Howard S. Kim

Association of Emergency Department Opioid Initiation with Recurrent Opioid Use

STUDY OBJECTIVE Acute pain complaints are commonly treated in the emergency department (ED). Short courses of opioids are presumed to be safe for acute pain; however, the risk of recurrent opioid use after receipt of an ED opioid prescription is unknown. We describe the risk of recurrent opioid use in patients receiving an opioid prescription from the ED for an acute painful condition. METHODS This is a retrospective cohort study of all patients discharged from an urban academic ED with an acute painful condition during a 5-month period. Clinical information was linked to data from Colorados prescription drug monitoring program. We compared opioid-naive patients (no opioid prescription during the year before the visit) who filled an opioid prescription or received a prescription but did not fill it to those who did not receive a prescription. The primary outcome was the rate of recurrent opioid use, defined as filling an opioid prescription within 60 days before or after the first anniversary of the ED visit. RESULTS Four thousand eight hundred one patients were treated for an acute painful condition; of these, 52% were opioid naive and 48% received an opioid prescription. Among all opioid-naive patients, 775 (31%) received and filled an opioid prescription, and 299 (12%) went on to recurrent use. For opioid-naive patients who filled a prescription compared with those who did not receive a prescription, the adjusted odds ratio for recurrent use was 1.8 (95% confidence interval 1.3 to 2.3). For opioid-naive patients who received a prescription but did not fill it compared with those who did not receive a prescription, the adjusted odds ratio for recurrent use was 0.8 (95% confidence interval 0.5 to 1.3). CONCLUSION Opioid-naive ED patients prescribed opioids for acute pain are at increased risk for additional opioid use at 1 year.

Marijuana Tourism and Emergency Department Visits in Colorado

At a large hospital in Colorado, the rate of ED visits related to cannabis use doubled for out-of-state patients, with little change for in-state patients, from 2013 through 2014, the first year of retail marijuana sales. Statewide data confirmed these differential trends.

Colorado Cannabis Legalization and Its Effect on Emergency Care

Colorado legalized the use of medical marijuana in 2000, although it was not truly commercialized in the state until the US attorney general ceased the prosecution of marijuana users and suppliers in 2009. The result was striking: from January 2009 to January 2011, the number of registered medical marijuana licenses in Colorado increased from 5,051 to 118,895 (Figure 1). Figure 1 Number of active marijuana licenses in Colorado. In 2012, Colorado voted to legalize recreational marijuana beginning in 2014, making it the first state alongside Washington to permit recreational use. Several other states have recently legalized the use of medical or recreational marijuana, with other states considering similar measures (Figure 2).1 Given this trend, emergency physicians in training will likely be confronted with increasing volumes of marijuana-related emergency department (ED) visits and may learn from Colorado’s recent experience with increased availability of marijuana products. Figure 2 Marijuana legalization by state (as of May 2015). THE EPIDEMIOLOGIC EFFECT OF LEGALIZATION Although the significant increase in medical marijuana registrations does not prove its increased use, this inference is supported by various survey data. According to the National Survey on Drug Use and Health, the percentage of young Coloradan adults aged 18 to 25 years reporting marijuana use within the past year increased significantly after medical marijuana legalization (35% in 2007 to 2008 versus 43% in 2010 to 2011). Simultaneously, the percentage of adults aged 26 years or older perceiving “great risk” to marijuana use significantly decreased, from 45% to 31%.2 Interstate comparisons also show a higher prevalence of marijuana use in states in which it has been legalized versus those in which it has not. According to National Survey on Drug Use and Health responses from 2011 to 2013, the prevalence of Coloradan adults endorsing marijuana use within the last month was 19% compared with a national prevalence of 12%.3 According to data from the National Epidemiologic Survey on Alcohol and Related Conditions, residents of states with medical marijuana legalization were twice as likely to endorse marijuana use compared with residents of states without legalized medical marijuana.4

Benzodiazepine-opioid co-prescribing in a national probability sample of ED encounters

Background: Benzodiazepine‐opioid combination therapy is potentially harmful due to the risk of synergistic respiratory depression, and the rate of death due to benzodiazepine‐opioid overdose is increasing. Little is known about the prevalence and characteristics of benzodiazepine‐opioid co‐prescribing from the ED setting. Methods: Secondary analysis of data from the National Hospital Ambulatory Medical Care Survey, using sample weights to generate population estimates. The primary objective was to describe the annual prevalence of benzodiazepine‐opioid co‐prescribing from 2006 to 2012, using 95% confidence intervals (95% CI) to compare adjacent years. The secondary objective was to compare characteristics of ED encounters receiving a benzodiazepine‐opioid co‐prescription versus those receiving an opioid prescription alone, using a multivariable logistic regression. Results: The prevalence of benzodiazepine‐opioid co‐prescribing did not significantly change from 2006 to 2012. During this period, 2.7% (95% CI: 2.5–2.8%) of ED encounters prescribed an opioid were also prescribed a benzodiazepine. Relative to encounters receiving an opioid prescription alone, encounters receiving a co‐prescription were more likely to represent a follow‐up rather than initial visit (Odds Ratio [OR] 1.52), receive more medications (OR 1.41) and fewer procedures (OR 0.48) while in the ED, and more likely to have a diagnosis related to mental disorder (OR 20.60) or musculoskeletal problem (OR 3.71). Conclusions: From 2006 to 2012, almost 3% of all ED encounters receiving an opioid prescription also received a benzodiazepine co‐prescription. The odds of benzodiazepine‐opioid co‐prescribing were significantly higher in ED encounters representing a follow‐up visit and in diagnoses relating to a mental disorder or musculoskeletal problem.

ED opioid prescribing is not associated with higher patient satisfaction scores

Despite the popular belief that providing an opioid prescription increases patient satisfaction [1], this association has not been well studied in the emergency department (ED) setting. Although a prior study found no association between patient satisfaction scores and opioid analgesics administered in the ED [2], providing an opioid prescription may reasonably differ. Prescription opioids may serve as physical tokens of the index ED visit at the time of survey response and may increase patient satisfaction similarly to the provision of an antibiotic prescription [3]. The potential association between opioid prescribing and patient satisfaction is worthy of investigation. Although not all opioid prescriptions result in misuse, the potential harm of indiscriminate prescribing practices is becoming increasingly evident, as unintentional opioid overdoses have now surpassed motor vehicle accidents as the leading cause of injury [4]. In a recent national survey of ED providers, 12% of respondents reported prescribing an opioid analgesic to improve patient satisfaction [5]. We conducted an institutional review board–approved retrospective cohort study of adult patients completing a Press Ganey survey relating to an ED visit in 2010 to a single urban academic ED in Chicago, IL (85 000 annual visits). Per institutional protocol, 30% of discharged patients are randomly selected to receive a survey bymail. ED providers at this institution do not receive financial incentives for patient satisfaction scores. We stratified patients into 1 of 3 exposure groups (no analgesic prescription, nonopioid analgesic prescription, or any opioid prescription) based on Multum coding of prescribed medications and investigated the association between prescription type and Press Ganey survey scores. The patient satisfaction survey is composed of 38 individual questions, each scored on a 5-point Likert scale (1 = very poor, 5= very good), and organized into 8 domains: Arrival, Nurses, Doctors, Tests, Family/Friends, Personal/Insurance Information, Personal

A comparison of analgesic prescribing among ED back and neck pain visits receiving physical therapy versus usual care

OBJECTIVE Physical therapy (PT) is commonly cited as a non-opioid pain strategy, and previous studies indicate PT reduces opioid utilization in outpatients with back pain. No study has yet examined whether PT is associated with lower analgesic prescribing in the ED setting. METHODS This was a retrospective cohort study of discharged ED visits with a primary ICD-10 diagnosis relating to back or neck pain from 10/1/15 to 2/21/17 at an urban academic ED. Visits receiving a PT evaluation were matched with same-date visits receiving usual care. We compared the primary outcomes of opioid and benzodiazepine prescribing between the two cohorts using chi-squared test and multivariable logistic regression. RESULTS 74 ED visits received PT during the study period; these visits were matched with 390 same-date visits receiving usual care. Opioid prescribing among ED-PT visits was not significantly higher compared to usual care visits on both unadjusted analysis (50% vs 42%, p = 0.19) and adjusted analysis (adjOR 1.05, 95% CI 0.48-2.28). However, benzodiazepine prescribing among ED-PT visits was significantly higher than usual care visits on both unadjusted (45% vs 23%, p < 0.001) and adjusted analysis (adjOR 3.65, 95% CI 1.50-8.83). CONCLUSIONS In this single center study, ED back and neck pain visits receiving PT were no less likely to receive an opioid prescription and were more likely to receive a benzodiazepine than visits receiving usual care. Although prior studies demonstrate that PT may reduce opioid utilization in the subsequent year, these results indicate that analgesic prescribing is not reduced at the initial ED encounter.

Physical therapy in the emergency department: A new opportunity for collaborative care

ABSTRACT Emergency department‐initiated physical therapy (ED PT) is an emerging resource in the United States, with the number of ED PT programs in the United States growing rapidly over the last decade. In this collaborative model of care, physical therapists are consulted by the treating ED physician to assist in the evaluation and treatment of a number of movement and functional disorders, such as low back pain, peripheral vertigo, and various gait disturbances. Patients receiving ED PT benefit from the physical therapists expertise in musculoskeletal and vestibular conditions and from the individualized attention provided in a typical bedside evaluation and treatment session, which includes education on expected symptom trajectory, recommendations for activity modulation, and facilitated outpatient follow‐up. Early data suggest that both physicians and patients view ED PT services favorably, and that ED PT is associated with improvement of several important clinical and operational outcomes. Hospital systems interested in building their own ED PT program may benefit from the key steps outlined in this review, as well as a summary of the typical clinical volumes and practice patterns encountered at existing programs around the country.

A Case of Recalcitrant Urinary Tract Infection

A 51-year-old woman without significant medical history presented to the Emergency Department with 3 days of vaginal bleeding and pelvic pain. She also reported 8 months of intermittent urinary frequency, hesitancy, dysuria, and pelvic pain for which she had been placed on three different courses of outpatient antibiotics. During the course of the interview, the patient hadmultiple paroxysms of suprapubic pain, forcing her to run to the bathroom in an attempt to void, although she was unsuccessful on each attempt. Vital signs on presentation were notable for a heart rate of 112 beats/min, respiratory rate of 24 breaths/min, and temperature 36.2 C (97.2 F). Physical examination was remarkable for suprapubic distension and tenderness, and an absence of vaginal bleeding on pelvic examination. A urine sample obtained via straight catheterizationwas noted to be grossly bloody. Laboratory studies were remarkable for a white blood cell count of 14.1 10/L, normal platelet count, and normal coagulation studies. Urinalysis revealed 4885 white blood cells, 68,064 red blood cells, and rare bacteria. As the patient was not able to void spontaneously, a bedside ultrasound was performed, which revealed a distended bladder containing complex heterogeneous material. A triplephase computed tomography (CT) scan of the abdomen and pelvis was obtained (Figures 1 and 2), which demonstrated an anterior bladder wall mass and a gascontaining fluid collection consistent with pyocystis.

Patients are aware of risks of opioid dependence, yet note poor communication from providers about pain and pain management

Commentary on : Smith RJ, Rhodes K, Paciotti B, et al. Patient perspectives of acute pain management in the era of the opioid epidemic. Ann Emerg Med 2015;66:246–52.e1.[OpenUrl][1][CrossRef][2][PubMed][3] Emergency department (ED) providers are frequently faced with the dilemma of providing adequate pain relief while preventing the potential harms of opioids. In light of the increasing number of deaths related to opioid overdose, many different strategies are being promoted to curb opioid abuse and dependence. However, little is known about the patients perspective on pain management strategies and the risk of opioid abuse and dependence. In … [1]: {openurl}?query=rft.jtitle%253DAnn%2BEmerg%2BMed%26rft.volume%253D66%26rft.spage%253D246%26rft_id%253Dinfo%253Adoi%252F10.1016%252Fj.annemergmed.2015.03.025%26rft_id%253Dinfo%253Apmid%252F25865093%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/external-ref?access_num=10.1016/j.annemergmed.2015.03.025&link_type=DOI [3]: /lookup/external-ref?access_num=25865093&link_type=MED&atom=%2Febnurs%2F19%2F3%2F88.atom

Opioid prescription fill rates after emergency department discharge

PURPOSE Opioid prescription fill rates and the time to fill after emergency department (ED) discharge were studied. METHODS Data were evaluated for all patients discharged from the ED between September 1, 2011, who were February 1, 2012, who were diagnosed with one of the following: dental pain, jaw pain, flank pain, abdominal pain, pelvic pain, back pain, neck pain, knee pain, headache, fracture, or sprain. Clinical information was abstracted via computer algorithm, and prescription filling within 100 days of prescription writing was determined by cross-referencing patient demographics with the state prescription drug monitoring program. Logistic regression analysis and a Cox proportional hazards model were used to determine if any clinical and demographic characteristics were associated with fill rates or the time to fill, respectively. RESULTS Of the 2243 patients who received an opioid prescription at ED discharge, 1775 (79%) filled it, with a median time to fill of 0 days. On adjusted analysis, characteristics associated with filling the opioid prescriptions included Caucasian race, being insured by the federal government or through a state indigent assistance program, a chief complaint of back pain, and a history of filling an opioid prescription within the past year. No characteristics were predictive of a prolonged time to filling. CONCLUSION One in five patients who received an opioid prescription at discharge from an urban academic ED did not fill it. Several factors may be associated with a greater likelihood of filling, such as insurance status and history of filling an opioid prescription within the past year.