A research agenda for gender and substance use disorders in the emergency department

Research priority setting in emergency care: A scoping review

Objective

Priority areas for emergency care research are emerging and becoming ever more important. The objectives of this scoping review were to (1) provide a comprehensive overview of published emergency care priority‐setting studies by collating and comparing priority‐setting methodology and (2) describe the resulting research priorities identified.

Methods

The Joanna Briggs Institute methodological framework was used. Inclusion criteria were peer‐review articles available in English, published between January 1, 2008 and March 31, 2019 and used 2 or more search terms. Five databases (Scopus, AustHealth, EMBASE, CINAHL, and Ovid MEDLINE) were searched. REporting guideline for PRIority SEtting of health research (REPRISE) criteria were used to assess the quality of evidence of included articles.

Results

Forty‐five studies were included. Fourteen themes for emergency care research were considered within 3 overarching research domains: emergency populations (pediatrics, geriatrics), emergency care workforce and processes (nursing, shared decision making, general workforce, and process), and emergency care clinical areas (imaging, falls, pain management, trauma care, substance misuse, infectious diseases, mental health, cardiology, general clinical care). Variation in the reporting of research priority areas was evident. Priority areas to drive the global agenda for emergency care research are limited given the country and professional group‐specific context of existing studies.

Conclusion

This comprehensive summary of generated research priorities across emergency care provides insight into current and future research agendas. With the nature of emergency care being inherently broad, future priorities may warrant population (eg, children, geriatrics) or subspecialty (eg, trauma, toxicology, mental health) focus and be derived using a rigorous framework and patient engagement.

Parenting style and its effect on eating disorders and substance abuse across the young population

This article attempts to examine the occurrence of two behavioural changes, namely, substance abuse and eating disorders in order of onset mediated by ineffective parenting styles during young age. The four parenting styles and their consequential behavioural adverse effects are taken as the focal point of this study and are synthesized to provide an outlook on the status of ineffective parenting and deviant offspring behaviours. A review of literature was primarily undertaken to examine the characteristic features of ineffective parenting. A causal relationship was then drawn between the onset of behavioural disorders with an emphasis on substance abuse and eating disorders, along the parenting spectrum. We probed into the order and directionality of the offspring behavioural changes against ineffective parenting. The current available data shows the superimposition of the parenting style spectrum on a bell-shaped distribution of behavioural outcomes as exemplified by authoritarian, permissive and neglectful parenting as a prime determinant of several disorders among the young age; parenting styles being at the extremities of the parenting spectrum. The sweet spot of parenting, mainly associated to the authoritative approach, bears the most positive effect on the growing child. The extreme ends of parenting as per the varying degree of responsiveness and demandingness, generally observed in authoritarian and neglectful parenting precipitate concomitant deviant behaviours cascading from one another; intricately linking substance abuse and eating disorders. A number of studies describe the isolated effects of ineffective parenting on the development of substance abuse and eating disorders during the adolescent period. However, the relationship between both eating disorders and substance abuse is underplayed and need to be stressed upon to tailor behaviour-specific targeted therapies and restore the normalcy of these altered behaviours.

How the parenting style adopted can lead to a concurrent amalgam of disordered eating patterns and substance abuse.

How disordered eating behaviours and substance abuse are initiated as coping strategies to deal with the consequences of poor parenting.

Isolation of specific risk factors to deter the development of those deviant behaviours in addition to improvement of parenting methods.

Mortality, morbidity, and cardiac surgery in Injection Drug Use (IDU)-associated versus non-IDU infective endocarditis: The need to expand substance use disorder treatment and harm reduction services

Background

The addiction crisis is widespread, and unsafe injection practices among people who inject drugs (PWID) can lead to infective endocarditis.

Methods

A retrospective analysis of adult patients with definite or possible infective endocarditis admitted to a tertiary care center in Portland, Maine was performed over three-year period. Our primary objective was to examine differences in demographics, health characteristics, and health service utilization between injection drug use (IDU)-associated infective endocarditis and non-IDU infective endocarditis. The association between IDU and mortality, morbidity (defined as emergency department visits within 3 months of discharge), and cardiac surgery was examined. Bivariate and multivariate analyses were performed. A subgroup descriptive analysis of PWID was also performed to better examine substance use disorder (SUD) characteristics, treatment with medication for opioid use disorder (MOUD) and health service utilization.

Results

One-hundred and seven patients were included in the study, of which 39.2% (n = 42) had IDU-associated infective endocarditis. PWID were more likely to be homeless, uninsured, and lack a primary care provider. PWID were notably younger and had less documented comorbidities, however had similar in-hospital mortality rates (10% vs. 14%, p = 0.30), ED visits (50% vs. 54%, p = 0.70) and cardiac surgery (33% vs. 26%, p = 0.42) compared to those with non-IDU infective endocarditis. Ninety-day mortality was less among PWID (19.0% vs. 36.9%, p = 0.05). IDU was not associated with morbidity (adjusted odds ratio (AOR) 0.73, 95% CI 0.18–3.36), 90-day mortality (AOR 0.72, 95% CI 0.17–3.01), or cardiac surgery (AOR 0.15, 95% CI 0.03–0.69). Ninety-day mortality among PWID who received MOUD was lower (3% vs 15%, p = 0.45), as were ED visits (10% vs. 41%, p = 0.42) compared to those who did not receive MOUD.

Conclusions

Our results highlight existing differences in health characteristics and social determinants of health in people with IDU-associated versus non-IDU infective endocarditis. PWID had less comorbidities and were significantly younger than those with non-IDU infective endocarditis and yet still had similar rates of cardiac surgery, ED visits, and in-hospital mortality. These findings emphasize the need to deliver comprehensive health services, particularly MOUD and other harm reduction services, to this marginalized population.

Gender Differences in Smoking Among an Urban Emergency Department Sample

Background:

Urban emergency department (ED) patients have elevated smoking and substance use compared with the general population. We analyzed gender differences in smoking among an urban ED sample and assessed the contribution of substance use, demographic, and couple factors.

Methods:

We conducted a secondary analysis of data obtained from a cross-sectional, observational survey (N = 1037 participants) on drinking, drug use, and intimate partner violence (IPV). Gender-specific logistic regression models for current (past 30-day) smoking and multinomial regression models for smoking intensity (light: ⩽5 cigarettes per day [CPD]; moderate: 6 to 10 CPD; heavier: >10 CPD) were estimated.

Results:

Smoking prevalence was higher among men than women (35.5% vs 18.9%; P < .001). Substance use (frequency of intoxication, marijuana, amphetamine, and cocaine use), demographic (food insufficiency, unemployment), and couple-related factors (having a spouse/partner who smoked, IPV involvement, being in a same-gender couple) were differentially associated with current smoking and level of intensity among men and women.

Conclusions:

Emergency department staff should consider the impact of polysubstance use, food insufficiency, unemployment, and whether both partners in the couple smoke when screening patients for smoking and formulating cessation treatment plans. Women in same-gender relationships and those who have experienced IPV involvement may require additional referral.

Gender differences in discharge dispositions of emergency department visits involving drug misuse and abuse-2004-2011

Background

Drug use-related visits to the emergency department (ED) can undermine discharge planning and lead to recurrent use of acute services. Yet, little is known about where patients go post discharge. We explored trends in discharge dispositions of drug-involved ED visits, with a focus on gender differences.

Methods

We extracted data from the 2004–2011 Drug Abuse Warning Network, a national probability sample of drug-related visits to hospital EDs in the U.S. We computed weighted multinomial logistic regression models to estimate discharge dispositions over time and to examine associations between gender and the relative risk of discharge dispositions, controlling for patient characteristics.

Results

The final pooled sample included approximately 1.2 million ED visits between 2004 and 2011. Men accounted for more than half (57.6%) of all ED visits involving drug misuse and abuse. Compared with women, men had a greater relative risk of being released to the police/jail, being referred to outpatient detox or other treatment, and leaving against medical advice than being discharged home. The relative risk of being referred to outpatient detox/drug treatment than discharged home increased over time for men versus women.

Conclusions

Greater understanding of gender-based factors involved in substance-related ED visits and treatment needs may inform discharge planning and preventive interventions.

Gender Differences in Emergency Department Visits and Detox Referrals for Illicit and Nonmedical Use of Opioids

INTRODUCTION

Visits to the emergency department (ED) for use of illicit drugs and opioids have increased in the past decade. In the ED, little is known about how gender may play a role in drug-related visits and referrals to treatment. This study performs gender-based comparison analyses of drug-related ED visits nationwide.

METHODS

We performed a cross-sectional analysis with data collected from 2004 to 2011 by the Drug Abuse Warning Network (DAWN). All data were coded to capture major drug categories and opioids. We used logistic regression models to find associations between gender and odds of referral to treatment programs. A second set of models were controlled for patient "seeking detox," or patient explicitly requesting for detox referral.

RESULTS

Of the 27.9 million ED visits related to drug use in the DAWN database, visits by men were 2.69 times more likely to involve illicit drugs than visits by women (95% CI [2.56, 2.80]). Men were more likely than women to be referred to detox programs for any illicit drugs (OR 1.12, 95% CI [1.02-1.22]), for each of the major illicit drugs (e.g., cocaine: OR 1.27, 95% CI [1.15-1.40]), and for prescription opioids (OR 1.30, 95% CI [1.17-1.43]). This significant association prevailed after controlling for "seeking detox."

CONCLUSION

Women are less likely to receive referrals to detox programs than men when presenting to the ED regardless of whether they are "seeking detox." Future research may help determine the cause for this gender-based difference and its significance for healthcare costs and health outcomes.

"I need to hear from women who have 'been there'": Developing a woman-focused intervention for drug use and partner violence in the emergency department

OBJECTIVE

Addressing violence and linking women to community services in parallel with drug change goals is critical for women with coexisting intimate partner violence (IPV) and substance use disorders (SUD). Our objective was to develop a Web-based intervention to address violence and drug use among women patients in the ED.

METHODS

The intervention was developed in a five-step process: 1) Initial intervention development based on selected theoretical frameworks; 2) In-depth interviews with the target population; 3) Intervention adaptation, with iterative feedback from further interviews; 4) Beta testing and review by an advisory committee of domestic violence advocates; 5) Acceptability and feasibility testing in a small open trial.

RESULTS

Themes supported the selection of MI and empowerment models but also guided major adaptations to the intervention, including the introduction of videos and a more robust booster phone call. Participants in the open trial reported high scores for satisfaction, usability, and consistency with essential elements of motivational interviewing.

CONCLUSIONS

This qualitative work with our target population of women in the ED with SUD experiencing IPV underscored the importance of connection to peers and empathetic human contact. We developed an acceptable and feasible intervention distinct from prior ED-based brief interventions for substance-using populations.

Sex Differences in Substance Use Among Adult Emergency Department Patients: Prevalence, Severity, and Need for Intervention

BACKGROUND

Substance use is prevalent among emergency department (ED) patients, and sex has been implicated as an important factor in the etiology, pathophysiology, sequelae, and treatment of substance use disorders. However, additional information is needed about the epidemiology of substance use as it relates to sex among ED patients.

OBJECTIVES

This study examined sex differences in the prevalence and severity of self-reported tobacco, alcohol, and drug use among adult ED patients.

METHODS

A random sample of English- or Spanish-speaking, non-critically ill or injured, 18- to 64-year-old patients was approached at two urban EDs and asked to self-report their lifetime and past 3-month tobacco, alcohol, and drug use. Participants completed the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) using an audio computer-assisted self-interview. Participants were categorized by their substance severity (ASSIST score) and need for a brief or more intensive intervention per World Health Organization recommendations. Substance misuse prevalence, frequency, severity, and need for interventions were compared between sexes by substance category. Multivariable logistic regression models were used to examine the association between sexes and the need for intervention after adjusting for sociodemographic characteristics.

RESULTS

Of the 6,432 participants in the study, the median age was 37 years (interquartile range = 26 to 48 years), and 56.6% were female. Overall, lifetime, and past 3-month use was higher for men across all substances (tobacco, alcohol, and drugs). Among those reporting past 3-month use, the frequency of use was similar between sexes for tobacco and all drugs, but men reported more frequent alcohol use. Men had higher mean ASSIST scores compared to women, 30.3 (standard error [SE] ± 0.8) vs. 21.1 (SE ± 0.5); mean difference 9.2 (95% confidence interval [CI] = 7.4 to 10.9). The need for any intervention (brief or intensive) was similar between sexes for tobacco and drugs. After sociodemographic factors were adjusted for, women were less likely than men to need any intervention for alcohol (odds ratio [OR] = 0.6; 95% CI = 0.4 to 0.8), but not other substances: tobacco (OR = 0.9; 95% CI = 0.6 to 1.3), marijuana (OR = 0.8; 95% CI = 0.6 to 1.1), or other drugs (OR = 1.1; 95% CI = 0.7 to 1.7).

CONCLUSIONS

Although men have a higher overall prevalence of substance use, the frequency and severity of use were similar for men and women for most substances. After other characteristics were adjusted for, sex appears associated with the need for interventions for alcohol, but not tobacco, marijuana, or other drugs.

Treatment outcomes for substance use disorder among women of reproductive age in Massachusetts: a population-based approach

INTRODUCTION

Longitudinal patterns of treatment utilization and relapse among women of reproductive age with substance use disorder (SUD) are not well known. In this statewide report spanning seven years we describe SUD prevalence, SUD treatment utilization, and differences in subsequent emergency department (ED) use and post-treatment relapse rates by type of treatment: none, 'acute only' (detoxification/stabilization), or 'ongoing' services.

METHODS

We linked a statewide dataset of hospital discharge, observation stay and ED records with SUD treatment admission records from hospitals and freestanding facilities, and birth/fetal death certificates, in Massachusetts, 2002-2008. We aggregated episodes into individual woman records, identified evidence of SUD and treatment, and tested post-treatment outcomes.

RESULTS

Nearly 150,000 (8.5%) of 1.7 million Massachusetts women aged 15-49 were identified as SUD-positive. Nearly half of SUD-positive women (71,533 or 48.3%) had evidence of hospital or facility-based SUD treatment; among these, 12% received acute care/detoxification only while 88% obtained 'ongoing' treatment. Treatment varied by substance type; women with dual diagnosis and those with opiate use were least likely to receive 'ongoing' treatment. Treated women were older and less likely to have a psychiatric history or chronic illness. Women who received 'acute only' services were more likely to relapse (12.4% vs. 9.6%) and had a 10% higher rate of ED visits post-treatment than women receiving 'ongoing' treatment.

CONCLUSIONS

Many Massachusetts women of reproductive age need but do not receive adequate SUD treatment. 'Ongoing' services beyond detoxification/stabilization may reduce the likelihood of post-treatment relapse and/or reliance on the ED for subsequent medical care.

Female drivers increasingly involved in impaired driving crashes: actions to ameliorate the risk

Emergency physicians are confronted daily with the care of traumatically injured patients. A considerable proportion of blunt trauma cases are due to motor vehicle crashes. While men have historically been overrepresented in crash-related injuries and deaths, unfavorable trends for women in alcohol-impaired driving crashes have emerged. This extended commentary with in-depth review presents an examination of the evolving role of sex and gender in alcohol-impaired driving and its outcomes.

The intersecting roles of violence, gender, and substance use in the emergency department: a research agenda

The relationship between gender, violence, and substance use in the emergency department (ED) is complex. This article examines the role of gender in the intersection of substance use and three types of violence: peer violence, intimate partner violence, and firearm violence. Current approaches to treatment of substance abuse and violence are similar across both genders; however, as patterns of violence and substance abuse differ by gender, interventions may be more effective if they are designed with a specific gender focus.