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Background: Timely evaluation of acute chest pain is necessary, although most evaluations will not find significant coronary disease. With employers increasingly adopting high-deductible health plans (HDHP), how HDHPs impact subsequent care after an emergency department (ED) diagnosis of nonspecific chest pain is unclear. Methods: Using a commercial and Medicare Advantage claims database, we identified members 19 to 63 years old whose employers exclusively offered low-deductible (≤$500) plans in 1 year, then, at an index date, mandated enrollment in HDHPs (≥$1000) for a subsequent year. We matched them with contemporaneous members whose employers only offered low-deductible plans. Primary outcomes included population rates of index ED visits with a principal diagnosis of nonspecific chest pain, admission during index ED visits, and index ED visits followed by noninvasive cardiac testing within 3 and 30 days, coronary revascularization, and acute myocardial infarction hospitalization within 30 days. We performed a cumulative interrupted time-series analysis, comparing changes in annual outcomes between the HDHP and control groups before and after the index date using aggregate-level segmented regression. Members from higher-poverty neighborhoods were a subgroup of interest. Results: After matching, we included 557 501 members in the HDHP group and 5 861 990 in the control group, with mean ages of 42.0 years, 48% to 49% female, and 67% to 68% non-Hispanic White individuals. Employer-mandated HDHP switches were associated with a relative decrease of 4.3% (95% CI, –5.9 to –2.7; absolute change, –4.5 [95% CI, –6.3 to –2.8] per 10 000 person-years) in nonspecific chest pain ED visits and 11.3% (95% CI, –14.0 to –8.6) decrease (absolute change, –1.7 per 10 000 person-years [95% CI, –2.1 to –1.2]) in visits leading to hospitalization. There was no significant decrease in subsequent noninvasive testing or revascularization procedures. An increase in 30-day acute myocardial infarction admissions was not statistically significant (15.9% [95% CI, –1.0 to 32.7]; absolute change, 0.3 per 10 000 person-years [95% CI, –0.01 to 0.5]) but was significant among members from higher-poverty neighborhoods. Conclusions: Employer-mandated HDHP switches were associated with decreased nonspecific chest pain ED visits and hospitalization from these ED visits, but no significant change in post-ED cardiac testing. However, HDHP enrollment was associated with increased 30-day acute myocardial infarction admission after ED diagnosis of nonspecific chest pain among members from higher-poverty neighborhoods.

Objectives To determine the effect of one-click integration of a state’s prescription drug monitoring program (PDMP) on the number of PDMP searches and opioid prescriptions, stratified by specialty. Methods Our large health system worked with the state department of public health to integrate the PDMP with the electronic health record (EHR), which enabled providers to query the data with a single click inside the EHR environment. We evaluated Schedule II or III opioid prescriptions reported to the Massachusetts PDMP 6 months before (November 15, 2017-May 15, 2018) and 6 months after (May 16, 2018, to November 16, 2018) integration. Search counts, prescriptions, patients, morphine milligram equivalents, as well as prescriber specialty were compared. Results There were 3,185 unique prescribers with a record of a Schedule II and/or III opioid prescription in both study periods that met inclusion criteria. After integration, the number of PDMP searches increased from 208,684 in the pre-integration phase to 298,478 searches in the post-integration phase (+43.0%). The number of opioid prescriptions dispensed decreased by 4.8%, the number of patients receiving a prescription decreased by 5.1%, and the mean morphine milligram equivalents (MMEs) per prescriber decreased by 5.4%. There were some notable specialty-specific differences in these measures. Conclusions Integration of the PDMP into the EHR markedly increased the number of searches but was associated with modest decreases in opioids prescribed and patients receiving a prescription. Single click EHR integration of the PDMP, if implemented broadly, may be a way for states to significantly increase PDMP utilization.

Objective Back pain is one of the most common pain syndromes in the United States, but there has been limited recent description of the role of emergency departments (EDs) in caring for patients with back pain. We investigated trends in the evaluation and management of back pain in U.S. EDs from 2007 to 2016. Methods We performed a retrospective analysis of the National Hospital Ambulatory Medical Care Survey, a nationally representative annual survey of ED visits, which includes data on patient-, hospital-, and visit-level characteristics. We evaluated trends among adult ED visits for back pain, including demographics, resource utilization, and disposition. Trends were assessed through the use of survey-weighted analyses. Results Visit rates as a proportion of overall ED visits were stable from 2007 to 2016 (9.1% [95% confidence interval (CI): 8.5–9.6] vs. 9.3% [95% CI: 8.6–10.0]; P = 0.44). Admission rates declined from 6.4% (95% CI: 5.1–8.0) to 5.0% (95% CI: 3.5–6.9; P Conclusions Opioid utilization during ED visits for back pain decreased from 2007 to 2016, whereas tramadol use more than doubled. Care intensity increased significantly despite declining admission rates. Further research into optimal strategies for back pain management in the ED is needed.

BACKGROUND: The United States is currently facing 2 epidemics: sustained morbidity and mortality from substance use and the more recent COVID-19 pandemic. We tested the hypothesis that the pandemic has disproportionately affected individuals with substance use disorder by evaluating average daily 9-1-1 ambulance calls for substance use-related issues compared with all other calls. METHODS: This was a retrospective cross-sectional analysis of 9-1-1 ambulance calls before and after the start of COVID-19 in Massachusetts. We used consecutive samples of 9-1-1 ambulance calls, categorized into those which were substance-related or not. An interrupted time series analysis was performed to determine if there were changes in numbers of daily calls before a statewide declaration of emergency for COVID-19 (February 15–March 9, 2020), from the emergency declaration until a stay-at-home advisory (March 10–March 22, 2020) and following the stay-at-home advisory (March 23–May 15, 2020). RESULTS: Compared with prior to the statewide emergency, the post-statewide emergency average of daily ambulance calls decreased from 2,453.2 to 1,969.6, a 19.7% decrease. Similarly, calls for substance-related reasons decreased by 16.4% compared with prior to the statewide emergency. However, despite an initial decrease in calls, after the stay-at-home advisory calls for substance use began increasing by 0.7 (95% confidence interval (CI) 0.4–1.1) calls/day, while calls for other reasons did not significantly change (+1.2 (95% CI −0.8 to 3.1) calls/day). Refusal of transport for substance-related calls increased from 5.0% before the statewide emergency to 7.5% after the declaration (p < 0.001). CONCLUSIONS: After an initial decline in substance-related ambulance calls following a statewide declaration of emergency, calls for substance use increased to pre-COVID-19 levels, while those for other reasons remained at a lower rate. The results suggest that COVID-19 is disproportionately affecting individuals with substance use disorder.

Objective This study evaluated the characteristics of opioid prescriptions, including prescriber specialty, given to opioid-naïve patients and their association with chronic use. Design Cross-sectional analysis of the Ohio prescription drug monitoring program from January 2010 to November 2017. Setting Ohio, USA. Subjects Patients who had no opioid prescriptions from 2010 to 2012 and a first-time prescription from January 2013 to November 2016. Methods Chronic use was defined as at least six opioid prescriptions in one year and either one or more years between the first and last prescription or an average of ≤30 days not covered by an opioid during that year. Results A total of 4,252,809 opioid-naïve patients received their first opioid prescription between 2013 and 2016; 364,947 (8.6%) met the definition for chronic use. Those who developed chronic use were older (51.7 vs 45.6 years) and more likely to be female (53.6% vs 52.8%), and their first prescription had higher pill quantities (44.9 vs 30.2), higher morphine milligram equivalents (MME; 355.3 vs 200.0), and was more likely to be an extended-release formulation (2.9% vs 0.7%, all P Conclusions Eight point six percent of opioid-naïve individuals who received an opioid prescription developed chronic use. This rate varied depending on the specialty of the provider who wrote the prescription. The risk of chronic use increased with higher MME content of the initial prescription and use of extended-release opioids.

Objective Emergency physicians are commonly compared by their patients' length of stay (LOS). We test the hypothesis that LOS is associated with patient characteristics and that accounting for these features impacts physician LOS rankings. Methods This was a retrospective observational study of all encounters at an emergency department in 2010 to 2015. We compared the characteristics of patients seen by physicians in different quartiles of LOS. Primary outcome was variation in patient characteristics at time of physician assignment (age, sex, comorbidities, Emergency Severity Index [ESI], and chief complaint) across LOS quartiles. We also quantified the change in LOS rankings after accounting for difference in characteristics of patients seen by different physicians. Results A total of 264,776 encounters seen by 62 attending physicians met inclusion criteria. Physicians in the longest LOS quartile saw patients who were older (age = 49.1 vs 48.6 years, difference = +0.5 years, 95% confidence interval [CI] = 0.3 to 0.7) with more comorbidities (Gagne score = 1.3 vs. 0.9, difference = +0.4, 95% CI = 0.4 to 0.4) and higher acuity (ESI = 2.8 vs. 2.9, difference = -0.1, 95% CI = 0.1 to 0.1) than physicians in the shortest LOS quartile. The odds ratio (OR) of physicians in the longest LOS quartile seeing patients over age 50 compared to the shortest LOS quartile was 1.1 (95% CI = 1.0 to 1.1); the OR of physicians in the longest LOS quartile seeing patients with ESI of 1 or 2 was also 1.1 (95% CI = 1.0 to 1.1). Accounting for variation in patient characteristics seen by different physicians resulted in substantial reordering of physician LOS rankings: 62.9% (39/62) of physicians reclassified into a different quartile with mean absolute percentile change of 25.8 (95% CI = 20.3 to 31.3). A total of 62.5% (10/16) of physicians in the shortest LOS quartile and 56.3% (9/16) in the longest LOS quartile moved into a different quartile after accounting for variation in patient characteristics. Conclusions Length of stay was significantly associated with patient characteristics, and accounting for variation in patient characteristics resulted in substantial reordering of relative physician rankings by LOS. Comparisons of emergency physicians by LOS that do not account for patient characteristics should be reconsidered.

STUDY OBJECTIVE: Prehospital use of naloxone for presumed opioid overdose has increased markedly in recent years because of the current opioid overdose epidemic. In this study, we determine the one-year mortality of suspected opioid overdose patients who were treated with naloxone by EMS and initially survived. METHODS: This was a retrospective observational study of patients using three linked statewide datasets in Massachusetts: emergency medical services (EMS), a master demographics file, and death records. We included all suspected opioid overdose patients who were treated with naloxone by EMS. The primary outcome measures were death within 3 days of treatment and between 4 days and 1 year of treatment. RESULTS: Between July 1, 2013 and December 31, 2015, there were 9,734 individuals who met inclusion criteria and were included for analysis. Of these, 807 (8.3% (95% confidence interval (CI) 7.7%-8.8%)) died in the first 3 days, 668 (6.9% (95% CI 6.4%-7.4%)) died between 4 days and 1 year, and 8,259 (84.8% (95% CI 84.1%-85.6%)) were still alive at one year. Excluding those who died within 3 days, 668 of the remaining 8,927 individuals (7.5% (95% CI 6.9%-8.0%)) died within one year. CONCLUSION: The one-year mortality of those who are treated with naloxone for opioid overdose by EMS is high. Communities should focus both on primary prevention and interventions for this patient population, including strengthening regional treatment centers and expanding access to medication for opioid use disorder.

BACKGROUND Prior studies have found conflicting effects of Medicaid expansion on emergency department (ED) utilization but have not studied the reasons patients go to EDs. OBJECTIVES Examine the changes in reasons for ED use associated with Medicaid expansion. RESEARCH DESIGN Difference-in-difference analysis. SUBJECTS We included sample adults from the 2012 to 2017 National Health Interview Survey who were US citizens and reported a total family income below 138% federal poverty level (n=30,259). MEASURES We examined changes in the proportion of study subjects reporting: (1) any ED visits; (2) ED visits due to perceived illness severity; (3) office not open; and (4) barriers to outpatient care, comparing expansion and nonexpansion states. RESULTS Overall, 30.6% of low-income adults reported ED use in the past year, of which 74.1% reported illness acuity, 12.4% reported office not open, 9.5% reported access barriers, and 4.0% did not report any reason. Medicaid expansion was not associated with statistically significant changes in overall ED use [-2.2% (95% confidence interval-CI), -5.5% to 1.2%), P=0.21], ED visits due to perceived illness severity [0.5% (95% CI, -2.4% to 3.5%), P=0.73], or office not open [-0.9% (95% CI, -2.3% to 0.5%); P=0.22], but was associated with significant decrease in ED visits due to access barriers [-1.4% (95% CI, -2.6% to -0.2%), P=0.022]. CONCLUSIONS Medicaid expansion was associated with a decrease in low-income adults who reported outpatient care barriers as reasons for ED visits. There were no significant changes in overall ED utilization, likely because the majority of respondent reported ED use due to concerns with illness severity or outpatient office was closed.

Study objective Despite the increased availability of naloxone, death rates from opioid overdose continue to increase. The goal of this study is to determine the 1-year mortality of patients who were treated for a nonfatal opioid overdose in Massachusetts emergency departments (EDs). Methods This was a retrospective observational study of patients from 3 linked statewide Massachusetts data sets: a master demographics list, an acute care hospital case-mix database, and death records. Patients discharged from the ED with a final diagnosis of opioid overdose were included. The primary outcome measure was death from any cause within 1 year of overdose treatment. Results During the study period, 17,241 patients were treated for opioid overdose. Of the 11,557 patients who met study criteria, 635 (5.5%) died within 1 year, 130 (1.1%) died within 1 month, and 29 (0.25%) died within 2 days. Of the 635 deaths at 1 year, 130 (20.5%) occurred within 1 month and 29 (4.6%) occurred within 2 days. Conclusion The short-term and 1-year mortality of patients treated in the ED for nonfatal opioid overdose is high. The first month, and particularly the first 2 days after overdose, is the highest-risk period. Patients who survive opioid overdose should be considered high risk and receive interventions such as being offered buprenorphine, counseling, and referral to treatment before ED discharge.

Background Buprenorphine is a widely used treatment option for patients with opioid use disorder (OUD). Premature discontinuation from this treatment has many negative health and societal consequences. Objective To develop and evaluate a machine learning based two-stage clinical decision-making framework for predicting which patients will discontinue OUD treatment within less than a year. The proposed framework performs such prediction in two stages: (i) at the time of initiating the treatment, and (ii) after two/three months following treatment initiation. Methods For this retrospective observational analysis, we utilized Massachusetts All Payer Claims Data (MA APCD) from the year 2013 to 2015. Study sample included 5190 patients who were commercially insured, initiated buprenorphine treatment between January and December 2014, and did not have any buprenorphine prescription at least one year prior to the date of treatment initiation in 2014. Treatment discontinuation was defined as at least two consecutive months without a prescription for buprenorphine. Six machine learning models (i.e., logistic regression, decision tree, random forest, extreme-gradient boosting, support vector machine, and artificial neural network) were tested using a five-fold cross validation on the input data. The first-stage models used patients’ demographic information. The second-stage models included information on medication adherence during the early phase of treatment based on the proportion of days covered (PDC) measure. Results A substantial percentage of patients (48.7%) who started on buprenorphine discontinued the treatment within one year. The area under receiving operating characteristic curve (C-statistic) for the first stage models varied within a range of 0.55 to 0.59. The inclusion of knowledge regarding patients’ adherence at the early treatment phase in terms of two-months and three-months PDC resulted in a statistically significant increase in the models’ discriminative power (p-value Conclusion Machine learning models can predict which patients are most at-risk of premature treatment discontinuation with reasonable discriminative power. The proposed machine learning framework can be used as a tool to help inform a clinical decision support system following further validation. This can potentially help prescribers allocate limited healthcare resources optimally among different groups of patients based on their vulnerability to treatment discontinuation and design personalized support systems for improving patients’ long-term adherence to OUD treatment.

Emergency medicine is a profession that requires good leadership skills. Emergency physicians must be able to instill confidence in both the staff and patients, inspire the best in others, have the enthusiasm to take on a surplus of responsibilities, and maintain calmness during unexpected circumstances. Accordingly, residency program directors look carefully for leadership qualities and potential among their applicants. Although some people do have a predisposition to lead, leadership can be both learned and taught. In this article, we provide medical students with the tools that will help them acquire those qualities and thus make them more desirable by program directors.

Enhanced recovery after surgery (ERAS) programs are now standard of care for colorectal surgery. Efforts have been aimed at decreasing postoperative opioid consumption. The goal of this study is to evaluate the effect of liposomal bupivacaine transversus abdominis plane (TAP) blocks on opioid use and its downstream effect on rates of ileus and hospital length of stay (LOS). We performed a retrospective pre- and postintervention time-trend analysis (2016–2018) of ERAS patients undergoing laparoscopic colorectal surgery at two academic medical centers within the same hospital system. The intervention was liposomal bupivacaine TAP blocks versus standard local infiltration with bupivacaine with a primary outcome of total morphine milligram equivalents (MME) administered within 72 h of surgery. Secondary outcomes included hospital LOS and rate of postoperative ileus. There were 556 patients included at the control hospital, and 384 patients were included at the treatment hospital. Patients at both hospitals were similar with regard to age, body mass index, comorbidities, and surgical indication. In an adjusted time-trend analysis, the treatment hospital was associated with a significant decrease in MME administered (– 15.9 mg, p = 0.04) and hospital LOS (– 0.8 days, p < 0.001). There was no significant decrease in the rate of ileus at the treatment hospital (– 6.9%, p = 0.08). In a time-trend analysis, the addition of liposomal bupivacaine TAP blocks into the ERAS protocol resulted in significantly reduced opioid use and shorter hospital LOS for patients undergoing surgery at the treatment hospital. Liposomal bupivacaine TAP blocks should be considered for inclusion in the standard ERAS protocol.

OBJECTIVES: Prescription drug monitoring programs (PDMPs) are state-based databases that contain information about controlled substance prescriptions dispensed by pharmacies. Many states now mandate PDMP use by prescribers, despite unclear effectiveness. We hypothesize that it is possible to improve the interpretability, and hence effectiveness, of PDMPs by enhancing them. METHODS: This was a real-time simulation of an enhanced PDMP. Fifty practicing physicians (25 primary care, 25 emergency medicine) were randomized to see three cases with a standard profile or an enhanced profile that included graphical representation of prescriptions and identified risky prescribing patterns. After a two-month washout period, participants were placed in the opposite group. RESULTS: Physicians presented with the enhanced profile were more likely to correctly identify patients with multiple providers (97.0% vs. 85.8%, p=0.002), overlapping opioid and benzodiazepine prescriptions (94.7% vs. 87.5%, p=0.03), overlapping opioid prescriptions (89.5% vs. 70.8%, p

As the consequences of liberal opioid prescribing have become apparent, efforts to address the role of the health care system in supporting more balanced opioid use and the prevention and treatment of opioid use disorder have increased. Developing a unified and multidisciplinary approach can lead to an integrated care model that emphasizes primary prevention, harm reduction, and transition to life-sustaining treatment while also maintaining attentiveness to effective pain management. A model for this, which follows the nomenclature in proscribing antimicrobial use, is the development of an opioid stewardship program. Such programs allow for the integration of diverse perspectives and new mandates and uses a patient-centered approach with an iterative evaluation process. We describe a group of adoptable efforts that have been utilized successfully at our institutions and may be adapted and optimized to the needs and resources of other hospitals and health care systems.

BackgroundMutations in GLIS3 cause a rare syndrome characterized by neonatal diabetes mellitus (NDM), congenital hypothyroidism, congenital glaucoma and cystic kidneys. To date, 14 mutations in GLIS3 have been reported, inherited in an autosomal recessive manner. GLIS3 is a key transcription factor involved in β-cell development, insulin expression, and development of the thyroid, eyes, liver and kidneys.CasesWe describe non-identical twins born to consanguineous parents presenting with NDM, congenital hypothyroidism, congenital glaucoma, hepatic cholestasis, cystic kidney and delayed psychomotor development. Sequence analysis of GLIS3 identified a novel homozygous nonsense mutation, c.2392C>T, p.Gln798Ter (p.Q798*), which results in an early stop codon. The diabetes was treated with a continuous subcutaneous insulin infusion pump and continuous glucose monitoring. Fluctuating blood glucose and intermittent hypoglycemia were observed on follow-up.ConclusionsThis report highlights the importance of early molecular diagnosis for appropriate management of NDM. We describe a novel nonsense mutation of GLIS3 causing NDM, extend the phenotype, and discuss the challenges in clinical management. Our findings provide new areas for further investigation into the roles of GLIS3 in the pathophysiology of diabetes mellitus.

OBJECTIVE. Our objective is to describe how we combine, at an individual level, multiple administrative datasets to create a Comprehensive Opioid Risk Registry (CORR). The CORR will characterize the role that individual characteristics, household characteristics, and community characteristics have on an individual’s risk of opioid use disorder or opioid overdose. DATA SOURCES. Study data sources include the voluntary Oregon All Payer Claims Database (APCD), American Community Survey Census Data, Oregon Death Certificate data, Oregon Hospital Discharge Data (HDD), and Oregon Prescription Drug Monitoring (PDMP) Data in 2013 through 2018. STUDY DESIGN. To create the CORR we first prepared the APCD data set by cleaning and geocoding addresses, creating a community grouper and adding census indices, creating household grouper, and imputing patient race. Then we deployed a probabilistic linkage methodology to incorporate other data sources maintaining compliance with strict data governance regulations. DATA COLLECTION / EXTRACTION METHODS. Administrative datasets were obtained through an executed data use agreement with each data owner. The APCD served as the population universe to which all other data sources were linked. PRINCIPAL FINDINGS. There were 3,628,992 unique people in the APCD over the entire study period. We identified 968,767 unique households in 2013 and 1,209,236 in 2018, and geocoded patient addresses representing all census tracts in Oregon. Census, death certificate, HDD, and PDMP datasets were successfully linked to this population universe. CONCLUSIONS. This methodology can be replicated in other states and may also apply to a broad array of health services research topics.

Objective Bone staples are internal fixation devices that are frequently used in the foot, ankle, and hand to provide stabilization. Fixation stability is vital after fusion or fracture surgeries to ensure proper bone healing. Patients undergoing surgeries that require fixation to keep bones aligned and stable may present with diminishing bone mechanical properties, and this may compromise the ability of the fixation hardware to maintain a stable construct. The purpose of this study was to investigate the mechanical performance of shape memory and superelastic nitinol bone staples with different bridge geometries in normal, osteopenic, and osteoporotic bone models. Contact forces and maximum principal stress and strain in the bone were recorded. Methods Finite element simulations of a bone staple fixation procedure were performed to examine the initial and post-surgery contact force, as well as the maximum principal stress and strain of 15 mm bridge and 20 mm bridge staple-bone constructs. Results Shape memory nitinol staples exhibited higher contact forces compared to superelastic nitinol staples. Nitinol bone staples with 20 mm bridge lengths displayed higher contact forces and lower stresses in all bone types, as well as lower strains in osteoporotic bone models compared to nitinol staples with a 15 mm bridge length. Conclusion Nitinol bone staple constructs with 20 mm bridge length staples provide higher contact forces and display lower stresses in the bone than 15 mm bridge staple-bone constructs, which may be beneficial in bone with diminishing mechanical properties. Both superelastic and shape memory effect nitinol staples provide adequate compression and stress relief. However, if osteopenia is present, shape memory effect nitinol staples with a 20 mm bridge length may provide more stress relief and compression, if the bone anatomy allows.

Hospitals in the United States are assessed and ranked by several agencies and services, including U.S. News & World Report. Frequently, though, the key hospital throughput metric of inpatient boarding time in the emergency department (ED) is not considered when ranking hospitals. As a result, there is a discordance in which highly ranking hospitals may be poor performers in boarding of patients, a practice with known adverse safety effects. This article outlines the rationale for considering ED boarding in hospital ranking and quality assessments.

Outpatient total shoulder arthroplasty (TSA) is an alternative to surgery with inpatient admission for appropriate patients. Controlled studies assessing differences in perioperative outcomes between inpatient and outpatient TSA are lacking. In this study, the primary outcome was 30-day all-cause hospital readmission following inpatient vs outpatient TSA. The National Surgical Quality Improvement Program (NSQIP) database was used to identify patients undergoing both primary and revision TSA from 2010 to 2017. Patients were identified using Current Procedural Terminology codes. A 1:1 propensity score matching was used to create two groups of patients, those who underwent outpatient surgery and those who underwent inpatient surgery, while matching for age, sex, American Society of Anesthesiologists classification, primary vs revision surgery, smoking, diabetes, chronic obstructive pulmonary disease, and congestive heart failure. This study had a power of 85% to detect a difference of 1% in 30-day readmission. Following 1:1 propensity score matching, 1714 patients who underwent inpatient TSA and 1714 patients who underwent outpatient TSA were analyzed. All-cause 30-day readmission rates were 3.4% in the outpatient group and 1.7% in the inpatient group ( P P =.32). Although patients who underwent outpatient TSA had an increased risk of all-cause 30-day readmission compared with equally matched controls who underwent inpatient TSA, readmission for surgical complications was equivalent between the two groups. Careful patient selection for outpatient TSA should be emphasized to minimize the potential for postoperative hospital admission. [ Orthopedics . 2021;44(2):e173–e178.]

Background Prescription opioid misuse has become an epidemic in the United States and is a leading cause of death in Americans. Postoperative opioid prescriptions are a significant contributor to the opioid epidemic, with orthopedic surgeons being the third highest prescribers of opioid prescriptions among physicians across all specialties. Our aim was to retrospectively evaluate overall opioid consumption patterns following surgical treatment for shoulder pathology and recommend evidence-based guidelines for standardized postoperative opioid prescriptions. Methods We conducted a retrospective chart review of patients who underwent shoulder arthroscopy or arthroplasty from a single shoulder/elbow fellowship-trained surgeon (principal investigator). Patient and surgery characteristics were summarized for the entire sample and further stratified by surgery type. Total opioid consumption at the time of the first postoperative visit and refill patterns were compared between each surgery group. Opioid consumption was analyzed in morphine milligram equivalents (MMEs) and is reported in the equivalent number of 5-mg oxycodone tablets. Results A total of 119 patients were included in our analysis. The average age was 58 ± 13 years, and 59% of patients were male. Rotator cuff repair was the most frequent surgery (n = 52), followed by arthroplasty (n = 35) and arthroscopy (n = 28). On average, the patients in the study used 82.5 ± 233 MME units, equivalent to 11 ± 31.067 tablets of 5-mg oxycodone. Sixteen percent of patients did not use any opioids. There was no significant difference in opioid consumption or refills across surgery type. In the bivariate analysis for the entire sample, age was the only predictor that was statistically significantly associated with the amount of opioid consumption. In the multivariable model for patient demographics, significant predictors of opioid consumption were age, gender, and pain scores. In the multivariate analysis by surgery type, significant predictors of higher opioid consumption were age, gender, pain score, and surgery performed on the dominant side. Conclusion On the basis of the consumption patterns observed in our patient cohort, we recommend prescribing 112.5 MME (15 tablets of 5-mg oxycodone) for arthroscopic shoulder procedures, and 75 MME (10 tablets of 5-mg oxycodone) for shoulder arthroplasties.

Objective To evaluate the impact of coronavirus disease 2019 (COVID‐19) on emergency medical services (EMS) use for time‐sensitive medical conditions. We examined EMS use for cardiac arrest, stroke, and other cardiac emergencies across Massachusetts during the peak of the COVID‐19 pandemic, evaluating their relationship to statewide COVID‐19 incidence and a statewide emergency declaration. Methods A retrospective analysis of all EMS calls between February 15 and May 15, 2020 and the same time period for 2019. EMS call volumes were compared before and after March 10, the date of a statewide emergency declaration. Results A total of 408,758 calls were analyzed, of which 49,405 (12.1%) represented stroke, cardiac arrest, or other cardiac emergencies. Average call volume before March 10 was similar in both years but decreased significantly after March 10, 2020 by 18.7% (P

Objective To examine the effect of an employer-mandated switch to high-deductible health plans (HDHP) on emergency department (ED) low-value imaging. Data sources Claims data of a large national insurer between 2003 and 2014. Study design Difference-in-differences analysis with matched control groups. Data collection/extraction methods The primary outcome is low-value imaging during ED visits for syncope, headache, or low back pain. We included members aged 19-63 years whose employers offered only low-deductible (≤$500) plans for one (baseline) year and, in the next (follow-up) year, offered only HDHPs (≥$1000). Contemporaneous members whose employers offered only low-deductible plans for two consecutive years served as controls. The groups were matched by person and employer propensity for HDHP switch, employer size, baseline calendar year, and baseline year quarterly number of total and imaged ED visits for each condition. We modeled the visit-level probability of low-value imaging using multivariable logistic regression with member-clustered standard errors. We also calculated population level monthly cumulative ED visit rates and modeled their trends using generalized linear regression adjusting for serial autocorrelation. Principal findings After matching, we included 524 998 members in the HDHP group and 5 448 803 in the control group with a mean age of approximately 42 years and 48% female in both groups. On visit-level analyses, there were no significant differential changes in the probability of low-value imaging use in the HDHP and control groups. In population-level analyses, compared with control group members, members who switched to HDHPs experienced a relative decrease of 5.9% (95% CI - 10.3, -1.6) in ED visits for the study conditions and a relative decrease of 5.1% (95%CI -9.6, -0.6) in the subset of ED visits with low-value imaging. Conclusion Though HDHP switches decreased ED utilization, they had no significant effect on low-value imaging use after patients have decided to seek ED care.

BACKGROUND : Opioids are prescribed in excess after surgery. We leveraged our continuous quality improvement infrastructure to implement opioid prescribing guidelines and subsequently evaluate changes in postoperative opioid prescribing, consumption and patient satisfaction/pain in a statewide regional health system. METHODS : We collected data regarding postoperative prescription size, opioid consumption and patient-reported outcomes from February 2017 to May 2019, from a 70-hospital surgical collaborative. Three iterations of prescribing guidelines were released. An interrupted time series analysis before and after each guideline release was performed. Linear regression was used to identify trends in consumption and patient-reported outcomes over time. RESULTS : We included 36 022 patients from 69 hospitals who underwent one of nine procedures in the guidelines, of which 15 174 (37.3%) had complete patient-reported outcomes data following surgery. Before the intervention, prescription size was decreasing over time (slope: −0.7 tablets of 5 mg oxycodone/month, 95% CI −1.0 to −0.5 tablets, p

Case A 32-year-old pregnant woman presented with new wrist pain after a fall. She had undergone surgical repair to the same wrist 6 years previously for a distal radius fracture. At that time, there was no evidence of a bone lesion. Current radiographs revealed a radiolucent lesion in the metaepiphyseal region. Intraoperative frozen section confirmed a giant cell tumor (GCT). Definitive management consisted of intralesional curettage, burring, and cementation of the distal radius with reapplication of distal radius plate. Conclusion Currently, there is no known link between GCT and fracture or pregnancy.

Background In July of 2017, after more than 15 months of negotiations, an academic teaching hospital in Boston failed to reach an agreement on the terms of contract renewal with its nursing union resulting in a strike. Replacement nurses were hired by the hospital to fulfill nursing duties for five days. Objectives This study aims to measure the effects of this nursing strike on the patients seen in the emergency department (ED) by examining operational metrics before and during the strike. Methods: Retrospective analysis of patient visits occurring for the five days of the strike (July 12-16, 2017) compared with the analogous five-day period immediately preceding that of the strike (July 5-9, 2017). Results During the strike, ED volume decreased by 23.6% (691 vs. 528 visits), and the decrease was more pronounced for adult vs. pediatric visits. There were no differences in patient sex, race/ethnicity or age groups. EMS transports decreased by 49.1% (171 vs. 87 transports). Although patient dispositions were similar in both periods, length of stay decreased for discharged patients (median 204 vs 178 minutes, p=0.01), and did not change significantly for admitted patients (median 322 vs. 320 minutes, p=0.33). There was one patient death in each of the periods. Conclusion Although rare, nursing strikes do occur. These data may be useful for hospitals preparing for a strike.

RESEARCH OBJECTIVE: A variety of state and federal policies have been enacted to curtail prescription opioid overdoses, including implementation of statewide opioid prescribing guidelines and rescheduling of hydrocodone from DEA Schedule III to Schedule II. We aimed to use data from the Ohio Prescription Drug Monitoring Program (PDMP) to evaluate the effects of these policies. STUDY DESIGN: Retrospective study of all opioid prescriptions dispensed in the state of Ohio from 2010 to 2017. We first determined the number and characteristics of opioid prescriptions stratified by specialty. We then used an interrupted time series analysis to determine the effect on opioid prescribing after (a) the release of statewide opioid prescribing guidelines in 2012 and (b) the federal rescheduling of hydrocodone in 2014. POPULATION STUDIED: The state of Ohio. Prescriptions for the nine most common pill form opioid pain relievers dispensed in Ohio were included. The PDMP includes all prescriptions dispensed to individuals in the state, regardless of payer. PRINCIPAL FINDINGS: The number and characteristics of opioid prescriptions and trends over time varied greatly between different prescriber specialties. The mean number of pills/prescription and morphine content of the prescriptions were highest for physical medicine/rehabilitation (91.2 pills, 1532 mg, n = 1 680 579), anesthesiology/pain (89.3 pills, 1484 mg, n = 3 261 449), hematology/oncology (88.2 pills, 1534 mg, n = 516,596), and neurology (84.4 pills, 1230 mg, n = 573 389). Overall, family medicine (21.8%) and internal medicine (17.6%) prescribed the most opioids. The implementation of emergency department opioid prescribing guidelines was associated with a 12% decrease (95% CI −17.7% to −6.3%) in the level of statewide total prescriptions/month and an additional decrease of 0.9% (95% CI −1.1% to −0.7%) relative to the trend before the guidelines. Rescheduling of hydrocodone was associated with a level change of −26 358 (95% CI −36 700 to −16 016) prescriptions (−5.8%) and an additional decrease of −1568 (95% CI −2296 to −839) prescriptions/month. Rescheduling was associated with a temporary substitution effect (increase) of codeine and with a decrease in the prescribing of tramadol. CONCLUSIONS: The characteristics of opioid prescriptions vary widely by specialty and suggest the need for specialty‐specific guidance. Opioid guidelines targeting the emergency department were associated with a decrease in prescribing beyond the secular trend. The rescheduling of hydrocodone was associated with a decrease in hydrocodone prescriptions beyond the secular trend, but also appeared to affect the prescribing of other opioids as well. IMPLICATIONS FOR POLICY OR PRACTICE: PDMPs are state‐based prescribing databases that can be used to influence prescriber decision‐making at the point of care. However, their powerful data can also be used to describe prescribing behaviors overall and evaluate the effectiveness of implemented opioid‐related policies.

Introduction Emergency department (ED) visits related to opioid use disorder (OUD) have increased nearly twofold over the last decade. Treatment with buprenorphine has been demonstrated to decrease opioid-related overdose deaths. In this study, we aimed to better understand ED clinicians' attitudes toward the initiation of buprenorphine treatment in the ED. Methods We performed a mixed-methods study consisting of a survey of 174 ED clinicians (attending physicians, residents, and physician assistants) and semi-structured interviews with 17 attending emergency physicians at a tertiary-care academic hospital. Results A total of 93 ED clinicians (53% of those contacted) completed the survey. While 80% of respondents agreed that buprenorphine should be administered in the ED for patients requesting treatment, only 44% felt that they were prepared to discuss medication for addiction treatment. Compared to clinicians with fewer than five years of practice, those with greater experience were less likely to approve of ED-initiated buprenorphine. In our qualitative analysis, physicians had differing perspectives on the role that the ED should play in treating OUD. Most physicians felt that a buprenorphine-based intervention in the ED would be feasible with institutional support, including training opportunities, protocol support within the electronic health record, counseling and support staff, and a robust referral system for outpatient follow-up. Conclusion ED clinicians' perception of buprenorphine varied by years of practice and training level. Most ED clinicians did not feel prepared to initiate buprenorphine in the ED. Qualitative interviews identified several addressable barriers to ED-initiated buprenorphine.

A female singleton is delivered at 30 6/7 weeks’ gestational age via cesarean for preterm labor and breech presentation. The mother is a 37-year-old grand multipara in her 10th pregnancy. The pregnancy is notable for severe fetal anemia, high-output cardiac failure with normal cardiac anatomy, polyhydramnios, and a placental chorioangioma diagnosed at 26 weeks of gestation. Evaluation for congenital infections is negative. At 25 and 28 weeks’ gestation, the fetus had received in utero red blood cell transfusions for severe fetal anemia. At birth, the infant has respiratory depression requiring intubation and ventilation. Apgar scores are 7, 6, and 8 at 1, 5, and 10 minutes, respectively, and her birthweight is 1,416 g. The neonate is noted to have a protuberant abdomen with significant hepatosplenomegaly, diffuse subcutaneous edema, petechiae, and ecchymoses. The infant requires significant ventilator support for the first few weeks after birth. Chest radiography shows no evidence of pleural or pericardial effusion. Echocardiography shows normal cardiac segmental anatomy with significant biventricular hypertrophy, though blood pressure is maintained. Significant anemia, thrombocytopenia, and coagulopathy are noted over the first days after birth, for which the newborn requires multiple blood products. Profound jaundice necessitates multiple double-volume exchange transfusions. Thrombocytopenia and coagulopathy gradually improve over the first week after birth. However, the infant develops significant cholestasis, reaching a peak direct bilirubin of 12.5 mg/dL (213.8 μmol/L) at 2 weeks of age. The unique constellation of findings in this case, anemia, thrombocytopenia, high-output failure, and cholestasis, presented a broad differential diagnosis. The differential included congenital heart disease and vascular malformations, infectious etiologies, metabolic and genetic disorders, and various renal, hepatic, gastrointestinal, and hematologic pathologies. Sepsis evaluation was performed on admission and …

Pre-stationing naloxone, a competitive antagonist that can reverse the effects of opioid overdose, in public spaces may expedite antidote delivery. Our study aimed to determine the feasibility of bystander-assisted overdose treatment using pre-stationed naloxone.Convenience sample of bystanders in Cambridge, Massachusetts in April 2017. Subjects assisted a simulated patient described as unconscious. Subjects interacted with simulated EMS dispatch to locate a nearby box, unlock it, and administer naloxone.Fifty participants completed the simulation. Median time from simulated ambulance dispatch to naloxone administration was 189 seconds, and from arrival at patient side to administration 61 seconds. All but one participant (98.0%) correctly administered naloxone. Subjects' comfort with administration and willingness to provide medical care increased from before to after the trial. Comfort in administering naloxone varied significantly with level of previous training prior to, but not following, study participation.Bystanders are willing and able to access pre-stationed naloxone and administer it to a simulated patient in a public space. Public access naloxone stations may be a useful tool to reduce time to naloxone administration, particularly in areas where opioid overdoses are clustered.

There has been an increased focus on the opioid epidemic in the United States, yet policy-based interventions such as prescription limits, restrictions on doctor shopping, and notification programs for high-volume prescribers have had no significant impact. In this paper, the authors explore a novel public health policy: a joint public-private partnership between the federal government and hospitals to establish long-term treatment centers for patients admitted to the emergency department after an overdose. These centers would provide medication for opioid use disorder, give individuals the necessary support for recovery, and reduce healthcare expenditures. Similar longitudinal strategies may be used in other areas of public health.

THE OPIOID EPIDEMICOpioid-related morbidity and mortality has reached epidemic levels in the United States, with tragic results.1 Since 2000, the national age-adjusted drug overdose rate has more than doubled, from 6.2 per 100 000 persons in 2000, to 14.7 per 100 000 in 2014.2 In 2015, there were ov

Background The current US opioid epidemic is attributed to the large volume of prescribed opioids. This study analyzed the contribution of different medical specialties to overall opioids by evaluating the pill counts and morphine milligram equivalents (MMEs) of opioid prescriptions, stratified by provider specialty, and determined temporal trends. Methods This was an analysis of the Ohio prescription drug monitoring program database, which captures scheduled medication prescriptions filled in the state as well as prescriber specialty. We extracted prescriptions for pill versions of opioids written in the calendar years 2010 to 2014. The main outcomes were the number of filled prescriptions, pill counts, MMEs, and extended-released opioids written by physicians in each specialty, and annual prescribing trends. Results There were 56,873,719 prescriptions for the studied opioids dispensed, for which 41,959,581 (73.8%) had prescriber specialty type available. Mean number of pills per prescription and MMEs were highest for physical medicine/rehabilitation (PMR 91.2 pills, 1,532 mg, N = 1,680,579), anesthesiology/pain (89.3 pills, 1,484 mg, N = 3,261,449), hematology/oncology (88.2 pills, 1,534 mg, N = 516,596), and neurology (84.4 pills, 1,230 mg, N = 573,389). Family medicine (21.8%) and internal medicine (17.6%) wrote the most opioid prescriptions overall. Time trends in the average number of pills and MMEs per prescription also varied depending on specialty. Conclusions The numbers of pills and MMEs per opioid prescription vary markedly by prescriber specialty, as do trends in prescribing characteristics. Pill count and MME values define each specialty's contribution to overall opioid prescribing more accurately than the number of prescriptions alone.

Objectives: The intranasal route of administration for naloxone delivery is one treatment for opioid overdose, but treatment failures with this modality have been documented. This study determines the incidence of obstructive nasal pathology in patients who experienced serious opioid-induced respiratory depression (OIRD). Design: Retrospective analysis of the IMS LifeLink: Health Plan Claims Database to detect patients with at least one opioid pharmacy claim from 2009 to 2013 and who experienced serious OIRD. Four controls were randomly assigned to each case. Main Outcome Measures: A multivariable analysis determined the adjusted odds ratio of OIRD for patients with obstructive nasal pathology. Results: A total of 7,234 patients experienced a serious OIRD event; 840 (11.6 percent) had obstructive nasal pathology: 20 (2.4 percent) had deviated nasal septum (International Classification of Disease, 9th revision [ICD-9] 470), 246 (29.3 percent) had polyp of the nasal cavity (ICD-9 470.1), 130 (15.5 percent) had hypertrophy of nasal turbinates (ICD-9 478.0), and 659 (78.5 percent) had other disease of the nasal cavity (ICD-9 478.19). The adjusted odds ratio for patients who experienced serious OIRD having concurrent obstructive nasal pathology was 1.28 (95% confidence interval 1.13-1.46). Conclusions: Obstructive nasal pathology is relatively common in patients who experience serious OIRD, and in itself is associated with a higher risk of having OIRD.

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.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).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 to10 % of patients at risk. Most EDs (74 %) reported prescribing/dispensing buprenorphine to10 % of patients with OUD. Comparing 2018 to 2014, the greatest difference in policy use was in prescribing/dispensing naloxone (+55 %, p0.001).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.

Background We quantified opioid prescribing after the 2014 rescheduling of hydrocodone from schedule III to II in the United States using a state-wide prescription database and studied trends three years before and after the policy change, focusing on certain specialties. Methods We used Ohio’s state prescription drug monitoring program database, which includes all filled schedule II and III prescriptions regardless of payer or pharmacy, to conduct an interrupted time series analysis of the nine most prescribed opioids: hydrocodone, oxycodone, tramadol, codeine, and others. We analyzed hydrocodone prescribing trends for the physician specialties of internal medicine, anesthesiology, and emergency medicine. We evaluated trends 37 months before and after the rescheduling change. Results Rescheduling was associated with a hydrocodone level change of –26,358 (95% confidence interval [CI] = –36,700 to –16,016) prescriptions (–5.8%) and an additional decrease in prescriptions of –1,568 (95% CI = –2,296 to –839) per month (–0.8%). Codeine prescribing temporarily increased, at a level change of 6,304 (95% CI = 3,003 to 9,606) prescriptions (18.5%), indicating a substitution effect. Hydrocodone prescriptions by specialty were associated with a level change of –805 (95% CI = –1,280 to –330) prescriptions (–8.5%) for anesthesiologists and a level change of –14,619 (95% CI = –23,710 to –5,528) prescriptions (–10.2%) for internists. There was no effect on prescriptions by emergency physicians. Conclusions The 2014 federal rescheduling of hydrocodone was associated with declines in hydrocodone prescriptions in Ohio beyond what had already been occurring, and hydrocodone may have been briefly substituted with codeine. These results indicate that rescheduling did have a lasting effect but affected prescribing specialties variably.

Background Patients who are resuscitated with naloxone frequently refuse a period of observation, even though they may be suffering from a variety of medical and psychiatric comorbidities. Emergency physicians (EPs) are then confronted with the challenge of how best to serve patients’ interests while respecting autonomy. Objectives We sought to characterize how EPs think about this kind of dilemma and the strategies they use to resolve them. Methods We conducted qualitative semi-structured interviews with a convenience sample of 59 emergency physicians attending the American College of Emergency Physicians’ Scientific Assembly in October 2018. Three case vignettes highlighting different clinical and ethical features served as prompts. Interviews were analyzed using a constant comparative method to identify patterns of responses and derive key themes. Results Across the vignettes, EPs demonstrated diverse approaches to observation, assessing decision-making capacity and encouraging compliance. Some EPs refused to comply with a patient's wishes even when they had determined a patient demonstrated capacity. Conversely, a few EPs were willing to allow patients to leave the emergency department (ED) without assessing capacity, or despite determining that the patient lacked capacity. Common reasons for complying with patients' demands were concerns about the patients' rights and concerns about the safety of staff. Most physicians interviewed reported no institutional guidelines or education on the topic, and many physicians expressed an interest in providing medication for addiction treatment in the ED. Conclusions EPs approach this clinical and ethical dilemma in widely divergent ways. Consensus about strategies for navigating patients’ wishes relative to clinical concerns are needed to help EPs manage these challenging cases.

Objective Many states have begun implementing enhancements to PDMP patient profiles such as summaries or graphics to highlight issues of concern and enhance comprehension. The purpose of this study was to examine how physicians respond to sample enhanced PDMP profiles based on patient vignettes. Design Brief semistructured interviews with physicians. Setting Three national medical conferences for targeted specialties. Subjects Ninety-three physicians practicing in primary care, emergency medicine, or pain management. Methods We presented participants with one of three patient vignettes with corresponding standard and enhanced PDMP profiles and conducted brief interviews. Results Findings indicated that enhanced profiles could increase ease of comprehension, reduce time burden, and aid in communicating with patients about opioid risks. Physicians also expressed concern about liability for prescribing when the enhanced profile indicates risk and cautioned against any implication that risk warnings should override clinical judgment based on the patient’s complete medical history or presenting condition. Physicians emphasized the need for transparency of measures and evidence of validation of risk scores. We found little indication that enhanced profiles would change opioid prescribing decisions, though decisions varied by physician. Conclusions Our study underscores the importance of involving prescribers in developing and testing PDMP profile enhancements, as well as providing guidance in the interpretation and clinical use of enhanced profiles. Reduced time burden is an important benefit to consider as the number of states mandating PDMP use increases.

Objective Opioid analgesics are a mainstay for acute pain management, but postoperative opioid administration has risks. We examined the prevalence, risk factors, and consequences of opioid-related adverse drug events (ORADEs) in a previously opioid-free surgical population. Methods A retrospective, observational, cohort study using administrative, billing, clinical, and medication administration data from two hospitals. Data were collected for all adult patients who were opioid-free at admission, underwent surgery between October 1, 2015, and September 30, 2016, and received postoperative opioids. Potential ORADEs were determined based on inpatient billing codes or postoperative administration of naloxone. We determined independent predictors of ORADE development using multivariable logistic regression. We measured adjusted inpatient mortality, hospital costs, length of hospital stay, discharge destination, and readmission within 30 days for patients with and without ORADEs. Results Among 13,389 hospitalizations where opioid-free patients had a single qualifying surgery, 12,218 (91%) received postoperative opioids and comprised the study cohort. Of these, we identified 1111 (9.1%) with a potential ORADE. Independent predictors of ORADEs included older age, several markers of disease severity, longer surgeries, and concurrent benzodiazepine use. Opioid-related adverse drug events were strongly associated with the route and duration of opioids administered postoperatively: 18% increased odds per day on intravenous opioids. In analyses adjusted for several covariates, presence of an ORADE was associated with 29% higher costs of hospitalization, 55% longer postoperative length of stay, 29% lower odds of discharge home, and 2.9 times the odds of death. Conclusions We demonstrate a high rate and severe consequences of potential ORADEs in previously opioid-free patients receiving postoperative opioids. Knowledge of risk factors and predictors of ORADEs can help develop targeted interventions to minimize the development of these potentially dangerous and costly events.

Treating a medication-seeking patient can be one of the most challenging interactions in the emergency department. This chapter will define the problem and discuss ways to detect and effectively treat patients who present with this problem. We will discuss terminology, tips to identify patients with this behavior, including use of prescription drug-monitoring programs, and then describe an algorithm for the approach to patients with this behavior.