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Janssens WH, Van Den Noortgate NJ, Mouton V, Desmet P, Van Puyvelde K, Steen E, Maere C, Van Mulders K, De Raes E, Dekoninck J, Kympers C, Werbrouck B, Delaere J, Piers RD. Opioids in geriatric units in 14 Belgian hospitals: prevalence, dosage and associated factors. Ann Med 2024; 56:2310132. [PMID: 38294956 PMCID: PMC10833115 DOI: 10.1080/07853890.2024.2310132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 01/19/2024] [Indexed: 02/02/2024] Open
Abstract
Introduction: Adverse effects of opioids are common among older individuals, and undertreatment as well as overuse can be an issue. Epidemiological data on opioid use in older individuals are available, but scarce in hospitalized patients.Aims: The aim of this study is to examine the one-day prevalence of opioid use among older inpatients and identify the factors associated with both opioid use and dosage.Materials and methods: One-day cross-sectional study with data collected from geriatric units across 14 Belgian hospitals. The primary focus of the study is to assess the prevalence of opioid use and dosage, along with identifying associated factors. To achieve this, a multiple binary logistic regression model was fitted for opioid use, and a multiple linear regression model for opioid dose.Results: Opioids were used in 24.4% of 784 patients, of which 57.9% was treated with tramadol, 13.2% with oxycodone or morphine and 28.9% with transdermal buprenorphine or fentanyl. The odds for opioid use were 4.2 times higher in patients in orthogeriatric units compared to other patients (OR=4.2, 95% CI=2.50-7.05). The prevalence of opioid use was 34% higher in patients without dementia compared to patients with dementia (OR=0.66, 95% CI=0.46-0.95). The overall mean daily dosage was 14.07mg subcutaneous morphine equivalent. After adjustment for age, gender and dementia, dosage was only associated with type of opioid: the estimated mean opioid dose was 70% lower with tramadol (mean ratio=0,30,95% CI=0,23-0,39) and 67% lower with oxycodone and morphine (mean ratio=0,33, 95% CI=0,22-0,48) compared to transdermal buprenorphine and transdermal fentanyl.Conclusions: One in four patients received opioid treatment. It is not clear whether this reflects under- or overtreatment, but these results can serve as a benchmark for geriatric units to guide future pain management practices. The utilization of transdermal fentanyl and buprenorphine, resulting in higher doses of morphine equivalent, poses significant risks for side effects.
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Affiliation(s)
- Wim Henri Janssens
- Department of Geriatrics, University Hospital Ghent, Ghent, Belgium
- Department of Geriatrics, AZ Oudenaarde, Oudenaarde, Belgium
| | | | - Veerle Mouton
- Department of Geriatrics, AZ Groeninge, Kortrijk, Belgium
| | - Peter Desmet
- Department of Geriatrics, VITAZ, Sint-Niklaas, Belgium
| | | | - Elke Steen
- Department of Geriatrics, AZ Sint-Lucas Gent, Ghent, Belgium
| | - Caroline Maere
- Department of Geriatrics, AZ Sint-Lucas Brugge, Bruges, Belgium
| | | | | | | | | | - Bart Werbrouck
- Department of Geriatrics, AZ Jan Yperman, Ypres, Belgium
| | | | - Ruth D. Piers
- Department of Geriatrics, University Hospital Ghent, Ghent, Belgium
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Jarman MP, Jin G, Chen A, Losina E, Weissman JS, Berry SD, Salim A. Short-term outcomes of prehospital opioid pain management for older adults with fall-related injury. J Am Geriatr Soc 2024; 72:1384-1395. [PMID: 38418369 PMCID: PMC11090711 DOI: 10.1111/jgs.18830] [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: 12/06/2023] [Revised: 02/02/2024] [Accepted: 02/07/2024] [Indexed: 03/01/2024]
Abstract
BACKGROUND Opioids are recommended for pain management in patients being cared for and transported by emergency medical services, but no specific guidelines exist for older adults with fall-related injury. Prior research suggests prehospital opioid administration can effectively manage pain in older adults, but less is known about safety in this population. We compared short-term safety outcomes, including delirium, disposition, and length of stay, among older adults with fall-related injury according to whether they received prehospital opioid analgesia. METHODS We linked Medicare claims data with prehospital patient care reports for older adults (≥65) with fall-related injury in Illinois between January 1, 2014 and December 31, 2015. We used weighted regression models (logistic, multinomial logistic, and Poisson) to assess the association between prehospital opioid analgesia and incidence of inpatient delirium, hospital disposition, and length of stay. RESULTS Of 28,150 included older adults, 3% received prehospital opioids. Patients receiving prehospital opioids (vs. no prehospital opioids) were less likely to be discharged home from the emergency department (adjusted probability = 0.30 [95% CI: 0.25, 0.34] vs. 0.47 [95% CI: 0.46, 0.48]), more likely to be discharged to a non-home setting after an inpatient admission (adjusted probability = 0.43 [95% CI: 0.39, 0.48] vs. 0.30 [95% CI: 0.30, 0.31]), had inpatient length of stay 0.4 days shorter (p < 0.001) and ICU length of stay 0.7 days shorter (p = 0.045). Incidence of delirium did not vary between treatment and control groups. CONCLUSIONS Few older adults receive opioid analgesia in the prehospital setting. Prehospital opioid analgesia may be associated with hospital disposition and length of stay for older adults with fall-related injury. However, our findings do not provide evidence of an association with inpatient delirium. These findings should be considered when developing guidelines for prehospital pain management specific to the older adult population.
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Affiliation(s)
- Molly P Jarman
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Ginger Jin
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Annie Chen
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Elena Losina
- Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Joel S Weissman
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Sarah D Berry
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Hinda and Arthur Marcus Institute for Aging Research and Department of Medicine, Hebrew SeniorLife, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Ali Salim
- Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
- Division of Trauma, Burn, and Surgical Critical Care, Brigham and Woemn's Hospital, Boston, Massachusetts, United States
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Aghaie Meybodi M, Shah V, Razdan R, Amer K, Ahlawat S. National Trends and Predictors of Opioid Administration in Patients Presenting With Abdominal Pain to the Emergency Department (2010-2018). Gastroenterol Nurs 2024; 47:122-128. [PMID: 38567855 DOI: 10.1097/sga.0000000000000795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 09/27/2023] [Indexed: 04/05/2024] Open
Abstract
Given the current opioid crisis, in this study, we assess the national trend and factors associated with opioid administration for patients presenting to the emergency department with abdominal pain. This is a retrospective cross-sectional study conducted using the National Hospital Ambulatory Medical Care Survey from 2010 to 2018. Weighted multiple logistic regression was applied to assess the independent factors associated with opioid administration in the emergency department. Trends of opioid administration were evaluated using the linear trend analysis. There were an estimated total of 100,925,982 emergency department visits for abdominal pain. Overall, opioid was administered in 16.8% of visits. Age less than 25 years was associated with lower odds of receiving opioids. Patients living in the Northeast had the lower odds of receiving opioids (odds ratio [OR] = 0.82, p = .006) than patients living in the Midwest. Patients in the West had the highest odds of receiving opioids (OR = 1.16, p = .01). Non-Hispanic White patients had higher odds of opioid administration (OR = 1.29, p < .001). Trend analysis demonstrated a statistically significant reduction in opioid administration. From 2010 to 2018, opioid administration has approximately decreased in half. Living in the West and the non-Hispanic White racial group were the significant factors associated with a higher risk of opioid administration.
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Affiliation(s)
- Mohamad Aghaie Meybodi
- Mohamad Aghaie Meybodi, MD, is at Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey
- Vraj Shah, MD, is at Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey
- Reena Razdan, MD, is at Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey
- Kamal Amer, MD, is at Department of Medicine and Division of Gastroenterology and Hepatology, Rutgers New Jersey Medical School, Newark, New Jersey
- Sushil Ahlawat, MD, is at Department of Medicine and Division of Gastroenterology and Hepatology, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Vraj Shah
- Mohamad Aghaie Meybodi, MD, is at Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey
- Vraj Shah, MD, is at Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey
- Reena Razdan, MD, is at Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey
- Kamal Amer, MD, is at Department of Medicine and Division of Gastroenterology and Hepatology, Rutgers New Jersey Medical School, Newark, New Jersey
- Sushil Ahlawat, MD, is at Department of Medicine and Division of Gastroenterology and Hepatology, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Reena Razdan
- Mohamad Aghaie Meybodi, MD, is at Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey
- Vraj Shah, MD, is at Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey
- Reena Razdan, MD, is at Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey
- Kamal Amer, MD, is at Department of Medicine and Division of Gastroenterology and Hepatology, Rutgers New Jersey Medical School, Newark, New Jersey
- Sushil Ahlawat, MD, is at Department of Medicine and Division of Gastroenterology and Hepatology, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Kamal Amer
- Mohamad Aghaie Meybodi, MD, is at Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey
- Vraj Shah, MD, is at Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey
- Reena Razdan, MD, is at Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey
- Kamal Amer, MD, is at Department of Medicine and Division of Gastroenterology and Hepatology, Rutgers New Jersey Medical School, Newark, New Jersey
- Sushil Ahlawat, MD, is at Department of Medicine and Division of Gastroenterology and Hepatology, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Sushil Ahlawat
- Mohamad Aghaie Meybodi, MD, is at Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey
- Vraj Shah, MD, is at Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey
- Reena Razdan, MD, is at Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey
- Kamal Amer, MD, is at Department of Medicine and Division of Gastroenterology and Hepatology, Rutgers New Jersey Medical School, Newark, New Jersey
- Sushil Ahlawat, MD, is at Department of Medicine and Division of Gastroenterology and Hepatology, Rutgers New Jersey Medical School, Newark, New Jersey
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Barrington G, Davis K, Aandahl Z, Hose BA, Arthur M, Tran V. Influences of Software Changes on Oxycodone Prescribing at an Australian Tertiary Emergency Department: A Retrospective Review. PHARMACY 2024; 12:44. [PMID: 38525724 PMCID: PMC10961781 DOI: 10.3390/pharmacy12020044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 02/19/2024] [Accepted: 02/28/2024] [Indexed: 03/26/2024] Open
Abstract
Opioid prescribing and dispensing from emergency departments is a noteworthy issue given widespread opioid misuse and diversion in many countries, contributing both physical and economic harm to the population. High patient numbers and the stochastic nature of acute emergency presentations to emergency departments (EDs) introduce challenges for prescribers who are considering opioid stewardship principles. This study investigated the effect of changes to electronic prescribing software on prescriptions with an auto-populated quantity of oxycodone immediate release (IR) from an Australian tertiary emergency department following the implementation of national recommendations for reduced pack sizes. A retrospective review of oxycodone IR prescriptions over two six-month periods between 2019 and 2021 was undertaken, either side of a software adjustment to reduce the default quantities of tablets prescribed from 20 to 10. Patient demographic details were collected, and prescriber years of practice calculated for inclusion in linear mixed effects regression modelling. A reduction in the median number of tablets prescribed per prescription following the software changes (13.5 to 10.0, p < 0.001) with little change in the underlying characteristics of the patient or prescriber populations was observed, as well as an 11.65% reduction in the total number of tablets prescribed. The prescriber's years of practice, patient age and patient sex were found to influence increased prescription sizes. Reduced quantity of oxycodone tablets prescribed was achieved by alteration of prescribing software prefill parameters, providing further evidence to support systems-based policy interventions to influence health care providers behaviour and to act as a forcing function for prescribers to consider opioid stewardship principles.
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Affiliation(s)
- Giles Barrington
- Royal Hobart Hospital, Tasmanian Health Service, Hobart 7000, Australia; (B.-A.H.); (M.A.); (V.T.)
| | | | - Zach Aandahl
- School of Natural Sciences, University of Tasmania, Hobart 7000, Australia;
| | - Brodie-Anne Hose
- Royal Hobart Hospital, Tasmanian Health Service, Hobart 7000, Australia; (B.-A.H.); (M.A.); (V.T.)
| | - Mitchell Arthur
- Royal Hobart Hospital, Tasmanian Health Service, Hobart 7000, Australia; (B.-A.H.); (M.A.); (V.T.)
| | - Viet Tran
- Royal Hobart Hospital, Tasmanian Health Service, Hobart 7000, Australia; (B.-A.H.); (M.A.); (V.T.)
- School of Medicine, University of Tasmania, Hobart 7000, Australia
- Menzies Institute for Medical Research, University of Tasmania, Hobart 7000, Australia
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Boley S, Sidebottom A, Stenzel A, Watson D. Racial Disparities in Opioid Administration Practices Among Undifferentiated Abdominal Pain Patients in the Emergency Department. J Racial Ethn Health Disparities 2024; 11:416-424. [PMID: 36795292 DOI: 10.1007/s40615-023-01529-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 01/22/2023] [Accepted: 01/27/2023] [Indexed: 02/17/2023]
Abstract
OBJECTIVES The purpose of this study was to examine racial disparities in opioid prescribing practices for patients presenting to the emergency department (ED) with a common chief complaint of abdominal pain. METHODS Treatment outcomes were compared for non-Hispanic White (NH White), non-Hispanic Black (NH Black), and Hispanic patients seen over 12 months in three emergency departments in the Minneapolis/St. Paul metropolitan area. Multivariable logistic regression models were used to estimate odds ratios (OR) with 95% confidence intervals (CI) to measure the associations between race/ethnicity and outcomes of opioid administration during ED visits and discharge opioid prescriptions. RESULTS A total of 7309 encounters were included in the analysis. NH Black (n = 1988) and Hispanic patients (n = 602) were more likely than NH White patients (n = 4179) to be in the 18-39 age group (p < 0. 001). NH Black patients were more likely to report public insurance than NH White or Hispanic patients (p < 0.001). After adjusting for confounders, patients who identified as NH Black (OR: 0.64, 95% CI: 0.56-0.74) or Hispanic (OR: 0.78, 95% CI: 0.61-0.98) were less likely to be given opioids during their ED encounter when compared to NH White patients. Similarly, NH Black patients (OR: 0.62, 95% CI: 0.52-0.75) and Hispanic patients (OR: 0.66, 95% CI: 0.49-0.88) were less likely to receive a discharge opioid prescription. CONCLUSIONS These results confirm that racial disparities exist in the ED opioid administration within the department as well as at discharge. Future studies should continue to examine systemic racism as well as interventions to alleviate these health inequities.
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Affiliation(s)
- Sean Boley
- Emergency Care Consultants, Minneapolis, MN, USA.
| | | | - Ashley Stenzel
- Care Delivery Research, Allina Health, Minneapolis, MN, USA
| | - David Watson
- Research Institute, Children's Minnesota, Minneapolis, MN, USA
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Goodwin G, Marra E, Ramdin C, Alexander AB, Ye PP, Nelson LS, Mazer-Amirshahi M. A national analysis of ED presentations for early pregnancy and complications: Implications for post-roe America. Am J Emerg Med 2023; 70:90-95. [PMID: 37245403 DOI: 10.1016/j.ajem.2023.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 04/20/2023] [Accepted: 05/11/2023] [Indexed: 05/30/2023] Open
Abstract
BACKGROUND Most obstetric emergencies are initially managed in the emergency department (ED). The Supreme Court decision of Dobbs v. Jackson Women's Health Organization, overturning Roe v. Wade, in June 2022, eliminated constitutional protection of abortion rights, allowing states to swiftly enact laws that can greatly change reproductive medicine. In this post-Roe landscape, the ambiguity and uncertainty being imposed on clinicians regarding the legality of certain interventions may have catastrophic effects. To understand and plan for the changes that will come and attempt to mitigate adverse outcomes, the authors first assessed the current state of pregnancy-related complication care in the ED setting. This study utilized data obtained from the National Hospital Ambulatory Medical Care Survey (NHAMCS) to evaluate trends in pregnancy-related ED visits from 2016 to 2020 that could be impacted by restricted abortion access and trigger laws. The authors subsequently analyzed the legislative changes and translated the pertinent ones to dispel misunderstandings and provide a framework for appropriate medical practice. METHODS The retrospective study utilized data from the NHAMCS database from 2016 to 2020, encompassing an estimated total of 4,556,778 pregnancy-related ED visits. NHAMCS is a multi-stage probabilistic sample collected by the National Center for Health Statistics (NCHS) at the Centers for Disease Control and Prevention (CDC) using an annual survey of EDs in the United States. All data were summarized using descriptive statistics such as proportions and 95% confidence intervals Furthermore, the supreme court decision was analyzed in addition to multiple state laws and legal texts. The findings were summarized and discussed. RESULTS The majority (79.4%) of all studied visits were for patients between the ages of 18-34 years, capturing those in peak reproductive years. This age group also comprised of the bulk (76.4%) of visits for pathologic pregnancies, including ectopic and molar pregnancies, and 79.8% of visits for a spontaneous miscarriage or threatened miscarriage in early pregnancy. Black patients accounted for 25.7%, white patients 70.1%. Regarding ethnicity, patients were separated into Hispanic and non-Hispanic, with Hispanic patients comprising 27% of all ED visits for included diagnoses between 2016 and 2020. Most visits for complications following an induced abortion occurred in the south (70.8%) and were nearly twice as likely to occur in non-metropolitan areas. Approximately 18% patients presenting with a pathologic pregnancy required admission to the hospital and approximately 50% of those visits for pathologic pregnancies and visits for bleeding in pregnancy had a procedure in the ED (49.8% and 49.5%). There were 111,264 estimated visits in which methotrexate was administered, amounting to approximately 1 in 7 visits for ectopic or molar pregnancy. In this data set, approximately 14,000 miscarriage and early bleeding patients received misoprostol. CONCLUSION Pregnancy-related ED visits comprise of a significant proportion of emergency care. As it relates to many of the trends previously elucidated on, the true extent of the burden cannot be predicted. It must be emphasized that contrary to popular belief, Dobbs v. Jackson does not prohibit termination of pregnancy in the setting of life-threatening conditions to the mother, including ectopic pregnancy, preeclampsia, and others, but the resultant uncertainty and ambiguity surrounding the constitutional change is leading to an over-compliance of the law, necessarily obstructing reproductive health care. The authors recommend that physicians be mindful of the rapidly-evolving laws in their particular state, and to also practice in accordance with Emergency Medical Treatment and Active Labor Act (EMTALA). Patient safety must be prioritized.
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Affiliation(s)
- Glenn Goodwin
- Department of Emergency Medicine, Aventura Hospital and Medical Center, United States of America.
| | - Erin Marra
- Department of Emergency Medicine, Aventura Hospital and Medical Center, United States of America
| | - Christine Ramdin
- Department of Emergency Medicine, Rutgers New Jersey Medical School, United States of America
| | - Andreia B Alexander
- Department of Emergency Medicine, Indiana University School of Medicine, United States of America
| | - Peggy P Ye
- Georgetown University School of Medicine, MedStar Washington Hospital Center, United States of America
| | - Lewis S Nelson
- Department of Emergency Medicine, Rutgers New Jersey Medical School, United States of America
| | - Maryann Mazer-Amirshahi
- Department of Emergency Medicine, MedStar Washington Hospital Center, Georgetown University School of Medicine, United States of America
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Dalton MK, Semco RS, Ordoobadi AJ, Goralnick E, Chovanes J, Salim A, Jarman MP. Opioid administration in the prehospital setting for patients sustaining traumatic injuries: An evaluation of national emergency medical services data. Injury 2022; 53:2923-2929. [PMID: 35437168 PMCID: PMC10018388 DOI: 10.1016/j.injury.2022.03.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 03/16/2022] [Accepted: 03/30/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Despite concerns about long-term dependence, opioids remain the mainstay of treatment for acute pain from traumatic injuries. Additionally, early pain management has been associated with improved long-term outcomes in injured patients. We sought to identify the patterns of prehospital pain management across the United States. METHODS We used 2019 national emergency medical services (EMS) data to identify the use of pain management for acutely injured patients. Opioid specific dosing was calculated in morphine milligram equivalents (MME). The effects of opioids as well as adverse events were identified through objective patient data and structured provider documentation. RESULTS We identified a total of 3,831,768 injured patients, 85% of whom were treated by an advanced life support (ALS) unit. There were 269,281 (7.0%) patients treated with opioids, including a small number of patients intubated by EMS (n = 1537; 0.6%). The median opioid dose was 10 MME [IQR 5-10] and fentanyl was the most commonly used opioid (88.2%). Patients treated with opioids had higher initial pain scores documented by EMS than those not receiving opioids (median: 9 vs 4, p<0.001), and had a median reduction in pain score of 3 points (IQR 1-5) based on the final prehospital pain score. Adverse events associated with opioid administration, including episodes of altered mental status (n = 453; 0.2%) and respiratory compromise (n = 252; 0.1%), were rare. For patients with severe pain (≥8/10), 27.3% of patients with major injuries (ISS ≥15) were treated with opioids, compared with 24.8% of those with moderate injuries (ISS 9-14), and 21.4% of those with minor (ISS 1-8) injuries (p<0.001). CONCLUSION The use of opioids in the prehospital setting significantly reduced pain among injured patients with few adverse events. Despite its efficacy and safety, the majority of patients with major injuries and severe pain do not receive opioid analgesia in the prehospital setting.
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Affiliation(s)
- Michael K Dalton
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, MA, United States; Department of Surgery, Rutgers - New Jersey Medical School, Newark, NJ, United States.
| | - Robert S Semco
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, MA, United States.
| | - Alexander J Ordoobadi
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, MA, United States.
| | - Eric Goralnick
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, MA, United States; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, United States.
| | - John Chovanes
- Division of Trauma, Department of Surgery, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, United States; Section of Military, Diplomatic, and Field Affairs, Cooper University Hospital, Camden, NJ, United States.
| | - Ali Salim
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, MA, United States.
| | - Molly P Jarman
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, MA, United States.
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Ruskin D, Rasul R, McCann-Pineo M. Predictors of Emergency Department Opioid Use Among Adolescents and Young Adults. Pediatr Emerg Care 2022; 38:e1409-e1416. [PMID: 35686972 PMCID: PMC9351695 DOI: 10.1097/pec.0000000000002777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE It is well established that adolescents and young adults are increasingly vulnerable to the effects of early opioid exposures, with the emergency department (ED) playing a critical role in such introduction. Our objective was to identify predictors of ED opioid administration (ED-RX) and prescribing at discharge (DC-RX) among adolescent and young adults using a machine learning approach. METHODS We conducted a secondary analysis of ED visit data from the National Hospital Ambulatory Medical Care Survey from 2014 to 2018. Visits where patients were aged 10 to 24 years were included. Predictors of ED-RX and DC-RX were identified via machine learning methods. Separate weighted logistic regressions were performed to determine the association between each predictor, and ED-RX and DC-RX, respectively. RESULTS There were 12,693 ED visits identified within the study time frame, with the majority being female (58.6%) and White (70.7%). Approximately 12.3% of all visits were administered an opioid during the ED visit, and 11.5% were prescribed one at discharge. For ED-RX, the strongest predictors were fracture injury (odds ratio [OR], 5.24; 95% confidence interval [CI], 3.73-7.35) and Southern geographic region (OR, 3.01; 95% CI, 2.14-4.22). The use of nonopioid analgesics significantly reduced the odds of ED-RX (OR, 0.46; 95% CI, 0.37-0.57). Fracture injury was also a strong predictor of DC-RX (OR, 5.91; 95% CI, 4.24-8.25), in addition to tooth pain (OR, 5.47; 95% CI, 3.84-7.69). CONCLUSIONS Machine learning methodologies were able to identify predictors of ED-RX and DC-RX, which can be used to inform ED prescribing guidelines and risk mitigation efforts among adolescents and young adults.
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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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10
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Chhibba T, Guizzetti L, Seow CH, Lu C, Novak KL, Ananthakrishnan AN, Bernstein CN, Kaplan GG, Panaccione R, Ma C. Frequency of Opioid Prescription at Emergency Department Discharge in Patients with Inflammatory Bowel Disease: A Nationwide Analysis. Clin Gastroenterol Hepatol 2021; 19:2064-2071.e1. [PMID: 32683099 DOI: 10.1016/j.cgh.2020.07.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 07/05/2020] [Accepted: 07/08/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with inflammatory bowel disease (IBD) frequently experience chronic pain. Patients will often seek out care in the emergency department (ED) where short-term opioid use may be associated with potential treatment-related complications. We aimed to assess the rate and factors associated with opioid prescription in IBD patients discharged from the ED. METHODS We conducted a cross-sectional analysis of data collected in the US National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2006-2017. We determined the proportion of adult patients (≥18 years) with IBD prescribed an opioid in ED or at ED discharge. Logistic regression was used to evaluate predictors of opioid prescription. Time-trend analysis was performed to evaluate temporal patterns in opioid use. All analyses were adjusted for complex survey design. RESULTS We identified ∼965,000 weighted discharges from the ED for patients with IBD. In total, 51.9% [95% CI: 42.2% -61.6%] of visits resulted in opioid administration in ED and 35.3% [95% CI: 26.5% -45.2%] of IBD-related ED discharges were associated with an opioid prescription. IBD patients with moderate/severe pain (adjusted odds ratio aOR 5.06 [95% CI: 1.72 -14.90], p < 0.01) were more likely to receive opioids whereas older age (aOR 0.73 per decade [95% CI: 0.55 -0.98], p = 0.04) were less likely. In temporal analysis, a trend towards decreasing opioid use in ED and opioid prescriptions at discharge was observed in 2015-2017. CONCLUSIONS More than one third of IBD patients are prescribed an opioid at discharge from ED, highlighting a potential gap in care for accessing effective pain management solutions in this population.
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Affiliation(s)
- Tarun Chhibba
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Leonardo Guizzetti
- Alimentiv (formerly Robarts Clinical Trials, Inc), London, Ontario, Canada
| | - Cynthia H Seow
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Cathy Lu
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kerri L Novak
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Charles N Bernstein
- Inflammatory Bowel Disease Clinical and Research Centre, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Gilaad G Kaplan
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Remo Panaccione
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Christopher Ma
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Alimentiv (formerly Robarts Clinical Trials, Inc), London, Ontario, Canada.
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11
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Gwam CU, Emara AK, Chughtai N, Javed S, Luo TD, Wang KY, Chughtai M, O'Gara T, Plate JF. Trends and risk factors for opioid administration for non-emergent lower back pain. World J Orthop 2021; 12:700-709. [PMID: 34631453 PMCID: PMC8472449 DOI: 10.5312/wjo.v12.i9.700] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/08/2021] [Accepted: 08/24/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Non-emergent low-back pain (LBP) is one of the most prevalent presenting complaints to the emergency department (ED) and has been shown to contribute to overcrowding in the ED as well as diverting attention away from more serious complaints. There has been an increasing focus in current literature regarding ED admission and opioid prescriptions for general complaints of pain, however, there is limited data concerning the trends over the last decade in ED admissions for non-emergent LBP as well as any subsequent opioid prescriptions by the ED for this complaint.
AIM To determine trends in non-emergent ED visits for back pain; annual trends in opioid administration for patients presenting to the ED for back pain; and factors associated with receiving an opioid-based medication for non-emergent LBP in the ED
METHODS Patients presenting to the ED for non-emergent LBP from 2010 to 2017 were retrospectively identified from the National Hospital Ambulatory Medical Care Survey database. The “year” variable was transformed to two-year intervals, and a weighted survey analysis was conducted utilizing the weighted variables to generate incidence estimates. Bivariate statistics were used to assess differences in count data, and logistic regression was performed to identify factors associated with patients being discharged from the ED with narcotics. Statistical significance was set to a P value of 0.05.
RESULTS Out of a total of 41658475 total ED visits, 3.8% (7726) met our inclusion and exclusion criteria. There was a decrease in the rates of non-emergent back pain to the ED from 4.05% of all cases during 2010 and 2011 to 3.56% during 2016 and 2017. The most common opioids prescribed over the period included hydrocodone-based medications (49.1%) and tramadol-based medications (16.9), with the combination of all other opioid types contributing to 35.7% of total opioids prescribed. Factors significantly associated with being prescribed narcotics included age over 43.84-years-old, higher income, private insurance, the obtainment of radiographic imaging in the ED, and region of the United States (all, P < 0.05). Emergency departments located in the Midwest [odds ratio (OR): 2.42, P < 0.001], South (OR: 2.35, < 0.001), and West (OR: 2.57, P < 0.001) were more likely to prescribe opioid-based medications for non-emergent LBP compared to EDs in the Northeast.
CONCLUSION From 2010 to 2017, there was a significant decrease in the number of non-emergent LBP ED visits, as well as a decrease in opioids prescribed at these visits. These findings may be attributed to the increased focus and regulatory guidelines on opioid prescription practices at both the federal and state levels. Since non-emergent LBP is still a highly common ED presentation, conclusions drawn from opioid prescription practices within this cohort is necessary for limiting unnecessary ED opioid prescriptions.
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Affiliation(s)
- Chukwuweike U Gwam
- Department of Orthopedic Surgery, Wake Forest School of Medicine, Winston-Salem, NC 27157, United States
| | - Ahmed K Emara
- Department of Orthopedic Surgery, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| | - Noor Chughtai
- Department of Orthopedic Surgery, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| | - Sameer Javed
- Department of Orthopedic Surgery, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| | - T David Luo
- Department of Orthopedic Surgery, Wake Forest School of Medicine, Winston-Salem, NC 27157, United States
| | - Kevin Y Wang
- Department of Orthopedic Surgery, Wake Forest School of Medicine, Winston-Salem, NC 27157, United States
| | - Morad Chughtai
- Department of Orthopedic Surgery, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| | - Tadhg O'Gara
- Department of Orthopedic Surgery, Wake Forest School of Medicine, Winston-Salem, NC 27157, United States
| | - Johannes F Plate
- Department of Orthopaedic Surgery, University of Pittsburgh, 5200 Centre Avenue, Suite 415, Pittsburgh, PA 15232, USA
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Khan SR, Heller DA, Latty LL, LaSure M, Brown TV. A Retrospective Study of Psychotropic Drug Use and Prescription Opioid Initiation Among Older Adults. Popul Health Manag 2021; 25:126-133. [PMID: 34402688 DOI: 10.1089/pop.2021.0129] [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: 11/13/2022] Open
Abstract
Individuals with mental health problems may be more vulnerable to using prescription opioids than their counterparts. Therefore, the main objective of this study was to assess the initiation of prescription opioids in older adults who used psychotropic drugs compared with those who did not. The authors used a retrospective cohort design and included a sample of older adults enrolled in Pennsylvania's Pharmaceutical Assistance Contract for the Elderly program who did not use prescription opioids in 2013. Using pharmacy claims, patients who used anxiolytics/sedatives/hypnotics (n = 13,512) or antidepressants (n = 17,492) between October and December 2013 were identified and compared with those who did not use anxiolytics/sedatives/hypnotics (n = 114,091) or antidepressants (n = 110,111) during that period, to determine the incidence of prescription opioid use in 2014. Chi-square tests and multivariate logistic regressions were performed for analyses. Compared with patients who did not use anxiolytics/sedatives/hypnotics, those who used were more likely to initiate prescription opioids (15.0% versus 22.0%, P < .0001). Similarly, compared with patients who did not use antidepressants, those who used were more likely to initiate prescription opioids (14.7% versus 21.9%, P < .0001). Multivariate logistic regression indicated that the odds of prescription opioid initiation increased with anxiolytic/sedative/hypnotic use by 44% (AOR = 1.44; P < .0001) and antidepressant use by 48% (AOR = 1.48; P < .0001) among older adults after adjusting for potential confounding variables. Results showed that prescription opioid initiation is associated with prior anxiolytic/sedative/hypnotic or antidepressant use among older adults. Patients with mental health problems should also be queried about pain experiences for effective treatment.
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Affiliation(s)
- Shivani R Khan
- Magellan Rx Management/PACE, Harrisburg, Pennsylvania, USA
| | - Debra A Heller
- Magellan Rx Management/PACE, Harrisburg, Pennsylvania, USA
| | - Leroy L Latty
- Magellan Rx Management/PACE, Harrisburg, Pennsylvania, USA
| | | | - Theresa V Brown
- Pennsylvania Department of Aging, Bureau of Pharmaceutical Assistance, Harrisburg, Pennsylvania, USA
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Abstract
This paper is the forty-second consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2019 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, 65-30 Kissena Blvd., Flushing, NY, 11367, United States.
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14
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Wang PR, Lopez R, Seballos SS, Campbell MJ, Udeh BL, Phelan MP. Management of migraine in the emergency department: Findings from the 2010-2017 National Hospital Ambulatory Medical Care Surveys. Am J Emerg Med 2021; 41:40-45. [PMID: 33385884 DOI: 10.1016/j.ajem.2020.12.056] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 12/18/2020] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE The study objective was to describe trends in the medical management of migraine in the emergency department (ED) using the 2010-2017 National Hospital Ambulatory Medical Care Survey (NHAMCS) datasets. METHODS Using the 2010-2017 NHAMCS datasets, we analyzed visits with a discharge diagnosis of migraine. Drug prescription frequencies between years were compared with the Rao-Scott chi-squared test. Adjusted odds ratios of opioid administration from 2010 to 2017 were calculated using weighted multivariable logistic regression with sex, age, race/ethnicity, pain-score, primary expected source of payment, and year as predictor variables. RESULTS Our analysis captured 1846 ED visits with a diagnosis of migraine from 2010 to 2017, representing a weighted average of 1.2 million US ED visits per year. Parenteral opioids were prescribed in 49% (95% CI: 40, 58) of visits in 2010 and 28% (95% CI: 15, 45) of visits in 2017 (p = 0.03). From 2010 to 2017, there was a 10% yearly decrease in opioid prescriptions. Metoclopramide and ketorolac were prescribed more frequently in years 2015 through 2017 than in 2010. Increased opioid administration was associated with female sex, older age, white race, higher pain score, and having Medicare or private insurance as the primary expected source of payment for all years. CONCLUSION Opioid administration for migraine in EDs across the US declined 10% annually between 2010 and 2017, demonstrating improved adherence to migraine guidelines recommending against opioids. We identified several factors associated with opioid administration for migraine, identifying groups at higher risk for unnecessary opioids in the ED setting.
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Affiliation(s)
- Philip R Wang
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States of America.
| | - Rocio Lopez
- Center for Populations Health Research, Cleveland Clinic, Cleveland, OH, United States of America; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, United States of America
| | - Spencer S Seballos
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States of America
| | - Matthew J Campbell
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, United States of America
| | - Belinda L Udeh
- Center for Populations Health Research, Cleveland Clinic, Cleveland, OH, United States of America; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, United States of America; Neurological Institute Center for Outcomes Research, Cleveland Clinic, Cleveland, OH, United States of America
| | - Michael P Phelan
- Emergency Services Institute, Cleveland Clinic, Cleveland, OH, United States of America
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15
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Yang C, Stilley JA, Bedy SC, Goddard KB, Sampson CS. Leftover narcotic analgesics among emergency department patients and methods of disposal. J Am Coll Emerg Physicians Open 2020; 1:1486-1492. [PMID: 33392554 PMCID: PMC7771740 DOI: 10.1002/emp2.12161] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 05/07/2020] [Accepted: 05/28/2020] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE Given the increase in narcotic addiction and diversion, understanding how patients use their opioid prescriptions and store or dispose of any remainders is important. We set out to determine the frequency in which patients had leftover opioid quantities from prescriptions received in the emergency department (ED). In addition, we sought to describe patients' reasons for taking or not taking all of their prescribed medications and their strategies to manage and/or dispose of any excess or leftovers. METHODS This cross-sectional study took place at an academic center in an urban environment in mid-Missouri with an annual emergency department volume of 55,000 patients. Potential participants were identified using a patient discharge prescription log and consisted of adult patients who received opioid prescriptions. A single researcher recruited participants via phone and invited them to participate in the study by completing a short phone survey. RESULTS The discharge log included 301 patient encounters; of those, 170 potential participants were successfully contacted by phone and 89 agreed to participate in the survey. A majority of the participants indicated that they did not take the full prescription amount. Only 4.1% of participants disposed of their leftover opioids according to U.S. Food and Drug Administration recommendations. Those who did not dispose of their leftover opioids most frequently stored their remaining medication in a medicine cabinet or box, and a majority (77%) indicated that this storage location was unlocked. CONCLUSIONS A majority of patients discharged from the emergency department have leftover opioids, and almost all of these leftover medications were not disposed of or stored in compliance with US Food and Drug Administration recommendations. Future research to determine what interventions could increase proper storage and disposal of leftover opioids is recommended.
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Affiliation(s)
- Christopher Yang
- One Hospital DriveDepartment of Emergency MedicineUniversity of Missouri School of MedicineColumbiaMissouriUSA
| | - Julie A.W. Stilley
- One Hospital DriveDepartment of Emergency MedicineUniversity of Missouri School of MedicineColumbiaMissouriUSA
| | - Starr‐Mar'ee C. Bedy
- One Hospital DriveDepartment of Emergency MedicineUniversity of Missouri School of MedicineColumbiaMissouriUSA
| | - Kara B. Goddard
- One Hospital DriveDepartment of Emergency MedicineUniversity of Missouri School of MedicineColumbiaMissouriUSA
| | - Christopher S. Sampson
- One Hospital DriveDepartment of Emergency MedicineUniversity of Missouri School of MedicineColumbiaMissouriUSA
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16
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McCann-Pineo M, Ruskin J, Rasul R, Vortsman E, Bevilacqua K, Corley SS, Schwartz RM. Predictors of emergency department opioid administration and prescribing: A machine learning approach. Am J Emerg Med 2020; 46:217-224. [PMID: 33071093 DOI: 10.1016/j.ajem.2020.07.023] [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: 05/05/2020] [Revised: 07/08/2020] [Accepted: 07/10/2020] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION The opioid epidemic has altered normative clinical perceptions on addressing both acute and chronic pain, particularly within the Emergency Department (ED) setting, where providers are now confronted with balancing pain management and potential abuse. This study aims to examine patient sociodemographic and ED clinical characteristics to comprehensively determine predictors of opioid administration during an ED visit (ED-RX) and prescribing upon discharge (DC-RX). METHODS ED visit data of patients ≥18 years old from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2014 to 2017 were used. Opioid prescriptions were determined utilizing Lexicon narcotic drug classifications. Visit characteristics studied included sociodemographic variables, and ED clinical variables, such as chief complaint, and discharge diagnosis. Machine learning methods were used to determine predictors of ED-RX and DC-RX and weighted logistic regressions were performed using selected predictors. RESULTS Of the 44,227 ED visits identified, patients tended to be female (57.4%), and White (74.2%) with an average age of 46.4 years (SE = 0.3). Weighted proportions of ED-RX and DC-RX were 23.2% and 18.9%, respectively. The strongest predictors of ED-RX were CT scan ordered (OR = 2.18, 95% CI = 1.84-2.58), abdominal pain (OR = 1.93, 95% CI:1.59-2.34) and back pain (OR = 1.81, 95% CI:1.45-2.27). Tooth pain (OR = 6.94, 95% CI = 4.40-10.94) and fracture injury diagnoses (OR = 3.76, 95% CI = 2.72-5.19) were the strongest predictors of DC-RX. CONCLUSIONS These findings demonstrate the utility of machine learning for understanding clinical predictors of opioid administration and prescribing in the ED, and its potential in informing standardized prescribing recommendations and guidelines.
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Affiliation(s)
- Molly McCann-Pineo
- Department of Occupational Medicine, Epidemiology and Prevention, Northwell Health, 175 Community Drive, 2nd floor, Great Neck, NY 11021, USA; Department of Occupational Medicine, Epidemiology and Prevention, Northwell Health, 175 Community Drive, 2nd floor, Great Neck, NY 11021, USA; The Feinstein Institutes for Medical Research, Northwell Health, 350 Community Drive, Manhasset, NY 11030, USA; Joint Center for Disaster Health, Trauma and Resilience at Mount Sinai, Stony Brook University and Northwell Health, New York, USA.
| | - Julia Ruskin
- Department of Computer Science, Princeton University, 35 Olden St, Princeton, NJ 08540, USA.
| | - Rehana Rasul
- Department of Occupational Medicine, Epidemiology and Prevention, Northwell Health, 175 Community Drive, 2nd floor, Great Neck, NY 11021, USA; Department of Occupational Medicine, Epidemiology and Prevention, Northwell Health, 175 Community Drive, 2nd floor, Great Neck, NY 11021, USA; The Feinstein Institutes for Medical Research, Northwell Health, 350 Community Drive, Manhasset, NY 11030, USA; Joint Center for Disaster Health, Trauma and Resilience at Mount Sinai, Stony Brook University and Northwell Health, New York, USA.
| | - Eugene Vortsman
- Department of Occupational Medicine, Epidemiology and Prevention, Northwell Health, 175 Community Drive, 2nd floor, Great Neck, NY 11021, USA; Department of Emergency Medicine, Long Island Jewish Medical Center, Northwell Health, 270-05 76th Ave, Queens, NY 11040, USA,.
| | - Kristin Bevilacqua
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD 21205, USA.
| | - Samantha S Corley
- Department of Occupational Medicine, Epidemiology and Prevention, Northwell Health, 175 Community Drive, 2nd floor, Great Neck, NY 11021, USA; The Feinstein Institutes for Medical Research, Northwell Health, 350 Community Drive, Manhasset, NY 11030, USA; Joint Center for Disaster Health, Trauma and Resilience at Mount Sinai, Stony Brook University and Northwell Health, New York, USA.
| | - Rebecca M Schwartz
- Department of Occupational Medicine, Epidemiology and Prevention, Northwell Health, 175 Community Drive, 2nd floor, Great Neck, NY 11021, USA; Department of Occupational Medicine, Epidemiology and Prevention, Northwell Health, 175 Community Drive, 2nd floor, Great Neck, NY 11021, USA; The Feinstein Institutes for Medical Research, Northwell Health, 350 Community Drive, Manhasset, NY 11030, USA; Joint Center for Disaster Health, Trauma and Resilience at Mount Sinai, Stony Brook University and Northwell Health, New York, USA; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 500 Hofstra Blvd, Hempstead, NY 11549, USA; Institute for Translational Epidemiology and Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, 1425 Madison Avenue, Room 2-70A, New York, NY 10029, USA.
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17
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Harbaugh CM, Malani P, Solway E, Kirch M, Singer D, Englesbe MJ, Brummett CM, Waljee JF. Self-reported disposal of leftover opioids among US adults 50-80. Reg Anesth Pain Med 2020; 45:949-954. [PMID: 33024006 DOI: 10.1136/rapm-2020-101544] [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: 04/09/2020] [Revised: 08/30/2020] [Accepted: 09/02/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To test the association between self-reported opioid disposal education and self-reported disposal of leftover opioids among older adults. DESIGN Web-based survey from the National Poll on Healthy Aging (March 2018) using population-based weighting for nationally representative estimates. SUBJECTS Older adults aged 50-80 years who reported filling an opioid prescription within the past 2 years. METHODS Respondents were asked whether they received education from a prescriber or pharmacist on how to dispose of leftover opioids and whether they disposed of leftover opioids from recent prescriptions. The association between self-reported opioid disposal education and self-reported disposal of leftover opioids was estimated with multivariable logistic regression, testing for interactions with respondent demographics. RESULTS Among 2013 respondents (74% response rate), 596 (28.9% (26.8%-31.2%)) were prescribed opioids within the past 2 years. Education on opioid disposal was reported by 40.1% of respondents (35.8%-44.5%). Among 295 respondents with leftover medication, 19.0% (14.6%-24.5%) disposed of the leftover medications. Opioid disposal education was associated with a greater likelihood of self-reported disposal of leftover opioids among non-white respondents as compared with white non-Hispanic respondents (36.7% (16.8%-56.6%) vs 7.8% (0.1%-15.6%), p<0.01). CONCLUSIONS In this nationally representative survey, 49% had leftover opioids, yet only 20% of older adults reported disposal of leftover opioids. Opioid disposal education was variable in delivery, but was associated with disposal behaviors among certain populations. Strategies to promote disposal should integrate patient education on the risks of leftover opioid medications and explore additional barriers to accessing opioid disposal methods.
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Affiliation(s)
- Calista M Harbaugh
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA .,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Preeti Malani
- Division of Infectious Disease, Department of Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Erica Solway
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Matthias Kirch
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Dianne Singer
- Department of Pediatrics and the Susan B Meister Child Health Evaluation and Research (CHEAR) Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael J Englesbe
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Chad M Brummett
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA.,Division of Pain Medicine, Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Jennifer F Waljee
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
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Smith BC, Vigotsky AD, Apkarian AV, Schnitzer TJ. Temporal Factors Associated With Opioid Prescriptions for Patients With Pain Conditions in an Urban Emergency Department. JAMA Netw Open 2020; 3:e200802. [PMID: 32211867 PMCID: PMC7097712 DOI: 10.1001/jamanetworkopen.2020.0802] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
IMPORTANCE Opioid prescriptions for treatment of pain in emergency departments (EDs) are associated with long-term opioid use. The temporal pattern of opioid prescribing in the context of the opioid epidemic remains unknown. OBJECTIVE To examine the temporal pattern of opioid prescribing within an ED for varying pain conditions between 2009 and 2018. DESIGN, SETTING, AND PARTICIPANTS A population-based, cross-sectional study was conducted at the ED of an urban academic medical center. All patients treated within that ED between January 1, 2009, and December 31, 2018, were included. MAIN OUTCOMES AND MEASURES The proportion of patients prescribed an opioid for treatment of pain in the ED temporally by condition, condition type, patient demographics, and physician prescriber. RESULTS Between 2009 and 2018, 556 176 patient encounters took place in the ED, with 70 218 unique opioid prescriptions ordered. A total of 316 632 patients (55.9%) were female, 45 070 (42.6%) were of white race, and 43 412 (40.6%) were privately insured; the median age group was 41 to 45 years. Yearly opioid prescriptions decreased by 66.3% (from 16.3 to 5.5 opioids per 100 encounters) between 2013 and 2018, with a yearly adjusted odds ratio (aOR) of 0.808 (95% CI, 0.802-0.814) compared with the prior year. In patients with musculoskeletal pain (back, joint, limb, and neck pain), opioid prescribing decreased by 71.1% (from 36.7 to 10.6 opioids per 100 encounters between 2013 and 2018; aOR, 0.758; 95% CI, 0.744-0.773). In patients with musculoskeletal trauma (fracture, sprain, contusion, and injury), opioid prescribing decreased by 58.0% (from 34.2 to 14.8 opioids per 100 encounters; aOR, 0.811; 95% CI, 0.797-0.824). In patients with nonmusculoskeletal pain (abdominal pain, kidney stone, respiratory distress, and pharyngitis) opioid prescribing decreased by 53.7% (from 20.1 to 9.3 opioids per 100 encounters; aOR, 0.850; 95% CI, 0.834-0.868). Between 2009 and 2018, patients who were black (aOR, 0.760; 95% CI, 0.741-0.779) and those who were Asian (aOR, 0.714; 95% CI, 0.665-0.764) had the lowest odds of receiving an opioid compared with other racial/ethnic groups. CONCLUSIONS AND RELEVANCE There was a substantial temporal decrease in the number of opioid prescriptions within this ED during the study period. This decrease was associated with substantial relative reductions in opioid prescribing for treatment of musculoskeletal pain compared with fractures and kidney stones.
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Affiliation(s)
- Ben C. Smith
- Medical Student, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Andrew D. Vigotsky
- Department of Biomedical Engineering, Northwestern University, Evanston, Illinois
- Department of Statistics, Northwestern University, Evanston, Illinois
| | - A. Vania Apkarian
- Center for Translational Pain Research, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Thomas J. Schnitzer
- Anesthesiology and Medicine (Rheumatology), Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Veal F, Thompson A, Halliday S, Boyles P, Orlikowski C, Huckerby E, Bereznicki L. Does prescribing of immediate release oxycodone by emergency medicine physicians result in persistence of Schedule 8 opioids following discharge? Emerg Med Australas 2019; 32:489-493. [PMID: 31837655 DOI: 10.1111/1742-6723.13442] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 10/31/2019] [Accepted: 11/24/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To identify the prevalence of oxycodone immediate release (IR) prescribed during an ED admission and the persistence of Schedule 8 (S8) opioids following an ED admission. METHODS A retrospective cross-sectional audit was undertaken reviewing all admission at the ED of the Royal Hobart Hospital, Tasmania, between 1 August and 30 September 2016. The admissions lists for ED were cross matched with the narcotic registers for oxycodone IR (the most commonly supplied S8 in ED) to identify how many patients received IR oxycodone during their ED admissions. Determination of the persistence of opioid use in opioid naïve patients was then undertaken using the Tasmanian real time reporting database of all S8 opioid dispensed in Tasmania (DAPIS). RESULTS There were 8432 ED admissions for 7065 patients aged over 13 years. IR oxycodone was prescribed during 1049 of these admissions (12.4%). Of the patients who were not taking regularly prescribed S8 opioids prior to their ED admission (n = 853), 48 patients (5.6%) were taking S8 opioids at both 2 and 6 months following their ED admission. Thirty patients (2.8%) were approved for authorities for long-term opioids for non-cancer pain. CONCLUSION These findings suggest that prescribing of IR oxycodone within ED is lower than previous studies. Additionally, the progression to regular chronic opioid use following an ED admission where IR oxycodone was given was relatively low with 3.0% of opioid naïve patients being approved for indications related to chronic non-cancer pain in the following 6 months.
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Affiliation(s)
- Felicity Veal
- Unit for Medication Outcomes Research & Education (UMORE), Pharmacy, School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Angus Thompson
- Unit for Medication Outcomes Research & Education (UMORE), Pharmacy, School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Samuel Halliday
- Department of Health, Tasmanian Government, Hobart, Tasmania, Australia
| | - Peter Boyles
- Department of Health, Tasmanian Government, Hobart, Tasmania, Australia
| | | | - Emma Huckerby
- Emergency Department, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Luke Bereznicki
- Unit for Medication Outcomes Research & Education (UMORE), Pharmacy, School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
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Richards LJ, Hopkins NJ, Colwell NA, Sahmoun AE, Beal JR. The Association Between Patient Visit Demographics and Opioid Analgesic Received in the Emergency Department. Cureus 2019; 11:e5678. [PMID: 31723487 PMCID: PMC6825449 DOI: 10.7759/cureus.5678] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 09/16/2019] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Minimal research has been conducted on the prescribing patterns of emergency room physicians. The opioid epidemic is a well-known public health crisis and increased knowledge of providers' tendencies to prescribe opioids over other analgesia may help to update guidelines, improve patient safety, and lower the amount of opioid diversion and death from overdose. The purpose of this study was to determine the association between patient visit demographics and prescribed opiate analgesics. METHODS We conducted a retrospective study analyzing adult patient visits that were seen in the emergency setting for acute pain including chest pain, back pain, abdominal pain, headache, face/tooth/ear, or musculoskeletal pain, utilizing the 2011-2016 National Hospital Ambulatory Medical Care Survey Emergency Department Patient Record dataset. We analyzed the relationship between various patient visit characteristics and whether opiate analgesics were given or prescribed. Results: Our study included 73,983 visits for pain, representing an estimated 407 million weighted visits over the study period. We found that those who received opiates were more likely to be female, 62.9% vs. 60.2% and more likely to be white, 74.2% vs. 71.3 %. Furthermore, visits that received opiates were more likely to be younger, have private insurance, and be in increased pain (all P-values = 0.000). Conclusion: We found that certain patient visit characteristics - including being female, white, younger, and private insurance - were given opiates more in the emergency department. Females have been found to report more pain, the elderly have special considerations regarding pain medications (including the risk of delirium and drug-drug interactions), while insurance status may be confounded by age (Medicare being a large portion of government insurance). However, explanations for differences in prescription rates by race could not be easily discerned.
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Affiliation(s)
- Logan J Richards
- Miscellaneous, University of North Dakota School of Medicine and Health Sciences, Bismarck, USA
| | - Nicholas J Hopkins
- Miscellaneous, University of North Dakota School of Medicine, Grand Forks, USA
| | - Nicholas A Colwell
- Family & Community Medicine, University of North Dakota School of Medicine, Grand Forks, USA
| | - Abe E Sahmoun
- Internal Medicine, University of North Dakota School of Medicine and Health Sciences, Fargo, USA
| | - James R Beal
- Family & Community Medicine, University of North Dakota School of Medicine, Grand Forks, USA
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Geographic, Temporal, and Sociodemographic Differences in Opioid Poisoning. Am J Prev Med 2019; 57:153-164. [PMID: 31227281 DOI: 10.1016/j.amepre.2019.03.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 03/24/2019] [Accepted: 03/25/2019] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Not enough is known about the epidemiology of opioid poisoning to tailor interventions to help address the growing opioid crisis in the U.S. The objective of this study is to expand the current understanding of opioid poisoning through the use of data analytics to evaluate geographic, temporal, and sociodemographic differences of opioid poisoning- related hospital visits in a region of New York State with high opioid poisoning rates. METHODS This retrospective cohort study utilized patient-level New York State all-payer hospital data (2010-2016) combined with Census data to evaluate geographic, patient, and community factors for 9,714 Long Island residents with an opioid poisoning-related inpatient or outpatient hospital facility discharge. Temporal, 7-year opioid poisoning rates and trends were evaluated, and geographic maps were generated. Overall, significance tests and tests for linear trend were based upon logistic regression. Analyses were completed between 2017 and 2018. RESULTS Since 2010, Long Island and New York State opioid poisoning hospital visit rates have increased 2.5- to 2.7-fold (p<0.001). Opioid poisoning hospital visit rates decreased for men, white patients, and self-payers (p<0.001) and increased for Medicare payers (p<0.001). Communities with high opioid poisoning rates had lower median home values, higher percentages of high school graduates, were younger, and more often white patients (p<0.01). Maps displayed geographic patterns of communities with high opioid poisoning rates overall and by age group. CONCLUSIONS Findings highlight the changing demographics of the opioid poisoning epidemic and utility of data analytics tools to identify regions and patient populations to focus interventions. These population identification techniques can be applied in other communities and interventions.
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