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Peluso H, Mujadzic H, Abougergi MS, Mujadzic T, Azefor TB, Caffrey J. Opioid dependence and treatment outcomes among patients with burn injury. Burns 2022; 48:774-784. [PMID: 34922783 DOI: 10.1016/j.burns.2021.07.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 06/24/2021] [Accepted: 07/22/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Patients with burn injuries cause significant healthcare economic burden, often utilising extra-hospital resources, caregiving, and specialized care. METHODS We present a retrospective cohort analysis of the hospitalized patients in the USA with a primary diagnosis of burn injury. Opioid dependence was identified using ICD-10 CM codes. The 30-day all-cause readmission rate was the main outcome while secondary outcomes were inhospital mortality rate, resource utilization which included hospital length of stay, total hospitalization costs and charges and surgical procedures for burn injury treatment as well as the most important five principal diagnoses for admission and readmission. RESULTS Out of 22,348 patients included in the study, 597 had opioid dependence. Older patients (43 years, range: 38.6-47.2 years) as well as males (70.8%) were more likely to be opioid dependent. Opioid dependence was associated with higher 30-day readmission rates (aOR: 1.83, 95% confidence interval (CI): 1.30-2.57, p-value: <0.01), higher total hospitalization costs (aMD: $14,981, CI: $3820-$26,142, p-value: 0.01), total hospitalization charges (aMD: $47,078, CI: -$5093 to $89,063, p-value: 0.03), and a shorter mean length of stay (aMD: 5.13 days, CI: 2.60-7.66, p-value: <0.01). However, patients with and without opioid dependence had similar in-hospital mortality rates (aOR: 0.27, CI: 0.06-1.28, p-value: 0.10). CONCLUSION We are the first to our knowledge to report the association of treatment outcomes and opioid dependence in patients hospitalized at the national level with a burn injury. We show that there were higher 30-day all-cause readmission rates and in-hospital resource utilization among patients with opioid-dependence.
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Affiliation(s)
- Heather Peluso
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Temple University Hospital and Lewis Katz School of Medicine, Philadelphia, PA, USA; Catalyst Medical Consulting, 722 Elmbrook Drive, Simpsonville, SC 29681, USA.
| | - Hata Mujadzic
- Department of Internal Medicine, Prisma Health Midlands, 5 Medical Park Road, Columbia, SC 29203, USA.
| | - Marwan S Abougergi
- Catalyst Medical Consulting, 722 Elmbrook Drive, Simpsonville, SC 29681, USA; Division of Gastroenterology, Department of Internal Medicine, Prisma Health Midlands, 5 Medical Park Road, Columbia, SC 29203, USA.
| | - Tariq Mujadzic
- Department of Surgery, Division of Plastic Surgery, Prisma Health Midlands, 5 Medical Park Road, Columbia, SC 29203, USA.
| | - Tangwan B Azefor
- Department of Anesthesia & Critical Care Medicine, Johns Hopkins Bayview Medical Center, 4940 Eastern Ave, Baltimore, MD 21224, USA.
| | - Julie Caffrey
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University Medical Center, Burn Unit, Bayview Campus, 4940 Eastern Ave, Baltimore, MD 21224, USA.
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Archibald P, Subramoney K, Beydoun HA, Harris CM. The impact of obesity in patients hospitalized with opioid/opiate overdose. Subst Abus 2022; 43:253-259. [PMID: 34214401 PMCID: PMC9629180 DOI: 10.1080/08897077.2021.1941505] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background: Although a direct link between opioid use in obese patients and risk of overdose has not been established, obesity is highly associated with higher risk for opioid/opiate overdose. Evidence for clinical impact of obesity on patients with opioid/opiate overdose is scarce. The aim of this study was to determine effects of obesity on health-care outcomes and mortality trends in hospitalized patients who presented with opioid/opiate overdose in the United States between 2010 and 2014. Design: Multivariate logistic and linear regression analysis compared clinical outcomes and hospital resource utilization between obese and nonobese patients. Trend analysis of in-hospital mortality was also analyzed. Setting: United States. Participants: 302,863 adults ≥ 18 years and hospitalized with a principle diagnosis of opioid/opiate overdoses between 2010 and 2014. Measurements: Primary measurement was in-hospital mortality. Secondary measurements included respiratory failure, cardiogenic shock, mechanical ventilations/intubations, hospital charges, and length of stay. Findings: Prevalence for in-hospital mortality was lower in patients with obesity (2.2% vs 2.9%). Obese patients had higher adjusted odds for respiratory failure (aOR = 1.7, [(CI) 1.6-1.8]) and mechanical ventilation/intubation (aOR = 1.17, [(CI) 1.10-1.2]). They also had longer length of stays (aMD = 0.4 days, [(CI) 0.25-0.58 days] and higher total hospital charges (aMD = $5,561, [(CI) $3,638-$7,483]. Trends of in-hospital mortality for patients with obesity did not significantly increase (2.1% in 2010 to 2.4% in 2014, p trend = 0.37), but significantly increased for obese patients (2.4% in 2010 to 3.4% in 2014; p trend <0.01). Conclusions: Prevalence and trends of mortality were lower in patients with obesity hospitalized for opiate/opioid overdose compared to those without obesity between 2010 and 2014 in the United States.
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Affiliation(s)
- Paul Archibald
- School of Health Sciences, Department of Social Work, City University of New York, United States of America
| | - Kavitha Subramoney
- Department of Medicine, Division of Hospital Medicine, University of Indiana, United States of America
| | - Hind A. Beydoun
- Department of Research Programs, Fort Belvoir Community Hospital, Fort Belvoir, Virginia, United States of America
| | - Ché Matthew Harris
- Department of General Internal Medicine, Johns Hopkins School of Medicine, Division of Hospital Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, United States of America
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The association of gender and persistent opioid use following an acute pain event: A retrospective population based study of renal colic. PLoS One 2021; 16:e0256582. [PMID: 34437612 PMCID: PMC8389463 DOI: 10.1371/journal.pone.0256582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 08/10/2021] [Indexed: 11/19/2022] Open
Abstract
Introduction This study aims to explore gender-related differences in persistent opioid use following an acute pain episode and evaluate potential explanatory variables. Methods This retrospective population-based study using administrative databases included all opioid-naïve patients in Ontario with renal colic between 2013 and 2017. The primary outcome was to assess any association between persistent opioid use at 3–6 months by gender. Key confounding covariates and explanatory variables examined included both care- and patient-related factors, specifically past evidence of mental health diagnoses. Results The dataset of 64,240 males and 37,656 females demonstrated that 8.7% of males and 9.6% of females had evidence of persistent opioid use 3–6 months after presentation (OR 1.11, 95% CI 1.05, 1.17). Females had a higher incidence of mental health services utilization [44.5% vs 29.6% (p<0.001)] and were more likely to be on a provincial disability program [5.1% vs 3.8% (p<0.001)]. Age, income quintile, mental health diagnoses and dose of opioid prescribed were associated with the primary outcome in both genders. On adjusted analysis for multiple confounding and explanatory variables, females were still more likely than males to demonstrate persistent opioid use (OR 1.07, 95% CI 1.01, 1.13) with even more pronounced associations at 1–2 years. Interpretation After controlling for key covariates, females are at slightly higher risk of demonstrating long term opioid use following an episode of renal colic. Evidence of prior mental health service utilization and acute colic care did not appear to significantly explain these observations.
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Huntley K, Einstein E, Postma T, Thomas A, Ling S, Compton W. Advancing emergency department-initiated buprenorphine. J Am Coll Emerg Physicians Open 2021; 2:e12451. [PMID: 34179878 PMCID: PMC8208651 DOI: 10.1002/emp2.12451] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 04/01/2021] [Accepted: 04/23/2021] [Indexed: 01/10/2023] Open
Abstract
Opioids are the main driver of drug overdose deaths in the United States, and there has been a marked increase in opioid-related overdoses during the COVID-19 public health emergency. Many emergency departments (EDs) across the country are implementing ED-initiated buprenorphine programs, and this is a method to address and prevent opioid overdoses. Resources are available to overcome barriers and take action.
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Affiliation(s)
- Kristen Huntley
- Center for the Clinical Trials NetworkThe National Institute on Drug AbuseBethesdaMarylandUSA
| | - Emily Einstein
- Office of Science Policy and CommunicationsThe National Institute on Drug AbuseBethesdaMarylandUSA
| | - Terri Postma
- Center for MedicareCenters for Medicare & Medicaid ServicesBaltimoreMarylandUSA
| | - Anita Thomas
- Center for Clinical Standards and QualityCenters for Medicare & Medicaid ServicesBaltimoreMarylandUSA
| | - Shari Ling
- Center for Clinical Standards and QualityCenters for Medicare & Medicaid ServicesBaltimoreMarylandUSA
| | - Wilson Compton
- Office of the DirectorThe National Institute on Drug AbuseBethesdaMarylandUSA
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5
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Naloxone provision to emergency department patients recognized as high-risk for opioid use disorder. Am J Emerg Med 2020; 40:173-176. [PMID: 33243535 DOI: 10.1016/j.ajem.2020.10.061] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 10/19/2020] [Accepted: 10/29/2020] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Patients with opioid use disorder (OUD) are at increased risk for overdose and death. Clinical practice guidelines and professional organization policy statements recommend providing naloxone to patients at risk for overdose. We sought to characterize fidelity to naloxone practice recommendations in a cohort of Emergency Department (ED) patients in whom opioid use disorder was suspected by the treating physician. METHODS This single-center cross-sectional study evaluated electronic health records from an urban academic ED with 73,000 annual encounters in a region with a high prevalence of OUD. Patients ≥18 years old with encounters from January 1, 2018 to November 30, 2019 were included if discharged from the ED and either administered buprenorphine in the ED or referred to outpatient substance use treatment. The primary outcome measure was the percentage of included patients provided naloxone (take-home or prescription). We used random effects multivariable logistic regression (accounting for multiple patient encounters) to estimate the odds ratio (OR) for receiving naloxone. RESULTS Of 1036 eligible patient encounters, 320 resulted in naloxone provision (30.9%, 95% CI: 28.1-33.8). Naloxone provision occurred for 33.6% (95% CI 30.5-36.7) of 900 patients referred to outpatient substance use treatment without ED buprenorphine administration, 10.6% (95% CI 5.0-19.2) of 85 patients administered buprenorphine and not referred to outpatient substance use treatment, and 17.6% (95% CI 8.4-30.9) of 51 patients administered buprenorphine and referred to outpatient treatment. After controlling for age, sex, race, and prior provision of naloxone, the administration of buprenorphine was associated with a 94% lower odds (aOR = 0.06 [95% CI 0.011-0.33]) for naloxone provision compared to those only referred to outpatient treatment. CONCLUSION A majority of ED patients who received an intervention targeted at OUD, in an ED where take-home naloxone is freely available, did not receive either take-home naloxone or a prescription for naloxone at discharge. Patients receiving buprenorphine were less likely to receive naloxone than patients only referred to outpatient treatment. These data suggest barriers other than recognition of potential OUD and naloxone availability impact provision of naloxone and argue for a treatment "bundle" as a conceptual model for care of ED patients with suspected OUD.
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Hosier GW, McGregor T, Beiko D, Tasian GE, Booth C, Whitehead M, Siemens DR. Increased risk of new persistent opioid use in pediatric and young adult patients with kidney stones. Can Urol Assoc J 2020; 14:237-244. [PMID: 33626317 DOI: 10.5489/cuaj.6796] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Adolescents and young adults are a vulnerable patient population for development of substance use disorder. However, the long-term impact of opioid prescribing in young adult patients with renal colic is not known. Our objective was to describe rates of opioid prescription and identify risk factors for persistent opioid use in patients age 25 years or younger with renal colic from kidney stones. METHODS Using previously validated, linked administrative databases, we performed a population-based, retrospective cohort study of opioid-naive patients age 25 years or younger with renal colic between July 1, 2013 and September 30, 2017 in Ontario. All family practitioner, urgent care, and specialist visits in the province were captured. Our primary outcome was persistent opioid use, defined as filling a prescription for an opioid between 91 and 180 days after initial visit. Ontario uses a narcotic monitoring system, which captures all opioids dispensed in the province. RESULTS Of the 6962 patients identified, 56% were prescribed an opioid at presentation and 34% of those were dispensed more than 200 oral morphine equivalents. There was persistent opioid use in 313 (8.1%) patients who filled an initial opioid prescription. In adjusted analysis, those prescribed an opioid initially had a significantly higher risk of persistent opioid use (odds ratio [OR] 1.85; 95% confidence interval [CI] 1.50-2.29) and opioid overdose (OR 3.45; 1.08-11.04). There was a dose-dependent increase in risk of persistent opioid use with escalating initial opioid dose. History of mental illness (OR 1.32; 1.02-1.71) and need for surgery (OR 1.71; 1.24-2.34) were also associated with persistent opioid use. CONCLUSIONS Among patients with kidney stones age 25 years or younger, filling an opioid prescription after presentation is associated with an increased risk of persistent opioid use 3-6 months later and a higher risk of serious long-term complications, such as opioid overdose.
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Affiliation(s)
| | | | - Darren Beiko
- Department of Urology, Queen's University, Kingston, ON
| | - Gregory E Tasian
- Department of Pediatric Urology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Christopher Booth
- Department of Oncology, Queen's University, Kingston, ON, Canada.,Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Queen's University, Kingston, ON, Canada
| | - Marlo Whitehead
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Queen's University, Kingston, ON, Canada
| | - D Robert Siemens
- Department of Urology, Queen's University, Kingston, ON.,Department of Oncology, Queen's University, Kingston, ON, Canada
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Usmani B, Latif A, Amarasekera S, Mukhtar S, Iftikhar M, Kherani S, Sepah YJ, Raghavan D, Smith WD, Jhanji V, Dansingani KK, Shah SMA. Eye-Related Emergency Department Visits and The Opioid Epidemic: a 10-Year Analysis. Ophthalmic Epidemiol 2020; 27:300-309. [PMID: 32223491 DOI: 10.1080/09286586.2020.1744165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE To describe the epidemiology of Emergency Department (ED) visits related to opioid abuse with primary ophthalmic diagnoses in the United States (US). METHODS This retrospective cross-sectional study used National ED Sample (NEDS) (2006-2015), a representative sample of all US EDs, to analyze and compare the epidemiology of primary ophthalmic diagnoses in opioid abusers and a control group of non-opioid users. National incidence and descriptive statistics were calculated for demographics and prevalent diagnoses. Multivariable logistic regression was used to compare outcomes between primary ophthalmic diagnoses in opioid and non-opioid abusers. RESULTS An estimated 10,617 visits had a primary ophthalmic diagnosis and an accompanying opioid abuse diagnosis, and the incidence increased from 0.2 in 2006 to 0.6 per 100,000 US population in 2015. Opioid abuse group had more adults (6,747:63.5%) and middle-aged (3,361:31.7%) patients, while in controls adults (7,905,003:40.4%) and children (4,068,534:20.8%) were affected more. Leading etiologies were similar: traumatic and infectious etiologies were most common; however, opioid abuse patients had more severe ophthalmic diagnoses such as orbital fractures (8.4%), orbital cellulitis (7.4%), globe injury (3.4%) and endophthalmitis (3.2%) compared to controls. Patients in the opioid abuse group were also more likely to be admitted (adjusted Odds Ratio [aOR], 28.38 [95% CI, 24.50-32.87]). CONCLUSIONS In the era of opioid crisis, an increase in ED visits with ophthalmic complaints is seen, with increasing direct and indirect costs on the healthcare system. More research is needed to establish causality and devise strategies to lower this burden.
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Affiliation(s)
- Bushra Usmani
- Department of Ophthalmology, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania, USA
| | - Asad Latif
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine , Baltimore, Maryland, USA
| | - Sohani Amarasekera
- Department of Ophthalmology, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania, USA
| | - Sabrina Mukhtar
- Department of Ophthalmology, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania, USA
| | - Mustafa Iftikhar
- Wilmer Eye Institute, Johns Hopkins University School of Medicine , Baltimore, Maryland, USA
| | - Saleema Kherani
- Wilmer Eye Institute, Johns Hopkins University School of Medicine , Baltimore, Maryland, USA
| | - Yasir J Sepah
- Byers Eye Institute, Stanford University , Palo Alto, California, USA
| | - Deepta Raghavan
- Department of Ophthalmology, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania, USA
| | - William D Smith
- Department of Ophthalmology, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania, USA
| | - Vishal Jhanji
- Department of Ophthalmology, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania, USA
| | - Kunal K Dansingani
- Department of Ophthalmology, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania, USA
| | - Syed M A Shah
- Department of Ophthalmology, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania, USA
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Abstract
This paper is the fortieth consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2017 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, CUNY, 65-30 Kissena Blvd., Flushing, NY, 11367, United States.
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9
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Wagner KD, Oman RF, Smith KP, Harding RW, Dawkins AD, Lu M, Woodard S, Berry MN, Roget NA. “Another tool for the tool box? I'll take it!”: Feasibility and acceptability of mobile recovery outreach teams (MROT) for opioid overdose patients in the emergency room. J Subst Abuse Treat 2020; 108:95-103. [DOI: 10.1016/j.jsat.2019.04.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 04/24/2019] [Accepted: 04/26/2019] [Indexed: 10/26/2022]
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10
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Krawczyk N, Eisenberg M, Schneider KE, Richards TM, Lyons BC, Jackson K, Ferris L, Weiner JP, Saloner B. Predictors of Overdose Death Among High-Risk Emergency Department Patients With Substance-Related Encounters: A Data Linkage Cohort Study. Ann Emerg Med 2020; 75:1-12. [PMID: 31515181 PMCID: PMC6928412 DOI: 10.1016/j.annemergmed.2019.07.014] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 05/22/2019] [Accepted: 07/05/2019] [Indexed: 10/26/2022]
Abstract
STUDY OBJECTIVE Persons with substance use disorders frequently utilize emergency department (ED) services, creating an opportunity for intervention and referral to addiction treatment and harm-reduction services. However, EDs may not have the appropriate tools to distinguish which patients are at greatest risk for negative outcomes. We link hospital ED and medical examiner mortality databases in one state to identify individual-level risk factors associated with overdose death among ED patients with substance-related encounters. METHODS This retrospective cohort study linked Maryland statewide ED hospital claims records for adults with nonfatal overdose or substance use disorder encounters in 2014 to 2015 with medical examiner mortality records in 2015 to 2016. Logistic regression was used to identify factors in hospital records associated with risk of opioid overdose death. Predicted probabilities for overdose death were calculated for hypothetical patients with different combinations of overdose and substance use diagnostic histories. RESULTS A total of 139,252 patients had substance-related ED encounters in 2014 to 2015. Of these patients, 963 later experienced an opioid overdose death, indicating a case fatality rate of 69.2 per 10,000 patients, 6 times higher than that of patients who used the ED for any cause. Factors most strongly associated with death included having both an opioid and another substance use disorder (adjusted odds ratio 2.88; 95% confidence interval 2.04 to 4.07), having greater than or equal to 3 previous nonfatal overdoses (adjusted odds ratio 2.89; 95% confidence interval 1.54 to 5.43), and having a previous nonfatal overdose involving heroin (adjusted odds ratio 2.24; 95% confidence interval 1.64 to 3.05). CONCLUSION These results highlight important differences in overdose risk among patients receiving care in EDs for substance-related conditions. The findings demonstrate the potential utility of incorporating routine data from patient records to assess risk of future negative outcomes and identify primary targets for initiation and linkage to lifesaving care.
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Affiliation(s)
- Noa Krawczyk
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
| | - Matthew Eisenberg
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Kristin E Schneider
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Tom M Richards
- Johns Hopkins Center for Population and Health and Information Technology, Baltimore, MD
| | - B Casey Lyons
- Behavioral Health Administration, Maryland Department of Health, Columbia, MD
| | - Kate Jackson
- Behavioral Health Administration, Maryland Department of Health, Columbia, MD
| | - Lindsey Ferris
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Chesapeake Regional Information System for Our Patients, Columbia, MD
| | - Jonathan P Weiner
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Johns Hopkins Center for Population and Health and Information Technology, Baltimore, MD
| | - Brendan Saloner
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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11
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Keen C, Young JT, Borschmann R, Kinner SA. Non-fatal drug overdose after release from prison: A prospective data linkage study. Drug Alcohol Depend 2020; 206:107707. [PMID: 31757517 DOI: 10.1016/j.drugalcdep.2019.107707] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 10/10/2019] [Accepted: 10/21/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Adults released from prison are at increased risk of poor health outcomes and preventable mortality, including from overdose. Non-fatal overdose (NFOD) is a strong predictor of future overdose and associated with considerable morbidity. This study aims to the determine the incidence, predictors and clinical characteristics of NFOD following release from prison. METHODS We used pre-release interview data collected for a randomised controlled trial in 2008-2010, and linked person-level, state-wide ambulance, emergency department, and hospital records, from a representative sample of 1307 adults incarcerated in Queensland, Australia. The incidence of NFOD following release from prison was calculated. A multivariate Andersen-Gill model was used to identify demographic, health, social, and criminal justice predictors of NFOD. RESULTS The crude incidence rate (IR) of NFOD was 47.6 (95%CI 41.1-55.0) per 1000 person-years and was highest in the first 14 days after release from prison (IR = 296 per 1000 person-years, 95%CI 206-426). In multivariate analyses, NFOD after release from prison was positively associated with a recent history of substance use disorder (SUD), dual diagnosis of mental illness and SUD, lifetime history of injecting drug use, lifetime history of NFOD, being dispensed benzodiazepines after release, a shorter index incarceration, and low perceived social support. The risk of NFOD was lower for people with high-risk alcohol use and while incarcerated. CONCLUSIONS Adults released from prison are at high risk of non-fatal overdose, particularly in the first 14 days after release. Providing coordinated transitional care between prison and the community is likely critical to reduce the risk of overdose.
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Affiliation(s)
- Claire Keen
- Justice Health Unit, Centre for Health Equity, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia.
| | - Jesse T Young
- Justice Health Unit, Centre for Health Equity, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia; Centre for Adolescent Health, Murdoch Children's Research Institute, Parkville, Victoria, Australia; School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia; National Drug Research Institute, Curtin University, Perth, Western Australia, Australia
| | - Rohan Borschmann
- Justice Health Unit, Centre for Health Equity, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia; Centre for Adolescent Health, Murdoch Children's Research Institute, Parkville, Victoria, Australia; Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK; Melbourne School of Psychological Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Stuart A Kinner
- Justice Health Unit, Centre for Health Equity, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia; Centre for Adolescent Health, Murdoch Children's Research Institute, Parkville, Victoria, Australia; Mater Research Institute-UQ, University of Queensland, Brisbane, Queensland, Australia; Griffith Criminology Institute, Griffith University, Brisbane, Queensland, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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12
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Peluso H, Cull JD, Abougergi MS. The Effect of Opioid Dependence on Firearm Injury Treatment Outcomes: A Nationwide Analysis. J Surg Res 2019; 247:241-250. [PMID: 31718813 DOI: 10.1016/j.jss.2019.10.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 08/28/2019] [Accepted: 10/05/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Both the opioid and gun violence epidemics are recurrent public health issues in the United States. We sought to determine the effect of opioid dependence on gunshot injury treatment outcomes. MATERIALS AND METHODS Using the 2016 National Readmission Database, patients were included if they had a principal diagnosis of firearm injury. Opioid dependence was identified using appropriate International Classification of Diseases, 10th Revision, Clinical Modification codes. The primary outcome was 30-day all-cause readmission. Secondary outcomes were in-hospital and 1-year mortality, resource utilization, and most common reasons for admission and readmission. Confounders were adjusted for using multivariate regression analysis. RESULTS A total of 31,303 patients were included, 695 of whom were opioid dependent. Opioid-dependent patients were more likely to be young (35.1 y, range: 33.4-36.7 y) and male (89.9%) compared with patients without opioid dependence. Opioid dependence was associated with higher 30-day readmission rates (adjusted odds ratio [aOR]: 1.67, 95% confidence interval [CI]: 1.12-2.50, P = 0.01). However, opioid dependence was associated with lower in-hospital (aOR: 0.16, CI: 0.07-0.38, P < 0.01) and 1-year (aOR: 0.15, CI: 0.06-0.38, P < 0.01) mortality, longer mean length of stay (adjusted mean difference [aMD]: 2.09 d, CI: 0.43-3.76, P = 0.03), and total hospitalization costs (aMD: $6,318, CI: $ 257-$12,380, P = 0.04). Both groups had similar total hospitalization charges (aMD: $$10,491, CI: -$12,618-$33,600, P-value = 0.37). CONCLUSIONS Opioid dependence leads to higher rates of 30-day readmission and resource utilization among patients with firearm injuries. However, the in-hospital and 1-year mortality rates are lower among patients with opioid dependence secondary to lower injury acuity.
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Affiliation(s)
| | - John D Cull
- Department of surgery, Greenville, South Carolina
| | - Marwan S Abougergi
- Catalyst Medical Consulting, Simpsonville, South Carolina; Division of Gastroenterology, Department of Internal Medicine, University of South Carolina School of Medicine, Columbia, South Carolina.
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Goedel WC, Marshall BDL, Samuels EA, Brinkman MG, Dettor D, Langdon KJ, Mahoney LA, Merchant RC, Nizami T, O'Toole GA, Ramsey SE, Yedinak JL, Beaudoin FL. Randomised clinical trial of an emergency department-based peer recovery support intervention to increase treatment uptake and reduce recurrent overdose among individuals at high risk for opioid overdose: study protocol for the navigator trial. BMJ Open 2019; 9:e032052. [PMID: 31719087 PMCID: PMC6858243 DOI: 10.1136/bmjopen-2019-032052] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 10/15/2019] [Accepted: 10/16/2019] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Effective approaches to increase engagement in treatment for opioid use disorder (OUD) and reduce the risk of recurrent overdose and death following emergency department (ED) presentation for opioid overdose remain unknown. As such, we aim to compare the effectiveness of behavioural interventions delivered in the ED by certified peer recovery support specialists relative to those delivered by licensed clinical social workers (LCSWs) in promoting OUD treatment uptake and reducing recurrent ED visits for opioid overdose. METHODS AND ANALYSIS Adult ED patients who are at high risk for opioid overdose (ie, are being treated for an opioid overdose or identified by the treating physician as having OUD) (n=650) will be recruited from two EDs in a single healthcare system in Providence, Rhode Island into a two-arm randomised trial with 18 months of follow-up postrandomisation. Eligible participants will be randomly assigned (1:1) in the ED to receive a behavioural intervention from a certified peer recovery support specialist or a behavioural intervention from an LCSW. The primary outcomes are engagement in formal OUD treatment within 30 days of the initial ED visit and recurrent ED visits for opioid overdose within 18 months of the initial ED visit, as measured through statewide administrative records. ETHICS AND DISSEMINATION This protocol was approved by the Rhode Island Hospital institutional review board (Approval Number: 212418). Data will be presented at national and international conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT03684681.
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Affiliation(s)
- William C Goedel
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Brandon D L Marshall
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Elizabeth A Samuels
- Department of Emergency Medicine, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
| | - Mark G Brinkman
- Department of Emergency Medicine, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Debra Dettor
- Anchor Recovery Community Center, Pawtucket, Rhode Island, USA
| | - Kirsten J Langdon
- Department of Psychiatry and Human Behavior, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
| | - Linda A Mahoney
- Rhode Island Department of Behavioral Healthcare Developmental Disabilities and Hospitals, Cranston, Rhode Island, USA
| | - Roland C Merchant
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
- Department of Emergency Medicine, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
| | - Tarek Nizami
- Department of Emergency Medicine, Rhode Island Hospital, Providence, Rhode Island, USA
| | | | - Susan E Ramsey
- Department of Psychiatry and Human Behavior, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
- Department of Medicine, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
| | - Jesse L Yedinak
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Francesca L Beaudoin
- Department of Emergency Medicine, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
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Hosier GW, McGregor T, Beiko D, Jaeger M, Booth C, Whitehead M, Siemens DR. Persistent Opioid Use Among Patients with Urolithiasis: A Population based Study. Eur Urol Focus 2019; 6:745-751. [PMID: 31515088 DOI: 10.1016/j.euf.2019.08.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 08/04/2019] [Accepted: 08/20/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Urolithiasis can result in acute, short-lived pain for which opioids are often prescribed. The risk of persistent opioid use following an initial presentation for urolithiasis is unknown. OBJECTIVE To describe rates of opioid prescription and identify risk factors for persistent opioid use among patients with urolithiasis. DESIGN, SETTING, AND PARTICIPANTS This was a population-based study of all patients diagnosed with urolithiasis in Ontario between 2013 and 2017 using administrative databases. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary outcome was persistent opioid use, defined as dispensing of opioids between 91 and 180 d after presentation. Multivariable logistic regression and Cox proportional hazard models were used to identify factors associated with outcomes. RESULTS AND LIMITATIONS Of 101 896 previously opioid-naïve patients, 66% were prescribed opioids at diagnosis and 41% of those were dispensed more than 200 oral morphine equivalents (OMEs). For those patients prescribed opioids, 9% had continued use. In adjusted analysis, the number of health care visits and having a stone intervention were associated with a higher risk of persistent opioid use (p< 0.0001). Total OME dispensed at presentation was highly associated with persistent use: for >300 OME the odds ratio (OR) was 1.59 (95% confidence interval [CI] 1.41-1.79). Among those who had an intervention, the number and type of procedure were also associated with persistent use: the OR for shockwave lithotripsy compared to ureteroscopy was 1.65 (95% CI 1.42-1.92). This study is limited by the accuracy of the diagnostic and procedural administrative codes available. CONCLUSIONS The majority of urolithiasis patients were prescribed opioids and 9% of previously opioid-naïve patients exhibited persistent opioid use 91-180 d after their initial urolithiasis visit. PATIENT SUMMARY In this study we found that 9% of patients prescribed opioids at presentation for kidney stones filled an additional prescription 3-6 mo later. Risk factors for this continued use included a higher dose of opioids prescribed in the initial period and the type of kidney stone surgery.
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Affiliation(s)
| | | | - Darren Beiko
- Department of Urology, Queen's University, Kingston, Canada
| | - Melanie Jaeger
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Canada
| | - Christopher Booth
- Department of Oncology, Queen's University, Kingston, Canada; Division of Cancer Care and Epidemiology, Cancer Research Institute, Queen's University, Kingston, Canada
| | - Marlo Whitehead
- Division of Cancer Care and Epidemiology, Cancer Research Institute, Queen's University, Kingston, Canada
| | - D Robert Siemens
- Department of Urology, Queen's University, Kingston, Canada; Department of Oncology, Queen's University, Kingston, Canada; Division of Cancer Care and Epidemiology, Cancer Research Institute, Queen's University, Kingston, Canada.
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O'Brien DC, Dabbs D, Dong K, Veugelers PJ, Hyshka E. Patient characteristics associated with being offered take home naloxone in a busy, urban emergency department: a retrospective chart review. BMC Health Serv Res 2019; 19:632. [PMID: 31488142 PMCID: PMC6727417 DOI: 10.1186/s12913-019-4469-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 08/27/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Overdose deaths can be prevented by distributing take home naloxone (THN) kits. The emergency department (ED) is an opportune setting for overdose prevention, as people who use opioids frequently present for emergency care, and those who have overdosed are at high risk for future overdose death. We evaluated the implementation of an ED-based THN program by measuring the extent to which THN was offered to patients presenting with opioid overdose. We analyzed whether some patients were less likely to be offered THN than others, to identify areas for program improvement. METHODS We retrospectively reviewed medical records from all ED visits between April 2016 and May 2017 with a primary diagnosis of opioid overdose at a large, urban tertiary hospital located in Alberta, Canada. A wide array of patient data was collected, including demographics, opioid intoxicants, prescription history, overdose severity, and whether a naloxone kit was offered and accepted. Multivariable analyses were used to identify patient characteristics and situational variables associated with being offered THN. RESULTS Among the 342 ED visits for opioid overdose, THN was offered in 49% (n = 168) of cases. Patients were more likely to be offered THN if they had been found unconscious (Adjusted Odds Ratio 3.70; 95% Confidence Interval [1.63, 8.37]), or if they had smoked or injected an illegal opioid (AOR 6.05 [2.15,17.0] and AOR 3.78 [1.32,10.9], respectively). In contrast, patients were less likely to be offered THN if they had a current prescription for opioids (AOR 0.41 [0.19, 0.88]), if they were admitted to the hospital (AOR 0.46 [0.22,0.97], or if they unexpectedly left the ED without treatment or before completing treatment (AOR 0.16 [0.22, 0.97). CONCLUSIONS In this real-world evaluation of an ED-based THN program, we observed that only half of patients with opioid overdose were offered THN. ED staff readily identify patients who use illegal opioids or experience a severe overdose as potentially benefitting from THN, but may miss others at high risk for future overdose. We recommend that hospital EDs provide additional guidance to staff to ensure that all eligible patients at risk of overdose have access to THN.
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Affiliation(s)
- Daniel C O'Brien
- University of Alberta, School of Public Health, 3-300 Edmonton Clinic Health Academy, 11405 - 87 Ave, Edmonton, Alberta, T6G 1C9, Canada
| | - Daniel Dabbs
- University of Alberta, Faculty of Medicine and Dentistry, 2J2.00 WC Mackenzie Health Sciences Centre, 8440 112 St. NW, Edmonton, Alberta, T6G 2R7, Canada
| | - Kathryn Dong
- University of Alberta, Faculty of Medicine and Dentistry, 790 University Terrace Building, 8303 112 St. NW, Edmonton, Alberta, T6G 2T4, Canada
| | - Paul J Veugelers
- University of Alberta, School of Public Health, 33-50 University Terrace, 8303 - 112 Ave, Edmonton, Alberta, T6G 2T4, Canada
| | - Elaine Hyshka
- University of Alberta, School of Public Health, 3-300 Edmonton Clinic Health Academy, 11405 - 87 Ave, Edmonton, Alberta, T6G 1C9, Canada.
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16
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Wakeman SE, Herman G, Wilens TE, Regan S. The prevalence of unhealthy alcohol and drug use among inpatients in a general hospital. Subst Abus 2019; 41:331-339. [PMID: 31368860 DOI: 10.1080/08897077.2019.1635961] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Background: Unhealthy substance use is a growing public health issue. Intersections with the health care system offer an opportunity for intervention; however, recent estimates of prevalence for unhealthy substance use among all types of hospital inpatients are unknown. Methods: Universal screening for unhealthy alcohol or drug use was implemented across a 999-bed general hospital between January 1 and December 31, 2015. Nurses completed alcohol screening using the Alcohol Use Disorders Identification Test alcohol consumption questions (AUDIT-C) with a cutoff of ≥5 for moderate risk and ≥8 for high risk and drug screening using the single-item screening question with ≥1 episode of use considered positive. Results: Out of 35,288 unique inpatients, screens were completed on 21,519. There were 3,451 positive screens (16% of all completed screens), including 1,291 (6%) moderate risk and 1,111 (5%) high risk screens for alcohol and 1,657 (8%) positive screens for drug use. Among screens that were positive for moderate- or high-risk alcohol use, 221 (17%) and 297 (27%), respectively, were concurrently positive for drug use. The majority (61%) of patients with unhealthy alcohol use was on the medical services. Men, those who were white or Hispanic, middle-aged, single, unemployed, or screened positive for drug use were more likely to screen positive for high-risk alcohol use. Those who were younger, single, worked less than full time, or screened high risk for alcohol were more likely to screen positive for drug use. Discordance between diagnosis coding and screening results was noted: 29% of high-risk alcohol use screens had no alcohol diagnosis coding associated with that admission, and 51% of patients with a DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) diagnosis code of alcohol dependence had AUDIT-C scores of <8. Conclusions: Across a general hospital, 16% of patients screened positive for unhealthy substance use, with the highest volume on medical floors. Nursing-led screening may offer an opportunity to identify and engage patients with unhealthy substance use during hospitalization.
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Affiliation(s)
- Sarah E Wakeman
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Grace Herman
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Timothy E Wilens
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Susan Regan
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
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Omran SS, Chatterjee A, Chen ML, Lerario MP, Merkler AE, Kamel H. National Trends in Hospitalizations for Stroke Associated With Infective Endocarditis and Opioid Use Between 1993 and 2015. Stroke 2019; 50:577-582. [PMID: 30699043 PMCID: PMC6396300 DOI: 10.1161/strokeaha.118.024436] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background and Purpose- There has been a recent sharp rise in opioid-related deaths in the United States. Intravenous opioid use can lead to infective endocarditis (IE) which can result in stroke. There are scant data on recent trends in this neurological complication of opioid abuse. We hypothesized that increasing opioid abuse has led to a higher incidence of stroke associated with IE and opioid use. Methods- We used the 1993 to 2015 releases of the National Inpatient Sample and validated International Classification of Diseases, Ninth Revision, Clinical Modification codes ( ICD-9-CM) to identify hospitalizations with the combination of opioid abuse, IE, and stroke (defined as ischemic stroke, intracerebral hemorrhage, or subarachnoid hemorrhage). Survey weights provided by the National Inpatient Sample were used to calculate nationally representative estimates and population estimates from the United States. Census data were used to calculate annual hospitalization rates per 10 million person-years. Joinpoint regression was used to assess trends. Results- From 1993 through 2015, there were 5283 hospitalizations with stroke associated with IE and opioid use. Across this period, the rate of such hospitalizations increased from 2.4 (95% CI, 0.5-4.3) to 18.8 (95% CI, 14.4-23.3) per 10 million US residents. Joinpoint regression detected 2 segments: no significant change in the hospitalization rate was apparent from 1993 to 2008 (annual percentage change, 1.9%; 95% CI, -2.2% to 6.1%), and then rates significantly increased from 2008 to 2015 (annual percentage change, 20.3%; 95% CI, 10.5%-30.9%), most dramatically in non-Hispanic white patients in the Northeastern and Southern United States. Conclusions- US hospitalization rates for stroke associated with IE and opioid use were stable for ≈2 decades but then sharply increased starting in 2008, coinciding with the emergence of the opioid epidemic.
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Affiliation(s)
- Setareh Salehi Omran
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University Medical Center, New York, NY
| | - Abhinaba Chatterjee
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Monica L. Chen
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Michael P. Lerario
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
- Department of Neurology, NewYork-Presbyterian Queens, Flushing, NY
| | - Alexander E. Merkler
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
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Schechter‐Perkins EM, Miller NS, Hall J, Hartman JJ, Dorfman DH, Andry C, Linas BP. Implementation and Preliminary Results of an Emergency Department Nontargeted, Opt-out Hepatitis C Virus Screening Program. Acad Emerg Med 2018; 25:1216-1226. [PMID: 29851238 DOI: 10.1111/acem.13484] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 05/24/2018] [Accepted: 05/25/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND Emergency department (ED) visits provide an opportunity for hepatitis C virus (HCV) screening for patients who otherwise might not be tested. We report on a novel nontargeted, opt-out HCV screening and linkage-to-care (LTC) program implemented in an urban ED. METHODS This is a descriptive analysis from 3 months (November 2016-January 2017) of a nontargeted, opt-out ED HCV screening and LTC program among patients at least 13 years old undergoing phlebotomy for clinical purposes. A multipurpose best practice advisory (BPA) alerted providers to the program and generated order labels. For patients who authorized testing, specimens were drawn in the ED for HCV antibody (Ab) and reflex confirmatory RNA tests. Public health navigators attempted to contact RNA-positive patients and arrange outpatient visits. RESULTS HCV Ab tests were performed on 3,808 patients, a 6,950% increase from preprogram. The proportion of HCV Ab test positivity was 13.2% (504/3,808, 95% confidence interval [CI] = 12.2%-14.3%) and of those 97.8% (493/504) had a follow-up RNA test performed. A total of 292 were confirmed positive for active infection, for an overall RNA positivity rate of 7.7% (95% CI = 6.8%-8.5%). Of those with active infection, 155 (53%) were outside the Centers for Disease Control and Prevention birth cohort for increased risk for HCV including 46 (15.8%, 95% CI = 11.8%-20.4%) who also did not report injection drug use. Linkage attempts were documented on 223 (76.4%) patients and appointments were scheduled for 102 (38% of attempted). Sixty-six patients attended their LTC visit (22.5% of all RNA-positive patients, 30% of linkage-eligible patients). CONCLUSIONS Nontargeted opt-out HCV testing can be successfully implemented in an ED setting. A number of patients diagnosed were outside traditional risk groups. Once diagnosed, an ED population may be difficult to engage in care, but a structured interdisciplinary program can successfully link patients to HCV care.
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Affiliation(s)
| | - Nancy S. Miller
- Department of Pathology and Laboratory Medicine Boston University School of Medicine and Boston Medical Center Boston MA
| | - Jon Hall
- Department of Internal Medicine/Section of Infectious Diseases Boston University School of Medicine and Boston Medical Center Boston MA
| | - Joshua J. Hartman
- Department of Internal Medicine/Section of Infectious Diseases Boston University School of Medicine and Boston Medical Center Boston MA
| | - David H. Dorfman
- Department of Pediatrics Boston University School of Medicine and Boston Medical Center Boston MA
| | - Chris Andry
- Department of Pathology and Laboratory Medicine Boston University School of Medicine and Boston Medical Center Boston MA
| | - Benjamin P. Linas
- Department of Internal Medicine/Section of Infectious Diseases Boston University School of Medicine and Boston Medical Center Boston MA
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Alemi F, Avramovic S, Schwartz MD. Electronic Health Record-Based Screening for Substance Abuse. BIG DATA 2018; 6:214-224. [PMID: 30283729 PMCID: PMC6154440 DOI: 10.1089/big.2018.0002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Existing methods of screening for substance abuse (standardized questionnaires or clinician's simply asking) have proven difficult to initiate and maintain in primary care settings. This article reports on how predictive modeling can be used to screen for substance abuse using extant data in electronic health records (EHRs). We relied on data available through Veterans Affairs Informatics and Computing Infrastructure (VINCI) for the years 2006 through 2016. We focused on 4,681,809 veterans who had at least two primary care visits; 829,827 of whom had a hospitalization. Data included 699 million outpatient and 17 million inpatient records. The dependent variable was substance abuse as identified from 89 diagnostic codes using the Agency for Healthcare Quality and Research classification of diseases. In addition, we included the diagnostic codes used for identification of prescription abuse. The independent variables were 10,292 inpatient and 13,512 outpatient diagnoses, plus 71 dummy variables measuring age at different years between 20 and 90 years. A modified naive Bayes model was used to aggregate the risk across predictors. The accuracy of the predictions was examined using area under the receiver operating characteristic (AROC) curve in 20% of data, randomly set aside for the evaluation. Many physical/mental illnesses were associated with substance abuse. These associations supported findings reported in the literature regarding the impact of substance abuse on various diseases and vice versa. In randomly set-aside validation data, the model accurately predicted substance abuse for inpatient (AROC = 0.884), outpatient (AROC = 0.825), and combined inpatient and outpatient (AROC = 0.840) data. If one excludes information available after substance abuse is known, the cross-validated AROC remained high, 0.822 for inpatient and 0.817 for outpatient data. Data within EHRs can be used to detect existing or predict potential future substance abuse.
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Affiliation(s)
- Farrokh Alemi
- Health Informatics Program, Department of Health Administration and Policy, George Mason University, Fairfax, Virginia
- Address correspondence to: Farrokh Alemi, Health Informatics Program, Department of Health Administration and Policy, George Mason University 1J3, 4400 University Drive, Fairfax, VA 22030,
| | - Sanja Avramovic
- Health Informatics Program, Department of Health Administration and Policy, George Mason University, Fairfax, Virginia
| | - Mark D. Schwartz
- Department of Population Health, New York University School of Medicine, New York, New York
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Yes, not now, or never: an analysis of reasons for refusing or accepting emergency department-based take-home naloxone. CAN J EMERG MED 2018; 21:226-234. [PMID: 29789030 DOI: 10.1017/cem.2018.368] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Take-home naloxone (THN) reduces deaths from opioid overdose. To increase THN distribution to at-risk emergency department (ED) patients, we explored reasons for patients' refusing or accepting THN. METHODS In an urban teaching hospital ED, we identified high opioid overdose risk patients according to pre-specified criteria. We offered eligible patients THN and participation in researcher-administered surveys, which inquired about reasons to refuse or accept THN and about THN dispensing location preferences. We analyzed refusal and acceptance reasons in open-ended responses, grouped reasons into categories (absolute versus conditional refusals,) then searched for associations between patient characteristics and reasons. RESULTS Of 247 patients offered THN, 193 (78.1%) provided reasons for their decision. Of those included, 69 (35.2%) were female, 91 (47.2%) were under age 40, 61 (31.6%) were homeless, 144 (74.6%) reported injection drug use (IDU), and 131 (67.9%) accepted THN. Of 62 patients refusing THN, 19 (30.7%) felt "not at risk" for overdose, while 28 (45.2%) gave conditional refusal reasons: "too sick," "in a rush," or preference to get THN elsewhere. Non-IDU was associated with stating "not at risk," while IDU, homelessness, and age under 40 were associated with conditional refusals. Among acceptances, 86 (65.7%) mentioned saving others as a reason. Most respondents preferred other dispensing locations beside the ED, whether or not they accepted ED THN. CONCLUSION ED patients refusing THN felt "not at risk" for overdose or felt their ED visit was not the right time or place for THN. Most accepting THN wanted to save others.
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Song Z. Mortality Quadrupled Among Opioid-Driven Hospitalizations, Notably Within Lower-Income And Disabled White Populations. Health Aff (Millwood) 2017; 36:2054-2061. [PMID: 29200349 PMCID: PMC5814297 DOI: 10.1377/hlthaff.2017.0689] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Hospitals play an important role in caring for patients in the current opioid crisis, but data on the outcomes and composition of opioid-driven hospitalizations in the United States have been lacking. Nationally representative all-payer data for the period 1993-2014 from the National Inpatient Sample were used to compare the mortality rates and composition of hospitalizations with opioid-related primary diagnoses and those of hospitalizations for other drugs and for all other causes. Mortality among opioid-driven hospitalizations increased from 0.43 percent before 2000 to 2.02 percent in 2014, an average increase of 0.12 percentage points per year relative to the mortality of hospitalizations due to other drugs-which was unchanged. While the total volume of opioid-driven hospitalizations remained relatively stable, it shifted from diagnoses mostly involving opioid dependence or abuse to those centered on opioid or heroin poisoning (the latter have higher case fatality rates). After 2000, hospitalizations for opioid/heroin poisoning grew by 0.01 per 1,000 people per year, while hospitalizations for opioid dependence or abuse declined by 0.01 per 1,000 people per year. Patients admitted for opioid/heroin poisoning were more likely to be white, ages 50-64, Medicare beneficiaries with disabilities, and residents of lower-income areas. As the United States combats the opioid epidemic, efforts to help hospitals respond to the increasing severity of opioid intoxication are needed, especially in vulnerable populations.
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Affiliation(s)
- Zirui Song
- Zirui Song ( ) is an assistant professor of health care policy at Harvard Medical School and an internal medicine physician at Massachusetts General Hospital, both in Boston, Massachusetts
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22
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Drainoni ML, Koppelman EA, Feldman JA, Walley AY, Mitchell PM, Ellison J, Bernstein E. Why is it so hard to implement change? A qualitative examination of barriers and facilitators to distribution of naloxone for overdose prevention in a safety net environment. BMC Res Notes 2016; 9:465. [PMID: 27756427 PMCID: PMC5070095 DOI: 10.1186/s13104-016-2268-z] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 10/06/2016] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND The increase in opioid overdose deaths has become a national public health crisis. Naloxone is an important tool in opioid overdose prevention. Distribution of nasal naloxone has been found to be a feasible, and effective intervention in community settings and may have potential high applicability in the emergency department, which is often the initial point of care for persons at high risk of overdose. One safety net hospital introduced an innovative policy to offer take-home nasal naloxone via a standing order to ensure distribution to patients at risk for overdose. The aims of this study were to examine acceptance and uptake of the policy and assess facilitators and barriers to implementation. METHODS After obtaining pre-post data on naloxone distribution, we conducted a qualitative study. The PARiHS framework steered development of the qualitative guide. We used theoretical sampling in order to include the range of types of emergency department staff (50 total). The constant comparative method was initially used to code the transcripts and identify themes; the themes that emerged from the coding were then mapped back to the evidence, context and facilitation constructs of the PARiHS framework. RESULTS Acceptance of the policy was good but uptake was low. Primary themes related to facilitators included: real-world driven intervention with philosophical, clinician and leadership support; basic education and training efforts; availability of resources; and ability to leave the ED with the naloxone kit in hand. Barriers fell into five general categories: protocol and policy; workflow and logistical; patient-related; staff roles and responsibilities; and education and training. CONCLUSIONS The actual implementation of a new innovation in healthcare delivery is largely driven by factors beyond acceptance. Despite support and resources, implementation was challenging, with low uptake. While the potential of this innovation is unknown, understanding the experience is important to improve uptake in this setting and offer possible solutions for other facilities to address the opioid overdose crisis. Use of the PARiHS framework allowed us to recognize and understand key evidence, contextual and facilitation barriers to the successful implementation of the policy and to identify areas for improvement.
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Affiliation(s)
- Mari-Lynn Drainoni
- Boston University School of Public Health, 715 Albany Street, T3 W, Boston, MA 02118 USA
- Boston University School of Medicine, Boston, MA USA
- Center for Healthcare Organization and Implementation Research, ENRM Veterans Administration Hospital, Bedford, MA USA
| | - Elisa A. Koppelman
- Boston University School of Public Health, 715 Albany Street, T3 W, Boston, MA 02118 USA
- Center for Healthcare Organization and Implementation Research, ENRM Veterans Administration Hospital, Bedford, MA USA
| | - James A. Feldman
- Boston University School of Medicine, Boston, MA USA
- Boston Medical Center, Boston, MA USA
| | - Alexander Y. Walley
- Boston University School of Medicine, Boston, MA USA
- Boston Medical Center, Boston, MA USA
| | - Patricia M. Mitchell
- Boston University School of Medicine, Boston, MA USA
- Boston Medical Center, Boston, MA USA
| | - Jacqueline Ellison
- Boston University School of Public Health, 715 Albany Street, T3 W, Boston, MA 02118 USA
| | - Edward Bernstein
- Boston University School of Public Health, 715 Albany Street, T3 W, Boston, MA 02118 USA
- Boston University School of Medicine, Boston, MA USA
- Boston Medical Center, Boston, MA USA
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