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Criswell A, Duck AA, Hall KC. Willingness to Provide Naloxone Resources for Patients at Risk of Opioid Overdose: A National Survey of Emergency Registered Nurses. J Emerg Nurs 2024:S0099-1767(24)00163-6. [PMID: 39001772 DOI: 10.1016/j.jen.2024.06.003] [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: 03/27/2024] [Revised: 06/03/2024] [Accepted: 06/06/2024] [Indexed: 07/15/2024]
Abstract
INTRODUCTION Opioid-related events continue to claim lives in the United States at alarming rates. Naloxone-dispensing rates fall dramatically short of national expectations. Emergency registered nurses are uniquely poised to connect at-risk patients with naloxone resources. This study sought to (1) describe the emergency registered nurses' willingness to provide naloxone resources and (2) explore variables that may influence the nurse's willingness to provide resources. METHODS A cross-sectional, survey-based design was deployed using an online branch logic approach to include a national sample of emergency registered nurses. The Willingness to Provide, a validated questionnaire, measured the registered nurse's willingness to provide naloxone resources for patients at risk of opioid overdose. Eight variables were assessed for potential influence on willingness. RESULTS A total of 159 nurses from 32 states and the District of Columbia completed the online survey via the Research Electronic Data Capture platform. The results revealed a mean Willingness to Provide score of 38.64 indicating a willingness to provide naloxone resources. A statistically significant relationship was identified between the nurse's willingness and years of nursing experience (P = .001), knowledge (P = .015), desire (P = .001), and responsibility (P < .001). DISCUSSION In this representative sample, emergency nurses are willing to provide naloxone resources; furthermore, results indicate that higher knowledge, desire, and responsibility scores increase the nurse's willingness to provide naloxone resources; with education and clear expectations, emergency nurses may be able to improve the connection of patients at risk of opioid overdose with naloxone, a potentially lifesaving connection.
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Sindhwani MK, Friedman A, O'Donnell M, Stader D, Weiner SG. Naloxone distribution programs in the emergency department: A scoping review of the literature. J Am Coll Emerg Physicians Open 2024; 5:e13180. [PMID: 38726467 PMCID: PMC11079430 DOI: 10.1002/emp2.13180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 03/28/2024] [Accepted: 04/12/2024] [Indexed: 05/12/2024] Open
Abstract
This scoping review summarized the literature regarding naloxone distribution from emergency departments (EDs) without a prescription. Our intention was to examine various naloxone distribution programs, their methodologies, and the level of effectiveness of each. Understanding these key aspects of naloxone distribution could lead to improved standardized protocols, saving countless additional lives from opioid overdose. This review evaluated studies reporting naloxone distribution from EDs in the United States. The included studies were written in English and published between January 1, 2017, and December 31, 2022. Searches were performed using PubMed and Embase. A total of 129 studies were reviewed, with only 12 meeting the necessary criteria for analysis. Heterogeneity was found across naloxone distribution programs, including how patients were identified, how naloxone was dispensed to patients, and the specific naloxone products made available. The protocols included various methods, such as patient screening, where information used for this screening was sometimes obtained from health records or patient interviews. Some programs detailed only the distribution of naloxone, while others included additional interventions such as behavior counseling, peer support, and education. In four studies, patients received buprenorphine with naloxone kits. The various programs differed in their implementation but were generally successful in improving naloxone distribution. However, among the studies reviewed, the percentage of ED patients receiving naloxone varied from ∼30% to 70%, suggesting that certain program elements may be more impactful. Further research is needed to identify key elements of the most impactful programs in order to improve naloxone distribution and improve patient odds of surviving an opioid overdose.
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Affiliation(s)
| | | | | | | | - Scott G. Weiner
- Department of Emergency MedicineBrigham and Women's HospitalBostonMassachusettsUSA
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Ramdin C, Zembrzuska M, Zembrzuski K, Nelson L. Layperson knowledge on naloxone and medications for opioid use disorder in an urban population: a cross sectional survey study. J Addict Dis 2024:1-9. [PMID: 38764149 DOI: 10.1080/10550887.2024.2353431] [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: 05/21/2024]
Abstract
BACKGROUND AND OBJECTIVES There has been little research in an urban population regarding knowledge of harm reduction measures and treatment options. The objective of our study was to evaluate knowledge and perceptions of harm reduction measures and types of treatment available for opioid use disorder among patients and family in an urban emergency department (ED) waiting room. METHODS We conducted a single center, cross-sectional survey study that occurred between September 2021 and August 2022. A convenience sample of patients and family members that were above 18 and English speaking were recruited by research assistants. Participants were assessed on knowledge and preferences around drug treatment options and harm reduction. Data were summarized using descriptive statistics and compared using the Freeman-Halton/Kruskall-Wallis/Mann-Whitney U tests. p-Values were reported at the 0.05 significance level. RESULTS We collected 200 responses. Of these, 104 people had a connection to someone with a substance use disorder (SUD) and 50 had an SUD. Of those who had a connection to someone with SUD, 63 had heard of naloxone (60.6%, CI: [50.5, 69.9]). Fewer than 60% of respondents in each group had heard of Medications for Opioid Use Disorder (MOUD) (p = 0.46) and fewer than 50% thought that among people who use drugs that they knew would be interested in receiving treatment (p = 0.10). DISCUSSION AND CONCLUSIONS Our study found that among people who came to an urban emergency department, there was a lack of awareness of harm reduction and MOUD. Interventions should be put into place to educate on the importance of MOUD and harm reduction.
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Affiliation(s)
- Christine Ramdin
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA
| | | | - Krzysztof Zembrzuski
- School of Medicine, Rowan-Virtua School of Osteopathic Medicine, Stratford, NJ, USA
| | - Lewis Nelson
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA
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4
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Mercer KJ, Brizzi MB, Burhoe DN, Senn JM, Rohani R, Nowicki DN, Januszka JE, Wordlaw R, Durham SH. Expanding expedited partner therapy and HIV prophylaxis in the emergency department. Am J Health Syst Pharm 2024; 81:279-290. [PMID: 38142223 DOI: 10.1093/ajhp/zxad322] [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: 12/20/2023] [Indexed: 12/25/2023] Open
Abstract
PURPOSE Sexually transmitted infections (STIs) continue to have a disproportionate impact on individuals belonging to sexual, gender, and racial minorities. Across the nation, many emergency medicine pharmacists (EMPs) possess the skills and knowledge to expand the provision of expedited partner therapy (EPT) for STIs and provide HIV prophylaxis within existing practice frameworks. This report serves as a call to action for expanded provision of EPT and HIV prophylaxis by EMPs and highlights current barriers and solutions to increase pharmacist involvement in these practice areas. SUMMARY Emergency medicine pharmacy practice continues to expand to allow for limited prescribing authority through collaborative practice agreements (CPAs). In recent years, CPA restrictions have been changed to facilitate treatment of more patients with less bureaucracy. This report addresses the unique challenges and opportunities for expanding EPT and HIV pre- and postexposure prophylaxis provision by pharmacists in emergency departments (EDs). Furthermore, current strategies and treatments for EPT, such as patient-delivered partner therapy and HIV prophylaxis, are discussed. Pharmacist involvement in STI treatment and HIV prevention is a key strategy to increase access to high-risk populations with high ED utilization and help close current gaps in care. CONCLUSION Expanding EMP provision of EPT and HIV prophylaxis may be beneficial to reducing the incidence of STIs and HIV infection in the community. CPAs offer a feasible solution to increase pharmacist involvement in the provision of these treatments. Legislative efforts to expand pharmacist scope of practice can also contribute to increasing access to EPT and HIV prophylaxis. With these efforts, EMPs can play an essential role in the fight against STIs and HIV.
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Affiliation(s)
- Kevin J Mercer
- University of Texas at Austin College of Pharmacy, Austin, TX
- Department of Pharmacy, Houston Methodist West Hospital, Katy, TX, USA
| | - Marisa B Brizzi
- Department of Pharmacy, University of Cincinnati Health, Cincinnati, OH, USA
| | - Devon N Burhoe
- Department of Pharmacy, St. Joseph's/Candler Health System, Savannah, GA, USA
| | - Joshua M Senn
- Department of Pharmacy, UofL Health - UofL Hospital, Louisville, KY
- Department of Emergency Medicine, University of Louisville School of Medicine, Louisville, KY, USA
| | - Roxane Rohani
- Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, IL
- Captain James A. Lovell Federal Health Care Center, North Chicago, IL, USA
| | - Diana Nicole Nowicki
- UNC Health, Chapel Hill, NC, and UNC Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Jenna E Januszka
- University of Illinois Chicago College of Pharmacy, Chicago, IL, USA
| | - Rudijah Wordlaw
- John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
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5
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Locke T, Salisbury-Afshar E, Coyle DT. Treatment Updates for Pain Management and Opioid Use Disorder. Med Clin North Am 2023; 107:1035-1046. [PMID: 37806723 DOI: 10.1016/j.mcna.2023.06.017] [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] [Indexed: 10/10/2023]
Abstract
The medical community has proposed several clinical recommendations to promote patient safety and health amid the opioid overdose public health crisis. For a frontline practicing physician, distilling the evidence and implementing the latest guidelines may prove challenging. This article aims to highlight pertinent updates and clinical care pearls as they relate to primary care management of chronic pain and opioid use disorder.
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Affiliation(s)
- Thomas Locke
- University of Colorado School of Medicine, 13001 East 17th Place, Aurora, CO 80045, USA.
| | - Elizabeth Salisbury-Afshar
- University of Wisconsin School of Medicine and Public Health, 610 North Whitney Way, Suite 200, Madison, WI 53705, USA
| | - David Tyler Coyle
- University of Colorado School of Medicine, 13001 East 17th Place, Aurora, CO 80045, USA
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6
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Fu W, Adzhiashvili V, Majlesi N. Demographics and Clinical Characteristics of Patients With Opioid Use Disorder and Offered Medication-Assisted Treatment in the Emergency Department. Cureus 2023; 15:e41464. [PMID: 37546079 PMCID: PMC10404131 DOI: 10.7759/cureus.41464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2023] [Indexed: 08/08/2023] Open
Abstract
Background and objective The opioid use disorder (OUD) epidemic is a persistent public health crisis in the United States. Medication-assisted treatment (MAT) with opioid agonists, including buprenorphine, is an effective treatment and is commonly initiated in the emergency department (ED). This study describes the demographics and clinical characteristics of OUD patients presenting to the ED and evaluated for MAT. Methodology A retrospective, single-center descriptive study of 129 adult patients presenting to the ED between July 2018 and July 2020 with OUD and evaluated for MAT. Results A total of 129 patients were assessed for MAT. About half (53%) received MAT; the remaining received only a referral (35%) or declined any intervention (12%). The median age was 36 years interquartile range (IQR, 28-46 years) and predominantly male (73%), single (65%), white (73%), unemployed (57%) with public insurance (55%), and without a primary care physician (58%). Majority of the patients presented with opioid withdrawal (62%) or intoxication (15%), while 23% presented with other complaints. About half of the patients (51%) were discharged with a naloxone kit. The majority of the patients were induced with buprenorphine with 4 mg or less (54%) and only 6% of patients received repeat dosing. Conclusions Male, white patients who are unmarried and unemployed, lack primary care follow-up, and rely on public insurance are more likely to be candidates for MAT. Providers should always maintain a high suspicion of opioid misuse and optimize treatment for those in withdrawal. Understanding these characteristics in conjunction with recent health policy changes will hopefully guide and encourage ED-initiated interventions in combating the opioid crisis.
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Affiliation(s)
- Wayne Fu
- Emergency Medicine, Mercy Hospital, Buffalo, USA
- Emergency Medicine, Staten Island University Hospital, Staten Island, USA
| | | | - Nima Majlesi
- Medical Toxicology, Staten Island University Hospital, Staten Island, USA
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Steenblik J, Jones A, Gold C, Seymour G, Garrett L, Griffith M, Blitch A, Langi S, Crump J, Madsen T. Improving access to naloxone and opioid resources through the emergency department. Am J Emerg Med 2023; 68:201-205. [PMID: 37061432 DOI: 10.1016/j.ajem.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 04/01/2023] [Accepted: 04/02/2023] [Indexed: 04/17/2023] Open
Affiliation(s)
- Jacob Steenblik
- University of Utah School of Medicine, Division of Emergency Medicine, Salt Lake City, UT, United States of America; University of Utah, College of Nursing, Salt Lake City, UT, United States of America.
| | - Andrew Jones
- University of Utah School of Medicine, Division of Emergency Medicine, Salt Lake City, UT, United States of America
| | - Carrie Gold
- University of Utah School of Medicine, Division of Emergency Medicine, Salt Lake City, UT, United States of America
| | - Gerrit Seymour
- University of Utah School of Medicine, Division of Emergency Medicine, Salt Lake City, UT, United States of America
| | - Larry Garrett
- University of Utah, College of Nursing, Salt Lake City, UT, United States of America
| | - Marina Griffith
- University of Utah School of Medicine, Division of Emergency Medicine, Salt Lake City, UT, United States of America
| | - Alejandro Blitch
- University of Utah School of Medicine, Division of Emergency Medicine, Salt Lake City, UT, United States of America
| | - Sikoti Langi
- University of Utah School of Medicine, Division of Emergency Medicine, Salt Lake City, UT, United States of America
| | - Jonathan Crump
- University of Utah School of Medicine, Division of Emergency Medicine, Salt Lake City, UT, United States of America
| | - Troy Madsen
- University of Utah School of Medicine, Division of Emergency Medicine, Salt Lake City, UT, United States of America
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Jennings LK, Ward R, Pekar E, Szwast E, Sox L, Hying J, Mccauley J, Obeid JS, Lenert LA. The effectiveness of a noninterruptive alert to increase prescription of take-home naloxone in emergency departments. J Am Med Inform Assoc 2023; 30:683-691. [PMID: 36718091 PMCID: PMC10018256 DOI: 10.1093/jamia/ocac257] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 12/21/2022] [Accepted: 12/31/2022] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVE Opioid-related overdose (OD) deaths continue to increase. Take-home naloxone (THN), after treatment for an OD in an emergency department (ED), is a recommended but under-utilized practice. To promote THN prescription, we developed a noninterruptive decision support intervention that combined a detailed OD documentation template with a reminder to use the template that is automatically inserted into a provider's note by decision rules. We studied the impact of the combined intervention on THN prescribing in a longitudinal observational study. METHODS ED encounters involving an OD were reviewed before and after implementation of the reminder embedded in the physicians' note to use an advanced OD documentation template for changes in: (1) use of the template and (2) prescription of THN. Chi square tests and interrupted time series analyses were used to assess the impact. Usability and satisfaction were measured using the System Usability Scale (SUS) and the Net Promoter Score. RESULTS In 736 OD cases defined by International Classification of Disease version 10 diagnosis codes (247 prereminder and 489 postreminder), the documentation template was used in 0.0% and 21.3%, respectively (P < .0001). The sensitivity and specificity of the reminder for OD cases were 95.9% and 99.8%, respectively. Use of the documentation template led to twice the rate of prescribing of THN (25.7% vs 50.0%, P < .001). Of 19 providers responding to the survey, 74% of SUS responses were in the good-to-excellent range and 53% of providers were Net Promoters. CONCLUSIONS A noninterruptive decision support intervention was associated with higher THN prescribing in a pre-post study across a multiinstitution health system.
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Affiliation(s)
- Lindsey K Jennings
- Department of Emergency Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ralph Ward
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ekaterina Pekar
- Biomedical Informatics Center, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Elizabeth Szwast
- Biomedical Informatics Center, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Luke Sox
- Biomedical Informatics Center, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Joseph Hying
- Biomedical Informatics Center, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jenna Mccauley
- Department of Psychiatry and Behavioral Science, Addiction Sciences Division, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jihad S Obeid
- Biomedical Informatics Center, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Leslie A Lenert
- Corresponding Author: Leslie A. Lenert, MD, Biomedical Informatics Center, Medical University of South Carolina, 22 West Edge Suite 13, Charleston, SC 29425, USA;
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9
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Ramdin C, Chandran K, Nelson L, Mazer-Amirshahi M. Trends in naloxone prescribed at emergency department discharge: A national analysis (2012-2019). Am J Emerg Med 2023; 65:162-167. [PMID: 36638613 DOI: 10.1016/j.ajem.2023.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 12/22/2022] [Accepted: 01/03/2023] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND While having access to naloxone is recommended for patients at risk for opioid overdose, little is known about trends in national naloxone prescribing rates in emergency departments (EDs) both for co-prescription with opioids and for patients who presented with opioid abuse or overdose. This study aims to evaluate the change in naloxone prescribing and opioid/naloxone co-prescribing at discharge using national data. METHODS We conducted an IRB exempt retrospective review of data collected by the National Hospital Ambulatory Medical Care Survey from 2012 to 2019. The primary outcome was trend in rate of naloxone prescribing at discharge from ED visits. We also computed the proportion of visits where naloxone was both administered in the ED and prescribed at discharge, where naloxone and opioids were co-prescribed at discharge, and where an opioid was administered during the ED visit and naloxone was prescribed at discharge. All data were summarized using descriptive statistics and Spearman's Rho (SR) or Pearson's correlation (PR) were used to describe trends. RESULTS There was an estimated total of 250,365 patient visits where naloxone was prescribed at discharge with an increasing rate over time (0% of all ED visits in 2012 to 0.075% in 2019, p = 0.002). There were also increases in naloxone being both administered in the ED and prescribed at discharge (PC: 0.8, p = 0.02) as well as in naloxone and opioid co-prescribing (SR: 0.76, P = 0.03). There was an increase in utilization of opioids during the ED visit and naloxone prescribing at discharge for the same visit (SR: 0.80, p = 0.02). CONCLUSION There are increases in naloxone prescribing at discharge, naloxone and opioid co-prescribing, and opioid utilization during the same visit where naloxone is prescribed at discharge. Future studies should be done to confirm such trends, and targeted interventions should be put into place to increase access to this life-saving antidote.
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Affiliation(s)
- Christine Ramdin
- Rutgers New Jersey Medical School, Department of Emergency Medicine, United States.
| | - Kira Chandran
- Georgetown University, School of Medicine, United States
| | - Lewis Nelson
- Rutgers New Jersey Medical School, Department of Emergency Medicine, United States
| | - Maryann Mazer-Amirshahi
- Georgetown University, School of Medicine, United States; Department of Emergency Medicine, MedStar Washington Hospital Center, United States
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Spadaro A, Agarwal AK, Sangha HK, Perrone J, Delgado MK, Lowenstein M. Motivation to Carry Naloxone: A Qualitative Analysis of Emergency Department Patients. Am J Health Promot 2023; 37:200-209. [PMID: 35686433 PMCID: PMC9949384 DOI: 10.1177/08901171221107908] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE Our aim was to explore perspectives of patients who received naloxone in the emergency department (ED) about (1) naloxone carrying and use following an ED visit and (2) motivation for performing these behaviors. DESIGN Semi-structured interviews of patients prescribed naloxone at ED discharge. SETTINGS Three urban academic EDs in Philadelphia, PA. PARTICIPANTS 25 participants completed the in-depth, semi-structured interviews and demographic surveys. Participants were majority male, African American, and had previously witnessed or experienced an overdose. METHODS Interviews were recorded, transcribed and analyzed using content analysis. We used a hybrid inductive-deductive approach that included prespecified and emergent themes. RESULTS We found that naloxone carrying behavior was variable and influenced by four main motivators: (1) naloxone access; (2) personal experience and salience of naloxone, (3) comfort with naloxone administration, and (4) societal influences on naloxone carrying. In particular, those with personal history of overdose or close friends or family at risk were motivated to carry naloxone. CONCLUSIONS Participants in this study reported several important motivators for naloxone carrying after an ED visit, including ease of naloxone access and comfort, perceived risk of experiencing or encountering an overdose, and social influences on naloxone carrying behaviors. EDs, health systems, and public health officials should consider these factors influencing motivation when designing future interventions to increase access, carrying, and use of naloxone.
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Affiliation(s)
- Anthony Spadaro
- Department of Emergency Medicine, Perelman School of Medicine and the Center for Public Health Initiatives at the University of Pennsylvania, Philadelphia, PA, USA
| | - Anish K. Agarwal
- Department of Emergency Medicine, Perelman School of Medicine the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Hareena K. Sangha
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jeanmarie Perrone
- Department of Emergency Medicine, Perelman School of Medicine the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Mucio Kit Delgado
- Department of Emergency Medicine, Perelman School of Medicine the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Margaret Lowenstein
- Division of General Internal Medicine, Perelman School of Medicine and the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
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Reed MK, Salcedo VJ, Hsiao T, Esteves Camacho T, Salvatore A, Siegler A, Rising KL. Pilot testing fentanyl test strip distribution in an emergency department setting: Experiences, lessons learned, and suggestions from staff. Acad Emerg Med 2022. [PMID: 36333960 DOI: 10.1111/acem.14624] [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: 06/29/2022] [Revised: 10/21/2022] [Accepted: 11/02/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Fentanyl test strips (FTSs) are increasingly used to address fentanyl contamination of the illicit drug supply by testing a drug for the presence of fentanyl, allowing people who use drugs (PWUD) to engage in overdose prevention. While emergency departments (EDs) have implemented various harm reduction strategies for PWUD, to date distribution of FTSs in EDs is limited and not evaluated. Thus, we sought to explore ED staff experiences distributing FTSs. METHODS Twenty-one staff serving different roles (e.g., physician, nurse, technician, social worker, certified recovery specialist) within two urban EDs in a major metropolitan area were enrolled in a pilot study to distribute FTS to patients who use drugs. Participants were interviewed about their experience at 3 weeks and again at 3 months. Interviews were recorded, transcribed verbatim, and coded using a conventional content analysis approach. RESULTS All participants endorsed the utility of FTS distribution in the ED. Across 42 interviews, participants discussed evolving strategies to approach patients about FTS, primarily favorable patient reactions to FTSs, improved dynamics between participants and patients, mixed intervention support from other staff, and named challenges of FTS distribution and recommendations to make FTS distribution in the ED widespread. Recommendations included medical records prompts to offer FTS, offering via different types of staff, and offering FTS during triage. CONCLUSIONS Implementing FTS distribution may improve patient rapport while providing patients with tools to avoid a fentanyl overdose. Participants generally reported positive experiences distributing FTSs within the ED but the barriers they identified limited opportunities to make distribution more integrated into their workflow. EDs considering this intervention should train staff on FTSs and how to identify and train patients and explore mechanisms to routinize distribution in the ED environment.
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Affiliation(s)
- Megan K Reed
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.,Center for Connected Care, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.,College of Population Health, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Venise J Salcedo
- Center for Connected Care, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - TingAnn Hsiao
- Center for Connected Care, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Tracy Esteves Camacho
- Center for Connected Care, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Amanda Salvatore
- Center for Connected Care, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | - Kristin L Rising
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.,Center for Connected Care, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.,College of Nursing, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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12
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Knaub RJ, Evans J, Yang C, Roura R, McGinn T, Verschoore B, Ricketts EP, Rothman RE, Latkin CA, Hsieh YH. A pilot study of a mixed-method approach to design an ED-based peer mHealth referral tool for HIV/HCV and opioid overdose prevention services. Drug Alcohol Depend 2022; 238:109585. [PMID: 35926299 PMCID: PMC9620482 DOI: 10.1016/j.drugalcdep.2022.109585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 07/20/2022] [Accepted: 07/20/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND The intersecting epidemics of opioid misuse, injection drug use, and HIV/HCV have resulted in record overdose deaths and sustained high levels of HIV/HCV transmissions. Literature on social networks suggests opportunities to connect people who use drugs (PWUD) and their peers to HIV/HCV and opioid overdose prevention services. However, little evidence exists on how to design such peer referral interventions in emergency department (ED) settings. METHODS A mixed-method study was conducted to assess the feasibility of an mHealth-facilitated 'patient to peer social network referral program' for PWUD. In-depth interviews (IDIs) and quantitative surveys were conducted with urban ED patients (n = 15), along with 3 focus group discussions (FGDs) (n = 19). RESULTS Overall, 34 participants were enrolled (71 % males, 53 % Black). 13/15 IDI participants reported a history of opioid overdose; all had witnessed overdose events; all received HIV/HCV testing. From survey responses, most would invite their peers for HIV/HCV testing and naloxone training; and anticipated peers to accept referrals (HIV: 60 %, HCV: 73 %, naloxone: 93 %). Qualitative data showed PWUD shared health-related information with each other but preferred word of mouth rather than text messages. Participants used smartphones regularly and suggested using Internet advertising for prevention services. Participants expressed enthusiasm for ED-based peer mHealth referral platform to prevention services, as well as referring their peers to proposed services, with monetary incentives. CONCLUSION ED-based peer referral intervention to HIV/HCV testing and naloxone training was viewed favorably by PWUD. Frequent smartphone use among PWUD suggests that the medium could be a promising mode for peer referral.
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Affiliation(s)
- Ross J. Knaub
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
| | - Julie Evans
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
| | - Cui Yang
- Department of Health, Behavior and Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, U.S.A
| | - Raúl Roura
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
| | - Tanner McGinn
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
| | - Benjamin Verschoore
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
| | - Erin P. Ricketts
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
| | - Richard E. Rothman
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
| | - Carl A. Latkin
- Department of Health, Behavior and Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, U.S.A
| | - Yu-Hsiang Hsieh
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Chhabra N, Smith DL, Maloney CM, Archer J, Sharma B, Thompson HM, Afshar M, Karnik NS. The Identification of Subphenotypes and Associations with Health Outcomes in Patients with Opioid-Related Emergency Department Encounters Using Latent Class Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19148882. [PMID: 35886733 PMCID: PMC9321801 DOI: 10.3390/ijerph19148882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 07/17/2022] [Accepted: 07/19/2022] [Indexed: 02/05/2023]
Abstract
The emergency department (ED) is a critical setting for the treatment of patients with opioid misuse. Detecting relevant clinical profiles allows for tailored treatment approaches. We sought to identify and characterize subphenotypes of ED patients with opioid-related encounters. A latent class analysis was conducted using 14,057,302 opioid-related encounters from 2016 through 2017 using the National Emergency Department Sample (NEDS), the largest all-payer ED database in the United States. The optimal model was determined by face validity and information criteria-based metrics. A three-step approach assessed class structure, assigned individuals to classes, and examined characteristics between classes. Class associations were determined for hospitalization, in-hospital death, and ED charges. The final five-class model consisted of the following subphenotypes: Chronic pain (class 1); Alcohol use (class 2); Depression and pain (class 3); Psychosis, liver disease, and polysubstance use (class 4); and Pregnancy (class 5). Using class 1 as the reference, the greatest odds for hospitalization occurred in classes 3 and 4 (Ors 5.24 and 5.33, p < 0.001) and for in-hospital death in class 4 (OR 3.44, p < 0.001). Median ED charges ranged from USD 2177 (class 1) to USD 2881 (class 4). These subphenotypes provide a basis for examining patient-tailored approaches for this patient population.
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Affiliation(s)
- Neeraj Chhabra
- Division of Medical Toxicology, Department of Emergency Medicine, Cook County Health, Chicago, IL 60612, USA
- Department of Emergency Medicine, Rush Medical College, Rush University, Chicago, IL 60612, USA
- Correspondence:
| | - Dale L. Smith
- Addiction Data Science Laboratory, Department of Psychiatry & Behavioral Science, Rush University Medical Center, Chicago, IL 60612, USA; (D.L.S.); (B.S.); (H.M.T.); (N.S.K.)
- Department of Psychology, Olivet Nazarene University, Bourbonnais, IL 60914, USA
| | - Caitlin M. Maloney
- Doctor of Medicine Program, Rush Medical College, Rush University, Chicago, IL 60612, USA;
| | - Joseph Archer
- School of Medicine and Public Health, University of Wisconsin, Madison, WI 53715, USA;
| | - Brihat Sharma
- Addiction Data Science Laboratory, Department of Psychiatry & Behavioral Science, Rush University Medical Center, Chicago, IL 60612, USA; (D.L.S.); (B.S.); (H.M.T.); (N.S.K.)
| | - Hale M. Thompson
- Addiction Data Science Laboratory, Department of Psychiatry & Behavioral Science, Rush University Medical Center, Chicago, IL 60612, USA; (D.L.S.); (B.S.); (H.M.T.); (N.S.K.)
| | - Majid Afshar
- Department of Medicine, University of Wisconsin-Madison, Madison, WI 53715, USA;
| | - Niranjan S. Karnik
- Addiction Data Science Laboratory, Department of Psychiatry & Behavioral Science, Rush University Medical Center, Chicago, IL 60612, USA; (D.L.S.); (B.S.); (H.M.T.); (N.S.K.)
- Institute for Juvenile Research, Department of Psychiatry, University of Illinois Chicago, Chicago, IL 60612, USA
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Dora‐Laskey A, Kellenberg J, Dahlem CH, English E, Gonzalez Walker M, Brummett CM, Kocher KE. Piloting a statewide emergency department take-home naloxone program: Improving the quality of care for patients at risk of opioid overdose. Acad Emerg Med 2022; 29:442-455. [PMID: 34962682 DOI: 10.1111/acem.14435] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 12/21/2021] [Accepted: 12/23/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Emergency department (ED) patients with nonfatal opioid overdose are at high risk for subsequent fatal overdose, yet ED programs aimed at reducing harm from opioid use remain underdeveloped. OBJECTIVES The objective was to pilot a statewide ED take-home naloxone program and improve the care of patients with opioid use disorder (OUD) and risky drug use through training and interprofessional network building. METHODS Nine hospital EDs with pharmacy, nurse, and physician champions were recruited, surveyed, and trained. Take-home naloxone rescue kits were developed, disseminated, and tracked. Two overdose prevention summits were convened prior to the COVID pandemic, and two X-waiver training courses aimed at emergency physicians and advanced practice providers were arranged, both in person and virtual. RESULTS A total of 872 naloxone rescue kits were distributed to ED patients at risk of opioid overdose during the first phase of this project, and more than 140 providers were trained in the use of medications for OUD in acute care settings. CONCLUSIONS A statewide ED take-home naloxone program was shown to be feasible across a range of different hospitals with varying maturity in preexisting OUD resources and capabilities. Future work will be aimed at both expanding and measuring the effectiveness of this work.
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Affiliation(s)
- Aaron Dora‐Laskey
- Department of Emergency Medicine Michigan State University College of Human Medicine East Lansing Michigan USA
| | - Joan Kellenberg
- Department of Anesthesiology University of Michigan Ann Arbor Michigan USA
| | - Chin Hwa Dahlem
- Department of Health Behavior and Biological Sciences School of Nursing University of Michigan Ann Arbor Michigan USA
| | - Elizabeth English
- Department of Anesthesiology University of Michigan Ann Arbor Michigan USA
| | | | - Chad M. Brummett
- Department of Anesthesiology University of Michigan Ann Arbor Michigan USA
| | - Keith E. Kocher
- Department of Emergency Medicine University of Michigan Ann Arbor Michigan USA
- Department of Learning Health Sciences University of Michigan Ann Arbor Michigan USA
- Institute for Healthcare Policy and Innovation University of Michigan Ann Arbor Michigan USA
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Schneider KE, Rouhani S, Weicker NP, Morris M, Sherman SG. Businesses in high drug use areas as potential sources of naloxone during overdose emergencies. Drug Alcohol Depend 2022; 233:109357. [PMID: 35259680 PMCID: PMC8957648 DOI: 10.1016/j.drugalcdep.2022.109357] [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: 11/16/2021] [Revised: 02/09/2022] [Accepted: 02/12/2022] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Naloxone distribution remains a cornerstone of a public health approach to combating the ongoing opioid overdose crisis. Most distribution programs focus on providing naloxone to individuals who use drugs or those closely associated with them (e.g., family). Utilizing businesses as fixed location sources of naloxone could be a valuable supplemental strategy to preventing fatal overdoses that is underexplored in the literature. METHODS We surveyed business owners and employees (N = 149) located in neighborhoods characterized by high rates of drug use in Baltimore City. Participants reported their interactions with people who use drugs as well as if they had heard of naloxone, if the business had naloxone on the premises, and how many employees were trained to use naloxone. RESULTS Most participants reported seeing individuals under the influence of drugs (93%), public drug use (80%), and overdose (66%) while at work. 66% of participants had heard of naloxone. Among those who had heard of naloxone, only 39% reported that there was a naloxone kit in the business and 28% of businesses had multiple employees trained to use naloxone. CONCLUSIONS Businesses are underutilized as potential reliable sources of naloxone. While study participants reported high levels of exposure to drug use and overdose in and around their businesses, their ability to intervene was limited. Efforts to train employees to respond to overdoses and to keep naloxone on site are warranted to supplement existing naloxone distribution efforts and can help empower business staff to help prevent overdose mortality in their communities.
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Affiliation(s)
- Kristin E Schneider
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD 21205, USA.
| | - Saba Rouhani
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD 21205, USA
| | - Noelle P Weicker
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD 21205, USA
| | - Miles Morris
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD 21205, USA
| | - Susan G Sherman
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD 21205, USA
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Chua KP, Dahlem CHY, Nguyen T, Brummett CM, Conti RM, Bohnert AS, Dora-Laskey AD, Kocher KE. Naloxone and Buprenorphine Prescribing Following US Emergency Department Visits for Suspected Opioid Overdose: August 2019 to April 2021. Ann Emerg Med 2022; 79:225-236. [PMID: 34802772 PMCID: PMC8860890 DOI: 10.1016/j.annemergmed.2021.10.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 09/28/2021] [Accepted: 09/30/2021] [Indexed: 02/04/2023]
Abstract
STUDY OBJECTIVE Nonfatal emergency department (ED) visits for opioid overdose are important opportunities to prescribe naloxone and buprenorphine, both of which can prevent future overdose-related mortality. We assessed the rate of this prescribing using national data from August 2019 to April 2021, a period during which US opioid overdose deaths reached record levels. METHODS We conducted a retrospective cohort analysis using Symphony Health's Integrated Dataverse, which includes data from 5,800 hospitals and 70,000 pharmacies. Of ED visits for opioid overdose between August 4, 2019, and April 3, 2021, we calculated the proportion with at least 1 naloxone prescription within 30 days and repeated this analysis for buprenorphine. To contextualize the naloxone prescribing rate, we calculated the proportion of ED visits for anaphylaxis with at least 1 prescription for epinephrine-another life-saving rescue medication-within 30 days. RESULTS Analyses included 148,966 ED visits for opioid overdose. Mean weekly visits increased 23.6% during the period between April 26, 2020 and October 3, 2020 compared with the period between August 4, 2019 to April 25, 2020. Visits declined to prepandemic levels between October 4, 2020 and March 13, 2021, after which visits began to rise. Naloxone and buprenorphine were prescribed within 30 days at 7.4% and 8.5% of the 148,966 visits, respectively. The naloxone prescribing rate (7.4%) was substantially lower than the epinephrine prescribing rate (48.9%) after ED visits for anaphylaxis. CONCLUSION Between August 4, 2019, and April 3, 2021, naloxone and buprenorphine were only prescribed after 1 in 13 and 1 in 12 ED visits for opioid overdose, respectively. Findings suggest that clinicians are missing critical opportunities to prevent opioid overdose-related mortality.
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Affiliation(s)
- Kao-Ping Chua
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, MI; Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI.
| | - Chin Hwa Y. Dahlem
- Department of Health Behavior and Biological Sciences, University of Michigan School of Nursing, Ann Arbor, MI
| | - Thuy Nguyen
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI
| | - Chad M. Brummett
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI,Michigan Opioid Prescribing Engagement Network, Institute for Healthcare Policy and Innovation, Ann Arbor, MI
| | - Rena M. Conti
- Department of Markets, Public Policy, And Law, Institute for Health System Innovation and Policy, Questrom School of Business, Boston University, Boston, MA
| | - Amy S. Bohnert
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI,VA Center for Clinical Management Research, VA Ann Arbor Health System, Ann Arbor, MI
| | - Aaron D. Dora-Laskey
- Department of Emergency Medicine, Michigan State University College of Human Medicine, East Lansing, MI
| | - Keith E. Kocher
- VA Center for Clinical Management Research, VA Ann Arbor Health System, Ann Arbor, MI,Department of Emergency Medicine, University of Michigan School of Medicine, Ann Arbor, MI,Department of Learning Health Sciences, University of Michigan School of Medicine, Ann Arbor, MI
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Suen LW, Davy-Mendez T, LeSaint KT, Riley ED, Coffin PO. Emergency department visits and trends related to cocaine, psychostimulants, and opioids in the United States, 2008-2018. BMC Emerg Med 2022; 22:19. [PMID: 35120449 PMCID: PMC8814795 DOI: 10.1186/s12873-022-00573-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 01/18/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Drug-related emergency department (ED) visits are escalating, especially for stimulant use (i.e., cocaine and psychostimulants such as methamphetamine). We sought to characterize rates, presentation, and management of ED visits related to cocaine and psychostimulant use, compared to opioid use, in the United States (US). METHODS We used 2008-2018 National Hospital Ambulatory Medical Care Survey data to identify a nationally representative sample of ED visits related to cocaine and psychostimulant use, with opioids as the comparator. To make visits mutually exclusive for analysis, we excluded visits related to 2 or more of the three possible drug categories. We estimated annual rate trends using unadjusted Poisson regression; described demographics, presenting concerns, and management; and determined associations between drug-type and presenting concerns (categorized as psychiatric, neurologic, cardiopulmonary, and drug toxicity/withdrawal) using logistic regression, adjusting for age, sex, race/ethnicity, and homelessness. RESULTS Cocaine-related ED visits did not significantly increase, while psychostimulant-related ED visits increased from 2008 to 2018 (2.2 visits per 10,000 population to 12.9 visits per 10,000 population; p < 0.001). Cocaine-related ED visits had higher usage of cardiac testing, while psychostimulant-related ED visits had higher usage of chemical restraints than opioid-related ED visits. Cocaine- and psychostimulant-related ED visits had greater odds of presenting with cardiopulmonary concerns (cocaine adjusted odds ratio [aOR] 2.95, 95% CI 1.70-5.13; psychostimulant aOR 2.46, 95% CI 1.42-4.26), while psychostimulant-related visits had greater odds of presenting with psychiatric concerns (aOR 2.69, 95% CI 1.83-3.95) and lower odds of presenting with drug toxicity/withdrawal concerns (aOR 0.47, 95%CI 0.30-0.73) compared to opioid-related ED visits. CONCLUSION Presentations for stimulant-related ED visits differ from opioid-related ED visits: compared to opioids, ED presentations related to cocaine and psychostimulants are less often identified as related to drug toxicity/withdrawal and more often require interventions to address acute cardiopulmonary and psychiatric complications.
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Affiliation(s)
- Leslie W. Suen
- National Clinician Scholars Program, Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, 290 Illinois Street, Suite 7227, Box 0936, San Francisco, CA 94158 USA
- San Francisco Veterans Affairs Medical Center, San Francisco, CA USA
| | - Thibaut Davy-Mendez
- Division of Infectious Diseases, Department of Medicine, University of North Carolina, Chapel Hill, NC USA
| | - Kathy T. LeSaint
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, CA USA
| | - Elise D. Riley
- Department of Medicine, Division of HIV, Infectious Diseases and Global Medicine, School of Medicine, University of California, San Francisco, San Francisco, CA USA
| | - Phillip O. Coffin
- Department of Medicine, Division of HIV, Infectious Diseases and Global Medicine, School of Medicine, University of California, San Francisco, San Francisco, CA USA
- Department of Public Health, San Francisco, CA USA
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18
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Martignetti L, Sun W. Perspectives of Stakeholders of Equitable Access to Community Naloxone Programs: A Literature Review. Cureus 2022; 14:e21461. [PMID: 35223245 PMCID: PMC8858082 DOI: 10.7759/cureus.21461] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2022] [Indexed: 12/02/2022] Open
Abstract
The purpose of this review is to examine the existing literature about facilitators and barriers influencing equitable access to naloxone programs by individuals who use opioids. A total of 49 published articles were examined, which generated four overarching themes:(1) Stigma as a barrier to access; (2) Lack of a wide range of stakeholder perspectives; (3) Need for a comprehensive understanding of factors affecting equitable access to naloxone programs; (4) Facilitators to increase the access of community naloxone programs. Our review highlighted the importance of advocacy in practice, education, administration, and policy to address the health inequities that exist in naloxone distribution programs. Advocacy activities involve the need for health care professionals to engage in social justice practice through evidence-based informed research about the facts of opioid use; challenging the stigma toward victim-blaming against naloxone users; as well as promoting program development and health policy to bring about equitable access to naloxone programs by marginalized and socially disadvantaged populations.
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19
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Emergency medicine services providers' attitudes toward naloxone distribution and training programs. Am J Emerg Med 2021; 51:76-78. [PMID: 34688204 DOI: 10.1016/j.ajem.2021.10.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 10/08/2021] [Accepted: 10/11/2021] [Indexed: 11/21/2022] Open
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Lipira L, Leichtling G, Cook RR, Leahy JM, Orellana ER, Korthuis PT, Menza TW. Predictors of having naloxone in urban and rural Oregon findings from NHBS and the OR-HOPE study. Drug Alcohol Depend 2021; 227:108912. [PMID: 34315014 PMCID: PMC8464511 DOI: 10.1016/j.drugalcdep.2021.108912] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 05/26/2021] [Accepted: 05/27/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Naloxone is an opioid antagonist that can be effectively administered by bystanders to prevent overdose. We determined the proportion of people who had naloxone and identified predictors of naloxone ownership among two samples of people who inject drugs (PWID) who use opioids in Portland and rural Western Oregon. BASIC PROCEDURES We used data from participants in Portland's National HIV Behavioral Surveillance (NHBS, N = 477) and the Oregon HIV/Hepatitis and Opioid Prevention and Engagement Study (OR-HOPE, N = 133). For each sample, we determined the proportion of participants who had naloxone and estimated unadjusted and adjusted relative risk of having naloxone associated with participant characteristics. MAIN FINDINGS Sixty one percent of NHBS and 30 % of OR-HOPE participants had naloxone. In adjusted analysis, having naloxone was associated with female gender, injecting goofballs (compared to heroin alone), housing stability, and overdose training in the urban NHBS sample, and having naloxone was associated with drug of choice, frequency of injection, and race in the rural OR-HOPE sample. In both samples, having naloxone was crudely associated with SSP use, but this was attenuated after adjustment. PRINCIPAL CONCLUSIONS Naloxone ownership was insufficient and highly variable among two samples of PWID who use opioids in Oregon. People who use methamphetamine, males, and people experiencing homelessness may be at increased risk for not having naloxone and SSP may play a key role in improving access.
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Affiliation(s)
- Lauren Lipira
- Regional Research Institute, Portland State University, 1600 SW 4(th)Avenue, Suite 900, Portland, OR, 97201, USA; Public Health Division, Oregon Health Authority, 800 NE Oregon Street, Portland, OR, 97232, USA.
| | | | - Ryan R Cook
- Department of Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA.
| | - Judith M Leahy
- Public Health Division, Oregon Health Authority, 800 NE Oregon Street, Portland, OR, 97232, USA.
| | - E Roberto Orellana
- Regional Research Institute, Portland State University, 1600 SW 4(th)Avenue, Suite 900, Portland, OR, 97201, USA.
| | - P Todd Korthuis
- Department of Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA.
| | - Timothy W Menza
- Public Health Division, Oregon Health Authority, 800 NE Oregon Street, Portland, OR, 97232, USA; Department of Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA.
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Conway A, Valerio H, Peacock A, Degenhardt L, Hayllar J, Harrod ME, Henderson C, Read P, Gilliver R, Christmass M, Dunlop A, Montebello M, Whitton G, Reid D, Lam T, Alavi M, Silk D, Marshall AD, Treloar C, Dore GJ, Grebely J. Non-fatal opioid overdose, naloxone access, and naloxone training among people who recently used opioids or received opioid agonist treatment in Australia: The ETHOS Engage study. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 96:103421. [PMID: 34452808 DOI: 10.1016/j.drugpo.2021.103421] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 07/07/2021] [Accepted: 08/08/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Overdose is a major cause of morbidity and mortality among people who use opioids. Naloxone can reverse opioid overdoses and can be distributed and administered with minimal training. People with experience of overdose are a key population to target for overdose prevention strategies. This study aims to understand if factors associated with recent non-fatal opioid overdose are the same as factors associated with naloxone access and naloxone training in people who recently used opioids or received opioid agonist treatment (OAT). METHODS ETHOS Engage is an observational study of people who inject drugs in Australia. Logistic regression models were used to estimate odds ratios for non-fatal opioid overdose, naloxone access and naloxone training. RESULTS Between May 2018-September 2019, 1280 participants who recently used opioids or received OAT were enrolled (62% aged >40 years; 35% female, 80% receiving OAT, 62% injected drugs in the preceding month). Recent opioid overdose (preceding 12 months) was reported by 7% of participants, lifetime naloxone access by 17%, and lifetime naloxone training by 14%. Compared to people receiving OAT with no additional opioid use, recent opioid, benzodiazepine (preceding six months), and hazardous alcohol use was associated with recent opioid overdose (aOR 3.91; 95%CI: 1.68-9.10) and lifetime naloxone access (aOR 2.12; 95%CI 1.29-3.48). Among 91 people who reported recent overdose, 65% had never received take-home naloxone or naloxone training. CONCLUSIONS Among people recently using opioids or receiving OAT, benzodiazepine and hazardous alcohol use is associated with non-fatal opioid overdose. Not all factors associated with non-fatal overdose correspond to factors associated with naloxone access. Naloxone access and training is low across all groups. Additional interventions are needed to scale up naloxone provision.
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Affiliation(s)
- A Conway
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia; Centre for Social Research in Health, UNSW Sydney, Sydney, NSW, Australia.
| | - H Valerio
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | - A Peacock
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, NSW, Australia; School of Psychology, University of Tasmania, Hobart, Tasmania, Australia
| | - L Degenhardt
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, NSW, Australia
| | - J Hayllar
- Alcohol and Drug Service, Metro North Mental Health, Metro North Hospital and Health Service, Brisbane, QLD, Australia
| | - M E Harrod
- NSW Users and AIDS Association, NSW, Australia
| | - C Henderson
- NSW Users and AIDS Association, NSW, Australia
| | - P Read
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia; Kirketon Road Centre, Sydney, NSW, Australia
| | - R Gilliver
- Kirketon Road Centre, Sydney, NSW, Australia
| | - M Christmass
- Next Step Drug and Alcohol Services, Mental Health Commission, WA, Australia; National Drug Research Institute, Curtin University, WA, Australia
| | - A Dunlop
- Centre for Translational Neuroscience and Mental Health, Hunter Medical Research Institute & University of Newcastle, Newcastle, NSW, Australia; Drug and Alcohol Clinical Services, Hunter New England Local Health District, Newcastle, NSW, Australia
| | - M Montebello
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, NSW, Australia; Drug and Alcohol Services, Northern Sydney Local Health District, Sydney, NSW, Australia; University of Sydney, Sydney, NSW, Australia
| | - G Whitton
- Drug Health Service, South West Sydney LHD, NSW, Australia
| | - D Reid
- Drug and Alcohol Service, Illawarra Shoalhaven Local Health District, Wollongong, NSW, Australia
| | - T Lam
- Drug Health, Western Sydney Local Health District, Sydney, NSW, Australia
| | - M Alavi
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | - D Silk
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | - A D Marshall
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia; Centre for Social Research in Health, UNSW Sydney, Sydney, NSW, Australia
| | - C Treloar
- Centre for Social Research in Health, UNSW Sydney, Sydney, NSW, Australia
| | - G J Dore
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | - J Grebely
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
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Abstract
In recent years the prescription opioid overdose epidemic has decreased, but has been more than offset by increases in overdose caused by fentanyl and fentanyl analogues. Opioid overdose patients should receive naloxone if they have significant respiratory depression and/or loss of protective airway reflexes. Patients who receive naloxone should be observed for recurrent opioid effects. Patients with opioid overdose may be admitted to the intensive care unit for naloxone infusions, treatment of noncardiogenic pulmonary edema, autonomic instability, or sequelae of hypoxia-ischemia or cardiac arrest. Primary and secondary prevention are important to reduce the number of people with life-threatening opioid overdose.
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Lennox R, Martin L, Brimner C, O'Shea T. Hospital policy as a harm reduction intervention for people who use drugs. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 97:103324. [PMID: 34153628 DOI: 10.1016/j.drugpo.2021.103324] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/24/2021] [Accepted: 05/28/2021] [Indexed: 01/19/2023]
Abstract
Hospitals are a critical touchpoint for people who use drugs (PWUD). However, hospital policies, both formal and informal, can have a detrimental impact on PWUD in acute care settings. Introducing new policies, or revising existing policies that inadvertently harm or stigmatize PWUD while hospitalized, could be an effective harm reduction intervention for this high-risk population. This paper explores seven areas where institutional policy change could improve the hospital experience of PWUD: (1) use of nonprescribed substances in hospital, (2) supporting inpatient addiction consultation services (3) in-hospital supervised consumption spaces (4) supply and distribution of safe drug use equipment and naloxone, (5) role of security services and personal searches, (6) use of hospital restrictions, and (7) involvement of PWUD in policy development.
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Affiliation(s)
- Robin Lennox
- Department of Family Medicine, McMaster University, Hamilton, Canada; St. Joseph's Healthcare, Hamilton, Canada.
| | - Leslie Martin
- Department of Medicine, Division of General Internal Medicine, McMaster University, Hamilton, Canada; St. Joseph's Healthcare, Hamilton, Canada
| | | | - Tim O'Shea
- St. Joseph's Healthcare, Hamilton, Canada; Department of Medicine, Division of Infectious Diseases, McMaster University, Hamilton, Canada
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Moustaqim-Barrette A, Dhillon D, Ng J, Sundvick K, Ali F, Elton-Marshall T, Leece P, Rittenbach K, Ferguson M, Buxton JA. Take-home naloxone programs for suspected opioid overdose in community settings: a scoping umbrella review. BMC Public Health 2021; 21:597. [PMID: 33771150 PMCID: PMC8004425 DOI: 10.1186/s12889-021-10497-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 02/24/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Opioid related overdoses and overdose deaths continue to constitute an urgent public health crisis. The implementation of naloxone programs, such as 'take-home naloxone' (THN), has emerged as a key intervention in reducing opioid overdose deaths. These programs aim to train individuals at risk of witnessing or experiencing an opioid overdose to recognize an opioid overdose and respond with naloxone. Naloxone effectively reverses opioid overdoses on a physiological level; however, there are outstanding questions on community THN program effectiveness (adverse events, dosing requirements, dose-response between routes of administration) and implementation (accessibility, availability, and affordability). The objective of this scoping review is to identify existing systematic reviews and best practice guidelines relevant to clinical and operational guidance on the distribution of THN. METHODS Using the Arksey & O'Malley framework for scoping reviews, we searched both academic literature and grey literature databases using keywords (Naloxone) AND (Overdose) AND (Guideline OR Review OR Recommendation OR Toolkit). Only documents which had a structured review of evidence and/or provided summaries or recommendations based on evidence were included (systematic reviews, meta-analyses, scoping reviews, short-cut or rapid reviews, practice/clinical guidelines, and reports). Data were extracted from selected evidence in two key areas: (1) study identifiers; and (2) methodological characteristics. RESULTS A total of 47 articles met inclusion criteria: 20 systematic reviews; 10 grey literature articles; 8 short-cut or rapid reviews; 4 scoping reviews; and 5 other review types (e.g. mapping review and comprehensive reviews). The most common subject themes were: naloxone effectiveness, safety, provision feasibility/acceptability of naloxone distribution, dosing and routes of administration, overdose response after naloxone administration, cost-effectiveness, naloxone training and education, and recommendations for policy, practice and gaps in knowledge. CONCLUSIONS Several recent systematic reviews address the effectiveness of take-home naloxone programs, naloxone dosing/route of administration, and naloxone provision models. Gaps remain in the evidence around evaluating cost-effectiveness, training parameters and strategies, and adverse events following naloxone administration. As THN programs continue to expand in response to opioid overdose deaths, this review will contribute to understanding the evidence base for policy and THN program development and expansion.
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Affiliation(s)
| | - Damon Dhillon
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Justin Ng
- BC Centre for Disease Control, Vancouver, BC, Canada
| | - Kristen Sundvick
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Farihah Ali
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), London, ON, Canada
| | - Tara Elton-Marshall
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), London, ON, Canada
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Pamela Leece
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Public Health Ontario (PHO), Toronto, ON, Canada
| | - Katherine Rittenbach
- Alberta Health Services (AHS), Edmonton, AB, Canada
- University of Alberta, Edmonton, AB, Canada
- University of Calgary, Calgary, AB, Canada
| | - Max Ferguson
- BC Centre for Disease Control, Vancouver, BC, Canada
| | - Jane A Buxton
- BC Centre for Disease Control, Vancouver, BC, Canada.
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.
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Funke M, Kaplan MC, Glover H, Schramm-Sapyta N, Muzyk A, Mando-Vandrick J, Gordee A, Kuchibhatla M, Sterrett E, Eucker SA. Increasing Naloxone Prescribing in the Emergency Department Through Education and Electronic Medical Record Work-Aids. Jt Comm J Qual Patient Saf 2021; 47:364-375. [PMID: 33811002 DOI: 10.1016/j.jcjq.2021.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 02/23/2021] [Accepted: 03/02/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Emergency department (ED) visits for opioid overdose continue to rise. Evidence-based harm reduction strategies for opioid use disorder (OUD), such as providing home naloxone, can save lives, but ED implementation remains challenging. METHODS The researchers aimed to increase prescribing of naloxone to ED patients with OUD and opioid overdose by employing a model for improvement methodology, a multidisciplinary team, and high-reliability interventions. Monthly naloxone prescribing rates among discharged ED patients with opioid overdose and OUD-related diagnoses were tracked over time. Interventions included focused ED staff education on OUD and naloxone, and creation of electronic medical record (EMR)-based work-aids, including a naloxone Best Practice Advisory (BPA) and order set. Autoregressive interrupted time series was used to model the impact of these interventions on naloxone prescribing rates. The impact of education on ED staff confidence and perceived barriers to prescribing naloxone was measured using a published survey instrument. RESULTS After adjusting for education events and temporal trends, ED naloxone BPA and order set implementation was associated with a significant immediate 21.1% increase in naloxone prescribing rates, which was sustained for one year. This corresponded to increased average monthly prescribing rates from 1.5% before any intervention to 28.7% afterward. ED staff education had no measurable impact on prescribing rates but was associated with increased nursing perceived importance and increased provider confidence in prescribing naloxone. CONCLUSIONS A significant increase in naloxone prescribing rates was achieved after implementation of high-reliability EMR work-aids and staff education. Similar interventions may be key to wider ED staff engagement in harm reduction for patients with OUD.
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McElhinny M, Chea K, Carter-Powell A, Mishler A, Bhattarai B, Geren K. Adult emergency department naloxone education and prescription program: Video and pamphlet education comparison. J Subst Abuse Treat 2021; 127:108346. [PMID: 34134864 DOI: 10.1016/j.jsat.2021.108346] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 01/04/2021] [Accepted: 02/18/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVES This study looked at the fill rate of naloxone prescriptions, after the implementation of an opioid overdose and naloxone education intervention for adult patients in the emergency department (ED). The study compared fill rates between recipients who received this education by video versus written format. METHODS This was a prospective, randomized controlled study of patients seen in the adult ED for opioid-related complaints between August 1, 2017, and December 1, 2018. The study randomized patients to education through video or written pamphlet, and all patients received a prescription for a free naloxone kit redeemable at the discharge pharmacy. The study calculated and compared naloxone prescription fill rates for the respective education methods. RESULTS Of the 770 patients reviewed for recruitment, the study excluded 703. Of the 67 patients enrolled, 59 were contacted at follow-up and eighteen (30.5%) had filled a naloxone prescription. Thirty-three percent (13/39) of patients who received video education and 25% (5/20) who received written pamphlet education filled naloxone prescriptions. The p-value of the chi-square for this data was 0.53. CONCLUSIONS There is a large population affected by opioid overdose both nationally and locally in Arizona. Opioid overdose and naloxone distribution education for ED patients through both video and pamphlet is feasible but requires more research to determine which education method is superior. Legislative changes, improved identification of patients at high risk for opioid overdose, opiate education for medical providers, and naloxone availability from multiple venues are needed to create a holistic approach to improve naloxone access to those who need it most.
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Affiliation(s)
- Megan McElhinny
- Creighton University School of Medicine - Phoenix Emergency Medicine Residency, United States of America; Valleywise Health Medical Center, 2601 E. Roosevelt St., Phoenix, AZ 85283, United States of America; University of Arizona College of Medicine- Phoenix, 475 N 5th St, Phoenix, AZ 85004, United States of America.
| | | | | | - Aimee Mishler
- Valleywise Health Medical Center, 2601 E. Roosevelt St., Phoenix, AZ 85283, United States of America
| | - Bikash Bhattarai
- Valleywise Health Medical Center, 2601 E. Roosevelt St., Phoenix, AZ 85283, United States of America
| | - Kara Geren
- Creighton University School of Medicine - Phoenix Emergency Medicine Residency, United States of America; Valleywise Health Medical Center, 2601 E. Roosevelt St., Phoenix, AZ 85283, United States of America; University of Arizona College of Medicine- Phoenix, 475 N 5th St, Phoenix, AZ 85004, United States of America
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Moe J, Chong M, Zhao B, Scheuermeyer FX, Purssell R, Slaunwhite A. Death after emergency department visits for opioid overdose in British Columbia: a retrospective cohort analysis. CMAJ Open 2021; 9:E242-E251. [PMID: 33731425 PMCID: PMC8096380 DOI: 10.9778/cmajo.20200169] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Visits to the emergency department are critical opportunities to engage individuals after an overdose. We sought to estimate and compare the 12-month mortality between persons with visits to the emergency department related to opioid overdose and those with non-overdose-related visits. METHODS We conducted a retrospective cohort study using the Provincial Overdose Cohort, which contains data for patients in British Columbia who had an opioid-related overdose between 2015 and 2017, along with a 20% random sample of BC residents for comparison. We examined all nonfatal visits to the emergency department between Jan. 1, 2015, and Dec. 31, 2016, among persons aged 14 to 74 years and compared the 12-month mortality between those with overdose-related visits and those with non-overdose-related visits. We estimated the hazard ratio for death, with adjustment for age, sex, comorbidity and disposition (discharged or left against medical advice). RESULTS We included 3593 persons with overdose-related visits and 216 453 with non-overdose-related visits to the emergency department. Those with overdose-related visits were younger, were predominantly male and had more mental health conditions. The 12-month crude mortality probability was 5.4% (95% confidence interval [CI] 4.7%-6.2%) in this group and 1.7% (95% CI 1.6%-1.8%) among those with non-overdose-related visits. After adjustment, for persons who were discharged, the 12-month mortality hazard was 3.5 (95% CI 3.0-4.2) times higher among those with overdose-related visits than those with non-overdose-related visits. For persons who left against medical advice, the mortality hazard was 7.1 (95% CI 4.0-12.5) times higher among those with opioid overdose. INTERPRETATION Among persons with overdose-related visits to the emergency department, 12-month mortality was higher than among those with non-overdose-related visits. Overdose-related visits should prompt urgent evidence-based interventions (e.g., take-home naloxone kits, buprenorphine-naloxone induction) to prevent future deaths.
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Affiliation(s)
- Jessica Moe
- Department of Emergency Medicine (Moe, Purssell), Vancouver General Hospital; British Columbia Centre for Disease Control (Moe, Chong, Zhao, Slaunwhite); Department of Emergency Medicine (Scheuermeyer), St. Paul's Hospital; British Columbia Drug and Poison Information Centre (Purssell); Department of Emergency Medicine (Moe, Scheuermeyer, Purssell), The University of British Columbia, Vancouver, BC
| | - Mei Chong
- Department of Emergency Medicine (Moe, Purssell), Vancouver General Hospital; British Columbia Centre for Disease Control (Moe, Chong, Zhao, Slaunwhite); Department of Emergency Medicine (Scheuermeyer), St. Paul's Hospital; British Columbia Drug and Poison Information Centre (Purssell); Department of Emergency Medicine (Moe, Scheuermeyer, Purssell), The University of British Columbia, Vancouver, BC
| | - Bin Zhao
- Department of Emergency Medicine (Moe, Purssell), Vancouver General Hospital; British Columbia Centre for Disease Control (Moe, Chong, Zhao, Slaunwhite); Department of Emergency Medicine (Scheuermeyer), St. Paul's Hospital; British Columbia Drug and Poison Information Centre (Purssell); Department of Emergency Medicine (Moe, Scheuermeyer, Purssell), The University of British Columbia, Vancouver, BC
| | - Frank X Scheuermeyer
- Department of Emergency Medicine (Moe, Purssell), Vancouver General Hospital; British Columbia Centre for Disease Control (Moe, Chong, Zhao, Slaunwhite); Department of Emergency Medicine (Scheuermeyer), St. Paul's Hospital; British Columbia Drug and Poison Information Centre (Purssell); Department of Emergency Medicine (Moe, Scheuermeyer, Purssell), The University of British Columbia, Vancouver, BC
| | - Roy Purssell
- Department of Emergency Medicine (Moe, Purssell), Vancouver General Hospital; British Columbia Centre for Disease Control (Moe, Chong, Zhao, Slaunwhite); Department of Emergency Medicine (Scheuermeyer), St. Paul's Hospital; British Columbia Drug and Poison Information Centre (Purssell); Department of Emergency Medicine (Moe, Scheuermeyer, Purssell), The University of British Columbia, Vancouver, BC
| | - Amanda Slaunwhite
- Department of Emergency Medicine (Moe, Purssell), Vancouver General Hospital; British Columbia Centre for Disease Control (Moe, Chong, Zhao, Slaunwhite); Department of Emergency Medicine (Scheuermeyer), St. Paul's Hospital; British Columbia Drug and Poison Information Centre (Purssell); Department of Emergency Medicine (Moe, Scheuermeyer, Purssell), The University of British Columbia, Vancouver, BC
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Winhusen T, Walley A, Fanucchi LC, Hunt T, Lyons M, Lofwall M, Brown JL, Freeman PR, Nunes E, Beers D, Saitz R, Stambaugh L, Oga EA, Herron N, Baker T, Cook CD, Roberts MF, Alford DP, Starrels JL, Chandler RK. The Opioid-overdose Reduction Continuum of Care Approach (ORCCA): Evidence-based practices in the HEALing Communities Study. Drug Alcohol Depend 2020; 217:108325. [PMID: 33091842 PMCID: PMC7533113 DOI: 10.1016/j.drugalcdep.2020.108325] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 09/08/2020] [Accepted: 09/09/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND The number of opioid-involved overdose deaths in the United States remains a national crisis. The HEALing Communities Study (HCS) will test whether Communities That HEAL (CTH), a community-engaged intervention, can decrease opioid-involved deaths in intervention communities (n = 33), relative to wait-list communities (n = 34), from four states. The CTH intervention seeks to facilitate widespread implementation of three evidence-based practices (EBPs) with the potential to reduce opioid-involved overdose fatalities: overdose education and naloxone distribution (OEND), effective delivery of medication for opioid use disorder (MOUD), and safer opioid analgesic prescribing. A key challenge was delineating an EBP implementation approach useful for all HCS communities. METHODS A workgroup composed of EBP experts from HCS research sites used literature reviews and expert consensus to: 1) compile strategies and associated resources for implementing EBPs primarily targeting individuals 18 and older; and 2) determine allowable community flexibility in EBP implementation. The workgroup developed the Opioid-overdose Reduction Continuum of Care Approach (ORCCA) to organize EBP strategies and resources to facilitate EBP implementation. CONCLUSIONS The ORCCA includes required and recommended EBP strategies, priority populations, and community settings. Each EBP has a "menu" of strategies from which communities can select and implement with a minimum of five strategies required: one for OEND, three for MOUD, and one for prescription opioid safety. Identification and engagement of high-risk populations in OEND and MOUD is an ORCCArequirement. To ensure CTH has community-wide impact, implementation of at least one EBP strategy is required in healthcare, behavioral health, and criminal justice settings, with communities identifying particular organizations to engage in HCS-facilitated EBP implementation.
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Affiliation(s)
- Theresa Winhusen
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH 45229, USA; Center for Addiction Research, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH 45267, USA.
| | - Alexander Walley
- Grayken Center for Addiction, Clinical Addiction Research and Education Unit, Boston Medical Center and Boston University School of Medicine, 801 Massachusetts Avenue, 2nd Floor, Boston, MA 02118, USA
| | - Laura C Fanucchi
- Division of Infectious Diseases, Department of Medicine, University of Kentucky College of Medicine, Center on Drug and Alcohol Research, 845 Angliana Avenue, Lexington, KY 40508, USA
| | - Tim Hunt
- Columbia University, School of Social Work, Center for Healing of Opioid and Other Substance Use Disorders (CHOSEN), 1255 Amsterdam, Avenue, Rm 806, New York, NY 10027, USA
| | - Mike Lyons
- Center for Addiction Research, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH 45267, USA; Department of Emergency Medicine, University of Cincinnati College of Medicine 231 Albert Sabin Way, Cincinnati, OH 45267, USA
| | - Michelle Lofwall
- Departments of Behavioral Science and Psychiatry, University of Kentucky College of Medicine, Center on Drug and Alcohol Research, 845 Angliana Avenue, Lexington, KY 40508, USA
| | - Jennifer L Brown
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH 45229, USA; Center for Addiction Research, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH 45267, USA
| | - Patricia R Freeman
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, 789 S Limestone St, Lexington, KY 40536, USA
| | - Edward Nunes
- Department of Psychiatry, Columbia University Irving Medical Center, New York State Psychiatric Institute, Division on Substance Use, 1051 Riverside Drive, New York, NY 10032, USA
| | - Donna Beers
- Grayken Center for Addiction, Clinical Addiction Research and Education Unit, Boston Medical Center and Boston University School of Medicine, 801 Massachusetts Avenue, 2nd Floor, Boston, MA 02118, USA
| | - Richard Saitz
- Grayken Center for Addiction, Clinical Addiction Research and Education Unit, Boston Medical Center and Boston University School of Medicine, 801 Massachusetts Avenue, 2nd Floor, Boston, MA 02118, USA; Department of Community Health Sciences, Boston University School of Public Health, 801 Massachusetts Avenue 4th Floor, Boston, MA, 02118, USA
| | - Leyla Stambaugh
- Center for Applied Public Health Research, Research Triangle Institute (RTI) International, 6110 Executive Boulevard, Suite 902, Rockville. MD 20852, USA
| | - Emmanuel A Oga
- Center for Applied Public Health Research, Research Triangle Institute (RTI) International, 6110 Executive Boulevard, Suite 902, Rockville. MD 20852, USA
| | - Nicole Herron
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH 45229, USA; Center for Addiction Research, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH 45267, USA
| | - Trevor Baker
- Grayken Center for Addiction, Clinical Addiction Research and Education Unit, Boston Medical Center and Boston University School of Medicine, 801 Massachusetts Avenue, 2nd Floor, Boston, MA 02118, USA
| | - Christopher D Cook
- Opioid/Substance Use Priority Research Area, University of Kentucky, 845 Angliana Ave Lexington, KY 40508, USA
| | - Monica F Roberts
- Opioid/Substance Use Priority Research Area, University of Kentucky, 845 Angliana Ave Lexington, KY 40508, USA
| | - Daniel P Alford
- Grayken Center for Addiction, Clinical Addiction Research and Education Unit, Boston Medical Center and Boston University School of Medicine, 801 Massachusetts Avenue, 2nd Floor, Boston, MA 02118, USA
| | - Joanna L Starrels
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, 111 E. 210th Street, Bronx, NY 10467, USA
| | - Redonna K Chandler
- National Institute on Drug Abuse, National Institutes of Health, 6001 Executive Boulevard, Rockville, MD 20892, USA
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Naloxone provision to emergency department patients recognized as high-risk for opioid use disorder. Am J Emerg Med 2020; 40:173-176. [PMID: 33243535 DOI: 10.1016/j.ajem.2020.10.061] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 10/19/2020] [Accepted: 10/29/2020] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Patients with opioid use disorder (OUD) are at increased risk for overdose and death. Clinical practice guidelines and professional organization policy statements recommend providing naloxone to patients at risk for overdose. We sought to characterize fidelity to naloxone practice recommendations in a cohort of Emergency Department (ED) patients in whom opioid use disorder was suspected by the treating physician. METHODS This single-center cross-sectional study evaluated electronic health records from an urban academic ED with 73,000 annual encounters in a region with a high prevalence of OUD. Patients ≥18 years old with encounters from January 1, 2018 to November 30, 2019 were included if discharged from the ED and either administered buprenorphine in the ED or referred to outpatient substance use treatment. The primary outcome measure was the percentage of included patients provided naloxone (take-home or prescription). We used random effects multivariable logistic regression (accounting for multiple patient encounters) to estimate the odds ratio (OR) for receiving naloxone. RESULTS Of 1036 eligible patient encounters, 320 resulted in naloxone provision (30.9%, 95% CI: 28.1-33.8). Naloxone provision occurred for 33.6% (95% CI 30.5-36.7) of 900 patients referred to outpatient substance use treatment without ED buprenorphine administration, 10.6% (95% CI 5.0-19.2) of 85 patients administered buprenorphine and not referred to outpatient substance use treatment, and 17.6% (95% CI 8.4-30.9) of 51 patients administered buprenorphine and referred to outpatient treatment. After controlling for age, sex, race, and prior provision of naloxone, the administration of buprenorphine was associated with a 94% lower odds (aOR = 0.06 [95% CI 0.011-0.33]) for naloxone provision compared to those only referred to outpatient treatment. CONCLUSION A majority of ED patients who received an intervention targeted at OUD, in an ED where take-home naloxone is freely available, did not receive either take-home naloxone or a prescription for naloxone at discharge. Patients receiving buprenorphine were less likely to receive naloxone than patients only referred to outpatient treatment. These data suggest barriers other than recognition of potential OUD and naloxone availability impact provision of naloxone and argue for a treatment "bundle" as a conceptual model for care of ED patients with suspected OUD.
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Development of a take-home naloxone program at an urban academic emergency department. J Am Pharm Assoc (2003) 2020; 60:e324-e331. [DOI: 10.1016/j.japh.2020.06.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 06/08/2020] [Accepted: 06/16/2020] [Indexed: 11/23/2022]
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Cao SS, Dunham SI, Simpson SA. Prescribing Buprenorphine for Opioid Use Disorders in the ED: A Review of Best Practices, Barriers, and Future Directions. Open Access Emerg Med 2020; 12:261-274. [PMID: 33116962 PMCID: PMC7569244 DOI: 10.2147/oaem.s267416] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 09/18/2020] [Indexed: 01/14/2023] Open
Abstract
ED-initiated addiction treatment holds promise for enhancing access to treatment for those with opioid use disorder (OUD). We present a literature review summarizing the evidence for buprenorphine induction in the ED including best practices for dosing, follow-up care, and reducing implementation barriers. A literature search of Pubmed, PsychInfo, and Embase identified articles studying OUD treatment in the ED published after 1980. Twenty-five studies were identified including eleven scientific abstracts. Multiple studies suggest that buprenorphine induction improves engagement in substance treatment up to 30 days after ED treatment. Many different induction protocols were presented, but no particular approach was best supported as criteria for induction and initial dosing vary widely. Similarly, transition of care models focused on either a "hub and spoke" model or "warm hand-offs" model, but no studies compared these approaches. Common barriers to implementing induction programs were provider inexperience, discomfort with addiction treatment, and limited time during the ED visit. No studies described the number of EDs offering induction. While ED buprenorphine induction is safe and enhances adherence to addiction treatment, uncertainty persists in how to best identify patients needing treatment, how to initiate buprenorphine, and how to enhance follow-up after ED-initiated treatment.
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Affiliation(s)
- Scott S Cao
- University of Colorado School of Medicine Anschutz Medical Campus, Aurora, CO, USA
| | - Samuel I Dunham
- University of Colorado School of Medicine Anschutz Medical Campus, Aurora, CO, USA
| | - Scott A Simpson
- University of Colorado School of Medicine Anschutz Medical Campus, Aurora, CO, USA
- Psychiatric Emergency Services, Denver Health Medical Center, Denver, CO, USA
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Coon SA, Hill LG, Hutchison RW, Arnold LM, Jarrett JB, Ottney AR, Oung AB, Painter NA, Smith MA, Stranges PM, Tran TH, McFee Winans AR, Bratberg JP. Mobilizing pharmacists to address the opioid crisis: A joint opinion of the ambulatory care and adult medicine practice and research networks of the American College of Clinical Pharmacy. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2020. [DOI: 10.1002/jac5.1331] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Scott A. Coon
- Department of Pharmacotherapeutics & Clinical Research University of South Florida, Taneja College of Pharmacy, Morsani College of Medicine Tampa Florida USA
| | - Lucas G. Hill
- Division of Pharmacy Practice The University of Texas at Austin College of Pharmacy Austin Texas USA
| | - Robert W. Hutchison
- Department of Pharmacy Practice Texas A&M Irma Lerma Rangel College of Pharmacy Round Rock Texas USA
| | - Lindsay M. Arnold
- Department of Pharmacy Services St. Elizabeth's Medical Center Brighton Massachusetts USA
| | - Jennie B. Jarrett
- Department of Pharmacy Practice University of Illinois at Chicago, College of Pharmacy Chicago Illinois USA
| | - Anne R. Ottney
- Department of Pharmacy Practice Ferris State University, College of Pharmacy Big Rapids Michigan USA
| | - Alvin B. Oung
- Department of Pharmacy Practice University of Wyoming School of Pharmacy Laramie Wyoming USA
| | - Nathan A. Painter
- Division of Clinical Pharmacy University of California San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences San Diego California USA
| | - Michael A. Smith
- Department of Clinical Pharmacy University of Michigan College of Pharmacy Ann Arbor Michigan USA
| | - Paul M. Stranges
- Department of Pharmacy Practice University of Illinois at Chicago, College of Pharmacy Chicago Illinois USA
| | - Tran H. Tran
- Department of Pharmacy Practice Midwestern University Chicago College of Pharmacy Downers Grove Illinois USA
| | - Amanda R. McFee Winans
- Section of Clinical Pharmacy, Department of Pharmaceutical Care Services Bassett Medical Center Cooperstown New York USA
| | - Jeffrey P. Bratberg
- Department of Pharmacy Practice University of Rhode Island College of Pharmacy Kingston Rhode Island USA
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Rudisill TM, Ashraf AJ, Linn HI, Sayres S, Jeffries JE, Gurka KK. Facilitators, barriers and lessons learnt from the first state-wide naloxone distribution conducted in West Virginia. Inj Prev 2020; 27:369-374. [PMID: 32873604 DOI: 10.1136/injuryprev-2020-043666] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 07/22/2020] [Accepted: 07/25/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND Overdose education and naloxone distribution programmes are known to reduce opioid-related deaths. A state-wide naloxone distribution effort of 8250 rescue kits was undertaken by government, community and university partners in West Virginia in 2016-2017. The purpose of this study was to discern the barriers, facilitators and lesson learnt from implementing this endeavour in a rural state with the highest opioid overdose fatality rate in the US. METHODS Structured interviews (n=26) were conducted among both internal and external stakeholders. Those who participated were >18 years of age and were the lead representative from agencies that either received naloxone (ie, external stakeholders) or helped implement the distribution (ie, internal stakeholders). The interviews followed standardised scripts and lasted approximately 40 min. Sessions were audio-recorded and transcribed. Qualitative content analysis was performed by two researchers to determine themes surrounding facilitators or barriers to programme implementation. RESULTS The primary facilitators reported by stakeholders included collaborative partnerships, ease of participating in the programme, being established in prevention efforts, demand for naloxone and the need for personal protection from overdose. The primary barriers identified by stakeholders included bureaucracy/policy/procedures of their organisation or agency, stigma, logistical or planning issues, problems with reporting, lack of communication post distribution and sustainability. Numerous lessons were learnt. CONCLUSIONS Based on the implementation of the programme in 87 organisations, including law enforcement and fire departments, the impact of facilitators outweighed that of barriers. These findings may inform others planning to conduct a similar, large-scale project.
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Affiliation(s)
- Toni Marie Rudisill
- Department of Epidemiology, West Virginia University, Morgantown, West Virginia, USA
| | - Alexandria J Ashraf
- School of Public Health, Health Research Center, Robert C Byrd Health Science Center, West Virginia University, Morgantown, West Virginia, USA
| | - Herbert I Linn
- School of Public Health, Health Research Center, Robert C Byrd Health Science Center, West Virginia University, Morgantown, West Virginia, USA
| | - Sheena Sayres
- Behavioral Medicine and Psychiatry, School of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - James E Jeffries
- West Virginia Department of Health and Human Resources, Bureau for Public Health, Office of Maternal, Child and Family Health, Charleston, West Virginia, USA
| | - Kelly K Gurka
- Department of Epidemiology, College of Public Health and Health Professions and College of Medicine, University of Florida, Gainesville, Florida, USA
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Emergency Nurse Perceptions of Naloxone Distribution in the Emergency Department. J Emerg Nurs 2020; 46:675-681.e1. [DOI: 10.1016/j.jen.2020.05.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 05/08/2020] [Accepted: 05/13/2020] [Indexed: 11/23/2022]
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Olives T, Willhite LA, Lee SC, Evans DK, Jensen A, Regelman HT, McGillis ES. Point-of-sale Naloxone: Novel Community-based Research to Identify Naloxone Availability. West J Emerg Med 2020; 21:1188-1194. [PMID: 32970574 PMCID: PMC7514389 DOI: 10.5811/westjem.7.2020.47252] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 07/09/2020] [Indexed: 12/03/2022] Open
Abstract
Introduction Expanding naloxone availability is important to reduce opioid-related deaths. Recent data suggest low, variable urban naloxone availability. No reports describe naloxone availability at the point of sale (POSN). We characterize POSN without prescription across a Midwestern metropolitan area, via a unique poison center-based study. Methods Pharmacies were randomly sampled within a seven-county metropolitan area, geospatially mapped, and distributed among seven investigators, who visited pharmacies and asked, “May I purchase naloxone here without a prescription from my doctor?” Following “No,” investigators asked, “Are you aware of the state statute that allows you to dispense naloxone to the public under a standing order?” Materials describing statutory support for POSN were provided. Responses were uploaded to REDCap in real time. We excluded specialty (veterinary, mail order, or infusion) pharmacies a priori. POSN availability is presented as descriptive statistics; characteristics of individual sites associated with POSN availability are reported. Results In total, 150 pharmacies were prospectively randomized, with 52 subsequently excluded or unavailable for survey. Thus, 98 were included in the final analysis. POSN was available at 71 (72.5%) of 98 pharmacies. POSN availability was more likely at chain than independent pharmacies (84.7% vs 38.5%, p<0.001); rural areas were more commonly served by independent than chain pharmacies (47.4% vs 21.5%, p = 0.022). Five chain and five independent pharmacies (18.5% each) were unaware of state statutory support for collaborative POSN agreements. Statutory awareness was similar between independent and chain pharmacies (68.8% vs 54.6%, p = 0.453). Rationale for no POSN varied. Conclusion POSN is widely available in this metropolitan area. Variability exists between chain and independent pharmacies, and among pharmacies of the same chain; awareness of statutory guidance does not. Poison centers can act to define local POSN availability via direct inquiry in their communities.
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Affiliation(s)
- Travis Olives
- Hennepin Healthcare, Department of Emergency Medicine, Minneapolis, Minnesota.,Minnesota Poison Control System, Minneapolis, Minnesota
| | - Laurie A Willhite
- Hennepin Healthcare, Minneapolis, Minnesota.,Minnesota Poison Control System, Minneapolis, Minnesota
| | | | - Danika K Evans
- Hennepin Healthcare, Department of Emergency Medicine, Minneapolis, Minnesota
| | - Ashley Jensen
- Minnesota Poison Control System, Minneapolis, Minnesota
| | | | - Eric S McGillis
- University of Calgary, Department of Emergency Medicine, Calgary, Alberta, Canada
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Holland WC, Nath B, Li F, Maciejewski K, Paek H, Dziura J, Rajeevan H, Lu CC, Katsovich L, D'Onofrio G, Melnick ER. Interrupted Time Series of User-centered Clinical Decision Support Implementation for Emergency Department-initiated Buprenorphine for Opioid Use Disorder. Acad Emerg Med 2020; 27:753-763. [PMID: 32352206 PMCID: PMC7496559 DOI: 10.1111/acem.14002] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 04/08/2020] [Accepted: 04/23/2020] [Indexed: 01/01/2023]
Abstract
OBJECTIVES Adoption of emergency department (ED) initiation of buprenorphine (BUP) for opioid use disorder (OUD) into routine emergency care has been slow, partly due to clinicians' unfamiliarity with this practice and perceptions that it is complicated and time-consuming. To address these barriers and guide emergency clinicians through the process of BUP initiation, we implemented a user-centered computerized clinical decision support system (CDS). This study was conducted to assess the feasibility of implementation and to evaluate the preliminary efficacy of the intervention to increase the rate of ED-initiated BUP. METHODS An interrupted time series study was conducted in an urban, academic ED from April 2018 to February 2019 (preimplementation phase), March 2019 to August 2019 (implementation phase), and September 2019 to December 2019 (maintenance phase) to study the effect of the intervention on adult ED patients identified by a validated electronic health record (EHR)-based computable phenotype consisting of structured data consistent with potential cases of OUD who would benefit from BUP treatment. The intervention offers flexible CDS for identification of OUD, assessment of opioid withdrawal, and motivation of readiness to start treatment and automates EHR activities related to ED initiation of BUP (including documentation, orders, prescribing, and referral). The primary outcome was the rate of ED-initiated BUP. Secondary outcomes were launch of the intervention, prescription for naloxone at ED discharge, and referral for ongoing addiction treatment. RESULTS Of the 141,041 unique patients presenting to the ED over the preimplementation and implementation phases (i.e., the phases used in primary analysis), 906 (574 preimplementation and 332 implementation) met OUD phenotype and inclusion criteria. The rate of BUP initiation increased from 3.5% (20/574) in the preimplementation phase to 6.6% (22/332) in the implementation phase (p = 0.03). After the temporal trend of the number of physician's with X-waiver training and other covariates were adjusted for, the relative risk of BUP initiation rate was 2.73 (95% confidence interval [CI] = 0.62 to 12.0, p = 0.18). Similarly, the number of unique attendings who initiated BUP increased modestly 7/53 (13.0%) to 13/57 (22.8%, p = 0.10) after offering just-in-time training during the implementation period. The rate of naloxone prescribed at discharge also increased (6.5% preimplementation and 11.5% implementation; p < 0.01). The intervention received a system usability scale score of 82.0 (95% CI = 76.7 to 87.2). CONCLUSION Implementation of user-centered CDS at a single ED was feasible, acceptable, and associated with increased rates of ED-initiated BUP and naloxone prescribing in patients with OUD and a doubling of the number of unique physicians adopting the practice. We have implemented this intervention across several health systems in an ongoing trial to assess its effectiveness, scalability, and generalizability.
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Affiliation(s)
| | | | - Fangyong Li
- Yale Center for Analytical SciencesNew HavenCT
| | | | - Hyung Paek
- Information Technology ServicesYale New Haven HealthNew HavenCT
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Scharf BM, Sabat DJ, Brothers JM, Margolis AM, Levy MJ. Best Practices for a Novel EMS-Based Naloxone Leave behind Program. PREHOSP EMERG CARE 2020; 25:418-426. [PMID: 32420791 DOI: 10.1080/10903127.2020.1771490] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Increasing naloxone access has been identified as a primary strategy to reduce opioid overdose deaths. To supplement community naloxone training and distribution access points, EMS systems have instituted public safety-based naloxone leave behind (NLB) programs that allow emergency medical responders to distribute "leave behind" naloxone kits on the scene of an overdose. This model presents an opportunity to expand naloxone access for individuals at high risk for future overdoses. Objectives: To evaluate the preliminary outcomes of a novel EMS-based NLB program in Howard County, Maryland. Methods: This exploratory study involved analysis of data from the Howard County NLB Program. Basic statistical analysis of program performance metrics and participant demographic characteristics were performed. Results: From June 2018 to June 2019, Howard County Department of Fire and Rescue Services responded to 239 overdose calls and distributed 120 naloxone kits to individuals on the scene of an overdose, a 50.21% distribution rate. The HCNLB program connected 143 patients (59.83%) to peer recovery specialists. Among the 143 patients linked to peer recovery support specialist services, 87 (60.84%) had accepted an NLB kit from EMS. The fully adjusted logistic regression model revealed that those whose kit was left with a family member on the scene were 5.16 times more likely to be connected to peer support specialists (OR = 5.16, CI= 2.35 - 11.29, p = 0.000) while those whose kit was left with a friend or given directly to the patient were 3.69 times (OR = 3.69, CI= 1.13 - 12.06, p < 0.05) and 2.37 times (OR = 2.37, CI= 1.10 - 5.14, p < 0.05) more likely, respectively, to be connected to follow up services as compared to those who did not accept a kit, controlling for other variables in the model. Conclusion: This study highlights the importance of engaging an individual's family and social network when offering connections to treatment and recovery resources. NLB initiatives can potentially augment existing community-based naloxone training structures, thus widening the scope of the life-saving drug and reaching those most at risk of dying from an opioid overdose.
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Affiliation(s)
- Becca M Scharf
- Howard County Department of Fire and Rescue Services, Marriottsville, Maryland (BMS, DJS, JMB, AMM, MJL).,Department of Public Policy, University of Maryland, Baltimore County, Baltimore, Maryland (BMS)
| | - David J Sabat
- Howard County Department of Fire and Rescue Services, Marriottsville, Maryland (BMS, DJS, JMB, AMM, MJL)
| | - James M Brothers
- Howard County Department of Fire and Rescue Services, Marriottsville, Maryland (BMS, DJS, JMB, AMM, MJL)
| | | | - Matthew J Levy
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, Maryland (AMM, MJL)
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Teferi MM, Boggs KM, Espinola JA, Herrington R, Mick NW, Rutman MS, Venkatesh AK, Zabbo CP, Hasegawa K, Samuels-Kalow ME, Weiner SG, Camargo CA. Change in opioid policies in New England emergency departments, 2014 vs 2018. Drug Alcohol Depend 2020; 213:108105. [PMID: 32615413 DOI: 10.1016/j.drugalcdep.2020.108105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 05/25/2020] [Accepted: 05/26/2020] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The U.S. opioid epidemic persists, yet it is unclear if opioid-related emergency department (ED) policies have changed. We investigated: 1) the prevalence of opioid use disorder (OUD) prevention and treatment policies in New England EDs in 2018, and 2) how these policies have changed since 2014. METHODS Using the National Emergency Department Inventory-USA, we identified and surveyed all New England EDs in 2015 and 2019 about opioid-related policies in 2014 and 2018, respectively. The surveys assessed OUD prevention policies (to use a screening tool, access the Prescription Drug Monitoring Program [PDMP], notify primary care providers, prescribe/dispense naloxone) and treatment policies (to refer to recovery resources, prescribe/dispense buprenorphine). RESULTS Of 194 EDs open in 2018, 167 (86 %) completed the survey. Of 193 EDs open in 2018 and 2014, 147 (76 %) completed both surveys. In 2018, the most commonly-reported policy was accessing the PDMP (96 %); the least commonly-reported policy was prescribing/dispensing buprenorphine to at risk patients (37 %). EDs varied in prescribing/dispensing naloxone: 35 % of EDs offered naloxone to ≥80 % of patients at risk of opioid overdose versus 33 % of EDs to <10 % of patients at risk. Most EDs (74 %) reported prescribing/dispensing buprenorphine to <10 % of patients with OUD. Comparing 2018 to 2014, the greatest difference in policy use was in prescribing/dispensing naloxone (+55 %, p < 0.001). CONCLUSION Implementation of opioid-related ED policies increased between 2014 and 2018. Continued effort is needed to understand the extent to which policy implementation translates to clinical care, and to best translate evidence-based policies into clinical practice.
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Affiliation(s)
- Maranatha M Teferi
- Department of Emergency Medicine, Massachusetts General Hospital, 125 Nashua St., Suite 920, Boston, MA 02114, United States.
| | - Krislyn M Boggs
- Department of Emergency Medicine, Massachusetts General Hospital, 125 Nashua St., Suite 920, Boston, MA 02114, United States.
| | - Janice A Espinola
- Department of Emergency Medicine, Massachusetts General Hospital, 125 Nashua St., Suite 920, Boston, MA 02114, United States.
| | - Ramsey Herrington
- Division of Emergency Medicine, University of Vermont, 111 Colchester Ave., Burlington, VT 05401, United States.
| | - Nathan W Mick
- Department of Emergency Medicine, Maine Medical Center, 22 Bramhall St., Portland, ME 04102, United States.
| | - Maia S Rutman
- Departments of Pediatrics and Medicine, Dartmouth-Hitchcock Medical Center, 1 Medical Center Dr., Lebanon, NH 03756, United States.
| | - Arjun K Venkatesh
- Department of Emergency Medicine, Yale University School of Medicine, 333 Cedar St., New Haven, CT 06510, United States.
| | - Christopher P Zabbo
- Department of Emergency Medicine, Kent Hospital, 455 Toll Gate Rd., Warwick, RI 02886, United States.
| | - Kohei Hasegawa
- Department of Emergency Medicine, Massachusetts General Hospital, 125 Nashua St., Suite 920, Boston, MA 02114, United States.
| | - Margaret E Samuels-Kalow
- Department of Emergency Medicine, Massachusetts General Hospital, 125 Nashua St., Suite 920, Boston, MA 02114, United States.
| | - Scott G Weiner
- Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis St., Boston, MA 02115, United States.
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, 125 Nashua St., Suite 920, Boston, MA 02114, United States.
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Hurt BR, Hussain A, Aledhaim A, Moayedi S, Schenkel SM, Kim HK. Access and Barriers to Take-Home Naloxone Use among Emergency Department Patients with Opioid Misuse in Baltimore, Maryland, USA. Subst Use Misuse 2020; 55:2237-2242. [PMID: 32729772 DOI: 10.1080/10826084.2020.1797811] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The opioid epidemic has prompted the expansion of take-home naloxone (THN) distribution programs. The proportion of emergency department (ED) patients with opioid misuse who have access to a naloxone kit (NK) and barriers to using it are unclear. Objective: Characterizing the access and barrier to NK use among at-risk ED patients. Methods: We enrolled a convenience sample of ED patients with active opioid misuse from May 21-July 31, 2018. We administered a survey to collect patients' demographic data, substance use history, and access to and use of NK. The primary outcome was NK access (prior receipt of a kit or prescription); secondary outcomes were knowledge and use of NK, and barriers to obtaining and using it. Results: Of 165 respondents, 71.5% knew of THN programs and 57.6% (n = 95) had access to THN by either having received a NK (n = 90) or a prescription (n = 5); 34 respondents received both. Among 39 (23.6%) who received a naloxone prescription, 25 (64.1%) filled it. 60.0% (n = 99) reported knowing how to administer naloxone; lack of training was the primary reason (n = 63/66, 96.9%) for their unfamiliarity. Patients who presented after an opioid overdose (25.5%; n = 42) were less likely to have knowledge of THN programs (57.1% vs. 76.4%), and to have received a NK (35.7% vs. 61.0%). Conclusion: Awareness of THN programs was high among our cohort. But approximately 60% the respondents received a NK or knew how to use it. Despite efforts to expand THN access, gaps in knowledge, access, and use exist.
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Affiliation(s)
- Brenten R Hurt
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Atizaz Hussain
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ali Aledhaim
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Siamak Moayedi
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Stephen M Schenkel
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Hong K Kim
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
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