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Hsieh CY, Hsu JY, Yang CC. Predictive factors for severe outcomes in substance abuse-related emergency visits: A 5-year retrospective analysis at a medical center in Taiwan. J Chin Med Assoc 2024; 87:40-47. [PMID: 37967467 DOI: 10.1097/jcma.0000000000001020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2023] Open
Abstract
BACKGROUND Substance abuse is a considerable medical issue worldwide, yet current surveillance systems in Taiwan offer limited insights into the clinical characteristics and outcomes of substance abuse patients. This study aimed to delineate the epidemiology of emergency department visits related to substance abuse at a hospital in Taiwan and to identify factors predictive of severe complications or mortality. METHODS A retrospective analysis was conducted on substance abuse-related emergency department visits at a medical center in Taiwan between 2009 and 2013. Eligible participants were individuals aged 20 or older who had confirmed substance abuse through urinalysis. Variables such as patient demographics, substances abused, clinical characteristics, and outcomes were collected. Severe outcomes were defined as admission to the intensive care unit, requirement for endotracheal intubation, or in-hospital death. Logistic regression models were employed to identify factors contributing to severe outcomes. RESULTS The cohort consisted of 623 patients, of whom 64.0% were female and 67.1% were aged between 20 and 49 years. Benzodiazepines were detected in 75.3% of patients, while z-drugs (specifically zopiclone, zolpidem, or zaleplon) were found in 27.8%. Depressants, stimulants, and hallucinogens were present in 14.9%, 10.6%, and 0.6% of the cases, respectively. Of the patient, 121 (19.4%) experienced severe outcomes, including 116 (18.6%) intensive care unit admissions, 73 (11.7%) intubations, and 11 (1.8%) in-hospital deaths. Multivariable logistic regression analysis revealed multiple predictors of severe outcomes, such as emergency department triage level, aspiration pneumonia, leukocytosis, abnormal hepatic function, abnormal renal function, hypernatremia, and hypocalcemia. CONCLUSION In Taiwan, benzodiazepines emerged as the most prevalent substance of abuse among emergency department visitors, and a significant proportion of these patients experienced severe outcomes. Continuous monitoring of severe outcome predictors is essential for enhanced understanding and management.
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Affiliation(s)
- Chia-Ying Hsieh
- Institute of Environmental and Occupational Health Sciences, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Jen-Yu Hsu
- Department of Occupational Medicine and Clinical Toxicology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Northern Regional Center, Centers for Disease Control, Ministry of Health and Welfare, Taoyuan, Taiwan, ROC
| | - Chen-Chang Yang
- Institute of Environmental and Occupational Health Sciences, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Occupational Medicine and Clinical Toxicology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
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Worth LM, Macias-Konstantopoulos W, Moy L, Perl HI, Crandall C, Chavez R, Forcehimes A, Mandler R, Bogenschutz MP. Optimizing Recruitment and Retention in Substance Use Disorder Research in Emergency Departments. West J Emerg Med 2023; 24:228-235. [PMID: 36976606 PMCID: PMC10047737 DOI: 10.5811/westjem.2022.11.57179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 11/16/2022] [Indexed: 03/29/2023] Open
Abstract
INTRODUCTION Clinical trial recruitment and retention of individuals who use substances are challenging in any setting and can be particularly difficult in emergency department (ED) settings. This article discusses strategies for optimizing recruitment and retention in substance use research conducted in EDs. METHODS Screening, Motivational Assessment, Referral, and Treatment in Emergency Departments (SMART-ED) was a National Drug Abuse Treatment Clinical Trials Network (CTN) protocol designed to assess the impact of a brief intervention with individuals screening positive for moderate to severe problems related to use of non-alcohol, non-nicotine drugs. We implemented a multisite, randomized clinical trial at six academic EDs in the United States and leveraged a variety of methods to successfully recruit and retain study participants throughout the 12-month study course. Recruitment and retention success is attributed to appropriate site selection, leveraging technology, and gathering adequate contact information from participants at their initial study visit. RESULTS The SMART-ED recruited 1,285 adult ED patients and attained follow-up rates of 88%, 86%, and 81% at the 3-, 6-, and 12-month follow-up periods, respectively. Participant retention protocols and practices were key tools in this longitudinal study that required continuous monitoring, innovation, and adaptation to ensure strategies remained culturally sensitive and context appropriate through the duration of the study. CONCLUSION Tailored strategies that consider the demographic characteristics and region of recruitment and retention are necessary for ED-based longitudinal studies involving patients with substance use disorders.
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Affiliation(s)
- Lindsay M Worth
- University of New Mexico, Department of Psychiatric Research, Albuquerque, New Mexico
| | | | | | | | - Cameron Crandall
- University of New Mexico, Department of Emergency Medicine, Albuquerque, New Mexico
| | - Roberta Chavez
- University of New Mexico Center on Alcoholism, Substance Use Disorder and Addictions, Albuquerque, New Mexico
| | | | - Raul Mandler
- National Institute on Drug Abuse Clinical Trials Network, Bethesda, Maryland
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Salottolo K, McGuire E, Madayag R, Tanner AH, Carrick MM, Bar-Or D. Validity between self-report and biochemical testing of cannabis and drugs among patients with traumatic injury: brief report. J Cannabis Res 2022; 4:29. [PMID: 35676744 PMCID: PMC9178863 DOI: 10.1186/s42238-022-00139-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 05/27/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
The relationship between drug use and traumatic injury is well documented, yet only a small proportion of patients are biochemically tested for cannabis and other substances. The study objective was to determine whether patient self-report can be used as a proxy for biochemical drug testing following traumatic injury.
Methods
This study was a secondary analysis that included 320 patients admitted to four level I trauma centers in Colorado and Texas, primarily involved in motor vehicle crash (89%). If performed, biochemical testing was collected via urine toxicology screen (“tox screen”) for cannabis, amphetamines, barbiturates, cocaine, opiates, PCP, and benzodiazepines. All patients were screened for self-reported current drug use, which was evaluated for any drug and specifically for cannabis use. Analyses used to compare results of self-reported drug use and tox screen included sensitivity, specificity, positive, and negative predictive values, and percent agreement.
Results
Among 320 patients, 23% (n = 75) self-reported drug use; cannabis was the most frequently reported drug (n = 63). A tox screen was performed in 59% of patients (n = 190); the proportion of patients who had a tox screen was similar for those self-reporting drug use (60.0%) to those who denied using drugs (59.2%), p = 0.90. Among patients who had a tox screen performed, 18% (n = 35) tested positive for any drug, 12% (n = 22) tested positive for THC, and 7% (n = 13) tested positive for opiates. The percent agreement was 80% for any drug and 81% for cannabis. The specificity was 84–85%, indicating a high likelihood that a patient will not have a positive tox screen if they do not report using drugs. Negative predictive values were 90–95%, indicating a negative self-report correctly identified nearly all patients testing negative on tox screen. Sensitivity was only 60% and positive predictive values were 30–47% for cannabis and drugs, respectively.
Conclusion
These findings may negate the need for biochemical drug testing in this population, particularly as a “rule out” based on self-reporting. Future studies are needed to confirm these findings and should address risk of selection bias.
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Yue JK, Phelps RRL, Winkler EA, Deng H, Upadhyayula PS, Vassar MJ, Madhok DY, Schnyer DM, Puccio AM, Lingsma HF, Yuh EL, Mukherjee P, Valadka AB, Okonkwo DO, Manley GT. Substance use on admission toxicology screen is associated with peri-injury factors and six-month outcome after traumatic brain injury: A TRACK-TBI Pilot study. J Clin Neurosci 2020; 75:149-156. [PMID: 32173156 DOI: 10.1016/j.jocn.2020.02.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 02/10/2020] [Indexed: 01/07/2023]
Abstract
Substance use is commonly associated with traumatic brain injury (TBI). We investigate associations between active substance use, peri-injury factors, and outcome after TBI across three U.S. Level I trauma centers. TBI subjects from the prospective Transforming Research and Clinical Knowledge in Traumatic Brain Injury Pilot (TRACK-TBI Pilot) with Marshall computed tomography (CT) score 1-3, no neurosurgical procedure/operation, and admission urine toxicology screen (tox+/-) were extracted. Associations between tox+/-, comorbidities, hospital variables, and six-month functional (GOSE) and neuropsychiatric (PCL-C, BSI18, RPQ-13, SWLS) outcomes were analyzed. Multivariable regression was performed for associations significant on univariate analysis with odds ratios (mOR) presented. Significance assessed at p < 0.05. In 133 subjects, tox+/tox- were 29.1%/72.9%. Tox+ was younger (35.5/43.6-years, p = 0.018), trended toward male sex (80.6%/63.9%, p = 0.067), was associated with history of seizures (27.8%/10.3%, p = 0.012), self-reported substance use (44.4%/17.5%, p = 0.001), prior TBI (58.8%/34.1%, p = 0.009), GCS < 15 (69.4%/48.4%, p = 0.031) and blood alcohol level >0.08-mg/dl (55.6%/30.8%, p = 0.022). In CT-negative subjects, tox+ was associated with increased hospital admission (95.7%/66.7%, p = 0.034). At six-months, tox+ was associated with screening positive for post-traumatic stress disorder (PCL-C: 40.0%/15.9%; mOR = 8.24, p = 0.022) and psychiatric symptoms (BSI18: 40.0%/14.3%, mOR = 11.06, p = 0.023). Active substance use in TBI may confound GCS assessment, triage to higher level of care, and be associated with increased six-month neuropsychiatric symptoms. Substance use screening should be integrated into standard emergency/acute care TBI protocols to optimize management and resource utilization. Clinicians should be vigilant in providing education, counselling, and follow-up for TBI patients with substance use.
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Affiliation(s)
- John K Yue
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA, USA; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Ryan R L Phelps
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA, USA; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Ethan A Winkler
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA, USA; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Hansen Deng
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Pavan S Upadhyayula
- Department of Neurosurgery, University of California San Diego, San Diego, CA, USA
| | - Mary J Vassar
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA, USA; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Debbie Y Madhok
- Department of Emergency Medicine, University of California San Francisco, San Francisco, CA, USA
| | - David M Schnyer
- Department of Psychology, University of Texas in Austin, Austin, TX, USA
| | - Ava M Puccio
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Hester F Lingsma
- Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Esther L Yuh
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA; Department of Radiology, University of California San Francisco, San Francisco, CA, USA
| | - Pratik Mukherjee
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA; Department of Radiology, University of California San Francisco, San Francisco, CA, USA
| | - Alex B Valadka
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, VA, USA
| | - David O Okonkwo
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Geoffrey T Manley
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA, USA; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA.
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Schieferle Uhlenbrock J, Hudson J, Prewitt J, Thompson JA, Pereira K. Retrospective Chart Review of the Triage Algorithm for Psychiatric Screening (TAPS) for Patients Who Present to Emergency Departments With Psychiatric Chief Complaints. J Emerg Nurs 2018; 44:459-465. [DOI: 10.1016/j.jen.2017.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 11/04/2017] [Accepted: 12/07/2017] [Indexed: 10/18/2022]
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Ashrafi S, Aminisani N, Soltani S, Sarbakhsh P, Shamshirgaran SM, Rashidi MR. The validity of self-reported drug use with urine test: results from the pilot phase of Azar cohort study. Health Promot Perspect 2018; 8:225-229. [PMID: 30087846 PMCID: PMC6064750 DOI: 10.15171/hpp.2018.30] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 05/22/2018] [Indexed: 11/09/2022] Open
Abstract
Background: The present study aimed at assessing the validity of self-reported drug use in people aged 35 and older in a pilot phase of a population-based cohort study. Methods: A total of 1038 adults over 35 years old in Khamene city in East Azerbaijan province were recruited for the pilot phase of Azar cohort; a province-level of a nationwide PERSIAN cohort study completing a questionnaire and providing biological samples from October to December 2014. Information about the history and duration of smoking tobacco, using drug and medication were obtained by the physician. The validity of the drug use was assessed through comparing the questionnaire response with three urine strip tests for the detection of morphine, amphetamine and methamphetamine among 259 randomly selected subjects. Results: The prevalence of drug use according to self-report was 2.6% (95% CI: 1.7%-3.8%).One-step drug test as the gold standard for the use of drug self-reported demonstrated a sensitivity(95% CI) and specificity 15% (10-22) and 99.7% (98.9%-99.9%) respectively. All participants with positive self-report were male; however, in the urine analysis drug test, it was positive for 7out of 68 randomly selected women. Conclusion: The validity of self-reported drug use in this population was low; therefore, the self reported use of the drug should be used with caution in this population. It is recommended to use alternative techniques to improve the validity of data using the self-report procedure.
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Affiliation(s)
- Shahnaz Ashrafi
- Epidemiology and Statistics Departement, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Nayyereh Aminisani
- Epidemiology and Statistics Departement, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Somaieh Soltani
- Department of Medicinal Chemistry, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Parvin Sarbakhsh
- Epidemiology and Statistics Departement, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Mohammad-Reza Rashidi
- Department of Medicinal Chemistry, Tabriz University of Medical Sciences, Tabriz, Iran
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Zaman T, Rife TL, Batki SL, Pennington DL. An electronic intervention to improve safety for pain patients co-prescribed chronic opioids and benzodiazepines. Subst Abus 2018; 39:441-448. [DOI: 10.1080/08897077.2018.1455163] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Tauheed Zaman
- Addiction Recovery Treatment Services, Department of Mental Health, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
- Department of Psychiatry, University of California, San Francisco School of Medicine, San Francisco, California, USA
| | - Tessa L. Rife
- Addiction Recovery Treatment Services, Department of Mental Health, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
- Department of Pharmacy, University of California, San Francisco School of Pharmacy, San Francisco, California, USA
| | - Steven L. Batki
- Addiction Recovery Treatment Services, Department of Mental Health, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
- Department of Psychiatry, University of California, San Francisco School of Medicine, San Francisco, California, USA
- Northern California Institute for Research and Education, San Francisco, California, USA
| | - David L. Pennington
- Addiction Recovery Treatment Services, Department of Mental Health, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
- Department of Psychiatry, University of California, San Francisco School of Medicine, San Francisco, California, USA
- Northern California Institute for Research and Education, San Francisco, California, USA
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8
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Wilson MP, Nordstrom K, Anderson EL, Ng AT, Zun LS, Peltzer-Jones JM, Allen MH. American Association for Emergency Psychiatry Task Force on Medical Clearance of Adult Psychiatric Patients. Part II: Controversies over Medical Assessment, and Consensus Recommendations. West J Emerg Med 2017; 18:640-646. [PMID: 28611885 PMCID: PMC5468070 DOI: 10.5811/westjem.2017.3.32259] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2016] [Revised: 03/14/2017] [Accepted: 03/15/2017] [Indexed: 11/11/2022] Open
Abstract
Introduction The emergency medical evaluation of psychiatric patients presenting to United States emergency departments (ED), usually termed “medical clearance,” often varies between EDs. A task force of the American Association for Emergency Psychiatry (AAEP), consisting of physicians from emergency medicine, physicians from psychiatry and a psychologist, was convened to form consensus recommendations for the medical evaluation of psychiatric patients presenting to U.S.EDs. Methods The task force reviewed existing literature on the topic of medical evaluation of psychiatric patients in the ED and then combined this with expert consensus. Consensus was achieved by group discussion as well as iterative revisions of the written document. The document was reviewed and approved by the AAEP Board of Directors. Results Eight recommendations were formulated. These recommendations cover various topics in emergency medical examination of psychiatric patients, including goals of medical screening in the ED, the identification of patients at low risk for co-existing medical disease, key elements in the ED evaluation of psychiatric patients including those with cognitive disorders, specific language replacing the term “medical clearance,” and the need for better science in this area. Conclusion The evidence indicates that a thorough history and physical examination, including vital signs and mental status examination, are the minimum necessary elements in the evaluation of psychiatric patients. With respect to laboratory testing, the picture is less clear and much more controversial.
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Affiliation(s)
- Michael P Wilson
- University of Arkansas for Medical Sciences, Department of Emergency Medicine, Little Rock, Arkansas
| | - Kimberly Nordstrom
- University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, Colorado.,Office of Behavioral Health, Department of Human Services, State of Colorado, Denver, Colorado
| | - Eric L Anderson
- University of Maryland, Department of Psychiatry, Cambridge, Maryland
| | - Anthony T Ng
- Uniformed Services School of Medicine, Department of Psychiatry, Bethesda, Maryland
| | - Leslie S Zun
- Chicago Medical School, Department of Emergency Medicine, Chicago, Illinois.,Mount Sinai Hospital, Department of Emergency Medicine, New York, New York
| | | | - Michael H Allen
- University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, Colorado
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Cochran G, Bacci JL, Ylioja T, Hruschak V, Miller S, Seybert AL, Tarter R. Prescription opioid use: Patient characteristics and misuse in community pharmacy. J Am Pharm Assoc (2003) 2016; 56:248-256.e6. [PMID: 27053277 PMCID: PMC4886233 DOI: 10.1016/j.japh.2016.02.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Revised: 02/11/2016] [Accepted: 02/12/2016] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Opioid pain medication misuse is a major concern for US public health. The purpose of this article is to: 1) describe the demographic and physical, behavioral, and mental health characteristics of patients who fill opioid medications in community pharmacy settings; and 2) describe the extent of opioid medication misuse behaviors among these patients. DESIGN We recruited and screened a convenience sample of patients with the use of a tablet computer-based assessment protocol that examined behavioral, mental, and physical health. Descriptive and inferential statistics were calculated to describe respondents and their opioid medication misuse and health characteristics. SETTING Patients were screened in 2 urban and 2 rural community pharmacies in southwestern Pennsylvania. PARTICIPANTS Survey participants were adult patients filling opioid pain medications who were not currently receiving treatment for a cancer diagnosis. INTERVENTION None. MAIN OUTCOME MEASURES Validated screening measures included the Prescription Opioid Misuse Index, Alcohol Use Disorders Identification Test C, Short Form 12, Drug Abuse Screening Test 10, Primary Care Post-traumatic Stress Disorder (PTSD) screen, and the Patient Health Questionnaire 2. RESULTS A total of 333 patients were screened (71.2% response rate). Nearly the entire population reported pain above and general health below national norms. Hydrocodone (19.2%) and morphine (20.8%) were found to be the medications with the highest rates of misuse-with hydrocodone having more than 4 times higher odds of misuse compared with other medications (adjusted odds ratio [AOR] 4.48, 95% confidence interval [CI] 1.1-17.4). Patients with positive screens for illicit drug use (AOR 8.07, 95% CI 2.7-24.0), PTSD (AOR 5.88, 95% CI 2.3-14.7), and depression (AOR 2.44, 95% CI 1.0-5.9) also had significantly higher odds for misuse compared with those with negative screening results. CONCLUSION These findings provide important foundational data that suggest implementation of regular opioid misuse screening protocols within community pharmacies. Such screening activities could foster a culture of prevention and overall reduction for misuse among patients filling opioid medications in community pharmacies.
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Cone EJ, DePriest AZ, Gordon A, Passik SD. Risks and responsibilities in prescribing opioids for chronic noncancer pain, part 2: best practices. Postgrad Med 2014; 126:129-38. [PMID: 25387221 DOI: 10.3810/pgm.2014.11.2841] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Opioids are increasingly prescribed to provide effective therapy for chronic noncancer pain, but increased use also means an increased risk of abuse. Primary care physicians treating patients with chronic noncancer pain are concerned about adverse events and risk of abuse and dependence associated with opioids, yet many prescribers do not follow established guidelines for the use of these agents, either through unawareness or in the mistaken belief that urine toxicology testing is all that is needed to monitor compliance and thwart abuse. Although there is no foolproof way to identify an abuser and prevent abuse, the best way to minimize the risk of abuse is to follow established guidelines for the use of opioids. These guidelines entail a careful assessment of the patient, the painful condition to be treated, and the estimated level of risk of abuse based on several factors: history of abuse and current or past psychiatric disorders; design of a therapeutic regimen that includes both pharmacotherapeutic and nonpharmacologic modalities; a formal written agreement with the patient that defines treatment expectations and responsibilities; selection of an appropriate agent, including consideration of formulations designed to deter tampering and abuse; initiation of treatment at a low dosage with titration in gradual increments as needed to achieve effective analgesia; regular reassessment to watch for signs of abuse, to perform drug monitoring, and to adjust medication as needed; and established protocols for actions to be taken in case of suspected abuse. By following these guidelines, physicians can prescribe opioids to provide effective analgesia while reducing the likelihood of abuse.
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Affiliation(s)
- Edward J Cone
- Associate Professor, Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Severna Park, MD
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12
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Macias Konstantopoulos WL, Dreifuss JA, McDermott KA, Parry BA, Howell ML, Mandler RN, Fitzmaurice GM, Bogenschutz MP, Weiss RD. Identifying patients with problematic drug use in the emergency department: results of a multisite study. Ann Emerg Med 2014; 64:516-25. [PMID: 24999283 PMCID: PMC4252835 DOI: 10.1016/j.annemergmed.2014.05.012] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Revised: 04/26/2014] [Accepted: 05/14/2014] [Indexed: 11/26/2022]
Abstract
STUDY OBJECTIVE Drug-related emergency department (ED) visits have steadily increased, with substance users relying heavily on the ED for medical care. The present study aims to identify clinical correlates of problematic drug use that would facilitate identification of ED patients in need of substance use treatment. METHODS Using previously validated tests, 15,224 adult ED patients across 6 academic institutions were prescreened for drug use as part of a large randomized prospective trial. Data for 3,240 participants who reported drug use in the past 30 days were included. Self-reported variables related to demographics, substance use, and ED visit were examined to determine their correlative value for problematic drug use. RESULTS Of the 3,240 patients, 2,084 (64.3%) met criteria for problematic drug use (Drug Abuse Screening Test score ≥ 3). Age greater than or equal to 30 years, tobacco smoking, daily or binge alcohol drinking, daily drug use, primary noncannabis drug use, resource-intense ED triage level, and perceived drug-relatedness of ED visit were highly correlated with problematic drug use. Among primary cannabis users, correlates of problematic drug use were age younger than 30 years, tobacco smoking, binge drinking, daily drug use, and perceived relatedness of the ED visit to drug use. CONCLUSION Clinical correlates of drug use problems may assist the identification of ED patients who would benefit from comprehensive screening, intervention, and referral to treatment. A clinical decision rule is proposed. The correlation between problematic drug use and resource-intense ED triage levels suggests that ED-based efforts to reduce the unmet need for substance use treatment may help decrease overall health care costs.
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Affiliation(s)
| | - Jessica A Dreifuss
- Department of Psychiatrys, Boston, MA; Harvard Medical School, Boston, MA; Behavioral Health Partial Program, McLean Hospital, Belmont, MA
| | | | - Blair Alden Parry
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Melissa L Howell
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Raul N Mandler
- Center for the Clinical Trials Network, National Institute on Drug Abuse, National Institutes of Health, Bethesda, MD
| | | | - Michael P Bogenschutz
- Department of Psychiatry, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Roger D Weiss
- Department of Psychiatrys, Boston, MA; Harvard Medical School, Boston, MA; Division of Alcohol and Drug Abuse, McLean Hospital, Belmont, MA
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Ditah I, Ditah F, Devaki P, Ewelukwa O, Ditah C, Njei B, Luma HN, Charlton M. The changing epidemiology of hepatitis C virus infection in the United States: National Health and Nutrition Examination Survey 2001 through 2010. J Hepatol 2014; 60:691-8. [PMID: 24291324 DOI: 10.1016/j.jhep.2013.11.014] [Citation(s) in RCA: 120] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Revised: 11/09/2013] [Accepted: 11/19/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS In light of the dramatically changing hepatitis C therapeutic landscape, knowledge of the current burden of HCV infection in the general population of the United States is critical. METHODS The National Health and Nutrition Examination survey collects nationally representative data on HCV infection in the civilian population of the United States. Data from 2001 to 2010 were combined for this study. HCV testing was completed in 38,025 participants. RESULTS The prevalence of anti-HCV in the United Sates decreased from 1.9% (95% CI 1.5%-2.5%) in 2001-2002 to 1.3% (95% CI 0.9%-1.8%) in 2005-2006, and remained stable up to 2010. About 67% of all infected persons were positive for HCV RNA, indicating 2.3 million people with chronic HCV infection, of whom 68% have genotype 1. Seventy percent of infected persons were born between 1945 and 1965, with prevalence of 3.5% (95% CI 2.2%-4.8%). The stable rate since 2006 is mostly related to prevalent cases and foreign born persons migrating into US. Other important risk factors include less education and low economic status. Race, HIV status, number of sexual partners, and blood transfusions are no longer associated with HCV infection. CONCLUSIONS As of 2010, approximately 2.3 million persons were chronically infected with Hepatitis C in the US. Most of those infected are prevalent, rather than incident cases. The prevalence of HCV was on the decline, but has stabilized since 2006. Future studies should explore reasons for no decline in HCV prevalence since 2006.
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Affiliation(s)
- Ivo Ditah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States.
| | - Fausta Ditah
- Division of Gastroenterology Hepatology, and Nutrition, Vanderbilt University School of Medicine, United States
| | | | | | | | - Basile Njei
- University of Connecticut School of Medicine, Birmingham, CT, United States
| | | | - Michael Charlton
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States
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Starrels JL, Fox AD, Kunins HV, Cunningham CO. They don't know what they don't know: internal medicine residents' knowledge and confidence in urine drug test interpretation for patients with chronic pain. J Gen Intern Med 2012; 27:1521-7. [PMID: 22815062 PMCID: PMC3475838 DOI: 10.1007/s11606-012-2165-7] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2011] [Revised: 05/23/2012] [Accepted: 06/18/2012] [Indexed: 11/30/2022]
Abstract
BACKGROUND Urine drug testing (UDT) can help identify misuse or diversion of opioid medications among patients with chronic pain. However, misinterpreting results can lead to false reassurance or erroneous conclusions about drug use. OBJECTIVE To examine the relationship between resident physicians' knowledge about UDT interpretation and confidence in their ability to interpret UDT results. DESIGN Cross-sectional survey. PARTICIPANTS Internal medicine residents in a university health system in the Bronx, from 2010 to 2011. MAIN MEASURES We assessed knowledge using a 7-item scale (UDT knowledge score), and confidence in UDT interpretation using a single statement ("I feel confident in my ability to interpret the results of urine drug tests"). We conducted chi-square tests, t-tests, and logistic regression to determine the association between knowledge and confidence, and in exploratory analyses to examine whether resident characteristics (gender, training level, and UDT use) moderated the relationship between knowledge and confidence. KEY RESULTS Among 99 residents, the mean UDT knowledge score was 3.0 out of 7 (SD 1.2). Although 55 (56 %) of residents felt confident in their ability to interpret UDT results, 40 (73 %) of confident residents had a knowledge score of 3 or lower. Knowledge score was not associated with confidence among the full sample or when stratified by training level or UDT use. The association between knowledge and confidence differed significantly by gender (interaction term p<0.01). Adjusting for training level and UDT use, knowledge was positively associated with confidence among females (AOR 1.79, 95 % CI: 1.06, 3.30), and negatively associated with confidence among males (AOR 0.47, 95 % CI: 0.23, 0.98). CONCLUSIONS Despite poor knowledge about UDT interpretation, most resident physicians felt confident in their ability to interpret UDT results. Gender differences warrant further exploration, but even confident physicians who use UDT should evaluate their proficiency in interpreting UDT results. Educational initiatives should emphasize the complexities of UDT interpretation.
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Affiliation(s)
- Joanna L Starrels
- General Internal Medicine, Albert Einstein College of Medicine, 111 E. 210 St, Bronx, NY, 10467, USA.
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Denniston MM, Klevens RM, McQuillan GM, Jiles RB. Awareness of infection, knowledge of hepatitis C, and medical follow-up among individuals testing positive for hepatitis C: National Health and Nutrition Examination Survey 2001-2008. Hepatology 2012; 55:1652-61. [PMID: 22213025 PMCID: PMC4586034 DOI: 10.1002/hep.25556] [Citation(s) in RCA: 296] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2011] [Accepted: 11/29/2011] [Indexed: 02/06/2023]
Abstract
UNLABELLED Many persons infected with hepatitis C virus (HCV) are unknown to the healthcare system because they may be asymptomatic for years, have not been tested for HCV infection, and only seek medical care when they develop liver-related complications. We analyzed data from persons who tested positive for past or current HCV infection during participation in the National Health and Nutrition Examination Survey (NHANES) from 2001 through 2008. A follow-up survey was conducted 6 months after examination to determine (1) how many participants testing positive for HCV infection were aware of their HCV status before being notified by NHANES, (2) what actions participants took after becoming aware of their first positive test, and (3) participants' knowledge about hepatitis C. Of 30,140 participants tested, 393 (1.3%) had evidence of past or current HCV infection and 170 (43%) could be contacted during the follow-up survey and interviewed. Only 49.7% were aware of their positive HCV infection status before being notified by NHANES, and only 3.7% of these respondents reported that they had first been tested for HCV because they or their doctor thought they were at risk for infection. Overall, 85.4% had heard of hepatitis C; correct responses to questions about hepatitis C were higher among persons 40-59 years of age, white non-Hispanics, and respondents who saw a physician after their first positive HCV test. Eighty percent of respondents indicated they had seen a doctor about their first positive HCV test result. CONCLUSION These data indicate that fewer than half of those infected with HCV may be aware of their infection. The findings suggest that more intensive efforts are needed to identify and test persons at risk for HCV infection.
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Affiliation(s)
- Maxine M. Denniston
- Epidemiology and Surveillance Branch, Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - R. Monina Klevens
- Epidemiology and Surveillance Branch, Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Geraldine M. McQuillan
- Division of Health and Nutrition Examination Surveys, National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, MD
| | - Ruth B. Jiles
- Epidemiology and Surveillance Branch, Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
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Bogstrand ST, Normann PT, Rossow I, Larsen M, Mørland J, Ekeberg Ø. Prevalence of alcohol and other substances of abuse among injured patients in a Norwegian emergency department. Drug Alcohol Depend 2011; 117:132-8. [PMID: 21316163 DOI: 10.1016/j.drugalcdep.2011.01.007] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2010] [Revised: 01/14/2011] [Accepted: 01/14/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND Studies have found a high prevalence of both alcohol and other impairing psychoactive drugs in injured patient populations. The aim of this study was to assess the prevalence of potentially impairing psychoactive substances in all patients admitted to a hospital emergency department with injuries from accidents, assault or deliberate self harm. METHODS A total of 1272 patients over 18 years of age, admitted to the hospital within 12h of injury, were included. Presence of alcohol was determined by an enzymatic method and other drugs by liquid chromatography-mass spectrometry (LC-MS) or gas chromatography-mass spectrometry (GC-MS), both highly specific analytical methods for determining recent intake. RESULTS There were 510 (40%) women in the sample. Of the patients, 38% of the women and 48% of the men had a positive blood sample for psychoactive substances on admission. The most prevalent psychoactive substance was alcohol (27%) with an average concentration of 1.5 g/kg. A further 21% of patients tested showed use of medicinal drugs, and 9% showed use of illicit substances. Cannabis was the most prevalent illicit drug (6.2%). Diazepam (7.4%) and zopiclone (5.3%) were the most prevalent medicinal drugs. In road traffic accidents, 25% of the car drivers had positive findings, about half of them for alcohol. CONCLUSION Psychoactive substances were found in nearly half the patients admitted with injuries. The most common substance was alcohol. Alcohol was particularly related to violence, whereas medicinal drugs were most prevalent in accidents at home.
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Affiliation(s)
- Stig Tore Bogstrand
- Emergency Department, Division of Critical Care, Oslo University Hospital, Ullevål, N-0407 Oslo, Norway.
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