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Seymour RB, Wally MK, Hsu JR. Impact of clinical decision support on controlled substance prescribing. BMC Med Inform Decis Mak 2023; 23:234. [PMID: 37864226 PMCID: PMC10588193 DOI: 10.1186/s12911-023-02314-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 09/29/2023] [Indexed: 10/22/2023] Open
Abstract
BACKGROUND Prescription drug overdose and misuse has reached alarming numbers. A persistent problem in clinical care is lack of easy, immediate access to all relevant information at the actionable time. Prescribers must digest an overwhelming amount of information from each patient's record as well as remain up-to-date with current evidence to provide optimal care. This study aimed to describe prescriber response to a prospective clinical decision support intervention designed to identify patients at risk of adverse events associated with misuse of prescription opioids/benzodiazepines and promote adherence to clinical practice guidelines. METHODS This study was conducted at a large multi-center healthcare system, using data from the electronic health record. A prospective observational study was performed as clinical decision support (CDS) interventions were sequentially launched (January 2016-July 2019). All data were captured from the medical record prospectively via the CDS tools implemented. A consecutive series of all patient encounters including an opioid/benzodiazepine prescription were included in this study (n = 61,124,172 encounters; n = 674,785 patients). Physician response to the CDS interventions was the primary outcome, and it was assessed over time using control charts. RESULTS An alert was triggered in 23.5% of encounters with a prescription (n = 555,626). The prescriber decision was influenced in 18.1% of these encounters (n = 100,301). As the number of risk factors increased, the rate of decision being influenced also increased (p = 0.0001). The effect of the alert differed by drug, risk factor, specialty, and facility. CONCLUSION The delivery of evidence-based, patient-specific information had an influence on the final prescription in nearly 1 in 5 encounters. Our intervention was sustained with minimal prescriber fatigue over many years in a large and diverse health system.
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Affiliation(s)
- Rachel B Seymour
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, 1000 Blythe Boulevard, Charlotte, NC, 28203, USA.
- Atrium Health Musculoskeletal Institute, 2001 Vail Avenue, 6th floor, Charlotte, NC, 28207, USA.
| | - Meghan K Wally
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, 1000 Blythe Boulevard, Charlotte, NC, 28203, USA
| | - Joseph R Hsu
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, 1000 Blythe Boulevard, Charlotte, NC, 28203, USA
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2
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Al-Hihi E, Gibson C, Lee J, Mount RR, Irani N, McGowan C. Improving appropriate imaging for non-specific low back pain. BMJ Open Qual 2022; 11:bmjoq-2021-001539. [PMID: 35190485 PMCID: PMC8862455 DOI: 10.1136/bmjoq-2021-001539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 01/15/2022] [Indexed: 12/03/2022] Open
Abstract
Non-specific low back pain (LBP) is a common condition in the USA, with approximately 80% of adults who will have LBP at some point during their life and roughly 30% of the adult population suffering from LBP at any given time. Although LBP is the most common cause of disability in the USA, it often has no identifiable anatomic or physiologic cause. Many patients seeking care for non-specific LBP receive X-rays and other imaging studies. However, for most acute LBP patients, symptoms resolve within 4 weeks and the use of routine imaging may result in unnecessary radiation exposure and add unnecessary costs and wasted time for patients without contributing to patient outcomes. The specific aim of the quality improvement (QI) project was to determine the effect of a multicomponent intervention to enhance the appropriate imaging utilisation for acute LBP to ≥90%. During the first 6 months of the QI project, 191 patients with LBP were seen. Of those patients, 156 (81.7%) received appropriate imaging over the 6-month intervention period, missing our targeted goal. Furthermore, this rate declined to baseline values after termination of the intervention, suggesting the need for additional prompts to sustain the initial intervention effect. Following a health system-wide deployment of practice-based alerts and quality score cards, the appropriate utilisation rate increased again and quickly to the target rate of 90%. To reduce variability in our clinical practice and to sustain an appropriate utilisation rate will require continued work. Health systems must find efficient methods to reduce LBP imaging and increase appropriate management of non-specific LBP in primary care. Increasing concordance with imaging guidelines can lessen harm associated with unnecessary radiation exposure and result in significant cost savings.
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Affiliation(s)
- Eyad Al-Hihi
- Internal Medicine, The University of Kansas Health System, Kansas City, Kansas, USA
| | - Cheryl Gibson
- Internal Medicine, The University of Kansas Health System, Kansas City, Kansas, USA
| | - Jaehoon Lee
- Educational Psychology, Leadership, and Counseling, Texas Tech University, Lubbock, Texas, USA
| | - Rebecca R Mount
- Internal Medicine, The University of Kansas Health System, Kansas City, Kansas, USA
| | - Neville Irani
- Radiology, The University of Kansas Health System, Kansas City, Kansas, USA
| | - Caylin McGowan
- Internal Medicine, The University of Kansas Health System, Kansas City, Kansas, USA
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Bestha D, Tomatsu S, Hutcheson B, Blankenship K, Yu Z, Wally MK, Wyatt S, Seymour RB, Hsu JR, Rachal J. Impact of an opioid prescribing alert system on patients with posttraumatic stress disorder. Am J Addict 2022; 31:123-131. [PMID: 35112432 DOI: 10.1111/ajad.13261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 12/17/2021] [Accepted: 01/15/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Posttraumatic stress disorder (PTSD) is associated with higher rates of chronic pain and increased risk of developing Opioid use disorder. This paper evaluates the impact of PRIMUM, an electronic health record-embedded (EHR) clinical decision support intervention on opioid prescribing patterns for patients with diagnosis of PTSD. METHODS Inpatient, emergency department (ED), urgent care, and outpatient encounters with ICD-10 codes F43.1 (PTSD), F43.10 (PTSD, unspecified), F43.11 (PTSD, acute), and F43.12 (PTSD, chronic) at Atrium Health between 1/1/2016 and 12/29/2018 were included in the study. RESULTS A total of 3121 patients with a diagnosis of PTSD were seen in 37,443 encounters during the study period. Ten percent (n = 3761) of the encounters resulted in prescriptions for opioids and PRIMUM alerts were triggered in 1488 of these encounters. These alerts resulted in "decision influenced" for 17% of patients (n = 255) or no prescriptions for opioids or benzodiazepines for 5.8% (n = 86). The majority of the prescriptions were below 50 Morphine milligram equivalents (MME)/day, but there were 570 (15.5%) prescriptions for doses of 50-90 MME and 721 (19.6%) prescriptions for >90 MME/day. DISCUSSION AND CONCLUSION The PRIMUM alert system helps improve patient safety. PRIMUM affected clinician decisions 17% of the time, and the effect was greater in patients with opioid overdose history and those presenting for early refills. SCIENTIFIC SIGNIFICANCE The effectiveness of clinical support interventions for opioid prescribing for patients with PTSD has not been documented previously. Our findings provide novel evidence that the EHR can be used to improve patient safety among patients with PTSD in the context of substance use.
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Affiliation(s)
- Durga Bestha
- Department of Psychiatry, Atrium Health, Charlotte, North Carolina, USA
| | - Shizuka Tomatsu
- Department of Psychiatry, Atrium Health, Charlotte, North Carolina, USA
| | | | - Kelly Blankenship
- Department of Psychiatry, Dayton Children's Hospital, Dayton, Ohio, USA
| | - Ziqing Yu
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, USA
| | - Meghan K Wally
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, USA
| | - Stephen Wyatt
- Department of Psychiatry, Atrium Health, Charlotte, North Carolina, USA
| | - Rachel B Seymour
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, USA
| | - Joseph R Hsu
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, USA
| | - James Rachal
- Department of Psychiatry, Atrium Health, Charlotte, North Carolina, USA
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Elder JW, Gu Z, Kim J, Moulin A, Bang H, Parikh A, May L. Assessing local California trends in emergency physician opioid prescriptions from 2012 to 2020: Experiences in a large academic health system. Am J Emerg Med 2021; 51:192-196. [PMID: 34763238 DOI: 10.1016/j.ajem.2021.10.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 10/17/2021] [Accepted: 10/18/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES There has been increased focus nationally on limiting opioid prescriptions. National data demonstrates a decrease in annual opioid prescriptions among emergency medicine physicians. We analyzed data from 2012 to 2020 from a large academic health system in California to understand trends in opioid prescribing patterns for emergency department (ED) discharged patients and assessed the potential impact of two initiatives at limiting local opioid prescriptions. METHODS In 2012-2020, monthly ED visit data was used to evaluate the total number of outpatient opioid prescriptions and percent of ED visits with opioid prescriptions (as primary outcomes). Descriptive statistics, graphic representation, and segmented regression with interrupted times series were used based on two prespecified time points associated with intensive local initiatives directed at limiting opioid prescribing1) comprehensive emergency medicine resident education and 2) electronic health record (EHR)-based intervention. RESULTS Between March 2012 and July 2020, a total of 41,491 ED discharged patients received an opioid prescription. The three most commonly prescribed drugs were hydrocodone (84.1%), oxycodone (10.8%), and codeine (2.8%). After implementing comprehensive emergency medicine resident education, the total number of opioid prescriptions, the percentage of opioid prescriptions over total ED visit numbers and the total tablet number showed decreasing trends (p's ≤ 0.01), in addition to the natural (pre-intervention) decreasing trends. In contrast, later interventions in the EHR tended to show attenuated decreasing trends. CONCLUSIONS From 2012 to 2020, we found that total opioid prescriptions decreased significantly for discharged ED patients. This trend is seen nationally. However, our specific interventions further heightened this downward trend. Evidence-based legislation, policy changes, and educational initiatives that impact prescribing practices should guide future efforts.
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Affiliation(s)
- Joshua W Elder
- Department of Emergency Medicine, University of California, Davis, School of Medicine, Sacramento, CA, United States of America.
| | - Zheng Gu
- Department of Research & Evaluation, Southern California Permanente Medical Group, Kaiser Permanente Research, Pasadena, CA, United States of America
| | - Jeehyoung Kim
- Department of Orthopedic Surgery, Seoul Sacred Heart General Hospital, Seoul, Republic of Korea
| | - Aimee Moulin
- Department of Emergency Medicine, University of California, Davis, School of Medicine, Sacramento, CA, United States of America
| | - Heejung Bang
- Department of Research & Evaluation, Southern California Permanente Medical Group, Kaiser Permanente Research, Pasadena, CA, United States of America.; Division of Biostatistics, Department of Public Health Sciences, University of California, Davis, CA, United States of America
| | - Aman Parikh
- Department of Emergency Medicine, University of California, Davis, School of Medicine, Sacramento, CA, United States of America
| | - Larissa May
- Department of Emergency Medicine, University of California, Davis, School of Medicine, Sacramento, CA, United States of America
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Joseph R, Tomanec A, McLaughlin T, Guardiola J, Richman P. A prospective study to compare serial changes in pain scores for patients with and without a history of frequent ED utilization. Heliyon 2021; 7:e07216. [PMID: 34159273 PMCID: PMC8203716 DOI: 10.1016/j.heliyon.2021.e07216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 05/03/2021] [Accepted: 06/01/2021] [Indexed: 12/03/2022] Open
Abstract
Background In the face of the opiate addiction epidemic, there is a paucity of research that evaluates limitations for our current pain rating methodologies for patient populations at risk for drug seeking behavior. Objective We hypothesized that VAS scores would be higher and show less serial improvement for patients with a history of frequent ED use. Methods This was a prospective, observational cohort study of a convenience sample of adult ED patients with chief complaint of pain. Initial VAS scores were recorded. Pain scores were subsequently updated 30–45 min after pain medication administration. ED frequenter defined as having >4 ED visits over a 1-year time period. Categorical data analyzed by chi-square; continuous data analyzed by t-tests. A multiple linear regression performed to control for confounding. Results 125 patients were enrolled; 51% ED frequenters. ED frequenters were similar to non-ED frequenters with respect to gender, mean age, Hispanic race, educational level, chief complaint type, and initial pain medication narcotic. ED frequenters more likely to have higher initial VAS score (9.17+/-1.25 vs. 8.51+/-1.68; p = 0.01) and higher second VAS scores (7.48+/-2.56 vs. 5.00+/-3.28; p <0.001) and significantly lower mean change in first to second VAS scores (1.69+/-2.17 vs. 3.51+/-3.25; p <0.001). Within our multiple linear regression model, only ED frequenter group (p < 0.001) and private insurance status (0.04) were associated with differences in mean reduction in pain scores. Conclusion We found that ED frequenters had significantly less improvement between first and second VAS measurements.
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Affiliation(s)
- Ryan Joseph
- Department of Emergency Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Alainya Tomanec
- Department of Emergency Medicine, CHRISTUS Health/Texas A&M, Corpus Christi, TX, USA
| | - Thomas McLaughlin
- Department of Emergency Medicine, CHRISTUS Health/Texas A&M, Corpus Christi, TX, USA
| | - Jose Guardiola
- Department of Mathematics, Texas A&M-Corpus Christi, Corpus Christi, TX, USA
| | - Peter Richman
- Department of Emergency Medicine, CHRISTUS Health/Texas A&M, Corpus Christi, TX, USA
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Gorbaty J, Odum SM, Wally MK, Seymour RB, Hamid N, Hsu JR, Beuhler M, Bosse MJ, Gibbs M, Griggs C, Jarrett S, Leas D, Roomian T, Runyon M, Saha A, Watling B, Wyatt S, Yu Z. Prevalence of Prescription Opioids for Nonoperative Treatment of Rotator Cuff Disease Is High. Arthrosc Sports Med Rehabil 2021; 3:e373-e379. [PMID: 34027445 PMCID: PMC8129054 DOI: 10.1016/j.asmr.2020.09.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 09/30/2020] [Indexed: 10/27/2022] Open
Abstract
Purpose To quantify the prevalence of opioid and benzodiazepine prescriptions for patients with rotator cuff disease across a large health care system and to describe evidence-based risk factors for opioid use within this population. Methods We conducted a retrospective cohort study at a major health care system of all patients with qualifying diagnostic codes. Emergency department, urgent care, and outpatient encounters between January and December 2016 for an acute rotator cuff tear, listed as the primary diagnosis, were included. Encounters with prescriptions for opioids or benzodiazepines were identified using the Prescription Reporting With Immediate Medication Utilization Mapping (PRIMUM) system. Descriptive statistics and the rate of controlled-substance prescribing were calculated for the population as a whole and among subgroups. Results We identified 9,376 encounters meeting the inclusion criteria. Of these encounters, 1,559 (16.6%) resulted in 1 or more prescriptions for an opioid or benzodiazepine that were issued during the visit. A total of 2,007 opioid and/or benzodiazepine prescriptions were issued for the 1,559 encounters (rate of 1.29 prescriptions per prescribing encounter). This represented 5,310 patients, of whom 1,096 (20.6%) received a prescription for an opioid or benzodiazepine during at least 1 of their encounters. Of patients who received a prescription, 20.9% had at least 1 risk factor for prescription misuse; 3.6% of patients had more than 1 risk factor. There were no demographic differences between patients with risk factors and patients without them. Conclusions The prescribing of opioids for the treatment of pain in patients with rotator cuff disease remains high across multiple locations and specialties within a large health care system. Using alternative pain management pathways as primary prevention for opioid misuse and abuse in high opioid-prescribing locations-and especially for patients identified as having a high risk of opioid misuse-is an important practice to continue in our shift away from opioid use as a health care system. Level of Evidence Level IV, case series.
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Affiliation(s)
- Jacob Gorbaty
- Department Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, U.S.A
| | - Susan M Odum
- Department Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, U.S.A
| | - Meghan K Wally
- Department Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, U.S.A
| | - Rachel B Seymour
- Department Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, U.S.A
| | - Nady Hamid
- Department Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, U.S.A.,OrthoCarolina Shoulder and Elbow Center, Charlotte, North Carolina, U.S.A
| | - Joseph R Hsu
- Department Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, U.S.A
| | | | - Michael Beuhler
- NC Poison Control, Atrium Health, Charlotte, North Carolina, U.S.A
| | - Michael J Bosse
- Department Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, U.S.A
| | - Michael Gibbs
- Department of Emergency Medicine, Carolinas Trauma Network Research Center of Excellence, Atrium Health, Charlotte, North Carolina, U.S.A
| | - Christopher Griggs
- Department of Emergency Medicine, Carolinas Trauma Network Research Center of Excellence, Atrium Health, Charlotte, North Carolina, U.S.A
| | - Steven Jarrett
- Patient Safety, Atrium Health, Charlotte, North Carolina, U.S.A
| | - Daniel Leas
- Department Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, U.S.A
| | - Tamar Roomian
- Department Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, U.S.A
| | - Michael Runyon
- Department of Emergency Medicine, Carolinas Trauma Network Research Center of Excellence, Atrium Health, Charlotte, North Carolina, U.S.A
| | - Animita Saha
- Department of Internal Medicine, Atrium Health, Charlotte, North Carolina, U.S.A
| | - Bradley Watling
- US Acute Care Solutions, Atrium Health, Pineville, North Carolina, U.S.A
| | - Stephen Wyatt
- Adult Psychiatry, Atrium Health, Charlotte, North Carolina, U.S.A
| | - Ziqing Yu
- Department Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, U.S.A
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Ford JA, Schepis TS, McCabe SE. Poly-prescription drug misuse across the life course: Prevalence and correlates across different adult age cohorts in the U.S. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 88:103017. [PMID: 33227640 PMCID: PMC8005409 DOI: 10.1016/j.drugpo.2020.103017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 10/22/2020] [Accepted: 10/23/2020] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Jason A Ford
- Department of Sociology, University of Central Florida, Orlando, FL United States.
| | - Ty S Schepis
- Department of Psychology, Texas State University, San Marcos, TX United States
| | - Sean Esteban McCabe
- Center for the Study of Drugs, Alcohol, Smoking and Health, School of Nursing, University of Michigan, Ann Arbor, MI, United States; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, United States; Institute for Research on Women and Gender, University of Michigan, Ann Arbor, MI, United States; Institute for Social Research, University of Michigan, Ann Arbor, MI, United States
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Shergill Y, Rice D, Smyth C, Tremblay S, Nelli J, Small R, Hebert G, Singer L, Rash JA, Poulin PA. Characteristics of frequent users of the emergency department with chronic pain. CAN J EMERG MED 2020; 22:350-358. [PMID: 32213214 DOI: 10.1017/cem.2019.464] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVES To identify the proportion of high-frequency users of the emergency department (ED) who have chronic pain. METHODS We reviewed medical records of adult patients with ≥ 12 visits to a tertiary-care, academic hospital ED in Canada in 2012-2013. We collected the following demographics: 1) patient age and sex; 2) visit details - number of ED visits, inpatient admissions, length of inpatient admissions, diagnosis, and primary location of pain; 3) current and past substance abuse, mental health and medical conditions. Charts were reviewed independently by two reviewers. ED visits were classified as either "chronic pain" or "not chronic pain" related. RESULTS We analyzed 4,646 visits for 247 patients, mean age was 47.2 years (standard deviation = 17.8), and 50.2% were female. This chart review study found 38% of high-frequency users presented with chronic pain to the ED and that women were overrepresented in this group (64.5%). All high-frequency users presented with co-morbidities and/or mental health concerns. High-frequency users with chronic pain had more ED visits than those without and 52.7% were prescribed an opioid. Chronic abdominal pain was the primary concern for 54.8% of high-frequency users presenting with chronic pain. CONCLUSIONS Chronic pain, specifically chronic abdominal pain, is a significant driver of ED visits among patients who frequently use the ED. Interventions to support high-frequency users with chronic pain that take into account the complexity of patient's physical and mental health needs will likely achieve better clinical outcomes and reduce ED utilization.
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Affiliation(s)
- Yaadwinder Shergill
- The Ottawa Hospital Research Institute, Ottawa, ON
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON
- One Elephant Integrative Health Team Inc., Oakville, ON
| | - Danielle Rice
- The Ottawa Hospital Research Institute, Ottawa, ON
- Department of Psychology, McGill University, Montreal, QC
| | - Catherine Smyth
- The Ottawa Hospital Research Institute, Ottawa, ON
- Department of Anesthesiology and Pain Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, ON
| | - Steve Tremblay
- Department of Psychology, McGill University, Montreal, QC
- Department of Anesthesiology and Pain Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON
| | - Jennifer Nelli
- Department of Anesthesiology, Hamilton Health Sciences, Hamilton, ON
| | - Rebecca Small
- Faculty of Medicine, Memorial University, St. John's, NL
| | - Guy Hebert
- Department of Emergency Medicine, The Ottawa Hospital, Ottawa, ON
| | - Lesley Singer
- Canadian Pain Network Patient Representative
- Patient Representative, Chronic Pain Network, Montreal, QC
| | - Joshua A Rash
- Department of Psychology, Memorial University, St. John's, NL
| | - Patricia A Poulin
- The Ottawa Hospital Research Institute, Ottawa, ON
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON
- Department of Psychology, The Ottawa Hospital, Ottawa, ON
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Averitt AJ, Slovis BH, Tariq AA, Vawdrey DK, Perotte AJ. Characterizing non-heroin opioid overdoses using electronic health records. JAMIA Open 2020; 3:77-86. [PMID: 32607490 PMCID: PMC7309230 DOI: 10.1093/jamiaopen/ooz063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 10/21/2019] [Accepted: 10/30/2019] [Indexed: 01/24/2023] Open
Abstract
INTRODUCTION The opioid epidemic is a modern public health emergency. Common interventions to alleviate the opioid epidemic aim to discourage excessive prescription of opioids. However, these methods often take place over large municipal areas (state-level) and may fail to address the diversity that exists within each opioid case (individual-level). An intervention to combat the opioid epidemic that takes place at the individual-level would be preferable. METHODS This research leverages computational tools and methods to characterize the opioid epidemic at the individual-level using the electronic health record data from a large, academic medical center. To better understand the characteristics of patients with opioid use disorder (OUD) we leveraged a self-controlled analysis to compare the healthcare encounters before and after an individual's first overdose event recorded within the data. We further contrast these patients with matched, non-OUD controls to demonstrate the unique qualities of the OUD cohort. RESULTS Our research confirms that the rate of opioid overdoses in our hospital significantly increased between 2006 and 2015 (P < 0.001), at an average rate of 9% per year. We further found that the period just prior to the first overdose is marked by conditions of pain or malignancy, which may suggest that overdose stems from pharmaceutical opioids prescribed for these conditions. CONCLUSIONS Informatics-based methodologies, like those presented here, may play a role in better understanding those individuals who suffer from opioid dependency and overdose, and may lead to future research and interventions that could successfully prevent morbidity and mortality associated with this epidemic.
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Affiliation(s)
- Amelia J Averitt
- Department of Biomedical Informatics, Columbia University, New York, New York, USA
| | - Benjamin H Slovis
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Abdul A Tariq
- NewYork-Presbyterian Hospital, The Value Institute, New York, New York, USA
| | - David K Vawdrey
- Geisinger, Steele Institute for Health Innovation, Danville, Pennsylvania, USA
| | - Adler J Perotte
- Department of Biomedical Informatics, Columbia University, New York, New York, USA
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10
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Copeland D. Drug‐seeking: A literature review (and an exemplar of stigmatization in nursing). Nurs Inq 2019; 27:e12329. [DOI: 10.1111/nin.12329] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 10/09/2019] [Accepted: 10/15/2019] [Indexed: 12/21/2022]
Affiliation(s)
- Darcy Copeland
- School of Nursing University of Northern Colorado Greeley CO USA
- St Anthony Hospital Centura Health Lakewood CO USA
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11
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Janakiram C, Chalmers NI, Fontelo P, Huser V, Mitnik GL, Iafolla TJ, Brow AR, Dye BA. Sex and race or ethnicity disparities in opioid prescriptions for dental diagnoses among patients receiving Medicaid. J Am Dent Assoc 2019; 150:e135-e144. [PMID: 31561765 PMCID: PMC6768087 DOI: 10.1016/j.adaj.2019.06.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 05/30/2019] [Accepted: 06/11/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND The objective of this study was to identify specific factors (sex, race or ethnicity, and health care provider type) associated with patient receipt of an opioid prescription after a dental diagnosis. METHODS The authors used Medicaid claims dated from January 1, 2013, through September 30, 2015, for 13 U.S. states in this study. The authors identified oral health-related conditions by using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes 520.0 through 529.9. RESULTS During the 2013 through 2015 study period, among the more than 1,008,400 Medicaid patients with a dental diagnosis, 19.8% filled an opioid prescription within 14 days of diagnosis. Female patients were 50% more likely to receive an opioid prescription for pain management of a dental condition than were men (odds ratio [OR], 1.50; 95% confidence interval [CI], 1.49 to 1.52). Non-Hispanic whites and African Americans were approximately twice as likely to receive opioids than were Hispanics (OR, 2.12; 95% CI, 2.05 to 2.19; OR, 1.90; 95% CI, 1.84 to 1.96, respectively). Patients receiving oral health care in an emergency department were more than 7 times more likely to receive an opioid prescription than were patients treated in a dental office (OR, 7.28; 95% CI, 7.13 to 7.43). Patients with a dental condition diagnosed were more than 4 times as likely to receive an opioid from a nurse practitioner as from a dentist (OR, 4.31; 95% CI, 4.19 to 4.44). Opioid use was substantially higher among African American female patients (OR, 2.02; 95% CI, 1.93 to 2.10) and non-Hispanic white female patients (OR, 2.16; 95% CI, 2.07 to 2.24) than among Hispanic female patients. CONCLUSIONS Opioid prescribing patterns differ depending on patient race or ethnicity, sex, and health care provider source in patients with a dental diagnosis in the United States. PRACTICAL IMPLICATIONS Dentists are providing substantially fewer opioid prescriptions compared with their medical colleagues for pain treatment after a dental diagnosis in the Medicaid population. When considering pain management for dental and related conditions, dentists should continue with conservative prescribing practices as recommended.
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Temporal Trends in Imaging Utilization for Suspected Substance Use Disorder in an Academic Emergency Radiology Department. J Am Coll Radiol 2019; 16:1440-1446. [DOI: 10.1016/j.jacr.2019.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 03/12/2019] [Accepted: 03/29/2019] [Indexed: 11/19/2022]
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Romanelli RJ, Shen Z, Szwerinski N, Scott A, Lockhart S, Pressman AR. 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. Ann Emerg Med 2019; 74:622-631. [PMID: 31272820 DOI: 10.1016/j.annemergmed.2019.05.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 04/29/2019] [Accepted: 05/09/2019] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Robert J Romanelli
- Sutter Health, Palo Alto Medical Foundation Research Institute, Palo Alto, CA.
| | - Zijun Shen
- Sutter Health, Division of Research, Development & Dissemination, Walnut Creek, CA
| | - Nina Szwerinski
- Sutter Health, Palo Alto Medical Foundation Research Institute, Palo Alto, CA
| | - Alexandra Scott
- Sutter Health, Division of Research, Development & Dissemination, Walnut Creek, CA
| | | | - Alice R Pressman
- Sutter Health, Division of Research, Development & Dissemination, Walnut Creek, CA
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Chalmers CE, Mullinax S, Brennan J, Vilke GM, Oliveto AH, Wilson MP. Screening Tools Validated in the Outpatient Pain Management Setting Poorly Predict Opioid Misuse in the Emergency Department: A Pilot Study. J Emerg Med 2019; 56:601-610. [PMID: 31043338 DOI: 10.1016/j.jemermed.2019.03.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 03/07/2019] [Accepted: 03/08/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Currently, no universally accepted methods exist to assess drug-related aberrant behaviors in emergency department (ED) patients. There are several screening tools to identify opioid misuse in patients with chronic pain, however, the validity of these screening tools to assess for misuse within the ED remains unclear. OBJECTIVES This study investigated the effectiveness of three commonly used screening tools, previously validated in outpatient pain management settings, to assess risk of opioid misuse in ED patients. METHODS This was a prospective observational study of 154 participants (median age 50 years; 49.6% female) presenting to an academic ED for a chief complaint of pain ≥ 6 months or an opioid refill request. Participants completed the Opioid Risk Tool, the Screener and Opioid Assessment for Patients with Pain-Revised, and the Current Opioid Misuse Measure. Scores for each were compared with electronic medical record (EMR) data alone or a reference standard comprising EMR + statewide prescription drug monitoring program (PDMP) + medical examiner database. RESULTS Using the combined reference standard, 55.8% of participants displayed at least one aberrant behavior. Regardless of the reference standard, the test characteristics of these screening tools were modest at best, with likelihood ratios close to 1. CONCLUSION Three screening tools previously validated in outpatient pain management settings poorly categorized risk among ED patients with chronic noncancer pain or requests for opioid refills, and should not be used to assess drug-aberrant behaviors in the ED. Review of the EMR alone or together with the PDMP may be more useful methods to assess drug-aberrant behaviors in the ED setting.
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Lange J, Gaddis G, Varner E, Schmidt S, Cohen R, Schwarz E. Resident Access to the St. Louis County Prescription Drug Monitoring Program: Why PDMPs Matter and How to Gain Access. MISSOURI MEDICINE 2018; 115:487-493. [PMID: 30643325 PMCID: PMC6312172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Prescription Drug Monitoring Programs (PDMPSs) permit physicians to determine whether patients obtained addictive substances from multiple physicians or pharmacies. In April 2017, the Saint Louis County Department of Public Health created its own PDMP. This manuscript evaluates evidence regarding the efficacy of PDMPs, in addition to discussing their impact on patient care and a provider's workflow. It also details how physicians can register to use the St. Louis County PDMP, Missouri's de-facto PDMP.
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Affiliation(s)
- Julia Lange
- Julia Lange, MD, is a PGY-2 Emergency Medicine Resident; Gary Gaddis, MD, PhD, MSMA member since 2002, is Professor of Emergency Medicine; and Evan Schwarz, MD, FACEP, FACMT, MSMA member since 2014, is Associate Professor of Emergency Medicine, Section Chief Medical Toxicology, Division of Emergency Medicine; all are at Washington University School of Medicine in St. Louis, Missouri. At the Saint Louis County Department of Public Health, Spring Schmidt, PhD(c), is the Acting Director; Emily varner, MPH, is the PDMP Coordinator; and Rachel Cohen, MPH, is the Public Health Coordinator
| | - Gary Gaddis
- Julia Lange, MD, is a PGY-2 Emergency Medicine Resident; Gary Gaddis, MD, PhD, MSMA member since 2002, is Professor of Emergency Medicine; and Evan Schwarz, MD, FACEP, FACMT, MSMA member since 2014, is Associate Professor of Emergency Medicine, Section Chief Medical Toxicology, Division of Emergency Medicine; all are at Washington University School of Medicine in St. Louis, Missouri. At the Saint Louis County Department of Public Health, Spring Schmidt, PhD(c), is the Acting Director; Emily varner, MPH, is the PDMP Coordinator; and Rachel Cohen, MPH, is the Public Health Coordinator
| | - Emily Varner
- Julia Lange, MD, is a PGY-2 Emergency Medicine Resident; Gary Gaddis, MD, PhD, MSMA member since 2002, is Professor of Emergency Medicine; and Evan Schwarz, MD, FACEP, FACMT, MSMA member since 2014, is Associate Professor of Emergency Medicine, Section Chief Medical Toxicology, Division of Emergency Medicine; all are at Washington University School of Medicine in St. Louis, Missouri. At the Saint Louis County Department of Public Health, Spring Schmidt, PhD(c), is the Acting Director; Emily varner, MPH, is the PDMP Coordinator; and Rachel Cohen, MPH, is the Public Health Coordinator
| | - Spring Schmidt
- Julia Lange, MD, is a PGY-2 Emergency Medicine Resident; Gary Gaddis, MD, PhD, MSMA member since 2002, is Professor of Emergency Medicine; and Evan Schwarz, MD, FACEP, FACMT, MSMA member since 2014, is Associate Professor of Emergency Medicine, Section Chief Medical Toxicology, Division of Emergency Medicine; all are at Washington University School of Medicine in St. Louis, Missouri. At the Saint Louis County Department of Public Health, Spring Schmidt, PhD(c), is the Acting Director; Emily varner, MPH, is the PDMP Coordinator; and Rachel Cohen, MPH, is the Public Health Coordinator
| | - Rachel Cohen
- Julia Lange, MD, is a PGY-2 Emergency Medicine Resident; Gary Gaddis, MD, PhD, MSMA member since 2002, is Professor of Emergency Medicine; and Evan Schwarz, MD, FACEP, FACMT, MSMA member since 2014, is Associate Professor of Emergency Medicine, Section Chief Medical Toxicology, Division of Emergency Medicine; all are at Washington University School of Medicine in St. Louis, Missouri. At the Saint Louis County Department of Public Health, Spring Schmidt, PhD(c), is the Acting Director; Emily varner, MPH, is the PDMP Coordinator; and Rachel Cohen, MPH, is the Public Health Coordinator
| | - Evan Schwarz
- Julia Lange, MD, is a PGY-2 Emergency Medicine Resident; Gary Gaddis, MD, PhD, MSMA member since 2002, is Professor of Emergency Medicine; and Evan Schwarz, MD, FACEP, FACMT, MSMA member since 2014, is Associate Professor of Emergency Medicine, Section Chief Medical Toxicology, Division of Emergency Medicine; all are at Washington University School of Medicine in St. Louis, Missouri. At the Saint Louis County Department of Public Health, Spring Schmidt, PhD(c), is the Acting Director; Emily varner, MPH, is the PDMP Coordinator; and Rachel Cohen, MPH, is the Public Health Coordinator
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Whiteside LK, Goldstick J, Dora-Laskey A, Thomas L, Walton M, Cunningham R, Bohnert AS. Patient Preference for Pain Medication in the Emergency Department Is Associated with Non-fatal Overdose History. West J Emerg Med 2018; 19:722-730. [PMID: 30013710 PMCID: PMC6040914 DOI: 10.5811/westjem.2018.4.37019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 03/06/2018] [Accepted: 04/09/2018] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Opioid overdose is a major public health problem. Emergency physicians need information to better assess a patient's risk for overdose or opioid-related harms. The purpose of this study was to determine if patient-reported preference for specific pain medications was associated with a history of lifetime overdose among patients seeking care in the emergency department (ED). METHODS ED patients (18-60 years) completed a screening survey that included questions on overdose history, ED utilization, opioid misuse behaviors as measured by the Current Opioid Misuse Measure (COMM), and analgesic medication preferences for previous ED visits for pain with specific responses for preference for hydromorphone (Dilaudid®), morphine, ketorolac (Toradol®), "no preference" or "never visited the ED for pain." We compared individuals who reported a lifetime history of overdose descriptively to those without a lifetime history of overdose. Logistic regression was used to determine factors associated with a history of overdose. RESULTS We included 2,233 adults in the analysis (71.5% response rate of patients approached) with 532 reporting at least one lifetime overdose. In the univariate analysis, medication preference was significantly associated with overdose history (p < .001); more patients in the overdose group reported preferring morphine and hydromorphone and those without a history of overdose were more likely to have no preference or say they had never visited the ED for pain. In the logistic regression analysis, patients with higher odds of overdose included those of Caucasian race, participants with a higher COMM score, preference for ketorolac, morphine or hydromorphone. Those who were younger, female and reported never having visited the ED for pain had lower odds of reporting a lifetime overdose. Having "any preference" corresponded to 48% higher odds of lifetime overdose. CONCLUSION Patients with a pain medication preference have higher odds of having a lifetime overdose compared to patients without a specific pain medication preference, even after accounting for level of opioid misuse. This patient-reported preference could cue emergency physicians to identifying high-risk patients for overdose and other substance-related harms.
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Affiliation(s)
- Lauren K. Whiteside
- University of Washington, Department of Emergency Medicine, Seattle, Washington
| | - Jason Goldstick
- University of Michigan Medical School, University of Michigan Injury Center, Ann Arbor, Michigan
| | - Aaron Dora-Laskey
- University of Michigan Medical School, University of Michigan Injury Center, Ann Arbor, Michigan
- University of Michigan Medical School, Department of Emergency Medicine, Ann Arbor, Michigan
| | - Laura Thomas
- University of Michigan Medical School, Addiction Center and Department of Psychiatry, Ann Arbor, Michigan
- VA Center for Clinical Management Research, Department of Veterans Affairs Healthcare System, Ann Arbor, Michigan
| | - Maureen Walton
- University of Michigan Medical School, University of Michigan Injury Center, Ann Arbor, Michigan
- University of Michigan Medical School, Addiction Center and Department of Psychiatry, Ann Arbor, Michigan
| | - Rebecca Cunningham
- University of Michigan Medical School, University of Michigan Injury Center, Ann Arbor, Michigan
- University of Michigan Medical School, Department of Emergency Medicine, Ann Arbor, Michigan
| | - Amy S.B. Bohnert
- University of Michigan Medical School, University of Michigan Injury Center, Ann Arbor, Michigan
- University of Michigan Medical School, Addiction Center and Department of Psychiatry, Ann Arbor, Michigan
- VA Center for Clinical Management Research, Department of Veterans Affairs Healthcare System, Ann Arbor, Michigan
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Zuckerman M, Vo T. Recurrent Ethylene Glycol Poisoning with Elevated Lactate Levels to Obtain Opioid Medications. J Emerg Med 2018; 54:815-818. [PMID: 29627349 DOI: 10.1016/j.jemermed.2018.01.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 12/22/2017] [Accepted: 01/25/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Malingering is when a patient feigns illness for secondary gain. While most patients with malingering manufacture or exaggerate symptoms, some patients may induce illness. Previous reports of malingering patients inducing illness include sepsis, kidney pain, migraine, and chest pain. However, acute poisoning as a manifestation of malingering appears to be rare. CASE REPORT We describe the case of a 39-year-old man who presented to the emergency department complaining of diffuse body pain. The patient reported multiple admission at outside hospitals for "lactate" and said, "it feels like it is happening again because of how my body feels." Laboratory findings were concerning for serum lactate of >20.0 mmol/L and ethylene glycol (EG) level of 19 mg/dL. A chart review found that the man had been admitted for elevated serum lactate 8 times to area hospitals in several years, often in the setting of EG poisoning. During these episodes he required intravenous fluids and frequent intravenous pain medications. When confronted about concern regarding the recurrent fallacious lactate levels in the setting of factitious EG ingestion, the patient often became combative and left against medical advice. The primary metabolite of EG, glycolic acid, can interfere with lactate assays, causing a false elevation. Our patient apparently recognized this and took advantage of it to be admitted and receive intravenous opioids. This is the only case known to us of malingering via EG ingestion. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians should be aware that metabolites of EG may interfere with serum lactate assay. In addition, they should be aware of possible malingering-related poisoning and plausible association with requests for intravenous opioid pain medications. This represents a risk to the patient and others if undiagnosed.
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Affiliation(s)
- Matthew Zuckerman
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Tim Vo
- Denver Health and Hospital Authority, Department of Emergency Medicine, Denver, Colorado
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Janakiram C, Chalmers NI, Fontelo P, Huser V, Lopez Mitnik G, Iafolla TJ, Brow AR, Dye BA. Sex and race or ethnicity disparities in opioid prescriptions for dental diagnoses among patients receiving Medicaid. J Am Dent Assoc 2018; 149:246-255. [PMID: 29599018 PMCID: PMC6152927 DOI: 10.1016/j.adaj.2018.02.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Revised: 02/09/2018] [Accepted: 02/12/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND The objective of this study was to identify specific factors (sex, race or ethnicity, and health care provider type) associated with patient receipt of an opioid prescription after a dental diagnosis. METHODS The authors used Medicaid claims dated from January 1, 2013, through September 30, 2015, for 13 US states in this study. The authors identified oral health-related conditions by using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes 520.0 through 529.9. RESULTS During the 2013-2015 study period, among the more than 890,000 Medicaid patients with a dental diagnosis, 23% received an opioid within 14 days of diagnosis. Female patients were 50% more likely to receive an opioid for pain management of a dental condition than were men (odds ratio [OR], 1.53; 95% confidence interval [CI], 1.52 to 1.55). Non-Hispanic whites and African Americans were approximately twice as likely to receive opioids than were Hispanics (OR, 2.11; 95% CI, 2.05 to 2.17 and OR, 1.88; 95% CI, 1.83 to 1.93, respectively). Patients receiving oral health care in an emergency department were nearly 5 times more likely to receive an opioid prescription than were patients treated in a dental office (OR, 4.66; 95% CI, 4.59 to 4.74). Patients with a dental condition diagnosed were nearly 3 times as likely to receive an opioid from a nurse practitioner as from a dentist (OR, 2.64; 95% CI, 2.57 to 2.70). Opioid use was substantially higher among African American female patients (OR, 3.29; 95% CI, 3.18 to 3.40) and non-Hispanic white female patients (OR, 3.24; 95% CI, 3.14 to 3.35) than among Hispanic female patients. CONCLUSIONS Opioid prescribing patterns differ depending on patient race or ethnicity, sex, and health care provider source in patients with a dental diagnosis in the United States. PRACTICAL IMPLICATIONS Dentists are providing substantially less opioid prescriptions compared to their medical colleagues for pain treatment following a dental diagnosis in the Medicaid population. When considering pain management for dental and related conditions, dentists should continue with conservative prescribing practices as recommended.
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Elder JW, DePalma G, Pines JM. Optimal Implementation of Prescription Drug Monitoring Programs in the Emergency Department. West J Emerg Med 2018; 19:387-391. [PMID: 29560070 PMCID: PMC5851515 DOI: 10.5811/westjem.2017.12.35957] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 12/20/2017] [Accepted: 12/19/2017] [Indexed: 11/11/2022] Open
Abstract
The opioid epidemic is the most significant modern-day, public health crisis. Physicians and lawmakers have developed methods and practices to curb opioid use. This article describes one method, prescription drug monitoring programs (PDMP), through the lens of how to optimize use for emergency departments (ED). EDs have rapidly become a central location to combat opioid abuse and drug diversion. PDMPs can provide emergency physicians with comprehensive prescribing information to improve clinical decisions around opioids. However, PDMPs vary tremendously in their accessibility and usability in the ED, which limits their effectiveness at the point of care. Problems are complicated by varying state-to-state requirements for data availability and accessibility. Several potential solutions to improving the utility of PDMPs in EDs include integrating PDMPs with electronic health records, implementing unsolicited reporting and prescription context, improving PDMP accessibility, data analytics, and expanding the scope of PDMPs. These improvements may help improve clinical decision-making for emergency physicians through better data, data presentation, and accessibility.
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Affiliation(s)
- Joshua W Elder
- University of California Davis School of Medicine, Department of Emergency Medicine, Sacramento, California
| | - Garrett DePalma
- University of California Davis School of Medicine, Department of Emergency Medicine, Sacramento, California.,The George Washington University School of Medicine and Health Sciences, Departments of Emergency Medicine and Health Policy & Management, Washington, District of Columbia
| | - Jesse M Pines
- The George Washington University School of Medicine and Health Sciences, Departments of Emergency Medicine and Health Policy & Management, Washington, District of Columbia
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20
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Pierson RC, Gufford BT, Desta Z, Eadon MT. Clinical and educational impact of pharmacogenomics testing: a case series from the INGENIOUS trial. Pharmacogenomics 2017; 18:835-841. [PMID: 28594278 DOI: 10.2217/pgs-2017-0042] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Pharmacogenomic testing has become increasingly widespread. However, there remains a need to bridge the gap between test results and providers lacking the expertise required to interpret these results. The Indiana Genomics Implementation trial is underway at our institution to examine total healthcare cost and patient outcomes after genotyping in a safety-net healthcare system. As part of the study, trial investigators and clinical pharmacology fellows interpret genotype results, review patient histories and medication lists and evaluate potential drug-drug interactions. We present a case series of patients in whom pharmacogenomic consultations aided providers in appropriately applying pharmacogenomic results within the clinical context. Formal consultations not only provide valuable patient care information but educational opportunities for the fellows to cement pharmacogenomic concepts.
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Affiliation(s)
- Rebecca C Pierson
- Department of Obstetrics, Gynecology & Women's Health, University of Louisville, KY 40202, USA
| | - Brandon T Gufford
- Department of Medicine, Division of Clinical Pharmacology, Indiana University, IN 46202, USA
| | - Zeruesenay Desta
- Department of Medicine, Division of Clinical Pharmacology, Indiana University, IN 46202, USA
| | - Michael T Eadon
- Department of Medicine, Division of Clinical Pharmacology, Indiana University, IN 46202, USA.,Department of Medicine, Division of Nephrology, Indiana University, IN 46202, USA
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Seymour RB, Leas D, Wally MK, Hsu JR. Prescription reporting with immediate medication utilization mapping (PRIMUM): development of an alert to improve narcotic prescribing. BMC Med Inform Decis Mak 2016; 16:111. [PMID: 27549364 PMCID: PMC4994311 DOI: 10.1186/s12911-016-0352-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 08/18/2016] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Rachel B. Seymour
- Department of Orthopaedic Surgery, Carolinas Health Care System, 1000 Blythe Boulevard, Charlotte, 28203 NC USA
- Carolinas Trauma Network Research Center of Excellence, Carolinas Health Care System, 1320 Scott Avenue, Charlotte, NC 28204 USA
| | - Daniel Leas
- Department of Orthopaedic Surgery, Carolinas Health Care System, 1000 Blythe Boulevard, Charlotte, 28203 NC USA
- Carolinas Trauma Network Research Center of Excellence, Carolinas Health Care System, 1320 Scott Avenue, Charlotte, NC 28204 USA
| | - Meghan K. Wally
- Department of Orthopaedic Surgery, Carolinas Health Care System, 1000 Blythe Boulevard, Charlotte, 28203 NC USA
- Carolinas Trauma Network Research Center of Excellence, Carolinas Health Care System, 1320 Scott Avenue, Charlotte, NC 28204 USA
| | - Joseph R. Hsu
- Department of Orthopaedic Surgery, Carolinas Health Care System, 1000 Blythe Boulevard, Charlotte, 28203 NC USA
- Carolinas Trauma Network Research Center of Excellence, Carolinas Health Care System, 1320 Scott Avenue, Charlotte, NC 28204 USA
| | - the PRIMUM Group
- Department of Orthopaedic Surgery, Carolinas Health Care System, 1000 Blythe Boulevard, Charlotte, 28203 NC USA
- Carolinas Trauma Network Research Center of Excellence, Carolinas Health Care System, 1320 Scott Avenue, Charlotte, NC 28204 USA
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Singhal A, Tien YY, Hsia RY. Racial-Ethnic Disparities in Opioid Prescriptions at Emergency Department Visits for Conditions Commonly Associated with Prescription Drug Abuse. PLoS One 2016; 11:e0159224. [PMID: 27501459 PMCID: PMC4976905 DOI: 10.1371/journal.pone.0159224] [Citation(s) in RCA: 180] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 06/29/2016] [Indexed: 11/18/2022] Open
Abstract
Prescription drug abuse is a growing problem nationally. In an effort to curb this problem, emergency physicians might rely on subjective cues such as race-ethnicity, often unknowingly, when prescribing opioids for pain-related complaints, especially for conditions that are often associated with drug-seeking behavior. Previous studies that examined racial-ethnic disparities in opioid dispensing at emergency departments (EDs) did not differentiate between prescriptions at discharge and drug administration in the ED. We examined racial-ethnic disparities in opioid prescription at ED visits for pain-related complaints often associated with drug-seeking behavior and contrasted them with conditions objectively associated with pain. We hypothesized a priori that racial-ethnic disparities will be present among opioid prescriptions for conditions associated with non-medical use, but not for objective pain-related conditions. Using data from the National Hospital Ambulatory Medical Care Survey for 5 years (2007-2011), the odds of opioid prescription during ED visits made by non-elderly adults aged 18-65 for 'non-definitive' conditions (toothache, back pain and abdominal pain) or 'definitive' conditions (long-bone fracture and kidney stones) were modeled. Opioid prescription at discharge and opioid administration at the ED were the primary outcomes. We found significant racial-ethnic disparities, with non-Hispanic Blacks being less likely (adjusted odds ratio ranging from 0.56-0.67, p-value < 0.05) to receive opioid prescription at discharge during ED visits for back pain and abdominal pain, but not for toothache, fractures and kidney stones, compared to non-Hispanic whites after adjusting for other covariates. Differential prescription of opioids by race-ethnicity could lead to widening of existing disparities in health, and may have implications for disproportionate burden of opioid abuse among whites. The findings have important implications for medical provider education to include sensitization exercises towards their inherent biases, to enable them to consciously avoid these biases from defining their practice behavior.
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Affiliation(s)
- Astha Singhal
- Health Policy and Health Services Research, Boston University School of Dental Medicine, Boston, Massachusetts, United States of America
| | - Yu-Yu Tien
- University of Iowa College of Pharmacy, Iowa City, Iowa, United States of America
| | - Renee Y. Hsia
- Department of Emergency Medicine and Philip R. Lee Institute for Health Policy Studies, University of California at San Francisco, San Francisco, California, United States of America
- * E-mail:
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Varney SM, Bebarta VS, Mannina LM, Ramos RG, Ganem VJ, Carey KR. Emergency medicine providers' opioid prescribing practices stratified by gender, age, and years in practice. World J Emerg Med 2016; 7:106-10. [PMID: 27313804 DOI: 10.5847/wjem.j.1920-8642.2016.02.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Emergency medicine providers (EMPs) prescribe about 25% of opioids, but the effect of EMP risk perception on decisions to prescribe opioids is unknown. This study was undertaken to identify factors that influence EMP risk and opioid prescribing practices. METHODS We distributed an anonymous questionnaire to EMPs at a military trauma and referral center. Response frequencies and distributions were assessed for independence using the Chi-square test. RESULTS Eighty-nine EMPs completed the questionnaire (100% response). Respondents were primarily younger male physicians (80%) in practice under five years (55%). Male EMPs were more likely to prescribe more opioid tablets than female ones both when and when not concerned for opioid misuse (P<0.001, P<0.007, respectively). Of the providers, 70% stated that patient age would influence their prescribing decisions. Hydrocodone and oxycodone were the opioids prescribed most frequently. About 60% of the providers reported changing their prescribing behavior would not prevent opioid misuse. Additionally, 40% of the providers believed at least 10% of patients seen at this military ED misused opioids. CONCLUSION Female EM providers reported prescribing fewer opioid tablets. Patient age influenced prescribing behavior, but the effect is unknown. Finally, EM providers reported that altering their prescribing behavior would not prevent prescription opioid misuse.
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Affiliation(s)
- Shawn M Varney
- Department of Emergency Medicine, University of Texas Health Science Center, San Antonio 78229, USA
| | - Vikhyat S Bebarta
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora 80045, USA
| | - Lisa M Mannina
- Department of Emergency Medicine, Mike O'Callaghan Federal Medical Center, Nellis 89191, USA
| | - Rosemarie G Ramos
- Department of Emergency Medicine, University of Texas Health Science Center, San Antonio 78229, USA
| | - Victoria J Ganem
- Air Force Enroute Care Research Center, Fort Sam Houston 78208, USA; The Geneva Foundation, Tacoma 98402, USA
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Sanders AN, Eassey JM, Stogner JM, Miller BL. Deception and Drug Acquisition: Correlates of "Success" Among Drug-Seeking Patients. J Prim Care Community Health 2016; 7:175-9. [PMID: 26846509 DOI: 10.1177/2150131916628462] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE Most research examining patient-based drug diversion neglects to assess physician deception directly. We attempt to determine if motives for deception are linked to success, and, similarly, if any health, demographic, or substance use history characteristics of the patients are predictive of being able to successfully deceive a physician. METHODS Stratified random sampling was utilized to obtain a sample of 2349 young adults. Respondents completed a survey detailing their substance use histories and whether they had ever deceived a physician for medication. Ninety-three of these respondents reported attempting to deceive a physician for a medication and compose the analytic sample for the study. RESULTS Of the 93 young adults who reported having attempted to deceive a physician for pharmaceuticals (4.0% of the general sample), 64 (68.8%) were successful. This included 24 only seeking medications for their own use, 9 only for financial purposes, and 31 with both motives. Respondents who reported recreationally using pharmaceuticals in the past were more likely to report successful attempts at obtaining a prescription compared with respondents without a history of abuse. With respect to demographic characteristics of the respondents, only race/ethnicity distinguished between successful attempts and failure. CONCLUSIONS Although a rare occurrence in the overall sample, significant correlates of successful deception did emerge. Respondents motivated to obtain a prescription in order to sell it to others were overwhelmingly likely to succeed in their pursuit to deceive as compared with respondents who sought prescriptions for their own abuse. Successful deceivers were also more likely to have been legitimately prescribed medication in the past. Successful respondents were more likely to be Caucasian than any other race/ethnicity.
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Affiliation(s)
| | | | - John M Stogner
- University of North Carolina at Charlotte, Charlotte, NC, USA
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Amlani A, Grewal GS, Feldman MD. Malingering by Proxy: A Literature Review and Current Perspectives. J Forensic Sci 2015; 61 Suppl 1:S171-6. [DOI: 10.1111/1556-4029.12977] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 03/30/2015] [Accepted: 04/18/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Adam Amlani
- The University of Alabama Tuscaloosa; AL c/o 2609 Crowne Ridge Court Birmingham AL 35243-5351
| | - Gurinder S. Grewal
- The University of Alabama Tuscaloosa; AL c/o 2609 Crowne Ridge Court Birmingham AL 35243-5351
| | - Marc D. Feldman
- The University of British Columbia; 2329 West Mall Vancouver BC Canada V6T 1Z4
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Weiner SG, Griggs CA, Langlois BK, Mitchell PM, Nelson KP, Friedman FD, Feldman JA. Characteristics of Emergency Department “Doctor Shoppers”. J Emerg Med 2015; 48:424-31.e1. [DOI: 10.1016/j.jemermed.2014.11.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Revised: 10/23/2014] [Accepted: 11/16/2014] [Indexed: 11/26/2022]
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Mannina L, Varney SM, Bebarta VS, Ganem VJ, Carey KR, Ramos RG. "Hard" and "soft" patient cues that influence ED prescribing for potential opioid misusers. Am J Emerg Med 2014; 33:109-11. [PMID: 25445857 DOI: 10.1016/j.ajem.2014.09.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 09/26/2014] [Accepted: 09/26/2014] [Indexed: 10/24/2022] Open
Affiliation(s)
- Lisa Mannina
- SAUSHEC Emergency Medicine PGYII, San Antonio Military Medical Center, San Antonio, TX.
| | - Shawn M Varney
- Department of Emergency Medicine, San Antonio Military Medical Center, San Antonio, TX.
| | - Vikhyat S Bebarta
- Department of Emergency Medicine, San Antonio Military Medical Center and Air Force Enroute Care Research Center, San Antonio, TX.
| | - Victoria J Ganem
- Department of Emergency Medicine, San Antonio Military Medical Center and Air Force Enroute Care Research Center, San Antonio, TX.
| | | | - Rose G Ramos
- Department of Emergency Medicine, San Antonio Military Medical Center, San Antonio, TX.
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