among individuals with an OUD diagnosis Medicaid claim. RESULTS Prescriptions for MOUD while incarcerated increased from 0.8% to 33.9% of the incarcerated population after MOUD implementation (OR = 67.4) and subsequently decreased with the onset of COVID-19 to 26.6% (OR = 0.7). After MOUD implementation, most prescriptions (63.1%) were to individuals who had not been receiving MOUD prior to incarceration, but this figure decreased to 53.9% with the onset of COVID-19 (OR = 0.7). Prescriptions for MOUD within 30 days after release increased from 33.9% of those with OUD before to 41.0% after MOUD implementation (OR = 1.4) but decreased to 35.6% with the onset of COVID-19 (OR = 0.8). Simultaneously, opioid-related nonfatal overdoses within 30 days after release decreased from 1.2% before to 0.8% after statewide MOUD implementation (OR = 0.3) but increased to 1.9% during COVID-19 (OR = 3.4). Fatal overdoses within 1 year after release decreased from 27 deaths before to ≤10 after statewide MOUD implementation and remained ≤10 during COVID-19. CONCLUSIONS This longitudinal evaluation demonstrated increased treatment engagement and a decrease in opioid-related overdose following implementation of MOUD in a statewide correctional system. In contrast, these improvements were somewhat attenuated with the onset of COVID-19, which was associated with decreased treatment engagement and an increase in nonfatal overdoses. Considered together, these findings demonstrate the benefits of statewide MOUD for incarcerated individuals as well as the need to identify and address barriers to continuation of care following release from incarceration in the context of COVID-19.
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Affiliation(s)
- Elias M Klemperer
- University of Vermont, College of Medicine, Department of Psychiatry, United States of America.
| | | | - Abigail Crocker
- University of Vermont, College of Engineering Mathematical Sciences, Department of Mathematics and Statistics, United States of America
| | - Jessica King-Mohr
- Vermont Agency of Human Services, Department of Corrections, United States of America
| | - Annie Ramniceanu
- Vermont Agency of Human Services, Department of Corrections, United States of America
| | - John R Brooklyn
- University of Vermont, College of Medicine, Department of Family Medicine, United States of America
| | - Kelly R Peck
- University of Vermont, College of Medicine, Department of Psychiatry, United States of America
| | - Richard A Rawson
- University of Vermont, College of Medicine, Department of Psychiatry, United States of America
| | - Elizabeth A Evans
- University of Massachusetts Amherst, School of Public Health & Health Sciences, United States of America
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28
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Yao X, McFaull SR, Champagne AS, Thompson W. An interrupted time series analysis of trends in opioid-related emergency department visits from pre-COVID-19 pandemic to pandemic, from the Canadian Hospitals Injury Reporting and Prevention Program. BMC Public Health 2023; 23:1483. [PMID: 37537534 PMCID: PMC10401736 DOI: 10.1186/s12889-023-16414-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 07/28/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND Opioid-related emergency department (ED) visits in Canada increased during the COVID-19 pandemic, but how trends in volume and case severity changed from pre-pandemic times through the pandemic is not known. Trends in ED visits related to specific types of opioids also remain unclear. Our objective was to describe pre-pandemic trends and how they changed with the onset of COVID-19 and thereafter. METHODS Based on data from the Canadian Hospitals Injury Reporting and Prevention Program, we identified opioid-related ED visits and constructed a time series from March 12, 2018 through March 7, 2021-two pre-COVID periods and one COVID period. We used an interrupted time series (ITS) analysis to examine trends in volume and case severity. We compared medians and means of monthly counts and percentages of severe cases between the periods, by sex, age, and opioid type. RESULTS Before the pandemic, there was an increasing trend in fentanyl-related visits for males, females and 25- to 64-year-olds, and a decreasing trend in heroin-related visits for males and 18- to 64-year-olds. Fentanyl-related visits for 18- to 24-year-olds showed an immediate increase at the start of the pandemic and a decreasing trend during the pandemic. Heroin-related visits for 12- to 17-year-olds had an immediate increase at the start of the pandemic; for 18- to 24-year-olds and 45- to 64-year-olds, the prior decreasing pre-pandemic trend ceased. For pooled opioid-related visits, no significant trend in the percentage of severe cases was observed throughout the entire study period. CONCLUSION This study shows that an ITS approach in trend analysis is a valuable supplement to comparisons of before and after measures (with or without controlling seasonal effects). The findings provide evidence on how ED presentations for opioid use evolved in Canada from 2018 to 2021. The results can inform policies designed to reduce opioid-related harm in the context of a public health emergency.
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Affiliation(s)
- Xiaoquan Yao
- The Public Health Agency of Canada, 785 Carling Avenue, Ottawa, ON, K1S 5H4, Canada.
| | - Steven R McFaull
- The Public Health Agency of Canada, 785 Carling Avenue, Ottawa, ON, K1S 5H4, Canada
| | - André S Champagne
- The Public Health Agency of Canada, 785 Carling Avenue, Ottawa, ON, K1S 5H4, Canada
| | - Wendy Thompson
- The Public Health Agency of Canada, 785 Carling Avenue, Ottawa, ON, K1S 5H4, Canada
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Farrow L, Gardner WT, Tang CC, Low R, Forget P, Ashcroft GP. Impact of COVID-19 on opioid use in those awaiting hip and knee arthroplasty: a retrospective cohort study. BMJ Qual Saf 2023; 32:479-484. [PMID: 34521769 PMCID: PMC8449843 DOI: 10.1136/bmjqs-2021-013450] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 08/22/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND COVID-19 has had a detrimental impact on access to hip and knee arthroplasty surgery. We set out to examine whether this had a subsequent impact on preoperative opioid prescribing rates for those awaiting surgery. METHODS Data regarding patient demographics and opioid utilisation were collected from the electronic health records of included patients at a large university teaching hospital. Patients on the outpatient waiting list for primary hip and knee arthroplasty as of September 2020 (COVID-19 group) were compared with historical controls (Controls) who had previously undergone surgery. A sample size calculation indicated 452 patients were required to detect a 15% difference in opioid prescription rates between groups. RESULTS A total of 548 patients (58.2% female) were included, 260 in the COVID-19 group and 288 in the Controls. Baseline demographics were similar between the groups. For those with data available, the proportion of patients on any opioid at follow-up in the COVID-19 group was significantly higher: 55.0% (143/260) compared with 41.2% (112/272) in the Controls (p=0.002). This remained significant when adjusted for confounding (age, gender, Scottish Index of Multiple Deprivation, procedure and wait time). The proportion of patients on a strong opioid was similar (4.2% (11/260) vs 4.8% (13/272)) for COVID-19 and Controls, respectively. The median waiting time from referral to follow-up was significantly longer in the COVID-19 group compared with the Controls (455 days vs 365 days; p<0.0001). CONCLUSION The work provides evidence of potential for an emerging opioid problem associated with the influence of COVID-19 on elective arthroplasty services. Viable alternatives to opioid analgesia for those with end-stage arthritis should be explored, and prolonged waiting times for surgery ought to be avoided in the recovery from COVID-19 to prevent more widespread opioid use.
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Affiliation(s)
- Luke Farrow
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
- Trauma & Orthopaedics, Woodend Hospital, Aberdeen, UK
| | - William T Gardner
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
- Trauma & Orthopaedics, Woodend Hospital, Aberdeen, UK
| | | | - Rachel Low
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Patrice Forget
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
- Trauma & Orthopaedics, Woodend Hospital, Aberdeen, UK
| | - George Patrick Ashcroft
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
- Trauma & Orthopaedics, Woodend Hospital, Aberdeen, UK
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Jones NW, Song SL, Thomasian N, Samuels EA, Ranney ML. Behavioral Health Decision Support Systems and User Interface Design in the Emergency Department. Appl Clin Inform 2023; 14:705-713. [PMID: 37673096 PMCID: PMC10482498 DOI: 10.1055/s-0043-1771395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 06/06/2023] [Indexed: 09/08/2023] Open
Abstract
OBJECTIVE The objective of this qualitative study is to gauge physician sentiment about an emergency department (ED) clinical decision support (CDS) system implemented in multiple adult EDs within a university hospital system. This CDS system focuses on predicting patients' likelihood of ED recidivism and/or adverse opioid-related events. METHODS The study was conducted among adult emergency physicians working in three EDs of a single academic health system in Rhode Island. Qualitative, semistructured interviews were conducted with ED physicians. Interviews assessed physicians' prior experience with predictive analytics, thoughts on the alert's placement, design, and content, the alert's overall impact, and potential areas for improvement. Responses were aggregated and common themes identified. RESULTS Twenty-three interviews were conducted (11 preimplementation and 12 postimplementation). Themes were identified regarding each physician familiarity with predictive analytics, alert rollout, alert appearance and content, and on alert sentiments. Most physicians viewed these alerts as a neutral or positive EHR addition, with responses ranging from neutral to positive. The alert placement was noted to be largely intuitive and nonintrusive. The design of the alert was generally viewed positively. The alert's content was believed to be accurate, although the decision to respond to the alert's call-to-action was physician dependent. Those who tended to ignore the alert did so for a few reasons, including already knowing the information the alert contains, the alert offering information that is not relevant to this particular patient, and the alert not containing enough information to be useful. CONCLUSION Ultimately, this alert appears to have a marginally positive effect on ED physician workflow. At its most beneficial, the alert reminded physicians to deeply consider the care provided to high-risk populations and to potentially adjust their care and referrals. At its least beneficial, the alert did not affect physician decision-making but was not intrusive to the point of negatively impacting workflow.
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Affiliation(s)
- Nicholas W. Jones
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, United States
| | - Sophia L. Song
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States
| | - Nicole Thomasian
- Department of Anesthesiology, New York Presbyterian-Weill Cornell Medical Center, New York, New York, United States
| | - Elizabeth A. Samuels
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States
| | - Megan L. Ranney
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States
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Kitzman JM, Mesheriakova VV, Borucki AN, Agarwal R. Substance Use Disorders in Adolescents and Young Adults: History and Perioperative Considerations From the Society for Pediatric Pain Medicine. Anesth Analg 2023:00000539-990000000-00608. [PMID: 37450650 DOI: 10.1213/ane.0000000000006623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
Substance use disorders (SUDs) are on the rise in children and young adults in the United States. According to reports, over 40 million people aged 12 and older had a diagnosed SUD in 2020.1 A recent report from the Centers for Disease Control and Prevention (CDC) found that overdose death in children aged 10 to 19 years old increased 109% from 2019 to 2021.2 Given the rapidly increasing prevalence of SUD, anesthesiologists will almost certainly encounter children, adolescents, and young adults with a history of recreational drug use or nonmedical use of prescription opioids in the perioperative period. Since the perioperative period can be a particularly challenging time for patients with SUD, anesthesiologists can tailor their perioperative care to reduce rates of relapse and can serve as both advocates and educators for this vulnerable patient population. This article examines the history of SUD and physiology of substance use in children, adolescents, and young adults, including reasons why young people are more susceptible to the addictive effects of many substances. The coronavirus disease 2019 (COVID-19) pandemic impacted many aspects of life, including increased social isolation and shifted dynamics at home, both thought to impact substance use.3 Substance use patterns in the wake of the COVID-19 pandemic are explored. Although current literature is mostly on adults, the evidence-based medical treatments for patients with SUD are reviewed, and recommendations for perioperative considerations are suggested. The emphasis of this review is on opioid use disorder, cannabis, and vaping particularly because these have disproportionately affected the younger population. The article provides recommendations and resources for recognizing and treating adolescents and young adults at risk for SUD in the perioperative period. It also provides suggestions to reduce new persistent postoperative opioid use.
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Affiliation(s)
- Jamie M Kitzman
- From the Department of Anesthesiology, Division of Pediatric Anesthesiology, Emory University School of Medicine, Atlanta, Georgia
| | - Veronika V Mesheriakova
- Department of Pediatrics, Division of Adolescent and Young Adult Medicine, University of California San Francisco, San Francisco, California
| | - Amber N Borucki
- Department of Anesthesiology, University of California San Francisco, San Francisco, California
| | - Rita Agarwal
- Department of Anesthesiology, Perioperative Medicine, and Pain Management, Stanford University School of Medicine, Stanford, California
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Holland WC, Li F, Nath B, Jeffery MM, Stevens M, Melnick ER, Dziura JD, Khidir H, Skains RM, D'Onofrio G, Soares WE. Racial and ethnic disparities in emergency department-initiated buprenorphine across five health care systems. Acad Emerg Med 2023; 30:709-720. [PMID: 36660800 PMCID: PMC10467357 DOI: 10.1111/acem.14668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 01/17/2023] [Accepted: 01/18/2023] [Indexed: 01/21/2023]
Abstract
BACKGROUND Opioid overdose deaths have disproportionately impacted Black and Hispanic populations, in part due to disparities in treatment access. Emergency departments (EDs) serve as a resource for patients with opioid use disorder (OUD), many of whom have difficulty accessing outpatient addiction programs. However, inequities in ED treatment for OUD remain poorly understood. METHODS This secondary analysis examined racial and ethnic differences in buprenorphine access using data from EMBED, a study of 21 EDs across five health care systems evaluating a clinical decision support system for initiating ED buprenorphine. The primary outcome was receipt of buprenorphine, ED administered or prescribed. Hospital type (academic vs. community) was evaluated as an effect modifier. Hierarchical models with cluster effects for site and clinician were used to assess buprenorphine receipt by race and ethnicity. RESULTS Black patients were less likely to receive buprenorphine (6.4% [51/801] vs. White patients 8.5% [268/3154], odds ratio [OR] 0.59, 95% confidence interval [CI] 0.45-0.78). This association persisted after adjusting for age, insurance, gender, clinician X-waiver, hospital type, and urbanicity (adjusted OR [aOR] 0.64, 95% CI 0.48-0.84) but not when discharge diagnosis was included (aOR 0.75, 95% CI 0.56-1.02). Hispanic patients were more likely to receive buprenorphine (14.8% [122/822] vs. non-Hispanic patients, 11.6% [475/4098]) in unadjusted (OR 1.57, 95% CI 1.09-1.83) and adjusted models (aOR 1.41, 95% CI 1.08-1.83) but not including discharge diagnosis (aOR 1.32, 95% CI 0.99-1.77). Odds of buprenorphine were similar in academic and community EDs by race (interaction p = 0.97) and ethnicity (interaction p = 0.64). CONCLUSIONS Black patients with OUD were less likely to receive buprenorphine whereas Hispanic patients were more likely to receive buprenorphine in academic and community EDs. Differences were attenuated with discharge diagnosis, as fewer Black and non-Hispanic patients were diagnosed with opioid withdrawal. Barriers to medication treatment are heterogenous among patients with OUD; research must continue to address the multiple drivers of health inequities at the patient, clinician, and community level.
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Affiliation(s)
| | - Fangyong Li
- Yale Center for Analytical Sciences, New Haven, Connecticut, USA
| | - Bidisha Nath
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Molly M Jeffery
- Department of Emergency Medicine and Department of Health Care Policy Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Maria Stevens
- Department of Emergency Medicine and Department of Health Care Policy Research, Mayo Clinic, Rochester, Minnesota, USA
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Edward R Melnick
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - James D Dziura
- Yale Center for Analytical Sciences, New Haven, Connecticut, USA
| | - Hazar Khidir
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
- National Clinician Scholars Program, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Rachel M Skains
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Gail D'Onofrio
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - William E Soares
- Department of Emergency Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield, Massachusetts, USA
- Department of Healthcare Delivery and Population Science, University of Massachusetts Chan Medical School-Baystate, Springfield, Massachusetts, USA
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Casey S, Regan S, Gale E, Adams ZM, Lambert E, Omede FO, Wakeman SE. Rapid Methadone Induction in a General Hospital Setting: A Retrospective, Observational Analysis. Subst Abus 2023; 44:177-183. [PMID: 37728091 DOI: 10.1177/08897077231185655] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
BACKGROUND Outpatient methadone guidelines recommend starting at a low dose and titrating slowly. As fentanyl prevalence and opioid-related mortality increases, there is a need for individuals to rapidly achieve a therapeutic methadone dose. Hospitalization offers a monitored setting for methadone initiation, however dosing practices and safety are not well described. METHODS Retrospective, observational analysis of hospitalized patients with opioid use disorder seen by an inpatient addiction consult team in an academic medical center who were newly initiated on methadone between 2016 and 2022. We calculated initial daily dose, maximum daily dose, timing interval of dose escalation, whether patients were connected to an opioid treatment program (OTP) prior to discharge, whether adverse effects or safety events occurred during the hospitalization, and whether such events were definitely or probably related versus possibly related or unrelated to methadone. RESULTS One hundred twelve patients were included. The mean initial daily methadone dose administered was 32 mg (range: 10-90 mg). The mean maximum dose reached was 76.8 mg (range 30-165 mg). The mean number of days from initial to peak dose was 5.6 days (range 1-19 days). Overall, 30% of patients experienced a safety event, most commonly sedation. Only 4 safety events were deemed probably or definitely related to methadone. In regression analyses, there was no significant difference between starting doses among patients with or without sedation but there was a relationship between last dose and the likelihood of any possibly related event, with those ending at a dose of 100 mg or higher having a higher likelihood event, compared to those ending at lower doses (47.8% vs 12.4%, P < .001). Seventy-six percent were connected to OTP before discharge. CONCLUSION Among hospitalized patients initiating methadone, rapid dose titration was infrequently associated with related safety events and most were connected to community-based methadone treatment before discharge.
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Affiliation(s)
- Sarah Casey
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Susan Regan
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Evan Gale
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Zoe M Adams
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Eugene Lambert
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Faith O Omede
- Department of Internal Medicine, Mass General Community Physicians, Salem, MA, USA
| | - Sarah E Wakeman
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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Stephenson A, Calvo-Friedman A, Altshuler L, Zabar S, Hanley K. Educational training to improve opioid overdose response among health center staff: a quality improvement initiative. Harm Reduct J 2023; 20:83. [PMID: 37391790 PMCID: PMC10311901 DOI: 10.1186/s12954-023-00803-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 06/06/2023] [Indexed: 07/02/2023] Open
Abstract
BACKGROUND There were seven opioid overdoses in this New York City (NYC) federally qualified health center from December 2018 through February 2019, reflecting the rising rate of overdose deaths in NYC overall at the time. In response to these overdoses, we sought to increase the readiness of health center staff to recognize and respond to opioid overdoses and decrease stigmatizing attitudes around opioid use disorder (OUD). METHODS An hour-long training focusing on opioid overdose response was administered to clinical and non-clinical staff of all levels at the health center. This training included didactic education on topics such as the overdose epidemic, stigma around OUD, and opioid overdose response, as well as discussion. A structured assessment was administered immediately before and following the training to evaluate change in knowledge and attitudes. Additionally, participants completed a feedback survey immediately after the training to assess acceptability. Paired t-tests and analysis of variance tests were used to assess changes in pre- and post-test scores. RESULTS Over 76% of the health center staff participated in the training (N = 310). There were large and significant increases in mean knowledge and attitudinal scores from pre- to post-test (p < .001 and p < .001, respectively). While there was no significant effect of profession on attitudinal change scores, profession did have a significant effect on knowledge change scores, with administrative staff, non-clinical support staff, other healthcare staff, and therapists learning significantly more than providers (p < .001). The training had high acceptability among participants from diverse departments and levels. CONCLUSIONS An interactive educational training increased staff's knowledge and readiness to respond to an overdose as well as improved attitudes toward individuals living with OUD. TRIAL REGISTRATION This project was undertaken as a quality improvement initiative at the health center and as such was not formally supervised by the Institutional Review Board per their policies. Further, per the guidelines of the International Committee of Medical Journal Editors, registration is not necessary for clinical trials whose sole purpose is to assess an intervention's effect on providers.
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Affiliation(s)
- Audrey Stephenson
- NYC Health + Hospitals/Gotham Health, Gouverneur, 227 Madison St., New York, NY, 10002, USA
- West Chester University of Pennsylvania, West Chester, PA, USA
| | - Alessandra Calvo-Friedman
- NYC Health + Hospitals/Gotham Health, Gouverneur, 227 Madison St., New York, NY, 10002, USA
- Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Lisa Altshuler
- Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Sondra Zabar
- NYC Health + Hospitals/Gotham Health, Gouverneur, 227 Madison St., New York, NY, 10002, USA
- Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Kathleen Hanley
- NYC Health + Hospitals/Gotham Health, Gouverneur, 227 Madison St., New York, NY, 10002, USA.
- Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA.
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Simpson MJ, Ritger C, Hoppe JA, Holland WC, Morris MA, Nath B, Melnick ER, Tietbohl C. Implementation strategies to address the determinants of adoption, implementation, and maintenance of a clinical decision support tool for emergency department buprenorphine initiation: a qualitative study. Implement Sci Commun 2023; 4:41. [PMID: 37081581 PMCID: PMC10117277 DOI: 10.1186/s43058-023-00421-7] [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: 11/17/2022] [Accepted: 03/22/2023] [Indexed: 04/22/2023] Open
Abstract
BACKGROUND Untreated opioid use disorder (OUD) is a significant public health problem. Buprenorphine is an evidence-based treatment for OUD that can be initiated in and prescribed from emergency departments (EDs) and office settings. Adoption of buprenorphine initiation among ED clinicians is low. The EMBED pragmatic clinical trial investigated the effectiveness of a clinical decision support (CDS) tool to promote ED clinicians' behavior related to buprenorphine initiation in the ED. While the CDS intervention was not associated with increased rates of buprenorphine treatment for patients with OUD at intervention ED sites, attending physicians at intervention EDs were more likely to initiate buprenorphine at least once over the duration of the study compared to those in the usual care arms (44.4% vs 34.0%, P = 0.01). This suggests the CDS intervention may be associated with increased adoption of buprenorphine initiation. As a secondary aim, we sought to identify the determinants of CDS adoption, implementation, and maintenance in a variety of ED settings and geographic locations. METHODS We purposively sampled and conducted semi-structured, in-depth interviews with clinicians across EMBED trial sites randomized to the intervention arm from five healthcare systems. Interviews elicited clinician experiences regarding buprenorphine initiation and CDS use. Interviews were analyzed using directed content analysis informed by the Practical, Robust Implementation and Sustainability Model (PRISM). We used a hybrid approach (a priori codes informed by PRISM and emergent codes) for codebook development. ATLAS.ti (version 9.0) was used for data management. Coded data were analyzed within individual interview transcripts and across all interviews to identify major themes. This process involved (1) combining, comparing, and making connections between codes; (2) writing analytic memos about observed patterns; and (3) frequent team meetings to discuss emerging patterns. RESULTS Twenty-eight interviews were conducted. Major themes that influenced the successful adoption, implementation, and maintenance of the EMBED intervention and ED-initiated BUP were organizational culture and commitment, clinician training and support, the ability to connect patients to ongoing treatment, and the ability to tailor implementation to each ED. These findings informed the identification of implementation strategies (framed using PRISM domains) to enhance the ED initiation of buprenorphine. CONCLUSION The findings from this qualitative analysis can provide guidance to build better systems to promote the adoption of ED-initiated buprenorphine.
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Affiliation(s)
- Matthew J Simpson
- Department of Family Medicine, University of Colorado Anschutz Medical Campus, 12631 E. 17th Avenue, Box F496, Aurora, CO, 80045, USA.
| | - Carly Ritger
- Adult and Child Center for Health Outcomes Research & Delivery Science, University of Colorado Anschutz Medical Campus, 13199 E. Montview Boulevard, Suite 300, Aurora, CO, 80045, USA
| | - Jason A Hoppe
- Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, 12631 E. 17th Avenue, Box B215, Aurora, CO, 80045, USA
| | - Wesley C Holland
- Yale University School of Medicine, 333 Cedar St., New Haven, CT, 06510, USA
| | - Megan A Morris
- Adult and Child Center for Health Outcomes Research & Delivery Science, University of Colorado Anschutz Medical Campus, 13199 E. Montview Boulevard, Suite 300, Aurora, CO, 80045, USA
| | - Bidisha Nath
- Department of Emergency Medicine, Yale School of Medicine, 464 Congress Ave., Ste 260, New Haven, CT, 06519, USA
| | - Edward R Melnick
- Department of Emergency Medicine, Yale School of Medicine, 464 Congress Ave., Ste 260, New Haven, CT, 06519, USA
| | - Caroline Tietbohl
- Adult and Child Center for Health Outcomes Research & Delivery Science, University of Colorado Anschutz Medical Campus, 13199 E. Montview Boulevard, Suite 300, Aurora, CO, 80045, USA
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Collins AB, Baird J, Nimaja E, Ashenafi Y, Clark MA, Beaudoin FL. Experiences of patients at high risk of opioid overdose accessing emergency department and behavioral health interventions: a qualitative analysis in an urban emergency department. BMC Health Serv Res 2023; 23:370. [PMID: 37069593 PMCID: PMC10110343 DOI: 10.1186/s12913-023-09387-7] [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: 10/14/2022] [Accepted: 04/11/2023] [Indexed: 04/19/2023] Open
Abstract
BACKGROUND Emergency Departments (EDs) have become critical 'touchpoints' for the identification and early engagement of patients at risk of overdose or who have an opioid use disorder (OUD). Our objectives were to examine patients' ED experiences, identify barriers and facilitators of service uptake in ED settings, and explore patients' experiences with ED staff. METHODS This qualitative study was part of a randomized controlled trial that evaluated the effectiveness of clinical social workers and certified peer recovery specialists in increasing treatment uptake and reducing opioid overdose rates for people with OUD. Between September 2019 and March 2020, semi-structured interviews were conducted 19 participants from the trial. Interviews sought to assess participants' ED care experiences across intervention type (i.e., clinical social worker or peer recovery specialist). Participants were purposively sampled across intervention arm (social work, n = 11; peer recovery specialist, n = 7; control, n = 1). Data were analyzed thematically with a focus on participant experiences in the ED and social and structural factors shaping care experiences and service utilization. RESULTS Participants reported varied ED experiences, including instances of discrimination and stigma due to their substance use. However, participants underscored the need for increased engagement of people with lived experience in ED settings, including the use of peer recovery specialists. Participants highlighted that ED provider interactions were critical drivers of shaping care and service utilization and needed to be improved across EDs to improve post-overdose care. CONCLUSIONS While the ED provides an opportunity to reach patients at risk of overdose, our results demonstrate how ED-based interactions and service provision can impact ED care engagement and service utilization. Modifications to care delivery may improve experiences for patients with OUD or at high risk for overdose. TRIAL REGISTRATION Clinical trial registration: NCT03684681.
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Affiliation(s)
- Alexandra B Collins
- Department of Epidemiology, Brown University School of Public Health, 121 S Main Street, Providence, RI, USA
| | - Janette Baird
- Department of Emergency Medicine, Warrant Alpert Medical School of Brown University, 55 Claverick Street 2Nd Floor, Providence, RI, 02903, USA
| | - Evelyn Nimaja
- Department of Emergency Medicine, Warrant Alpert Medical School of Brown University, 55 Claverick Street 2Nd Floor, Providence, RI, 02903, USA
| | - Yokabed Ashenafi
- Department of Epidemiology, Brown University School of Public Health, 121 S Main Street, Providence, RI, USA
| | - Melissa A Clark
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - Francesca L Beaudoin
- Department of Epidemiology, Brown University School of Public Health, 121 S Main Street, Providence, RI, USA.
- Department of Emergency Medicine, Warrant Alpert Medical School of Brown University, 55 Claverick Street 2Nd Floor, Providence, RI, 02903, USA.
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D’Onofrio G, Edelman EJ, Hawk KF, Chawarski MC, Pantalon MV, Owens PH, Martel SH, Rothman R, Saheed M, Schwartz RP, Cowan E, Richardson L, Salsitz E, Lyons MS, Freiermuth C, Wilder C, Whiteside L, Tsui JI, Klein JW, Coupet E, O’Connor PG, Matthews AG, Murphy SM, Huntley K, Fiellin DA. Implementation Facilitation to Promote Emergency Department-Initiated Buprenorphine for Opioid Use Disorder. JAMA Netw Open 2023; 6:e235439. [PMID: 37017967 PMCID: PMC10077107 DOI: 10.1001/jamanetworkopen.2023.5439] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 02/05/2023] [Indexed: 04/06/2023] Open
Abstract
Importance Emergency department (ED)-initiated buprenorphine for the treatment of opioid use disorder (OUD) is underused. Objective To evaluate whether provision of ED-initiated buprenorphine with referral for OUD increased after implementation facilitation (IF), an educational and implementation strategy. Design, Setting, and Participants This multisite hybrid type 3 effectiveness-implementation nonrandomized trial compared grand rounds with IF, with pre-post 12-month baseline and IF evaluation periods, at 4 academic EDs. The study was conducted from April 1, 2017, to November 30, 2020. Participants were ED and community clinicians treating patients with OUD and observational cohorts of ED patients with untreated OUD. Data were analyzed from July 16, 2021, to July 14, 2022. Exposure A 60-minute in-person grand rounds was compared with IF, a multicomponent facilitation strategy that engaged local champions, developed protocols, and provided learning collaboratives and performance feedback. Main Outcomes and Measures The primary outcomes were the rate of patients in the observational cohorts who received ED-initiated buprenorphine with referral for OUD treatment (primary implementation outcome) and the rate of patients engaged in OUD treatment at 30 days after enrollment (effectiveness outcome). Additional implementation outcomes included the numbers of ED clinicians with an X-waiver to prescribe buprenorphine and ED visits with buprenorphine administered or prescribed and naloxone dispensed or prescribed. Results A total of 394 patients were enrolled during the baseline evaluation period and 362 patients were enrolled during the IF evaluation period across all sites, for a total of 756 patients (540 [71.4%] male; mean [SD] age, 39.3 [11.7] years), with 223 Black patients (29.5%) and 394 White patients (52.1%). The cohort included 420 patients (55.6%) who were unemployed, and 431 patients (57.0%) reported unstable housing. Two patients (0.5%) received ED-initiated buprenorphine during the baseline period, compared with 53 patients (14.6%) during the IF evaluation period (P < .001). Forty patients (10.2%) were engaged with OUD treatment during the baseline period, compared with 59 patients (16.3%) during the IF evaluation period (P = .01). Patients in the IF evaluation period who received ED-initiated buprenorphine were more likely to be in treatment at 30 days (19 of 53 patients [35.8%]) than those who did not 40 of 309 patients (12.9%; P < .001). Additionally, there were increases in the numbers of ED clinicians with an X-waiver (from 11 to 196 clinicians) and ED visits with provision of buprenorphine (from 259 to 1256 visits) and naloxone (from 535 to 1091 visits). Conclusions and Relevance In this multicenter effectiveness-implementation nonrandomized trial, rates of ED-initiated buprenorphine and engagement in OUD treatment were higher in the IF period, especially among patients who received ED-initiated buprenorphine. Trial Registration ClinicalTrials.gov Identifier: NCT03023930.
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Affiliation(s)
- Gail D’Onofrio
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Yale School of Public Health, New Haven, Connecticut
| | - E. Jennifer Edelman
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Kathryn F. Hawk
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Marek C. Chawarski
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut
| | - Michael V. Pantalon
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Patricia H. Owens
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Shara H. Martel
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Richard Rothman
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mustapha Saheed
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Ethan Cowan
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Lynne Richardson
- Institute for Health Equity Research, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Edwin Salsitz
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Michael S. Lyons
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio
- Center for Addiction Research, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Caroline Freiermuth
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio
- Center for Addiction Research, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Christine Wilder
- Center for Addiction Research, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, Cincinnati, Ohio
| | - Lauren Whiteside
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle
| | - Judith I. Tsui
- Department of Medicine, University of Washington, Seattle
| | - Jared W. Klein
- Department of Medicine, University of Washington, Seattle
| | - Edouard Coupet
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Patrick G. O’Connor
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | | | | | - David A. Fiellin
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Yale School of Public Health, New Haven, Connecticut
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Kim S, Rajack N, Mondoux SE, Tardelli VS, Kolla NJ, Le Foll B. The COVID-19 impact and characterization on substance use-related emergency department visits for adolescents and young adults in Canada: Practical implications. J Eval Clin Pract 2023; 29:447-458. [PMID: 36752167 DOI: 10.1111/jep.13817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 01/27/2023] [Accepted: 01/29/2023] [Indexed: 02/09/2023]
Abstract
RATIONALE Coronavirus (COVID-19)-related stressors precipitated the mental health crisis and increased substance use in Canada and worldwide. As the pandemic continues to evolve, monitoring and updating substance use-related ED visit trends is essential to ensure the stability and quality of ED services under the prolonged pandemic timeline. AIMS AND OBJECTIVES This study examined the trends and characterization of substance use-related ED visits during the pandemic among adolescents and young adults (aged 13-25 years) in Ontario, Canada. METHODS Descriptive statistics and binary logistic regression analyses were conducted using population-based, repeated cross-sectional data. The volume, patient characteristics (age and sex) and hospital/ED visit features (triage to end time, timing of the visit, triage level and referral source) were compared before (2019) and during COVID-19 (2020 and 2021) by each substance type (alcohol, opioid, cannabis, sedatives, cocaine, stimulants and multiple psychoactive substances). RESULTS Substance use-related ED visits decreased by 1.5 times during the pandemic compared to the prepandemic level. However, opioid-related ED visits continued to show an increasing trend and did not recover to the prepandemic level in 2021. Moreover, a significant increase in emergent/life-threatening triage levels (Canadian Triage and Acuity Scales 1 and 2) in substance-related ED visits is alarming (2019 = 36.8%, 2020 = 38.7% and 2021 = 38.4%). We also found a general decrease in weekend visits, overnight visits and visits on statutory holidays, and substance use-related ED patients tended to stay longer (over 6 h) in the ED during the pandemic. CONCLUSION Our findings indicate unmet substance use treatment needs due to the limited accessibility and heightened threshold for ED visits during the pandemic. Providing access to substance treatment/programs outside ED is critical to reducing substance use-related complications presenting in the ED. Also, policies addressing the pandemic-related complexities in the ED and Health Human Resource challenges are warranted.
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Affiliation(s)
- Soyeon Kim
- Waypoint Research Institute, Waypoint Centre for Mental Health Care, Penetanguishene, Ontario, Canada.,Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
| | - Natalie Rajack
- Waypoint Research Institute, Waypoint Centre for Mental Health Care, Penetanguishene, Ontario, Canada
| | - Shawn E Mondoux
- Emergency Department, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada.,Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Vitor S Tardelli
- Centre for Addiction and Mental Health, University of Toronto, Toronto, Ontario, Canada.,Department of Psychiatry, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Nathan J Kolla
- Waypoint Research Institute, Waypoint Centre for Mental Health Care, Penetanguishene, Ontario, Canada.,Centre for Addiction and Mental Health, University of Toronto, Toronto, Ontario, Canada
| | - Bernard Le Foll
- Waypoint Research Institute, Waypoint Centre for Mental Health Care, Penetanguishene, Ontario, Canada.,Centre for Addiction and Mental Health, University of Toronto, Toronto, Ontario, Canada
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Johnson E, Axeen S, Vosooghi A, Lam CN, Bluthenthal R, Schneberk T. Interrupted Time Series Analysis: Patient Characteristics and Rates of Opioid-Use-Disorder-Related Emergency Department Visits in the Los Angeles County Public Hospital System during COVID-19. Healthcare (Basel) 2023; 11:healthcare11070979. [PMID: 37046906 PMCID: PMC10093818 DOI: 10.3390/healthcare11070979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/20/2023] [Accepted: 03/26/2023] [Indexed: 03/31/2023] Open
Abstract
The COVID-19 pandemic led to disruptions in care for vulnerable patients, in particular patients with opioid use disorder (OUD). We aimed to examine OUD-related ED visits before and during the COVID-19 pandemic and determine if patient characteristics for OUD-related ED visits changed in the context of the pandemic. We examined all visits to the three public safety net hospital EDs in Los Angeles County from April 2019 to February 2021. We performed interrupted time series analyses examining OUD-related ED visits from Period 1, April 2019 to February 2020, compared with Period 2, April 2020 to February 2021, by race/ethnicity and payor group. We considered OUD-related ED visits as those which included any of the following: discharge diagnosis related to OUD, patients administered buprenorphine or naloxone while in the ED, and visits where a patient was prescribed buprenorphine or naloxone on discharge. There were 5919 OUD-related ED visits in the sample. OUD-related visits increased by 4.43 (2.82–6.03) per 1000 encounters from the pre-COVID period (9.47 per 1000 in February 2020) to the COVID period (13.90 per 1000 in April 2020). This represented an increase of 0.41/1000 by white patients, 0.92/1000 by black patients, and 1.83/1000 by Hispanic patients. We found increases in OUD-related ED visits among patients with Medicaid managed care of 2.23/1000 and in LA County safety net patients by 3.95/1000 ED visits. OUD-related ED visits increased during the first year of the COVID pandemic. These increases were significant among black, white, and Hispanic patients, patients with Medicaid managed care, and LA County Safety net patients. These data suggest public emergency departments served as a stopgap for patients suffering from OUD in Los Angeles County during the pandemic and can be utilized to guide preventative interventions in vulnerable populations.
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Olds PK, Musinguzi N, Geisler BP, Haberer JE. Evaluating disparities by social determinants in hospital admission decisions for patients with COVID-19 quaternary hospital early in the pandemic. Medicine (Baltimore) 2023; 102:e33178. [PMID: 36897732 PMCID: PMC9997198 DOI: 10.1097/md.0000000000033178] [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: 12/15/2022] [Accepted: 02/13/2023] [Indexed: 03/11/2023] Open
Abstract
The COVID-19 pandemic has highlighted significant disparities in hospital outcomes when focusing on social determinants of health. Better understanding the drivers of these disparities is not only critical for COVID-19 care but also to ensure equitable treatment more generally. In this paper, we look at how hospital admission patterns, both to the medical ward and the intensive care unit (ICU), may have differed by race, ethnicity, and social determinants of health. We conducted a retrospective chart review of all patients who presented to the Emergency Department of a large quaternary hospital between March 8 and June 3, 2020. We built logistic regression models to analyze how race, ethnicity, area deprivation index, English as a primary language, homelessness, and illicit substance use impacted the likelihood of admission while controlling for disease severity and timing of admission in relation to the start of data collection. We had 1302 recorded Emergency Department visits of patients diagnosed with SARS-CoV-2. White, Hispanic, and African American patients made up 39.2%, 37.5%, and 10.4% of the population respectively. Primary language was recorded as English for 41.2% and non-English for 30% of patients. Among the social determinants of health assessed, we found that illicit drug use significantly increased the likelihood for admission to the medical ward (odds ratio 4.4, confidence interval 1.1-17.1, P = .04), and that having a language other than English as a primary language significantly increased the likelihood of ICU admission (odds ratio 2.6, confidence interval 1.2-5.7, P = .02). Illicit drug use was associated with an increased likelihood of medical ward admission, potentially due to clinician concerns for complicated withdrawal or blood-stream infections from intravenous drug use. The increased likelihood of ICU admission associated with a primary language other than English may have been driven by communication difficulties or differences in disease severity that our model did not detect. Further work is required to better understand drivers of disparities in hospital COVID-19 care.
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Affiliation(s)
- Peter K. Olds
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | - Benjamin P. Geisler
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Ludwig Maximilian University Munich, Munich, Germany
| | - Jessica E. Haberer
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Mbarara University of Science and Technology, Mbarara, Uganda
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Rapid induction onto extended-release injectable buprenorphine following opioid overdose: A case series. DRUG AND ALCOHOL DEPENDENCE REPORTS 2023; 7:100144. [PMID: 37033158 PMCID: PMC10073633 DOI: 10.1016/j.dadr.2023.100144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 03/08/2023] [Accepted: 03/14/2023] [Indexed: 03/17/2023]
Abstract
Background Buprenorphine treatment has been associated with reduced non-prescribed opioid use and opioid related overdose (OD). We evaluated initial outcomes of rapid induction onto extended-release injectable buprenorphine (BUP-XR) within 7 days of emergency department presentation for unintentional OD. Methods Between February 2019-February 2021, N = 19 patients with opioid use disorder received buprenorphine/naloxone (4/1 mg), followed by BUP-XR (300 mg) at induction and continued BUP-XR outpatient for 6 months. Primary outcomes included adverse events, repeat OD, and death. Results For patients who received at least one dose of BUP-XR, there were no treatment related serious adverse events or symptoms of precipitated withdrawal. In addition, there were no repeat visits for ODs or deaths within 6 months of the initial OD. Discussion These preliminary findings support the need for larger controlled clinical trials to examine the safety and efficacy of rapid induction of BUP-XR in patients with opioid use disorder at high risk of opioid OD. Rapid induction onto long-lasting injectable buprenorphine may be a promising and protective treatment approach in the future.
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Friedmann PD, Dunn D, Michener P, Bernson D, Stopka TJ, Pivovarova E, Ferguson WJ, Rottapel R, Hoskinson R, Wilson D, Evans EA. COVID-19 impact on opioid overdose after jail release in Massachusetts. DRUG AND ALCOHOL DEPENDENCE REPORTS 2023; 6:100141. [PMID: 36879616 PMCID: PMC9968665 DOI: 10.1016/j.dadr.2023.100141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 02/22/2023] [Accepted: 02/24/2023] [Indexed: 03/02/2023]
Abstract
Introduction Release from incarceration is a high-risk period for opioid overdose. Concern about COVID-19 spread in jails led to early releases; it is unknown whether pandemic era releases of persons with opioid use disorder (OUD) contributed to increases in community overdose rates. Methods Observational data compared overdose rates three months after release among jailed persons with OUD released before (9/1/2019-3/9/2020) and during the pandemic (3/10/2020-8/10/2020) from seven jails in Massachusetts. Data on overdoses come from the Massachusetts Ambulance Trip Record Information System and Registry of Vital Records Death Certificate file. Other information came from jail administrative data. Logistic models regressed overdose on release period, controlling for MOUD received, county of release, race/ethnicity, sex, age, and prior overdose. Results Pandemic releases with OUD had a higher risk of fatal overdose (adjusted odds ratio [aOR] 3.06; 95% CI, 1.49 to 6.26); 20 persons released with OUD (1.3%) experienced a fatal overdose within three months of release, versus 14 (0.5%) pre-pandemic. MOUD had no detectable relationship with overdose mortality. Pandemic release did not impact non-fatal overdose rates (aOR 0.84; 95% CI 0.60 to 1.18), though in-jail methadone treatment was protective (aOR 0.34; 95% CI 0.18 to 0.67). Conclusions Persons with OUD released from jail during the pandemic experienced higher overdose mortality compared to pre-pandemic, but the number of deaths was small. They did not experience significantly different rates of non-fatal overdose. Early jail releases during the pandemic were unlikely to explain much, if any, of the observed increase in community overdoses in Massachusetts.
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Affiliation(s)
- Peter D Friedmann
- University of Massachusetts Chan Medical School - Baystate and Baystate Health, Office of Research, 3601 Main Street, Springfield, MA 01107 USA
| | - Devon Dunn
- Massachusetts Department of Public Health, Office of Population Health - Special Analytic Projects, 250 Washington Street, 6th Floor, Boston, MA 02108 USA
| | - Pryce Michener
- University of Massachusetts Chan Medical School, 55 Lake Avenue North, Worcester, MA 01655 USA
| | - Dana Bernson
- Massachusetts Department of Public Health, Office of Population Health - Special Analytic Projects, 250 Washington Street, 6th Floor, Boston, MA 02108 USA
| | - Thomas J Stopka
- Department of Public Health and Community Medicine, Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA 02111 USA
| | - Ekaterina Pivovarova
- University of Massachusetts Chan Medical School, 55 Lake Avenue North, Worcester, MA 01655 USA
| | - Warren J Ferguson
- University of Massachusetts Chan Medical School, 55 Lake Avenue North, Worcester, MA 01655 USA
| | - Rebecca Rottapel
- University of Massachusetts Chan Medical School, 55 Lake Avenue North, Worcester, MA 01655 USA
| | - Randall Hoskinson
- University of Massachusetts Chan Medical School - Baystate and Baystate Health, Office of Research, 3601 Main Street, Springfield, MA 01107 USA
| | - Donna Wilson
- University of Massachusetts Chan Medical School - Baystate and Baystate Health, Office of Research, 3601 Main Street, Springfield, MA 01107 USA
| | - Elizabeth A Evans
- Department of Health Promotion and Policy, School of Public Health and Health Sciences, University of Massachusetts Amherst, 312 Arnold House, 715 North Pleasant St, Amherst, MA 01003, USA
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Huo S, Heil J, Salzman MS, Carroll G, Haroz R. METHADONE INITIATION IN THE EMERGENCY DEPARTMENT FOR OPIOID USE DISORDER: A CASE SERIES. J Emerg Med 2023; 64:391-396. [PMID: 37019500 DOI: 10.1016/j.jemermed.2023.01.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 01/02/2023] [Accepted: 01/06/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND In an era of fentanyl and continually rising rates of opioid overdose deaths, increasing access to evidence-based treatment for opioid use disorder (OUD) should be prioritized. Emergency department (ED) buprenorphine initiation for patients with OUD is considered best-practice. Methadone, though also evidence-based and effective, is under-utilized due to strict federal regulation, significant stigma, and lack of physician training. We describe the novel utilization of CFR Title 21 1306.07 (b), also known as the "72-hour rule," to initiate methadone for OUD in the ED. CASE SERIES We describe the cases of 3 patients with a history of OUD who were initiated on methadone for OUD in the ED, linked to an opioid treatment program, and attended an intake appointment. Why Should an Emergency Physician Be Aware of This? The ED can be a crucial point of intervention for vulnerable patients with OUD who may not interact with the health care system in other settings. Methadone and buprenorphine are both first-line options for medication for OUD, and methadone may be preferred in patients who have been unsuccessful with buprenorphine in the past or those at higher risk of treatment dropout. Patients may also prefer methadone to buprenorphine based on previous experience or understanding of the medications. ED physicians may utilize the "72-hour rule" to administer and initiate methadone for up to 3 consecutive days while arranging referral to treatment. EDs can develop methadone initiation and bridge programs utilizing similar strategies to those that have been described in developing buprenorphine programs.
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Affiliation(s)
- Samantha Huo
- Cooper University Health Care, Center for Healing, Division of Addiction Medicine, Camden, New Jersey; Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jessica Heil
- Cooper University Health Care, Center for Healing, Division of Addiction Medicine, Camden, New Jersey
| | - Matthew S Salzman
- Cooper University Health Care, Center for Healing, Division of Addiction Medicine, Camden, New Jersey; Cooper Medical School of Rowan University, Camden, New Jersey; Department of Emergency Medicine, Division of Addiction Medicine and Medical Toxicology
| | - Gerard Carroll
- Department of Emergency Medicine, Division of Addiction Medicine and Medical Toxicology; Department of Emergency Medicine, Division of EMS and Disaster Medicine, Cooper University Health Care, Camden, New Jersey
| | - Rachel Haroz
- Cooper University Health Care, Center for Healing, Division of Addiction Medicine, Camden, New Jersey; Cooper Medical School of Rowan University, Camden, New Jersey; Department of Emergency Medicine, Division of Addiction Medicine and Medical Toxicology
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Affiliation(s)
| | - J. Wesley Boyd
- Center for Bioethics, Harvard Medical School, Boston, MA
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45
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Frueh L, Collins AB, Newman R, Barnett NP, Rich JD, Clark MA, Marshall BDL, Macmadu A. Multi-level influences on increased overdose risk behaviors during the COVID-19 pandemic among people who use drugs in Rhode Island: a qualitative investigation. Harm Reduct J 2023; 20:14. [PMID: 36739417 PMCID: PMC9898862 DOI: 10.1186/s12954-023-00741-w] [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: 12/07/2022] [Accepted: 01/19/2023] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The ongoing COVID-19 pandemic has disproportionately affected structurally vulnerable populations including people who use drugs (PWUD). Increased overdose risk behaviors among PWUD during the pandemic have been documented, with research underscoring the role of influencing factors such as isolation and job loss in these behaviors. Here, we use qualitative methods to examine the impact of the COVID-19 pandemic and pandemic-related response measures on drug use behaviors in a sample of PWUD in Rhode Island. Using a social-ecological framework, we highlight the nested, interactive levels of the pandemic's influence on increased overdose risk behaviors. METHODS From July to October 2021, semi-structured interviews were conducted with 18 PWUD who self-reported any increase in behaviors associated with overdose risk (e.g., increased use, change in drug type and/or more solitary drug use) relative to before the pandemic. Thematic analysis was conducted using a codebook with salient themes identified from interview guides and those that emerged through close reading of transcribed interviews. Guided by a social-ecological framework, themes were grouped into individual, network, institutional, and policy-level influences of the pandemic on drug use behaviors. RESULTS Individual-level influences on increased overdose risk behaviors included self-reported anxiety and depression, isolation and loneliness, and boredom. Network-level influences included changes in local drug supply and changes in social network composition specific to housing. At the institutional level, drug use patterns were influenced by reduced access to harm reduction or treatment services. At the policy level, increased overdose risk behaviors were related to financial changes, job loss, and business closures. All participants identified factors influencing overdose risk behaviors that corresponded to several nested social-ecological levels. CONCLUSIONS Participants identified multi-level influences of the COVID-19 pandemic and pandemic-related response measures on their drug use behavior patterns and overdose risk. These findings suggest that effective harm reduction during large-scale crises, such as the COVID-19 pandemic, must address several levels of influence concurrently.
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Affiliation(s)
- Lisa Frueh
- grid.166341.70000 0001 2181 3113Department of Environmental and Occupational Health, Drexel University Dornsife School of Public Health, 3215 Market Street, Philadelphia, PA 19104 USA
| | - Alexandra B. Collins
- grid.40263.330000 0004 1936 9094Department of Epidemiology, Brown University School of Public Health, 121 South Main Street, Box G-S-121-2, Providence, RI 02912 USA
| | - Roxxanne Newman
- grid.40263.330000 0004 1936 9094Department of Epidemiology, Brown University School of Public Health, 121 South Main Street, Box G-S-121-2, Providence, RI 02912 USA
| | - Nancy P. Barnett
- grid.40263.330000 0004 1936 9094Department of Behavioral and Social Sciences, Brown University School of Public Health, 121 South Main Street, Providence, RI USA
| | - Josiah D. Rich
- grid.240267.50000 0004 0443 5079The Center for Health + Justice Transformation, The Miriam Hospital, 1125 North Main Street, Providence, RI USA
| | - Melissa A. Clark
- grid.40263.330000 0004 1936 9094Department of Health Services, Policy & Practice, Brown University School of Public Health, 121 South Main Street, Providence, RI USA
| | - Brandon D. L. Marshall
- grid.40263.330000 0004 1936 9094Department of Epidemiology, Brown University School of Public Health, 121 South Main Street, Box G-S-121-2, Providence, RI 02912 USA
| | - Alexandria Macmadu
- Department of Epidemiology, Brown University School of Public Health, 121 South Main Street, Box G-S-121-2, Providence, RI, 02912, USA.
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Stein BD, Landis RK, Sheng F, Saloner B, Gordon AJ, Sorbero M, Dick AW. Buprenorphine Treatment Episodes During the First Year of COVID: a Retrospective Examination of Treatment Initiation and Retention. J Gen Intern Med 2023; 38:733-737. [PMID: 36474004 PMCID: PMC9734477 DOI: 10.1007/s11606-022-07891-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 10/26/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND During the COVID pandemic, overall buprenorphine treatment appeared to remain relatively stable, despite some studies suggesting a decrease in patients starting buprenorphine. There is a paucity of empirical information regarding patterns of buprenorphine treatment during the pandemic. OBJECTIVE To better understand the patterns of buprenorphine episodes during the pandemic and how those patterns compared to pre-pandemic patterns. DESIGN Pharmacy claims representing approximately 92% of all prescriptions filled at retail pharmacies in all 50 US states and the District of Columbia. PARTICIPANTS Individuals filling buprenorphine prescriptions indicated for treatment of opioid use disorder. MAIN MEASURES The number of active, starting, and ending buprenorphine treatment episodes March 13 to December 1, 2020, and the expected number of such episodes in 2020 based on the growth in treatment episodes from March 13 to December 1, 2019. KEY RESULTS The observed number of active buprenorphine episodes in December 2020 was comparable to the expected number, but new treatment episodes starting between March 13 and December 1, 2020, were 17.2% fewer than expected based on the 2019 experience. Similarly, the number of episodes that ended between March 13 and December 1, 2020, was 16.0% fewer than expected. Decreases from expected episode starts and ends occurred throughout the period but were greatest in the 2 months after the declaration of the public health emergency. CONCLUSIONS AND RELEVANCE Beneath the apparent stability of buprenorphine patient numbers during the pandemic, the flow of individuals receiving buprenorphine treatment changed substantially. Our findings shed light on how policy changes meant to support buprenorphine prescribing influenced prescribing dynamics during that period, suggesting that while policy efforts may have been successful in maintaining existing patients in treatment, that success did not extend to individuals not yet in treatment.
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Affiliation(s)
- Bradley D Stein
- RAND Corporation, 4570 Fifth Avenue, Suite 600, Pittsburgh, PA, 15213, USA.
| | - Rachel K Landis
- George Washington University Trachtenberg School of Public Policy, Washington, DC, USA.,RAND Corporation, Arlington, VA, USA
| | | | - Brendan Saloner
- Department of Health Policy and Management, Johns Hopkins University, Baltimore, MD, USA
| | - Adam J Gordon
- VA Salt Lake City Health Care System and University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Mark Sorbero
- RAND Corporation, 4570 Fifth Avenue, Suite 600, Pittsburgh, PA, 15213, USA
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Childers R, Castillo EM, Cronin AO, Swee S, Lasoff D. Emergency Department-Initiated Buprenorphine Treatment in a Population with a High Rate of Homelessness: An Observational Study. J Emerg Med 2023; 64:129-135. [PMID: 36806434 DOI: 10.1016/j.jemermed.2022.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 11/20/2022] [Accepted: 12/12/2022] [Indexed: 02/19/2023]
Abstract
BACKGROUND Buprenorphine is an effective treatment for opioid use disorders. A previous randomized trial comparing emergency department (ED)-initiated buprenorphine to standard care showed dramatic improvement in follow-up. This is encouraging, but must be replicated to understand the generalizability of buprenorphine treatment. OBJECTIVES Evaluate the efficacy of an ED-initiated buprenorphine protocol similar to a previous randomized trial in a different population. METHODS This ED-based descriptive study described the results of a project implementing an opioid use disorder treatment protocol that included buprenorphine. Patients with opioid use disorder were offered treatment with buprenorphine, a buprenorphine prescription whenever possible, and a follow-up visit to a clinic providing addiction treatment. The primary outcome was engagement in formal addiction treatment 30 days after the index visit. RESULTS Of the 210 patients who accepted referral for outpatient medication-assisted treatment, 95 (45.2%) achieved the primary outcome. Two-thirds of these patients received a buprenorphine prescription at discharge; 40% were homeless. A regression analysis revealed one statistically significant predictor of the primary outcome: patients who were housed were 2.49 times more likely to engage in opioid use disorder treatment than patients who were homeless (p = 0.02). CONCLUSIONS In this descriptive study of an ED-initiated buprenorphine protocol, follow-up was less than that reported in a previous randomized controlled trial. Two important differences between our study and the randomized trial are the high rate of homelessness and the fact that not every patient received a prescription for buprenorphine. The efficacy of ED-initiated treatment may depend on certain population characteristics.
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Affiliation(s)
- Richard Childers
- Department of Emergency Medicine, University of California, San Diego, San Diego, California
| | - Edward M Castillo
- Department of Emergency Medicine, University of California, San Diego, San Diego, California
| | - Alexandrea O Cronin
- Department of Emergency Medicine, University of California, San Diego, San Diego, California
| | - Steven Swee
- Department of Emergency Medicine, University of California, San Diego, San Diego, California
| | - Daniel Lasoff
- Department of Emergency Medicine, University of California, San Diego, San Diego, California
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Murray-Krezan C, Dopp A, Tarhuni L, Carmody MD, Becker K, Anderson J, Komaromy M, Meredith LS, Watkins KE, Wagner K, Page K. Screening for opioid use disorder and co-occurring depression and post-traumatic stress disorder in primary care in New Mexico. Addict Sci Clin Pract 2023; 18:6. [PMID: 36707910 PMCID: PMC9881516 DOI: 10.1186/s13722-023-00362-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 01/18/2023] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Identifying patients in primary care services with opioid use disorder and co-occurring mental health disorders is critical to providing treatment. Objectives of this study were to (1) assess the feasibility of recruiting people to screen in-person for opioid use disorder and co-occurring mental health disorders (depression and/or post-traumatic stress disorder) in primary care clinic waiting rooms in preparation for a randomized controlled trial, and (2) compare results of detecting these disorders by universal in-person screening compared to electronic health record (EHR) diagnoses. METHODS This cross-sectional feasibility and pilot study recruited participants from four primary care clinics, two rural and two urban, from three health care organizations in New Mexico. Inclusion criteria were adults (≥ 18 years), attending one of the four clinics as a patient, and who spoke English or Spanish. Exclusion criteria were people attending the clinic for a non-primary care visit (e.g., dental, prescription pick up, social support). The main outcomes and measures were (1) recruitment feasibility which was assessed by frequencies and proportions of people approached and consented for in-person screening, and (2) relative differences of detecting opioid use disorder and co-occurring mental health disorders in waiting rooms relative to aggregate EHR data from each clinic, measured by prevalence and prevalence ratios. RESULTS Over two-weeks, 1478 potential participants were approached and 1145 were consented and screened (77.5% of patients approached). Probable opioid use disorder and co-occurring mental health disorders were identified in 2.4% of those screened compared to 0.8% in EHR. Similarly, universal screening relative to EHR identified higher proportions of probable opioid use disorder (4.5% vs. 3.4%), depression (17.5% vs. 12.7%) and post-traumatic stress disorder (19.0% vs. 3.6%). CONCLUSIONS Universal screening for opioid use disorder, depression, and post-traumatic stress disorder was feasible, and identified three times as many patients with these co-occurring disorders compared to EHR. Higher proportions of each condition were also identified, especially post-traumatic stress disorder. Results support that there are likely gaps in identification of these disorders in primary care services and demonstrate the need to better address the persistent public health problem of these co-occurring disorders.
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Affiliation(s)
- Cristina Murray-Krezan
- Department of Internal Medicine, Division of Epidemiology, Biostatistics and Preventive Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, 87131, USA.
- Department of Medicine, Division of General Internal Medicine, School of Medicine, University of Pittsburgh, 200 Meyran Ave, Suite 300, Pittsburgh, PA, 15213, USA.
| | - Alex Dopp
- Health Care Division, RAND Corporation, Santa Monica, CA, 90417-2038, USA
| | - Lina Tarhuni
- Department of Internal Medicine, Division of Epidemiology, Biostatistics and Preventive Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, 87131, USA
| | - Mary D Carmody
- Department of Internal Medicine, Division of Epidemiology, Biostatistics and Preventive Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, 87131, USA
| | - Kirsten Becker
- Health Care Division, RAND Corporation, Santa Monica, CA, 90417-2038, USA
| | - Jessica Anderson
- Department of Internal Medicine, Division of Epidemiology, Biostatistics and Preventive Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, 87131, USA
| | - Miriam Komaromy
- Grayken Center for Addiction, Boston Medical Center, Boston University, Boston, MA, 02118, USA
| | - Lisa S Meredith
- Health Care Division, RAND Corporation, Santa Monica, CA, 90417-2038, USA
| | | | - Katherine Wagner
- Department of Internal Medicine, Division of Epidemiology, Biostatistics and Preventive Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, 87131, USA
| | - Kimberly Page
- Department of Internal Medicine, Division of Epidemiology, Biostatistics and Preventive Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, 87131, USA
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Mavragani A, Purushothaman V, Calac AJ, McMann T, Li Z, Mackey T. Estimating County-Level Overdose Rates Using Opioid-Related Twitter Data: Interdisciplinary Infodemiology Study. JMIR Form Res 2023; 7:e42162. [PMID: 36548118 PMCID: PMC9909516 DOI: 10.2196/42162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 10/26/2022] [Accepted: 11/17/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND There were an estimated 100,306 drug overdose deaths between April 2020 and April 2021, a three-quarter increase from the prior 12-month period. There is an approximate 6-month reporting lag for provisional counts of drug overdose deaths from the National Vital Statistics System, and the highest level of geospatial resolution is at the state level. By contrast, public social media data are available close to real-time and are often accessible with precise coordinates. OBJECTIVE The purpose of this study is to assess whether county-level overdose mortality burden could be estimated using opioid-related Twitter data. METHODS International Classification of Diseases (ICD) codes for poisoning or exposure to overdose at the county level were obtained from CDC WONDER. Demographics were collected from the American Community Survey. The Twitter Application Programming Interface was used to obtain tweets that contained any of the 36 terms with drug names. An unsupervised classification approach was used for clustering tweets. Population-normalized variables and polynomial population-normalized variables were produced. Furthermore, z scores of the Getis Ord Gi clustering statistic were produced, and both these scores and their polynomial counterparts were explored in regression modeling of county-level overdose mortality burden. A series of linear regression models were used for predictive modeling to explore the interpretability of the analytical output. RESULTS Modeling overdose mortality with normalized demographic variables alone explained only 7.4% of the variability in county-level overdose mortality, whereas this was approximately doubled by the use of specific demographic and Twitter data covariates based on a backward selection approach. The highest adjusted R2 and lowest AIC (Akaike Info Criterion) were obtained for the model with normalized demographic variables, normalized z scores from geospatial analyses, and normalized topic counts (adjusted R2=0.133, AIC=8546.8). The z scores of the Getis Ord Gi statistic appeared to have improved utility over population-normalization alone. In this model, median age, female population, and tweets about web-based drug sales were positively associated with opioid mortality. Asian race and Hispanic ethnicity were significantly negatively associated with county-level burdens of overdose mortality. CONCLUSIONS Social media data, when transformed using certain statistical approaches, may add utility to the goal of producing closer to real-time county-level estimates of overdose mortality. Prediction of opioid-related outcomes can be advanced to inform prevention and treatment decisions. This interdisciplinary approach can facilitate evidence-based funding decisions for various substance use disorder prevention and treatment programs.
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Affiliation(s)
| | - Vidya Purushothaman
- Global Health Policy and Data Institute, San Diego, CA, United States.,San Diego Supercomputer Center, San Diego, CA, United States
| | - Alec J Calac
- School of Medicine, University of California, San Diego, La Jolla, CA, United States.,Global Health Policy and Data Institute, San Diego, CA, United States
| | - Tiana McMann
- Global Health Policy and Data Institute, San Diego, CA, United States.,San Diego Supercomputer Center, San Diego, CA, United States.,Department of Anthropology, University of California, San Diego, La Jolla, CA, United States.,S-3 Research, San Diego, CA, United States
| | - Zhuoran Li
- Global Health Policy and Data Institute, San Diego, CA, United States.,San Diego Supercomputer Center, San Diego, CA, United States.,S-3 Research, San Diego, CA, United States
| | - Tim Mackey
- Global Health Policy and Data Institute, San Diego, CA, United States.,San Diego Supercomputer Center, San Diego, CA, United States.,Department of Anthropology, University of California, San Diego, La Jolla, CA, United States.,S-3 Research, San Diego, CA, United States
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Zimmerman GM, Douglas SD, Turchan BS, Braga AA. The salience of social context, opioid antagonist use, and prior opioid exposure as determinants of fatal and non-fatal opioid overdoses. Health Place 2023; 79:102970. [PMID: 36638643 DOI: 10.1016/j.healthplace.2023.102970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 12/13/2022] [Accepted: 01/04/2023] [Indexed: 01/13/2023]
Abstract
This study examines the salience of social context for opioid overdoses in Boston from 2014 to 2019. Longitudinal negative binomial models with random effects indicated that higher levels of concentrated disadvantage, residential instability, and illicit drug activity increased annual block group counts of opioid overdoses. Logistic hierarchical and cross-classified random effects models indicated that the use of Narcan and greater exposure to drugs through previous opioid overdose and contextual lillicit drug crime activity reduced the odds of fatal opioid overdose relative to non-fatal opioid overdose. The findings suggest that the accurate tracking of both fatal and non-fatal overdoses, and a consideration of the broader social context, can facilitate effective public health resource allocation to reduce opioid overdoses.
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Affiliation(s)
- Gregory M Zimmerman
- School of Criminology and Criminal Justice, Northeastern University, Boston, MA, USA.
| | - Stephen D Douglas
- Department of Criminology, University of Pennsylvania, Philadelphia, PA, USA
| | - Brandon S Turchan
- Department of Criminology, University of Pennsylvania, Philadelphia, PA, USA
| | - Anthony A Braga
- Department of Criminology, University of Pennsylvania, Philadelphia, PA, USA
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