Treatment Initiation for Opioid Use Disorder in Emergency Departments

MedicalResearch.com Interview with:

Herbie Duber, MD, MPH, FACEP Associate Professor, Emergency Medicine Adjunct Associate Professor Department of Global Health Adjunct Associate Professor, Institute for Health Metrics and Evaluation University of Washington

Dr. Duber

Herbie Duber, MD, MPH, FACEP
Associate Professor, Emergency Medicine
Adjunct Associate Professor Department of Global Health
Adjunct Associate Professor
Institute for Health Metrics and Evaluation
University of Washington

MedicalResearch.com: What is the background for this study? What are the main findings? 

Response: Opioid use disorder (OUD) and opioid overdose deaths are a rapidly increasing public health crisis.  In this paper, we review and synthesize current evidence on the identification, management and transition of patients from the emergency department (ED) to the outpatient setting and present several key recommendations.

For patients identified to haveOpioid use disorder, we recommend ED-initiated mediation-assisted therapy (MAT) with buprenorphine, an opioid agonist.  Current evidence suggests that it safe and effective, leading to improved patient outcomes.  At the same time, a coordinated care plan should be put into motion which combines MAT with a rapid transition to outpatient care, preferably within 72 hours of ED evaluation.  Where possible, a warm handoff is preferred, as it has been shown in other settings to improve follow-up.  Outpatient care should combine MAT, psychological interventions and social support/case management in order to maximize impact Continue reading

Study Finds Pulmonary Embolus Rarely the Cause of Syncope

MedicalResearch.com Interview with:
Giorgio Costantino MD

Dipartimento di Medicina Interna
Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca’ Granda
Ospedale Maggiore Policlinico
Università degli Studi di Milano
Milan, Italy

MedicalResearch.com: What is the background for this study?

Response: Syncope is a common symptom that occurs in one in four people during their lifetime. Pulmonary embolism (PE) has long been recognized as an important and serious cause of syncope. PE has always been estimated a rare cause of syncope, present in less than 1.5% of patients. A recent study (PESIT), aiming at evaluating PE prevalence using a standardized algorithm in hospitalized patients after a first syncope episode, found a prevalence of PE as high as 17% in hospitalized patients. This means that patients with a first episode of syncope should be investigated with a standard diagnostic algorithm to exclude PE.

However, many patients might go through useless and potentially harmful tests, such as computed tomography pulmonary angiogram.

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How Much Non-Invasive Testing Is Necessary In ER To Rule Out Heart Attack?

MedicalResearch.com Interview with:

David L. Brown, MD, FACC Professor of Medicine Cardiovascular Division Washington University School of Medicine St. Louis, MO 63110

Dr. Brown

David L. Brown, MD, FACC
Professor of Medicine
Cardiovascular Division
Washington University School of Medicine
St. Louis, MO 63110

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Approximately 10 million patients present to emergency rooms in the US annually for evaluation of acute chest pain.

The goal of that evaluation is to rule out the diagnosis of an acute heart attack. Imaging with coronary CT angiography and stress testing are not part of the diagnostic algorithm for acute heart attack.  Nevertheless many chest pain patients undergo some form of noninvasive cardiac testing in the ER. We found that CCTA or stress testing adding nothing to the care of chest pain patients beyond what is achieved by a history, physical examination, ECG and troponin test.

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High Treatment Failure Rates Among Elderly With Purulent Skin Infections

MedicalResearch.com Interview with:

John P. Haran, MD Assistant Professor Department of Emergency Medicine University of Massachusetts Medical School UMass Memorial Medical Group Worcester, MA

Dr. John P. Haran

John P. Haran, MD
Assistant Professor
Department of Emergency Medicine
University of Massachusetts Medical School
UMass Memorial Medical Group
Worcester, MA

MedicalResearch.com: What is the background for this study?

Response: In 2014, the Infectious Disease Society of America (IDSA) updated their guidelines for the management of skin and soft tissue infection in response to high MRSA infection rates as well as high treatment failure rates for skin and soft tissue infections. Greater than 1 in 5 patients treated for a skin abscess will fail initial treatment.

Historically antibiotics have been shown to be unnecessary in the treatment of uncomplicated purulent infections. This notion has been recently challenges when authors published a randomized control trial using trimethoprim-sulfamethoxazone in the NEJM that demonstrated a minimal increase in cure rates for outpatient treatment of uncomplicated skin purulent skin infections. In this study they did not follow IDSA-guidelines nor model or stratify their analysis. It is possible their findings may be due to at-risk patient groups that did not receive antibiotics. Many widely used clinical decision rules incorporate age into their decision algorithms, however the IDSA did not do this with their recent guidelines.

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Dialysis Patients Use Emergency Rooms At Six Times Rate of General Population

MedicalResearch.com Interview with:

Rachel Patzer, PhD, MPH Director of Health Services Research, Emory Transplant Center Assistant Professor Emory University School of Medicine Department of Surgery Division of Transplantation

Dr. Rachel Patzer

Rachel Patzer, PhD, MPH
Director of Health Services Research,
Emory Transplant Center
Assistant Professor
Emory University School of Medicine
Department of Surgery
Division of Transplantation

MedicalResearch.com: What is the background for this study?

Response: Patients with End Stage Renal Disease (ESRD) make up less than 1% of all Medicare patients, but account for more than 7% of all Medicare expenses. Patients with ESRD have the highest risk of hospitalization of any patient with a chronic disease, and while hospital admissions have decreased over the last several years, emergency department utilization for this patient population has increased by 3% in the last 3 years. The purpose of the study we conducted was to describe the clinical and demographic characteristics associated with emergency department utilization.

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Mentally Ill, Homeless Patients Are High Intensity Emergency Department Users

MedicalResearch.com Interview with:

Paul E Ronksley, PhD Assistant Professor Department of Community Health Sciences Cumming School of Medicine University of Calgary Calgary, AB Canada

Dr. Paul Ronksley

Paul E Ronksley, PhD
Assistant Professor
Department of Community Health Sciences
Cumming School of Medicine
University of Calgary
Calgary, AB Canada

Medical Research: What is the background for this study?

Response: Numerous studies have shown that high users of the emergency department (ED) are often patients with complex medical needs and limited personal and social resources. It is also recognized that high users are a heterogeneous group driven by variability in the operational definition used to define this patient population. “High use” of ED services is often defined by the number of visits per year (namely ≥3 or ≥4 visits to the ED in a 1-year period) with little exploration of the distribution/pattern of these visits over time. The purpose of our study was to examine patient and encounter-level factors and costs related to periods of short-term resource intensity (clustered ED visits) among high users of the ED within a tertiary-care teaching facility. This is important as it may inform interventions that can focus on a more defined group with the goal of providing the needed care in a setting outside of the ED.

Medical Research: What are the main findings?

Response: Our main findings demonstrate that among high  emergency department users (i.e. patients with 3 or more ED visits in a 1-year period), approximately 1 in 7 patients had a period of high-intensity ED use (3 or more visits clustered within a week). These patients with clustered visits were more likely to be homeless, require psychiatric emergency services, and revisit the  emergency department for the same presenting complaints. The high-intensity users were also less likely to be admitted, more likely to leave without being seen and had lower costs per encounter, although their total ED cost across all visits was higher.

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BNP Testing in Heart Failure Resulted in More ER Admissions But Fewer Repeat Visits

MedicalResearch.com Interview with:
Justin A. Ezekowitz, MBBCh MSc
Associate Professor, University of Alberta
Co-Director, Canadian VIGOUR Centre
Cardiologist  and Director, Heart Function Clinic
Nariman Sepehrvand, MD
Research Fellow & Graduate Student
Mazankowski Alberta Heart Institute
University of Alberta Edmonton, Canada 

Medical Research: What is the background for this study?
Dr. Ezekowitz: Major practice guidelines recommend the use of natriuretic peptide (NP) testing for diagnosing acute heart failure (HF) in emergency departments (ED). Despite these guidelines, the majority of healthcare regions all around the world (except for the United States and New Zealand) have restricted access to NP testing due to concerns over cost to healthcare systems. In the province of Alberta, Canada, however, a province-wide access to NP testing was provided for all EDs in 2012. This study investigates the factors that are related to the utilization of NP testing in EDs.

Medical Research: What are the main findings?

Dr. Ezekowitz: There was a substantial geographic variation in testing for NPs, despite having a single payer system and the universal availability of NP testing in Alberta. Several factors (including male sex, some comorbidities like prior heart failure, urban residence, type of care provider and ED clinical volume) influenced the utilization of testing for NPs in routine ED practice.
Interestingly, patients with heart failure who were tested for NPs at ED, had a higher rate of hospital admission and lower 7 day and 90 day repeat ED visit rates compared to those who were not tested.

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ER Trial of Inhaling Isopropyl Alcohol From Pads Reduced Nausea

Michael D. April, MD, DPhil Department of Emergency Medicine San Antonio Uniformed Services Health Education Consortium San Antonio, TX

Dr. April

MedicalResearch.com Interview with:
Michael D. April, MD, DPhil
Department of Emergency Medicine
San Antonio Uniformed Services Health Education Consortium
San Antonio, TX 

Medical Research: What is the background for this study? What are the main findings?

Dr. April: Anesthesia research studies have found that nasal inhalation of isopropyl
alcohol has efficacy in treating nausea among post-operative patients. We
sought to study this agent among Emergency Department patients with nausea or
vomiting. We found that patients randomized to inhale isopropyl alcohol had
improved self-reported nausea scores compared to patients randomized to inhale
saline (placebo).

MedicalEditor’s note:  Do Not Do This Without Medical Supervision!

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Decreased Funding For Mental Health Services Results in Crowded, Strained Emergency Rooms

Dr. Arica Nesper

Dr. Nesper

MedicalResearch.com Interview with:
Arica Nesper, MD, MAS
Resident Physician
Stanford/Kaiser Emergency Medicine Residency
Stanford University Medical Center
Department of Emergency Medicine
Stanford

Medical Research: What is the background for this study? What are the main findings?
Dr. Nesper: Patients with severe mental illness are a distinct demographic in the emergency department. Unfortunately, resources to help these vulnerable patients are frequently the target of funding cuts. We aimed to describe the effect of these cuts on our emergency department and the care provided to our patients. In this study we evaluated data from before our county mental health facility cut its inpatient capacity by half and closed its outpatient unit, and compared this data with data collected after this closure. We found that the mean number of daily psychiatric consultations in our emergency department more than tripled and that the average length of stay for these patients increased by nearly eight hours. These two data combined demonstrate a five-fold increase in daily emergency department bed hours for psychiatric patients, placing a significant strain on the emergency department and demonstrating a delay in definitive care provided to these vulnerable patients.

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Co-ingestion of Benzodiazepines and Opioids Contributes to Overdose and Death

MedicalResearch.com Interview with:
Christopher M. Jones, Pharm D., M.P.H
Senior advisor, Office of Public Health Strategy and Analysis
Office of the Commissioner, Food and Drug Administration

Medical Research: What is the background for this study?

Dr. Jones: Opioid analgesics and benzodiazepines are the two most common drug classes involved in prescription drug overdose deaths. In 2010, 75% of prescription drug overdose deaths involved opioid analgesics and 29% involved benzodiazepines. Opioid analgesics and benzodiazepines are also the most common drugs associated with emergency department visits due to nonmedical use of prescription drugs.

Combined opioid and benzodiazepine use has been suggested as a risk factor for overdose death.

Opioids and benzodiazepines have complex drug interactions and in combination can result in synergistic respiratory depression, but the exact mechanisms by which benzodiazepines worsen opioid-related respiratory depression are not fully understood.

Widespread co-use of benzodiazepines and opioids has been documented in both chronic pain and addiction treatment settings. Studies suggest that among patients who receive long-term opioids for chronic non-cancer pain, 40% or more also use benzodiazepines. Among patients who abuse opioids, benzodiazepine abuse also is prevalent, and co-users report using benzodiazepines to enhance opioid intoxication.

This study builds on the prior literature by analyzing trends on how the combined use of opioids and benzodiazepines in the U.S. contributes to the serious adverse outcomes of nonmedical use–related ED visits and drug overdose deaths. A better understanding of the consequences of co-use of these medications will help identify at-risk populations, inform prevention efforts, and improve the risk–benefit balance of these medications.

Medical Research: What are the main findings?

Dr. Jones: From 2004 to 2011, the rate of nonmedical use–related Emergency Department visits involving both opioid analgesics and benzodiazepines increased from 11.0 to 34.2 per 100,000 population. During the same period, drug overdose deaths involving both drugs increased from 0.6 to 1.7 per 100,000. Statistically significant increases in Emergency Department visits occurred among males and females, non-Hispanic whites, non-Hispanic blacks, and Hispanics, and all age groups except 12–17-year-olds. For overdose deaths, statistically significant increases were seen in males and female, all three race/ethnicity groups, and all age groups except 12–17-year-olds. Benzodiazepine involvement in opioid analgesic overdose deaths increased each year, increasing from 18% of opioid analgesic overdose deaths in 2004 to 31% in 2011.

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