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Introduction: We sought to describe emergency department (ED) buprenorphine treatment variability among EDs with varying operational characteristics.Methods: We performed a retrospective cohort study of adult patients with opioid use disorder discharged from 12 hospital-based EDs within a large healthcare system as a secondary data analysis of a quality improvement study. Primary outcome of interest was buprenorphine treatment rate. We described treatment rates between EDs, categorized by tertile of operational characteristics including annual census, hospital and intensive care unit (ICU) admission rates, ED length of stay (LOS), and boarding time. Secondary outcomes were ED LOS and 30-day return rates.Results: There were 7,469 unique ED encounters for patients with opioid use disorder between January 2020–May 2021, of whom 759 (10.2%) were treated with buprenorphine. Buprenorphine treatment rates were higher in larger EDs and those with higher hospital and ICU admission rates. Emergency department LOS and 30-day ED return rate did not have consistent associations with buprenorphine treatment.Conclusion: Rates of treatment with ED buprenorphine vary according to the operational characteristics of department. We did not observe a consistent negative relationship between buprenorphine treatment and operational metrics, as many feared. Additional funding and targeted resource allocation should be prioritized by departmental leaders to improve access to this evidence-based and life-saving intervention.

Emergency departments (ED) are increasingly providing buprenorphine to persons with opioid use disorder. Buprenorphine programs in the ED have strong support from public health leaders and emergency medicine specialty societies and have proven to be clinically effective, cost effective, and feasible. Even so, few ED buprenorphine programs currently exist. Given this imbalance between evidence-based practice and current practice, proven behavior change approaches can be used to guide local efforts to expand ED buprenorphine capacity. In this paper, we use the theory of planned behavior to identify and address the 1) clinician factors, 2) institutional factors, and 3) external factors surrounding ED buprenorphine implementation. By doing so, we seek to provide actionable and pragmatic recommendations to increase ED buprenorphine availability across different practice settings.  [West J Emerg Med. 2022;23(4)461–467.]

BACKGROUND: Opioid medications are important therapeutic options to mitigate the harmful effects of pain but can also impair driving ability. We sought to explore opioid use, pain levels, and driving experiences among older drivers. METHODS: Cognitively intact drivers ages 65 to 79 years were recruited for the multisite AAA Longitudinal Research on Aging Drivers (LongROAD) study (n = 2990). This cross-sectional analysis used data from the baseline questionnaire and brown-bag medication review. RESULTS: Among LongROAD participants (47% male, 88% white, 41% aged 65 to 69 years), 169 (5.7%) reported currently taking an opioid, with a median daily dose of 20 morphine milligram equivalents. Participants did not differ significantly in opioid use by age, gender, race, or ethnicity (P > .05). After adjustment for age, gender, race and ethnicity, participants who were taking opioids (vs not) were significantly more likely to report self-regulated driving reduction and reduced driving ability. However, these effects became nonsignificant when hospitalization, impaired physical function and other factors associated with opioid use were controlled. CONCLUSIONS: In this study from a large, geographically diverse sample of older adults, there was an association between opioid use and several self-reported measures of driving behavior and ability. However, future work should clarify the effects on driving of opioid use from the effects of the painful medical conditions for which the opioids are being taken. Clinicians should continue to discuss the risks and benefits of opioid medications with patients, including risks related to driving safety.

Introduction: Screening of patients for opioid risk has been recommended prior to opioid prescribing. Opioids are prescribed frequently in the emergency department (ED) setting, but screening tools are often of significant length and therefore limited in their utility. We describe and evaluate three approaches to shortening a screening tool: creation of a short form; curtailment; and stochastic curtailment.Methods: To demonstrate the various shortening techniques, this retrospective study used data from two studies of ED patients for whom the provider was considering providing an opioid prescription and who completed the Screener and Opioid Assessment for Patients with Pain-Revised, a 24-item assessment. High-risk criteria from patients’ prescription drug monitoring program data were used as an endpoint. Using real-data simulation, we determined the sensitivity, specificity, and test length of each shortening technique.Results: We included data from 188 ED patients. The original screener had a test length of 24 questions, a sensitivity of 44% and a specificity of 76%. The 12-question short form had a sensitivity of 41% and specificity of 75%. Curtailment and stochastic curtailment reduced the question length (mean test length ranging from 8.1-19.7 questions) with no reduction in sensitivity or specificity.Conclusion: In an ED population completing computer-based screening, the techniques of curtailment and stochastic curtailment markedly reduced the screening tool’s length but had no effect on test characteristics. These techniques can be applied to improve efficiency of screening patients in the busy ED environment without sacrificing sensitivity or specificity.

Introduction: Despite treatment guidelines suggesting alternatives, as well as evidence of a lackof benefit and evidence of poor long-term outcomes, opioid analgesics are commonly prescribedfor back pain from the emergency department (ED). Variability in opioid prescribing suggests a lackof consensus and an opportunity to standardize and improve care. We evaluated the variation inattending emergency physician (EP) opioid prescribing for patients with uncomplicated, low acuityback pain (LABP).Methods: This retrospective study evaluated the provider-specific proportion of LABP patientsdischarged from an urban academic ED over a seven-month period with a prescription for opioids.LABP was strictly defined as (1) back pain chief complaint, (2) discharged from ED with nointerventions, and (3) predefined discharge diagnosis of back pain. We excluded providers if theyhad less than 25 LABP patients in the study period. The primary outcome was the physician-specificproportion of LABP patients discharged with an opioid analgesic prescription. We performed adescriptive analysis and then risk standardized prescribing proportion by adjusting for patient andclinical characteristics using hierarchical logistic regression.Results: During the seven-month study period, 23 EPs treated and discharged at least 25 LABPpatients and were included. Eight (34.8%) were female, and six (26.1%) were junior attendings (< 5years after residency graduation). There were 943 LABP patients included in the analysis. Providerspecificproportions ranged from 3.7% to 88.1% (mean 58.4% [SD +/- 22.2]), and we found a 22-foldvariation in prescribing proportions. There was a six-fold variation in the adjusted, risk-standardizedprescribing proportion with a range from 12.0% to 78.2% [mean 50.4% (SD +/-16.4)].Conclusion: We found large variability in opioid prescribing practices for LABP that persistedafter adjustment for patient and clinical characteristics. Our findings support the need to furtherstandardize and improve adherence to treatment guidelines and evidence suggesting alternatives toopioids.

Objectives: Emergency departments (EDs) are a critical point of entry into treatment for patients struggling with opioid use disorder (OUD). When initiated in the ED, buprenorphine is associated with increased addiction treatment engagement at 30 days when initiated. Despite this association, it has had slow adoption. The barriers to ED buprenorphine utilization are well documented; however, the benefits of prescribing buprenorphine for emergency physicians (EPs) have not been explored. This study utilized semistructured interviews to explore and understand how EPs perceive their experiences working in EDs that have successfully implemented ED bridge programs (EDBPs) for patients with OUD. Methods: Semistructured interviews were conducted with EPs from four geographically diverse academic hospitals with established EDBPs. Interviews were recorded and transcribed, and emergent themes were identified using codebook thematic analysis. Analysis credibility and transparency were confirmed with peer debriefing. Results: Twenty‐two interviews were conducted across the four sites. Three key themes were constructed during the analyses: (1) provided EPs agency; (2) transformed EPs' emotions, attitudes, and behaviors related to treating patients with OUD; and (3) improved EPs' professional quality of life. Conclusions: Participants in this study reported several common themes related to participation in their hospital's BP. Overall our results suggest that physicians who participate in EDBPs may feel a renewed sense of fulfillment and purpose in their personal and professional lives. These positive changes may lead to increased job satisfaction in hospitals that have successfully launched EDBP. [ABSTRACT FROM AUTHOR]

Introduction: Addressing pain is a crucial aspect of emergency medicine. Prescription opioids are commonly prescribed for moderate to severe pain in the emergency department (ED); unfortunately, prescribing practices are variable. High variability of opioid prescribing decisions suggests a lack of consensus and an opportunity to improve care. This quality improvement (QI) initiative aimed to reduce variability in ED opioid analgesic prescribing.Methods: We evaluated the impact of a three-part QI initiative on ED opioid prescribing by physicians at seven sites. Stage 1: Retrospective baseline period (nine months). Stage 2: Physicians were informed that opioid prescribing information would be prospectively collected and feedback on their prescribing and that of the group would be shared at the end of the stage (three months). Stage 3: After physicians received their individual opioid prescribing data with blinded comparison to the group means (from Stage 2) they were informed that individual prescribing data would be unblinded and shared with the group after three months. The primary outcome was variability of the standard error of the mean and standard deviation of the opioid prescribing rate (defined as number of patients discharged with an opioid divided by total number of discharges for each provider). Secondary observations included mean quantity of pills per opioid prescription, and overall frequency of opioid prescribing.Results: The study group included 47 physicians with 149,884 ED patient encounters. The variability in prescribing decreased through each stage of the initiative as represented by the distributions for the opioid prescribing rate: Stage 1 mean 20%; Stage 2 mean 13% (46% reduction, p

IntroductionOur study sought to examine the opioid analgesic (OA) prescribing decisions of emergency department (ED) providers who have themselves used OA therapeutically and those who have not. A second objective was to determine if OA prescribing decisions would differ based on the patient’s relationship to the provider. MethodsAn electronic survey was distributed to a random sample of ED providers at participating centers in a nationwide research consortium. Question topics included provider attitudes about OA prescribing, prior personal therapeutic use of OAs (indications, dosing, and disposal of leftover medication), and hypothetical analgesic prescribing decisions for their patients, family members, and themselves for different painful conditions. ResultsThe total survey population was 957 individuals; 515 responded to the survey, a 54% response rate. Prior personal therapeutic OA use was reported in 63% [95% CI, 58-68]. A majority of these providers (82%; 95% CI [77-87]) took fewer than half the number of pills prescribed. Regarding provider attitudes towards OA prescribing: 66% [95% CI, 61-71] agreed that OA could lead to addiction even with short-term use. When providers were asked if they would prescribe OA to a patient with 10/10 pain from an ankle sprain: 21% [95% CI, 17-25] would for an adult patient, 13% [95% CI, 10-16] would for an adult family member, and 6% [95% CI, 4-8] indicated they themselves would take an opioid for the same pain. When the scenario involved an ankle fracture: 86% [95% CI, 83-89] would prescribe OA for an adult patient, 75% [95% CI, 71-79] for an adult family member, and 52% [95% CI, 47-57] would themselves take OA. Providers who have personally used OA to treat their pain were consistently more likely to prescribe OA in different patient scenarios than those who had not. ConclusionED providers who had themselves used OA therapeutically to treat their own pain tended to be more likely to prescribe OA than those who had not. When making OA prescribing decisions, ED providers report that they are less likely to prescribe opioids to their family members, or themselves, than to an ED patient with the same painful condition.

The article focuses on a study on the impact of emergency department(ED)-based physical therapy (PT) (ED-PT) on PT access in both ED and outpatient settings. Topics discussed include the methods used in the study, the rates of outpatient PT referral and success outpatient PT participation, and conclusion of the study.

Introduction: To use Colorado’s prescription drug monitoring program (PDMP) to describe the recent opioid prescription history of patients discharged from our emergency department (ED) with a prescription for opioid pain medications.Methods: Retrospective cohort study of 300 adult ED patients who received an opioid prescription. We abstracted prescription histories for the six months prior to the ED visit from the PDMP, and abstracted clinical and demographic variables from the chart.Results: There were 5,379 ED visits during the study month, 3,732 of which were discharged. Providers wrote 1,165 prescriptions for opioid analgesics to 1,124/3,732 (30%) of the patients. Median age was 36 years. Thirty-nine percent were male. Patients were 46% Caucasian, 26% African American, 22% Hispanic, 2% Asian and 4% other. These were similar to our overall ED population. There was substantial variability in the number of prescriptions, prescribers and total number of pills. A majority (205/296) of patients had zero or one prescription. The 90th percentile for number of prescriptions was seven, while the 10th percentile was zero. Patients in the highest decile tended to be older, with a higher proportion of Caucasians and females. Patients in the lowest decile resembled the general ED population. The most common diagnoses associated with opioid prescriptions were abdominal pain (11.5%), cold/flu symptoms (9.5%), back pain (5.4%), flank pain (5.0%) and motor vehicle crash (4.7%).Conclusion: Substantial variability exists in the opioid prescription histories of ED patients, but a majority received zero or one prescription in the preceding six months. The top decile of patients averaged more than two prescriptions per month over the six months prior to ED visit, written by more than 6 different prescribers. There was a trend toward these patients being older, Caucasian and female. [West J Emerg Med. 2013;14(3):247–252.]

Clinical decision support (CDS) can prevent medical errors and improve patient outcomes. Electronic health record (EHR)-based CDS, designed to facilitate prescription drug monitoring program (PDMP) review, has reduced inappropriate opioid prescribing. However, the pooled effectiveness of CDS has exhibited substantial heterogeneity and current literature does not adequately detail why certain CDS are more successful than others. Clinicians regularly override CDS, limiting its impact. No studies recommend how to help nonadopters recognize and recover from CDS misuse. We hypothesized that a targeted educational intervention would improve CDS adoption and effectiveness for nonadopters. Over 10 months, we identified 478 providers consistently overriding CDS (nonadopters) and sent each up to 3 educational message(s) via email or EHR-based chat. One hundred sixty-one (34%) nonadopters stopped consistently overriding CDS and started reviewing the PDMP after contact. We concluded that targeted messaging is a low-resource way to disseminate CDS education and improve CDS adoption and best practice delivery. [ABSTRACT FROM AUTHOR]