Prevalence, predictors and trends of opioid prescribing for lower back pain in United States emergency departments

WHAT IS KNOWN AND OBJECTIVE

Current evidence-based guidelines for the treatment of acute low back pain (ALBP) recommend the use of opioid medications only after failure of nonpharmacological therapy, non-steroidal anti-inflammatory drugs and skeletal muscle relaxants and after thorough evaluation of risks and benefits. Despite this recommendation and the state of the opioid epidemic in the United States (US), opioids remain a common drug of choice for ALBP in the emergency department (ED). The purpose of this study was to quantify the prevalence and identify predictors of opioid prescribing for acute lower back pain (ALBP) in emergency departments (EDs) in the United States.

METHODS

This was a national, cross-sectional study of the National Hospital Ambulatory Care Survey from 2013-2016. ED visits for patients aged ≥18 years treated for ALBP were included. Patients presenting with specified reasons that an opioid may be indicated were excluded. The primary endpoint was frequency of opioids prescribed. A multivariate logistic regression model identified patient- and provider-level predictors of opioid use.

RESULTS AND DISCUSSION

This analysis included 2260 visits for ALBP. Opioids were prescribed in 32.3% of visits. Positive predictors of opioid prescribing were pain score of 7-10 (OR 1.85; 95% CI 1.26-2.70), and patients seen in the Southern (OR 2.53; 95% CI 1.47-4.36) or Western US (OR 2.10; 95% CI 1.19-3.70). Opioids were prescribed less often to patients who received a NSAID or acetaminophen (OR 0.38; 95% CI 0.28-0.52 and OR 0.03; 95% CI 0.01-0.10, respectively).

WHAT IS NEW AND CONCLUSION

Opioid prescribing rates for ALBP remain high and the predictors identified demonstrate that this prescribing pattern is not uniformly distributed across the patient and provider characteristics studied.

Utilization of multiple microbial tools to evaluate efficacy of restoration strategies to improve recreational water quality at a Lake Michigan Beach (Racine, WI)

Hydro-meteorological conditions facilitate transport of fecal indicator bacteria (FIB) to the nearshore environment, affecting recreational water quality. North Beach (Racine, Wisconsin, United States), is an exemplar public beach site along Lake Michigan, where precipitation-mediated surface runoff, wave encroachment, stormwater and tributary outflow were demonstrated to contribute to beach advisories. Multiple restoration actions, including installation of a stormwater retention wetland, were successfully deployed to improve recreational water quality. Implementation of molecular methods (e.g. human microbial source tracking markers and Escherichia coli (E. coli) qPCR) assisted in identifying potential pollution sources and improving public health response time. However, periodic water quality failures still occur. As local beach managers reassess restoration measures in response to climatic changes, use of expanded microbial methods (including bacterial community profiling) may contribute to a better understanding of these dynamic environments. In this 2-year study (2015 and 2019), nearshore/offshore Lake Michigan, stormwater, and tributary samples were collected to determine if, 1) the constructed wetland (~50 m from the shoreline) continued to provide stormwater separation/retention and 2) mixing between onshore sources, Root River and Lake Michigan, was increasing due to rising precipitation/lake levels. Monthly rainfall totals were 1.5× higher in 2019 than 2015, coinciding with a 0.63 m lake-level rise. The prevalence of more intense, onshore winds also increased, facilitating interaction between potential reservoirs of FIB with nearshore water through wind driven waves and lake intrusion, e.g. beach sands and the adjacent Root River. While a strong relationship existed between wet weather wetland and North Beach nearshore E. coli concentrations (all sites), bacterial communities were strikingly different. Conversely, bacterial community overlap existed between the Root River mouth and nearshore/offshore sites. These results suggest the constructed wetland can accommodate the climate-related changes observed in this study. Future restoration activities could be directed towards upstream tributary sources in order to minimize microbial contaminants entering Lake Michigan.

Correctional mental health

This article describes a prison program for mentally ill felons. It depicts the program's similarities to and differences from more traditional mental health programs. The unique qualities of the program are detailed, and possible future directions are considered.