Community-wide emergency department visits by patients suspected of drug-seeking behavior

Poly-prescription drug misuse across the life course: Prevalence and correlates across different adult age cohorts in the U.S

BACKGROUND

Most research on prescription drug misuse (PDM) focuses on the misuse of specific classes of psychoactive prescription drugs among adolescents or young adults. The current research addressed important gaps in the literature by assessing poly-prescription drug misuse (poly-PDM), the misuse of more than one class of psychoactive prescription drug, across different adult age cohorts.

METHODS

We used the 2015-2018 National Survey on Drug Use and Health to examine the prevalence of past-year poly-PDM and specific combinations of PDM. Multinomial logistic regression was used to identify demographic, health-related factors, and substance use behaviors that were significantly associated with poly-PDM.

RESULTS

The prevalence of poly-PDM decreases with age and is common among individuals who engage in PDM. Slightly more than one in four respondents in age cohorts 18-25 (31.66%, 95% CI = 30.35, 33.00) and 26-34 (29.92%, 95% CI = 25.82, 30.12) who engage in PDM, misused more than one class of prescription drug. Additionally, poly-PDM was identified as a high-risk type of PDM as roughly 60% of adults younger than 65 who endorse poly-PDM reported having a substance use disorder (SUD). While certain characteristics (i.e., race/ethnicity, marital status, depression, suicidal ideation, illegal drug use, and SUD) were consistently associated with poly-PDM across age cohorts, other characteristics (i.e., sexual identity, income, and justice involvement) varied across age cohorts. Finally, a comparison of poly-PDM to single PDM showed, in all age cohorts, that having an SUD was associated with an increased likelihood of poly-PDM, while Black adults were less likely than whites to report poly-PDM.

CONCLUSIONS

By identifying prevalence and correlates of poly-PDM across adult age cohorts, the current research has significant implications. Understanding stability and heterogeneity in the characteristics associated with poly-PDM should inform interventions, identify at-risk groups, and shape public health approaches to dealing with high-risk substance use behavior.

Predicting opioid use disorder in patients with chronic pain who present to the emergency department

Background

Emergency department (ED) patients with chronic pain challenge providers to make quick and accurate assessments without an in-depth pain management consultation. Emergency physicians need reliable means to determine which patients may receive opioid therapy without exacerbating opioid use disorder (OUD).

Methods

Eighty-nine ED patients with a chief complaint of chronic pain were enrolled. Researchers administered questionnaires and reviewed medical and state prescription monitoring database information. Participants were classified as either OUD or non-OUD. Statistical analysis included a bivariate analysis comparing differences between groups and multivariate logistic regression evaluating ORs.

Results

The 45 participants categorised as OUD had a higher proportion of documented or reported psychiatric diagnoses (p=0.049), preference of opioid treatment (p=0.005), current oxycodone prescription (p=0.043), borrowed pain medicine (p=0.004) and non-authorised dose increase (p<0.001). The state prescription monitoring database revealed the OUD group to have an increased number of opioid prescriptions (p=0.005) and pills (p=0.010). Participants who borrowed pain medicine and engaged in non-authorised dose increase were 5.2 (p=0.025, 95% CI 1.24 to 21.9) and 6.1 times (p=0.001, 95% CI 1.55 to 24.1) more likely to have OUD, respectively.

Limitations

Major limitations of our study include a small sample size, self-reported measures and convenience sample which may introduce selection bias.

Conclusion

Patients with chronic pain with OUD have distinguishable characteristics. Emergency physicians should consider such evidence-based variables prior to opioid therapy to ameliorate the opioid crisis and limit implicit bias.

Racial and Ethnic Disparities in Opioid Prescribing for Long Bone Fractures at Discharge From the Emergency Department: A Cross-sectional Analysis of 22 Centers From a Health Care Delivery System in Northern California

STUDY OBJECTIVE

We examine racial and ethnic differences in opioid prescribing and dosing for long bone fractures at emergency department (ED) discharge.

METHODS

We conducted an electronic health records-based cross-sectional study of adults with long bone fractures who presented to the ED across 22 sites from a health care delivery system (2016 to 2017). We examined differences in opioid prescribing at ED discharge and, among patients with a prescription, differences in opioid dosing (measured as morphine milligram equivalents) by race/ethnicity, using regression modeling with statistical adjustment for patient, fracture, and prescriber characteristics.

RESULTS

A total of 11,576 patients with long bone fractures were included in the study; 64.4% were non-Hispanic white; 16.4%, 7.3%, 5.8%, and 5.1%, respectively, were Hispanic, Asian, black, and of other or unknown race; and 65.6% received an opioid at discharge. After adjusting for other factors, rates of opioid prescribing were not different by race/ethnicity; however, among patients with an opioid prescription, total morphine milligram equivalent units prescribed were 4.3%, 6.0%, and 8.1% less for Hispanics, blacks, and Asians relative to non-Hispanic whites.

CONCLUSION

Racial and ethnic minority groups with long bone fractures receive similar frequencies of opioid prescriptions at discharge, with a small potency difference. How this affects pain relief and why it happens is unclear.

Characteristics of Frequent Users of Emergency Medical Services in Singapore

OBJECTIVES

This study aims to describe frequent users of Emergency Medical Services (EMS) conveyed to a Singapore tertiary hospital, focusing on a comparison between younger users (age <65) and older users in diagnoses and admission rates.

METHODS

All patients conveyed by EMS to a tertiary hospital 4 times or more over a 1-year period in 2015 had their EMS ambulance charts and Emergency Department (ED) electronic records retrospectively analyzed (n = 243), with admission the primary outcome.

RESULTS

The 243 frequent users were analyzed with a combined total of 1,705 visits, out of a total of 10,183 patients with 12,839 visits conveyed by EMS to Singapore General Hospital (SGH) in 2015. Younger frequent users (<65 years age) were found to be predominantly male (79.6%, p = 0.001) and were on average responsible for more visits than elderly frequent users (8.6 vs. 5.7, p = 0.004). Medical co-morbidities were significantly more prevalent in older users. Younger frequent users were more likely to be smokers (60.2% vs. 22.3%), heavy drinkers (51.3% vs. 8.5%), substance abusers (12.4% vs. 0.8%), and bad debtors (49.6% vs. 20.0%, p < 0.001). A larger proportion presented with altered mental states (11.7% vs. 5.4%, p < 0.001) and alcohol related diagnoses (34.7% vs. 5.3%, p < 0.001). Many were picked up from public areas (45.5% vs. 19.6%, p < 0.001), and had lower acuity triage scores at both EMS (p < 0.001) and ED (p = 0.001). They had lower admission rates (40.5% vs. 78.7%, p < 0.001) and shorter length of stay (4.3 vs. 5.9 days, p < 0.001). Univariable and multivariable analysis showed alcohol related diagnoses, history of alcohol abuse and lower triage scores were less likely to require admissions.

CONCLUSION

Frequent EMS users consume a disproportionate amount of healthcare resources. Two broad subgroups of patients were identified: younger patients with social issues and older patients with multiple medical conditions. EMS usage by older patients was significantly associated with higher rates of admission.

Effect of Automated Prescription Drug Monitoring Program Queries on Emergency Department Opioid Prescribing

STUDY OBJECTIVE

We assess whether an automated prescription drug monitoring program intervention in emergency department (ED) settings is associated with reductions in opioid prescribing and quantities.

METHODS

We performed a retrospective cohort study of ED visits by Medicaid beneficiaries. We assessed the staggered implementation (pre-post) of automated prescription drug monitoring program queries at 86 EDs in Washington State from January 1, 2013, to September 30, 2015. The outcomes included any opioid prescribed within 1 day of the index ED visit and total dispensed morphine milligram equivalents. The exposure was the automated prescription drug monitoring program query intervention. We assessed program effects stratified by previous high-risk opioid use. We performed multiple sensitivity analyses, including restriction to pain-related visits, restriction to visits with a confirmed prescription drug monitoring program query, and assessment of 6 specific opioid high-risk indicators.

RESULTS

The study included 1,187,237 qualifying ED visits (898,162 preintervention; 289,075 postintervention). Compared with the preintervention period, automated prescription drug monitoring program queries were not significantly associated with reductions in the proportion of visits with opioid prescribing (5.8 per 1,000 encounters; 95% confidence interval [CI] -0.11 to 11.8) or the amount of prescribed morphine milligram equivalents (difference 2.66; 95% CI -0.15 to 5.48). There was no evidence of selective reduction in patients with previous high-risk opioid use (1.2 per 1,000 encounters, 95% CI -9.5 to 12.0; morphine milligram equivalents 1.22, 95% CI -3.39 to 5.82). The lack of a selective reduction in high-risk patients was robust to all sensitivity analyses.

CONCLUSION

An automated prescription drug monitoring program query intervention was not associated with reductions in ED opioid prescribing or quantities, even in patients with previous high-risk opioid use.

An Opinion Survey on Patient Acceptance of a Two-Day Medication Supply Policy in Emergency Departments

Objective

To obtain an idea on patient acceptance of a two-day medication supply policy in emergency departments, an opinion survey was carried out at the Accident & Emergency (A&E) department of North District Hospital.

Methods

Questionnaire were distributed to 200 ambulatory patients attending the A&E department on 4 April 2000, asking for their opinions on the reasonable duration of medication supply and its possible impact on emergency department misuse. The questionnaires were collected and the data analysed.

Results

A total of 78 questionnaires (39%) were returned. Forty-nine respondents (62.8%) accepted that dispensing two days of medications from emergency departments reasonable. Ten out of the 27 patients who disagreed on two-day supply (37.0%) considered that a three-day supply would be optimal. More than half of the respondents (52.6%) agreed with the hypothesis that a two-day supply policy would discourage misuse of emergency department service.

Conclusion

The great majority of patients attending A&E departments supported the prescription of two to three days supply of medication. This policy has important resource implication. However, its possible impact on misuse of emergency department service is controversial. (Hong Kong j.emerg.med. 2002;9:3–9)

Impact of Hospital "Best Practice" Mandates on Prescription Opioid Dispensing After an Emergency Department Visit

OBJECTIVE

Washington State mandated seven hospital "best practices" in July 2012, several of which may affect emergency department (ED) opioid prescribing and provide a policy template for addressing the opioid prescription epidemic. We tested the hypothesis that the mandates would reduce opioid dispensing after an ED visit. We further assessed for a selective effect in patients with prior risky or chronic opioid use.

METHODS

We performed a retrospective, observational analysis of ED visits by Medicaid fee-for-service beneficiaries in Washington State, between July 1, 2011, and June 30, 2013. We used an interrupted time-series design to control for temporal trends and patient characteristics. The primary outcome was any opioid dispensing within 3 days after an ED visit. The secondary outcome was total morphine milligram equivalents (MMEs) dispensed within 3 days.

RESULTS

We analyzed 266,614 ED visits. Mandates were associated with a small reduction in opioid dispensing after an ED visit (-1.5%, 95% confidence interval [CI] = -2.8% to -0.15%). The mandates were associated with decreased opioid dispensing in 42,496 ED visits by patients with prior risky opioid use behavior (-4.7%, 95% CI = -7.1% to -2.3%) and in 20,238 visits by patients with chronic opioid use (-3.6%, 95% CI = -5.6% to -1.7%). Mandates were not associated with reductions in MMEs per dispense in the overall cohort or in either subgroup.

CONCLUSIONS

Washington State best practice mandates were associated with small but nonselective reductions in opioid prescribing rates. States should focus on alternative policies to further reduce opioid dispensing in subgroups of high-risk and chronic users.

A Randomized Controlled Trial of a Citywide Emergency Department Care-Coordination Program to Reduce Prescription Opioid-Related Visits: An Economic Evaluation

BACKGROUND

Care provided in the emergency department (ED) can cost up to five times as much as care received for comparable diagnoses in alternative settings. Small groups of patients, many of whom suffer from an opioid use disorder, often account for a large proportion of total ED visits. We recently conducted, and demonstrated the effectiveness of, the first randomized controlled trial of a citywide ED care-coordination program intending to reduce prescription-opioid-related ED visits. All EDs in the metropolitan study area were connected to a Web-based information exchange system.

OBJECTIVE

The objective of this article was to perform an economic evaluation of the 12-month trial from a third-party-payer perspective.

METHODS

We modeled the person-period monthly for the 12-month observation period, and estimated total treatment costs and return on investment (ROI) with regard to cost offsets, over time, for all visits where the patient was admitted to and discharged from the ED.

RESULTS

By the end of month 4, the mean cumulative cost differential was significantly lower for intervention relative to treatment-as-usual participants (-$1370; p = 0.03); this figure climbed to -$3200 (p = 0.02) by the end of month 12. The ROI trended upward throughout the observation period, but failed to reach statistical significance by the end of month 12 (ROI = 3.39, p = 0.07).

CONCLUSION

The intervention produced significant cost offsets by the end of month 4, which continued to accumulate throughout the trial; however, ROI was not significant. Because the per-patient administrative costs of the program are incurred at the time of enrollment, our results highlight the importance of future studies that are able to follow participants for a period beyond 12 months to more accurately estimate the program's ROI.

A Randomized Controlled Trial of a Citywide Emergency Department Care Coordination Program to Reduce Prescription Opioid Related Emergency Department Visits

BACKGROUND

Increasing prescription overdose deaths have demonstrated the need for safer emergency department (ED) prescribing practices for patients who are frequent ED users.

OBJECTIVES

We hypothesized that the care of frequent ED users would improve using a citywide care coordination program combined with an ED care coordination information system, as measured by fewer ED visits by and decreased controlled substance prescribing to these patients.

METHODS

We conducted a multisite randomized controlled trial (RCT) across all EDs in a metropolitan area; 165 patients with the most ED visits for complaints of pain were randomized. For the treatment arm, drivers of ED use were identified by medical record review. Patients and their primary care providers were contacted by phone. Each patient was discussed at a community multidisciplinary meeting where recommendations for ED care were formed. The ED care recommendations were stored in an ED information exchange system that faxed them to the treating ED provider when the patient presented to the ED. The control arm was subjected to treatment as usual.

RESULTS

The intervention arm experienced a 34% decrease (incident rate ratios = 0.66, p < 0.001; 95% confidence interval 0.57-0.78) in ED visits and an 80% decrease (odds ratio = 0.21, p = 0.001) in the odds of receiving an opioid prescription from the ED relative to the control group. Declines of 43.7%, 53.1%, 52.9%, and 53.1% were observed in the treatment group for morphine milligram equivalents, controlled substance pills, prescriptions, and prescribers, respectively.

CONCLUSION

This RCT showed the effectiveness of a citywide ED care coordination program in reducing ED visits and controlled substance prescribing.

Prescription reporting with immediate medication utilization mapping (PRIMUM): development of an alert to improve narcotic prescribing

BACKGROUND

Prescription narcotic overdoses and abuse have reached alarming numbers. To address this epidemic, integrated clinical decision support within the electronic medical record (EMR) to impact prescribing behavior was developed and tested.

METHODS

A multidisciplinary Expert Panel identified risk factors for misuse, abuse, or diversion of opioids or benzodiazepines through literature reviews and consensus building for inclusion in a rule within the EMR. We ran the rule "silently" to test the rule and collect baseline data.

RESULTS

Five criteria were programmed to trigger the alert; based on data collected during a "silent" phase, thresholds for triggers were modified. The alert would have fired in 21.75 % of prescribing encounters (1.30 % of all encounters; n = 9998), suggesting the alert will have a low prescriber burden yet capture a significant number of at-risk patients.

CONCLUSIONS

While the use of the EMR to provide clinical decision support is not new, utilizing it to develop and test an intervention is novel. We successfully built an alert system to address narcotic prescribing by providing critical, objective information at the point of care. The silent phase data were useful to appropriately tune the alert and obtain support for widespread implementation. Future healthcare initiatives can utilize similar methodology to collect data prospectively via the electronic medical record to inform the development, delivery, and evaluation of interventions.

Impact of a Chronic Pain Protocol on Emergency Department Utilization

OBJECTIVES

Patients suffering from chronic painful conditions frequently present to the emergency department (ED) for pain control. In an effort to better manage these patients we implemented and measured the effect of enrollment in a chronic pain protocol in a single ED.

METHODS

A retrospective (pre) and prospective (post) study design was utilized. We identified 46 frequent ED users suffering from chronic painful conditions. We then retrospectively documented their ED use and prescription controlled substance use for 6 months prior to enrollment in a chronic pain protocol and then 6 months postenrollment.

RESULTS

Preenrollment participating patients visited the ED on average 6.2 times in a 6-month period. Postenrollment their mean number of visits in the following 6 months decreased significantly to 2.2 times, or a 65% decrease (p < 0.001). Similarly, preenrollment, the patients were prescribed a median of 664 controlled substance pills in the entire state compared to 471 pills in the 6-month period postenrollment, or a 29% decrease (p < 0.022).

CONCLUSIONS

Through instituting a chronic pain protocol, we found significant reductions in the number of return visits to a single ED and the number of controlled substance medications prescribed by all providers. Additional studies using similar protocols could help establish their impact on the care of patients suffering from chronic pain and the potential to reduce healthcare costs, ED overcrowding, and prescription drug abuse.

Interpreting the National Hospital Ambulatory Medical Care Survey: United States Emergency Department Opioid Prescribing, 2006-2010

OBJECTIVES

Prescription opioid overdoses are a leading cause of death in the United States. Emergency departments (EDs) are potentially high-risk environments for doctor shopping and diversion. The hypothesis was that opioid prescribing rates from the ED have increased over time.

METHODS

The authors analyzed data on ED discharges from the 2006 through 2010 NHAMCS, a probability sample of all U.S. EDs. The outcome was documentation of an opioid prescription on discharge. The primary independent predictor was time. Covariates included severity of pain, a pain-related discharge diagnosis, age, sex, race, payer, hospital ownership, and geographic location of hospital. Up to three discharge diagnoses were available in NHAMCS to identify "pain-related" (e.g., back pain, fracture, dental/jaw pain, nephrolithiasis) ED visits. Multivariate logistic regression was performed to assess the independent associations between opioid prescribing and predictors. All analyses incorporated NHAMCS survey weights, and all results are presented as national estimates.

RESULTS

Opioids were prescribed for 18.7% (95% confidence interval = 17.7% to 19.7%) of all ED discharges, representing 18.8 million prescriptions per year. There were no significant temporal trends in opioid prescribing overall (adjusted p = 0.93). Pain-related discharge diagnoses that received the top three highest proportion of opioids prescriptions included nephrolithiasis (62.1%), neck pain (51.6%), and dental/jaw pain (49.7%). A pain-related discharge diagnosis, non-Hispanic white race, older age, male sex, uninsured status, and Western region were positively associated with opioid prescribing (p < 0.05).

CONCLUSIONS

No temporal trend toward increased prescribing from 2006 to 2012 was found. These results suggest that problems with opioid overprescribing are multifactorial and not solely rooted in the ED.

Randomized Controlled Trial of Electronic Care Plan Alerts and Resource Utilization by High Frequency Emergency Department Users with Opioid Use Disorder

Introduction

There is a paucity of literature supporting the use of electronic alerts for patients with high frequency emergency department (ED) use. We sought to measure changes in opioid prescribing and administration practices, total charges and other resource utilization using electronic alerts to notify providers of an opioid-use care plan for high frequency ED patients.

Methods

This was a randomized, non-blinded, two-group parallel design study of patients who had 1) opioid use disorder and 2) high frequency ED use. Three affiliated hospitals with identical electronic health records participated. Patients were randomized into “Care Plan” versus “Usual Care groups”. Between the years before and after randomization, we compared as primary outcomes the following: 1) opioids (morphine mg equivalents) prescribed to patients upon discharge and administered to ED and inpatients; 2) total medical charges, and the numbers of; 3) ED visits, 4) ED visits with advanced radiologic imaging (computed tomography [CT] or magnetic resonance imaging [MRI]) studies, and 5) inpatient admissions.

Results

A total of 40 patients were enrolled. For ED and inpatients in the “Usual Care” group, the proportion of morphine mg equivalents received in the post-period compared with the pre-period was 15.7%, while in the “Care Plan” group the proportion received in the post-period compared with the pre-period was 4.5% (ratio=0.29, 95% CI [0.07–1.12]; p=0.07). For discharged patients in the “Usual Care” group, the proportion of morphine mg equivalents prescribed in the post-period compared with the pre-period was 25.7% while in the “Care Plan” group, the proportion prescribed in the post-period compared to the pre-period was 2.9%. The “Care Plan” group showed an 89% greater proportional change over the periods compared with the “Usual Care” group (ratio=0.11, 95% CI [0.01–0.092]; p=0.04). Care plans did not change the total charges, or, the numbers of ED visits, ED visits with CT or MRI or inpatient admissions.

Conclusion

Electronic care plans were associated with an incremental decrease in opioids (in morphine mg equivalents) prescribed to patients with opioid use disorder and high frequency ED use.

Care plans reduce ED visits in those with drug-seeking behavior

Patients with drug-seeking behavior can be both labor and resource intensive to the emergency department (ED).

OBJECTIVE

To determine the effectiveness of ED care plans for individuals at high risk for drug-seeking behavior on ED visits.

METHODS

A retrospective, cohort observational study.

LOCATION

A suburban teaching hospital with an annual census of 80,000 patients. The number of ED visits was determined 1 year before and 2 subsequent years following care plan initiation.

EXCLUSION CRITERIA

Unclaimed letter, incomplete data, and/or non-drug-seeking care plan.

STATISTICS

Two-tailed Wilcoxon signed-rank test with significance of P < .05.

RESULTS

Sixty patients were enrolled and 7 were excluded, leaving 53 patients for analysis. Mean annual visits before care plan initiation were 7.6 (95% confidence interval [CI], 6.3-9.1). One year following implementation, mean visits decreased to 2.3 (95% CI, 1.5-3.1) (P ≤ .0001). Two years following implementation, mean visits continued to decline to 1.5 (95% CI, 0.9-2.1) (P ≤ .0001). A significant reduction in visits occurred 1 and 2 years following care plan implementation.

CONCLUSIONS

Emergency department care plans are an effective method to reduce ED visits in those with drug-seeking behavior.

Factors Contributing to Inappropriate Visits of Frequent Attenders and Their Economic Effects at an Emergency Department in Singapore

OBJECTIVES

This study aimed to determine which factors contribute to frequent visits at the emergency department (ED) and what proportion were inappropriate in comparison with nonfrequent visits.

METHODS

This study was a retrospective, case-control study comparing a random sample of frequent attenders and nonfrequent attenders, with details of their ED visits recorded over a 12-month duration. Frequent attenders were defined as patients with four or more visits during the study period.

RESULTS

In comparison with nonfrequent attenders (median age = 45.0 years, interquartile range [IQR] = 28.0 to 61.0 years), frequent attenders were older (median = 57.5 years, IQR = 34.0 to 74.8 years; p = 0.0003). They were also found to have more comorbidities, where 53.3% of frequent attenders had three or more chronic illnesses compared to 14% of nonfrequent attenders (p < 0.0001), and were often triaged to higher priority (more severe) classes (frequent 52.2% vs. nonfrequent 37.6%, p = 0.0004). Social issues such as bad debts (12.7%), heavy drinking (3.3%), and substance abuse (2.7%) were very low in frequent attenders compared to Western studies. Frequent attenders had a similar rate of appropriate visits to the ED as nonfrequent attenders (55.2% vs. 48.1%, p = 0.0892), but were more often triaged to P1 priority triage class (6.7% vs. 3.2%, p = 0.0014) and were more often admitted for further management compared to nonfrequent attenders (47.5% vs. 29.6%, p < 0.001). The majority of frequent attender visits were appropriate (55.2%), and of these, 81.1% resulted in admission. For the same number of patients, total visits made by frequent attenders ($174,247.60) cost four times as much as for nonfrequent attenders ($40,912.40). This represents a significant economic burden on the health care system.

CONCLUSIONS

ED frequent attenders in Singapore were associated with higher age and presence of multiple comorbidities rather than with social causes of ED use. Even in integrated health systems, repeat ED visits are frequent and expensive, despite minimal social causes of acute care. EDs in aging populations must anticipate the influx of vulnerable, elderly patients and have in place interventional programs to care for them.

Cost-effective: emergency department care coordination with a regional hospital information system

BACKGROUND

Frequent and unnecessary utilization of the emergency department (ED) is often a sign of serious latent patient issues, and the associated costs are shared by many. Helping these patients get the care they need in the appropriate setting is difficult given their complexity, and their tendency to visit multiple EDs.

STUDY OBJECTIVE

We analyzed the cost-effectiveness of a multidisciplinary ED-care-coordination program with a regional hospital information system capable of sharing patients' individualized care plans with cooperating EDs.

METHODS

ED visits, treatment costs, cost per visit, and net income were assessed pre- and postenrollment in the program using nonparametric bootstrapping techniques. Individuals were categorized as frequent (3-11 ED visits in the 365 days preceding enrollment) or extreme (≥12 ED visits) users. Regression to the mean was tested using an adjusted measure of change.

RESULTS

Both frequent and extreme users experienced significant decreases in ED visits (5 and 15, respectively; 95% confidence intervals [CI] 2-5 and 13-17, respectively) and direct-treatment costs ($1285; 95% CI $492-$2364 and $6091; 95% CI $4298-$8998, respectively), leading to significant hospital cost savings and increased net income ($431; 95% CI $112-$878 and $1925; 95% CI $1093-$3159, respectively). The results further indicate that fewer resources were utilized per visit. Regression to the mean did not seem to be an issue.

CONCLUSIONS

When examined as a whole, research on the program suggests that expanding it would be an efficient allocation of hospital, and possibly societal, resources.

Clinician impression versus prescription drug monitoring program criteria in the assessment of drug-seeking behavior in the emergency department

STUDY OBJECTIVE

We compare emergency provider impression of drug-seeking behavior with objective criteria from a state prescription drug monitoring program, assess change in opioid pain reliever prescribing after prescription drug monitoring program review, and examine clinical factors associated with suspected drug-seeking behavior.

METHODS

This was a prospective observational study of emergency providers assessing a convenience sample of patients aged 18 to 64 years who presented to either of 2 academic medical centers with chief complaint of back pain, dental pain, or headache. Drug-seeking behavior was objectively defined as present when a patient had greater than or equal to 4 opioid prescriptions by greater than or equal to 4 providers in the 12 months before emergency department evaluation. Emergency providers completed data forms recording their impression of the likelihood of drug-seeking behavior, patient characteristics, and plan for prescribing pre- and post-prescription drug monitoring program review. Descriptive statistics were generated. We calculated agreement between emergency provider impression of drug-seeking behavior and prescription drug monitoring program definition, and sensitivity, specificity, and positive predictive value of emergency provider impression, using prescription drug monitoring program criteria as the criterion standard. A multivariate logistic regression analysis was conducted to determine clinical factors associated with drug-seeking behavior.

RESULTS

Thirty-eight emergency providers with prescription drug monitoring program access participated. There were 544 patient visits entered into the study from June 2011 to January 2013. There was fair agreement between emergency provider impression of drug-seeking behavior and prescription drug monitoring program (κ=0.30). Emergency providers had sensitivity 63.2% (95% confidence interval [CI] 54.8% to 71.7%), specificity 72.7% (95% CI 68.4% to 77.0%), and positive predictive value 41.2% (95% CI 34.4% to 48.2%) for identifying drug-seeking behavior. After exposure to prescription drug monitoring program data, emergency providers changed plans to prescribe opioids at discharge in 9.5% of cases (95% CI 7.3% to 12.2%), with 6.5% of patients (n=35) receiving opioids not previously planned and 3.0% (n=16) no longer receiving opioids. Predictors for drug-seeking behavior by prescription drug monitoring program criteria were patient requests opioid medications by name (odds ratio [OR] 1.91; 95% CI 1.13 to 3.23), multiple visits for same complaint (OR 2.5; 95% CI 1.49 to 4.18), suspicious history (OR 1.88; 95% CI 1.1 to 3.19), symptoms out of proportion to examination (OR 1.83; 95% CI 1.1 to 3.03), and hospital site (OR 3.1; 95% CI 1.76 to 5.44).

CONCLUSION

Emergency providers had fair agreement with objective criteria from the prescription drug monitoring program in suspecting drug-seeking behavior. Program review changed management plans in a small number of cases. Multiple clinical factors were predictive of drug-seeking behavior.

How do emergency physicians interpret prescription narcotic history when assessing patients presenting to the emergency department with pain?

CONTEXT

Narcotics are frequently prescribed in the Emergency Department (ED) and are increasingly abused. Prescription monitoring programs affect prescribing by Emergency Physicians (EPs), yet little is known on how EPs interpret prescription records.

OBJECTIVE

To assess how EPs interpret prescription narcotic history for patients in the ED with painful conditions. DESIGN/MAIN Outcome Measures: We created an anonymous survey of EPs consisting of fictitious cases of patients presenting to the ED with back pain. For each case, we provided a prescription history that varied in the number of narcotic prescriptions, prescribing physicians, and narcotic potency. Respondents rated how likely they thought each patient was drug seeking, and how likely they thought that the prescription history would change their prescribing behavior. We calculated κ values to evaluate interobserver reliability of physician assessment of drug-seeking behavior.

RESULTS

We collected 59 responses (response rate = 70%). Respondents most suspected drug seeking in patients with greater than 6 prescriptions per month or greater than 6 prescribing physicians in 2 months. Medication potency did not affect physician interpretation of drug seeking. Respondents reported that access to a prescription history would change their prescribing practice in all cases. κ values for assessment of drug seeking demonstrated moderate agreement.

CONCLUSION

A greater number of prescriptions and a greater number of prescribing physicians in the prescription record increased suspicion for drug seeking. EPs believed that access to prescription history would change their prescribing behavior, yet interobserver reliability in the assessment of drug seeking was moderate.

How Frequently are "Classic" Drug-Seeking Behaviors Used by Drug-Seeking Patients in the Emergency Department?

Introduction:

Drug-seeking behavior (DSB) in the emergency department (ED) is a very common problem, yet there has been little quantitative study to date of such behavior. The goal of this study was to assess the frequency with which drug seeking patients in the ED use classic drug seeking behaviors to obtain prescription medication.

Methods:

We performed a retrospective chart review on patients in an ED case management program for DSB. We reviewed all visits by patients in the program that occurred during a 1-year period, and recorded the frequency of the following behaviors: complaining of headache, complaining of back pain, complaining of dental pain, requesting medication by name, requesting a refill of medication, reporting medications as having been lost or stolen, reporting 10/10 pain, reporting greater than 10/10 pain, reporting being out of medication, and requesting medication parenterally. These behaviors were chosen because they are described as “classic” for DSB in the existing literature.

Results:

We studied 178 patients from the case management program, who made 2,486 visits in 1 year. The frequency of each behavior was: headache 21.7%, back pain 20.8%, dental pain 1.8%, medication by name 15.2%, requesting refill 7.0%, lost or stolen medication 0.6%, pain 10/10 29.1%, pain greater than 10/10 1.8%, out of medication 9.5%, and requesting parenteral medication 4.3%. Patients averaged 1.1 behaviors per visit.

Conclusion:

Drug-seeking patients appear to exhibit “classically” described drug-seeking behaviors with only low to moderate frequency. Reliance on historical features may be inadequate when trying to assess whether or not a patient is drug-seeking.

Intravenous Opioids for Severe Acute Pain in the Emergency Department

Objective:

To review clinical trials of intravenous opioids for severe acute pain in the emergency department (ED) and to provide an approach for optimization of therapy.

Data Sources:

Articles were identified through a search of Ovid/MEDLINE (1948-August 2010), PubMed (1950-August 2010), Cochrane Central Register of Controlled Trials (1991-August 2010), and Google Scholar (1900-August 2010). The search terms used were pain, opioid, and emergency department.

Study Selection and Data Extraction:

The search was limited by age group to adults and by publication type to comparative studies. Studies comparing routes of administration other than intravenous or using non-opioid comparators were not included. Bibliographies of all retrieved articles were reviewed to obtain additional articles. The focus of the search was to identify original research that compared intravenous opioids used for treatment of severe acute pain for adults in the ED.

Data Synthesis:

At equipotent doses, randomized controlled trials have not shown clinically significant differences in analgesic response or adverse effects between opioids studied. Single opioid doses less than 0.1 mg/kg of intravenous morphine, 0.015 mg/kg of intravenous hydromorphone, or 1 μg/kg of intravenous fentanyl are likely to be inadequate for severe, acute pain and the need for additional doses should be anticipated. In none of the randomized controlled trials did patients develop respiratory depression requiring the use of naloxone. Future trials could investigate the safety and efficacy of higher doses of opioids. Implementation of nurse-initiated and patient-driven pain management protocols for opioids in the ED has shown improvements in timely provision of appropriate analgesics and has resulted in better pain reduction.

Conclusions:

Currently, intravenous administration of opioids for severe acute pain in the ED appears to be inadequate. Opioid doses in the ED should be high enough to provide adequate analgesia without additional risk to the patient. EDs could implement institution-specific protocols to standardize the management of pain.

Chronic pain management in the emergency department: a survey of attitudes and beliefs

OBJECTIVE

The emergency department (ED) can be a particularly challenging environment in which to offer care for chronic pain. This study tried to determine if beliefs held by patients and providers about noncancer-related chronic pain affect evaluation and management of pain in ED.

INTERVENTION

We surveyed 103 patients presenting to the ED with chronic pain, 34 ED physicians, and 44 ED nurses to assess the influence of 15 possible barriers to managing chronic pain in the ED.

RESULTS

Patients were significantly more likely than providers to believe that their pain had to have a diagnosed physical component to be treated. Providers were significantly more likely than patients to believe that patients came to the ED because they lacked a primary care physician. All agreed that chronic pain treatment was not a priority in the ED and the potential for addiction, dependence, diversion, and forged prescriptions was low.

CONCLUSIONS

Patients in chronic pain may need to be reassured that their pain will be treated, even in the absence of objective signs or magnified symptoms. Providers may wrongly believe that lack of a primary care physician brings these patients to the ED. Providers and patients appear to believe that treating chronic pain in the ED has a low priority. Both groups may underestimate the problems inherent with prescribing opioids in this setting.

A validation of self-reported substance use with biochemical testing among patients presenting to the emergency department seeking treatment for backache, headache, and toothache

PURPOSE

This study tests the validity of self-reported illicit substance use against biochemical testing among Emergency Department (ED) patients seeking treatment with narcotics for backache, headache, and toothache and to characterize patients who provide false reports.

METHODS

Retrospective chart review comparing the self-reported drug use history obtained during an ED visit during a six-year period (1995-2001) with the results of a biochemical drug screen obtained the same day.

RESULTS

248 patients met screening criteria, 79 (32%) of whom tested positive for unclaimed "drugs of abuse." Patients with a history of "drug abuse" and chronic pain were significantly more likely to test positive for unclaimed drugs than were their counterparts (p=.05 and p<.0001, respectively). No significant difference was found in comparing those with and without multiple ED visits or those requesting a specific narcotic.

CONCLUSION

Self-reported drug use is unreliable in this ED subpopulation. When this knowledge is critical for patient care, biochemical testing may be indicated.

Fiscal analysis of emergency admissions for chronic back pain: a pilot study from a Maine hospital

OBJECTIVE

Our study was designed to document fiscal data for emergency department admissions for acute exacerbation of chronic back pain.

DESIGN

This was a 12-month retrospective, descriptive study.

SETTING

The two emergency facilities operated by the Maine General Medical Center in central Maine provided the study data.

PATIENTS

We collected fiscal data for patients with emergency admissions for acute exacerbation of chronic nonmalignant back pain (International Classification of Disease code 724.1). Data were limited to patients with the top three of five Current Procedural Terminology (CPT) codes visits (99283-99285) for emergency department, indicating problems of moderate to high complexity. Records with event codes (E codes) for trauma and/or malignant disease were excluded.

OUTCOME MEASURES

We totaled charges for physician and provider services, laboratory tests, imaging studies, medications, and other billable items.

RESULTS

Of 1,397 emergency department visits for acute exacerbation of chronic back pain logged over the 12-month study for all five CPT codes, 1,039 visits were tagged with the three highest codes; 30% were multiple visits. Mean charges per visit ranged from $399 for CPT code 99283 to $1,943 for code 99285. While only 3% of the patients (N=46) were seen three or more times, they accounted for 12.4% of the total charges.

CONCLUSIONS

Emergency department care may be a costly venue for the management of chronic back pain. Because most patients obtain only short-term relief, they are likely to continue seeking urgent care intermittently until effective long-term pain management is widely available and reimbursable on an outpatient basis.

Effectiveness of nonnarcotic protocol for the treatment of acute exacerbations of chronic nonmalignant pain

INTRODUCTION

Emergency department (ED) overcrowding is a growing problem. Frequent visits for chronic pain are a significant subset of patients. The use of narcotics in these patients is controversial. The purpose of this study was to test a strict nonnarcotic protocol in reducing need for and number of ED visits for chronic pain while at the same time addressing their pain.

METHODS

This was a prospective observational study. We identified patients with more than 10 ED visits for exacerbations of chronic nonmalignant pain in the last 12 calendar months. Each patient and their physician were sent letters informing them of the concern of frequent ED use and the use of opioids for rescue therapy. Furthermore, the patient would receive medications other than narcotics in subsequent ED visits, and follow-up with the primary physician for alternatives was encouraged. Use of the ED for pain-related visits was then monitored for the subsequent 12-month period. Clinic use and outpatient medication uses were also monitored.

RESULTS

Fifteen patients were identified for the initial study. These patients averaged 19 ED visits per 12 months for pain-related complaints. All of them had a regular physician. After notification of the new protocol, ED visits decreased to an average of 2 visits per year. Visits with primary care physicians also dropped from an average of 19 visits per year to 7 visits. There were 7 patients who had been weaned off narcotic medications, 4 who had been converted to methadone maintenance, and 1 who had been switched to a fentanyl patch.

CONCLUSIONS

Initiation of a strict nonnarcotic protocol for treatment of patients with frequent ED visits for chronic nonmalignant pain results in a significant drop in the number of pain-related visits to the ED. These visits were not offset by a significant elevation in the number of clinic visits for pain complaints, and many were weaned off narcotics. Nonnarcotic protocols for acute exacerbations of chronic nonmalignant pain may be a viable alternative for reducing frequent pain-related ED visits in a select population.

Establishing an emergency department pain management system

Any ED system for the management of pain in the ED should consider the following: assessment of pain including mandatory use of some assessment tool, a guideline for treatment of pain, communication with other members of the health care team, assessment tools, program monitoring, and a continuous quality assurance program. The treatment guideline should consider acute versus chronic pain, potential medication tolerance, concurrent anxiety and psychiatric issues, special populations, and disease-specific conditions.

The drug-seeking patient in the emergency room

Drug-seeking patients include recreational drug abusers, addicts whose dependence occurred through abuse or the injudicious prescription of narcotics, and pseudoaddicts who have chronic pain that has not been appropriately managed. Opioids produce euphoria in some patients, providing the motivation for abuse, which can be detrimental even with occasional use. Even in the absence of overt euphoria, opioids are highly self-reinforcing and can be problematic in a large number of patients, requiring that acute care physicians exercise caution in whom they are administered. Habitual patient files, narcotic contracts, pain management letters, and patient tracking and management programs can be used for the benefit of both drug seeking-patients and chronic pain patients. For many patients, drug-seekers and chronic pain patients alike, withholding opioids may be an important part of their long-term management. For others, long-acting opioids such as long-acting morphine or methadone are a reasonable option.

Management of Chronic Pain in the Acute Care Setting

Chronic nonmalignant pain requires evaluation and treatment different from acute pain. The pathophysiology is different, and there is commonly some degree of psychosocial dysfunction. Opioids tend to be much less effective as analgesics for chronic pain, and may increase the sensitivity to pain when given long-term. Because they are self-reinforcing, opioids may be sought and be reported to improve chronic pain, even when they may make the condition worse over time. There are many effective alternatives to opioids for the treatment of chronic pain, but their use is complicated and may require considerable time and effort to determine which ones work. Patients, particularly those who have already been prescribed opioids, may resist these alternatives. An extensive physical and psychosocial evaluation is required in the management of chronic pain, which is difficult if not impossible to achieve in the emergency or urgent care settings. Consequently, emergency and urgent care physicians should work closely with the patient's pain management specialist or personal physician. Systems should be set up in advance to identify those patients whose frequent use of acute care services for obtaining opioids may be compromising their long-term management, putting themselves at risk for psychological and tolerance-induced adverse effects of frequent opioid use. Opioids may be used in carefully selected patients in consultation with their pain management specialist or personal physician, but care must be exercised not to initiate or exacerbate psychological or tolerance-related complications of chronic pain.

Chronic pain and aberrant drug-related behavior in the emergency department

Pain is the single most common reason patients seek care in the emergency department. Given the prevalence of pain as a presenting complaint, one might expect emergency physicians to assign its treatment a high priority; however, pain is often seemingly invisible to the emergency physician. Multiple research studies have documented that the undertreatment of pain, or oligoanalgesia, is a frequent occurrence. Pain that is not acknowledged and managed appropriately causes dissatisfaction with medical care, hostility toward the physician, unscheduled returns to the emergency department, delayed return to full function, and potentially, an increased risk of litigation. Failure to recognize and treat pain may result in anxiety, depression, sleep disturbances, increased oxygen demands with the potential for end organ ischemia, and decreased movement with an increased risk of venous thrombosis.

Inadequate analgesia in emergency medicine

Review of emergency department pain management practices demonstrates pain treatment inconsistency and inadequacy that extends across all demographic groups. This inconsistency and inadequacy appears to stem from a multitude of potentially remediable practical and attitudinal barriers that include (1) a lack of educational emphasis on pain management practices in nursing and medical school curricula and postgraduate training programs; (2) inadequate or nonexistent clinical quality management programs that evaluate pain management; (3) a paucity of rigorous studies of populations with special needs that improve pain management in the emergency department, particularly in geriatric and pediatric patients; (4) clinicians' attitudes toward opioid analgesics that result in inappropriate diagnosis of drug-seeking behavior and inappropriate concern about addiction, even in patients who have obvious acutely painful conditions and request pain relief; (5) inappropriate concerns about the safety of opioids compared with nonsteroidal anti-inflammatory drugs that result in their underuse (opiophobia); (6) unappreciated cultural and sex differences in pain reporting by patients and interpretation of pain reporting by providers; and (7) bias and disbelief of pain reporting according to racial and ethnic stereotyping. This article reviews the literature that describes the prevalence and roots of oligoanalgesia in emergency medicine. It also discusses the regulatory efforts to address the problem and their effect on attitudes within the legal community.

Repeat patients to the emergency department in a statewide database

OBJECTIVES

To describe the epidemiology of repeat users of the emergency department (ED) using a statewide database.

METHODS

Probabilistic linkage was used to convert three years of statewide ED visit data into a longitudinal, patient-based data set. Patients were classified as single, repeat (at least two visits within three years), or serial (four or more visits within a 365-day period) users of the ED. Serial patients were further stratified by the number of EDs attended. Descriptive statistics were used to assess differences between patient types.

RESULTS

There were 1,370,607 separate visits associated with 780,074 patients from 1996 to 1998. While repeat and serial patients represented 33% of the patients, they accounted for 62% of the ED visits during the study period. Repeat and serial patients were younger and had smaller median ED charges per visit than single-use patients. Serial patients attending five or more EDs were more likely to be coded as self-pay than other serial patients. Diagnosis codes relating to sprains, back problems, and headaches were prevalent among serial patients who visited five or more EDs. Approximately 30% of serial patients during the first year remained serial patients in the second year.

CONCLUSIONS

Due to the high turnover in serial patients, control groups in future studies are necessary to evaluate interventions aimed at decreasing serial ED use. The likelihood of serial ED users to use multiple EDs indicates that those studying serial ED use should collect data from multiple EDs.

Pain management in the ED

Recent regulatory and legal scrutiny has raised concerns about the over- and undertreatment of pain in the hospital. This debate stems from either the overly aggressive approach to the management of pain with opioids or, alternatively, to the barriers preventing the appropriate prescribing of these medications. The media attention on diversion of controlled substances for illicit purposes has intensified this debate, highlighting the possible overuse of these medications in the treatment of nonmalignant pain. Because pain is a highly common presenting complaint in the ED, EPs are pivotal players in these controversies. Accordingly, they must apprise themselves of pain management skills and continue to help those in need of appropriate medications while thwarting inappropriate prescribing. This review offers a synopsis of the pitfalls associated with ED pain management and provides recommendations for selected conditions.

Keeping lists and naming names: habitual patient files for suspected nontherapeutic drug-seeking patients

Emergency departments commonly keep files of patients who are suspected of frequently visiting them and fabricating symptoms to obtain prescription drugs, usually opioids, for nontherapeutic purposes. Such files have previously been given names such as "frequent flyer file," "repeater log," "kook-book," "problem patient file," "patient alert list," or "special needs file." Little has been written about the ethical, legal, and regulatory considerations that should be taken into account when establishing, maintaining, and using such files. This article explores these issues. The term "habitual patient files" is proposed because it is descriptive without being judgmental.

Pain responses in methadone-maintained opioid abusers

Providing pain management for known opioid abusers is a challenging clinical task, in part because little is known about their pain experience and analgesic requirements. This study was designed to describe pain tolerance and analgesic response in a sample of opioid addicts stabilized in methadone-maintenance (MM) treatment (n = 60) in comparison to matched nondependent control subjects (n = 60). By using a placebo-controlled, two-way factorial design, tolerance to cold-pressor (CP) pain was examined, both before and after oral administration of therapeutic doses of common opioid (hydromorphone 2 mg) and nonsteroidal anti-inflammatory (ketorolac 10 mg) analgesic agents. Results showed that MM individuals were significantly less tolerant of CP pain than control subjects, replicating previous work. Analgesic effects were significant neither for medication nor group. These data indicate that MM opioid abusers represent a pain-intolerant subset of clinical patients. Their complaints of pain should be evaluated seriously and managed aggressively.