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Charles R Caffrey, Patrick M Lank Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA Abstract: Patients can use numerous drugs that exist outside of existing regulatory statutes in order to get “legal highs.” Legal psychoactive substances represent a challenge to the emergency medicine physician due to the sheer number of available agents, their multiple toxidromes and presentations, their escaping traditional methods of analysis, and the reluctance of patients to divulge their use of these agents. This paper endeavors to cover a wide variety of “legal highs,” or uncontrolled psychoactive substances that may have abuse potential and may result in serious toxicity. These agents include not only some novel psychoactive substances aka “designer drugs,” but also a wide variety of over-the-counter medications, herbal supplements, and even a household culinary spice. The care of patients in the emergency department who have used “legal high” substances is challenging. Patients may misunderstand the substance they have been exposed to, there are rarely any readily available laboratory confirmatory tests for these substances, and the exact substances being abused may change on a near-daily basis. This review will attempt to group legal agents into expected toxidromes and discuss associated common clinical manifestations and management. A focus on aggressive symptom-based supportive care as well as management of end-organ dysfunction is the mainstay of treatment for these patients in the emergency department. Keywords: legal highs, novel psychoactive substances, toxicology, opioid toxidrome, anticholinergic toxidrome, sympathomimetic toxidrome, hallucinogens, inhalants

Objectives: United States drug overdose deaths now overwhelmingly involve fentanyl and fentanyl analogs. The emergency department (ED) is an important setting to provide harm reduction for persons who use drugs, but ED-based fentanyl test strip distribution has not yet been described., Methods: This is an observational study of patients with an opioid-related visit to an ED in downtown Chicago, Illinois. We offered fentanyl test strips alongside an existing take-home naloxone program and report on the number of patients who accepted fentanyl test strips. We assessed patient familiarity with fentanyl and fentanyl test strips during the index ED visit and attempted to contact patients 1 month after the ED visit to determine testing outcomes., Results: We offered fentanyl test strips to 23 consecutive ED patients (mean age, 39.8 years; male, 73.9%) with an opioid-related ED visit (87.0% for opioid overdose). Sixteen patients (69.5%) had heard of fentanyl, and 2 (8.7%) had prior experience using fentanyl test strips. Eighteen patients (78.2%) accepted the fentanyl test strips, 2 of which left the test strips behind in the ED alongside their take-home naloxone kit. Of the 16 total patients who departed with fentanyl test strips, we were able to reach 3 (18.8%) by phone 1 month after their ED visit; 9 had disconnected or wrong numbers listed. All 3 patients reported a positive fentanyl test strip result; tested substances included heroin, alprazolam, and cocaine., Conclusions: This report demonstrates the feasibility and acceptability of ED fentanyl test strip distribution among patients with opioid-related ED visits., Competing Interests: This work was unfunded. HSK reports unrelated research grant support (R01HS027426) and an unrelated stipend from the American Medical Association (Associate Editor, JAMA Network Open). RAL, LK, PML, and KCA have no conflicts of interest to declare., (Copyright © 2022 American Society of Addiction Medicine.)

This cross-sectional study characterizes Illinois unintentional opioid overdose deaths from July 2017 through June 2020 using data from the Centers for Disease Control and Prevention State Unintentional Drug Overdose Reporting System., Competing Interests: Conflict of Interest Disclosures: Dr Kim receives unrelated grant support from R01HS027426. Dr Mason receives unrelated grant support from NU17CE924941., (Copyright 2021 Kim HS et al. JAMA Health Forum.)

Objectives: Patient knowledge deficits related to opioid risks, including lack of knowledge regarding addiction, are well documented. Our objective was to characterize patients' perceptions of signs of addiction., Methods: This study utilized data obtained as part of a larger interventional trial. Consecutively discharged English-speaking patients, age >17 years, at an urban academic emergency department, with a new opioid prescription were enrolled from July 2015 to August 2017. During a follow-up phone interview 7 to 14 days after discharge, participants were asked a single question, "What are the signs of addiction to pain medicine?" Verbatim transcribed answers were analyzed using a directed content analysis approach and double coding. These codes were then grouped into themes., Results: There were 325 respondents, 57% female, mean age 43.8 years, 70.1% privately insured. Ten de novo codes were added to the 11 DSM-V criteria codes. Six themes were identified: (1) effort spent acquiring opioids, (2) emotional and physical changes related to opioid use, (3) opioid use that is "not needed, (4) increasing opioid use, (5) an emotional relationship with opioids, and (6) the inability to stop opioid use., Conclusions: Signs of addiction identified by opioid naive patients were similar to concepts identified in medical definitions. However, participants' understanding also included misconceptions, omissions, and conflated misuse behaviors with signs of addiction. Identifying these differences will help inform patient-provider risk communication, providing an opportunity for counseling and prevention., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 American Society of Addiction Medicine.)

Introduction: While burnout is occupation-specific, depression affects individuals comprehensively. Research on interventions for depression in emergency medicine (EM) residents is limited., Objectives: We sought to obtain longitudinal data on positive depression screens in EM residents, assess their association with burnout, and determine whether implementation of a wellness curriculum affected the rate of positive screens., Methods: In February 2017, we administered the Maslach Burnout Inventory and the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire two-question depression screen at 10 EM residencies. At five intervention sites, a year-long wellness curriculum was then introduced while five control sites agreed not to introduce new wellness initiatives during the study period. Study instruments were re-administered in August 2017 and February 2018., Results: Of 382 residents, 285 participated in February 2017; 40% screened positive for depression. In August 2017, 247/386 residents participated; 27.9% screened positive for depression. In February 2018, 228/386 residents participated; 36.2% screened positive. A positive depression screen was associated with higher burnout. There were similar rates of positive screens at the intervention and control sites., Conclusion: Rates of positive depression screens in EM residents ranged between 27.9% and 40%. Residents with a positive screen reported higher levels of burnout. Rates of a positive screen were unaffected by introduction of a wellness curriculum.

Objective: Multiple states have reported increases in opioid overdose deaths during the coronavirus disease 2019 (COVID-19) pandemic, however little is known about opioid-related presentations to the emergency department (ED)., Methods: This was a time series analysis of visits to 7 EDs in greater Chicago, Illinois from October 20, 2019 to July 25, 2020. We compared the number of ED visits for opioid-related diagnoses in the time period preceding the World Health Organization pandemic declaration (prepandemic period, October 20, 2019-July 3, 2020) to the time period following the World Health Organization declaration (pandemic period, March 8, 2020 to July 25, 2020) using a single-group interrupted time series analysis with Newey-West standard errors. We also present data on alcohol-related ED visits for comparison., Results: We evaluated a total of 177,405 visits across the 7 EDs during the study period. The mean number of weekly ED visits in the prepandemic and pandemic periods was 4841 and 4029 weekly visits, respectively. In the interrupted time series analysis, there was no significant immediate effect of the pandemic start on opioid-related ED visits (-0.44 visits per 1000 ED visits, 95% CI -2.47 to 1.58, P = 0.66), however, there was a significant immediate effect of the pandemic start on alcohol-related ED visits (-4.1, 95% CI: -8.25 to -0.01, P < 0.05)., Conclusions: Despite reductions in overall ED visit volumes and alcohol-related visits during COVID-19, the number of opioid-related visits was not significantly reduced during the early pandemic. These data reinforce the need to provide comprehensive treatment services for opioid use disorder during the co-occurring COVID-19 and opioid crises., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 American Society of Addiction Medicine.)

Objective: To examine prevalence, demographic, and incident factors associated with opioid-positivity in Illinois suicide decedents who died by causes other than poisoning., Method: Cross-sectional study of Illinois' suicide decedents occurring between January 2015 and December 2017. Data come from the National Violent Death Reporting System. We used Chi-square tests to compare decedent and incident circumstance characteristics by opioid toxicology screen status. Incident narratives were analyzed to obtain physical and mental health histories and circumstances related to fatal injury events., Results: Of 1007 non-poisoning suicide decedents screened for opioids, 16.4% were opioid-positive. White race, age 75 and over, and widowed or unknown marital status were associated with opioid-positivity. Among opioid-positive decedents, 25% had a history of substance use disorder (SUD), 61% depression, and 19% anxiety. The majority (52%) of opioid-positive decedents died by firearm, a higher percentage than opioid-negative decedents., Conclusion: The opioid overdose crisis largely has not overlapped with non-poisoning suicide in this study. Overall, our analyses have not identified additional risk factors for suicide among opioid-positive suicide decedents. However, the overlap between opioid-positivity, SUD, and physical and mental health problems found among decedents in our data suggest several suicide prevention opportunities. These include medication assisted treatment for SUD which has been shown to reduce suicide, screening for opioid/benzodiazepine overlap, and limiting access to lethal means during opioid use. Improved death scene investigations for substances and use of the Prescription Drug Monitoring Program to document prescriptions are needed to further understanding of the role of substances in non-poisoning suicide.

Objectives: Recent guidelines advise limiting opioid prescriptions for acute pain to a three-day supply; however, scant literature quantifies opioid use patterns after an emergency department (ED) visit. We sought to describe opioid consumption patterns after an ED visit for acute pain., Design: Descriptive study with data derived from a larger interventional study promoting safe opioid use after ED discharge., Setting: Urban academic emergency department (>88,000 annual visits)., Subjects: Patients were eligible if age >17 years, not chronically using opioids, and newly prescribed hydrocodone-acetaminophen and were included in the analysis if they returned the completed 10-day medication diary., Methods: Patient demographics and opioid consumption are reported. Opioid use is described in daily number of pills and daily morphine milligram equivalents (MME) both for the sample overall and by diagnosis., Results: Two hundred sixty patients returned completed medication diaries (45 [17%] back pain, 52 [20%] renal colic, 54 [21%] fracture/dislocation, 40 [15%] musculoskeletal injury [nonfracture], and 69 [27%] "other"). The mean age (SD) was 45 (15) years, and 59% of the sample was female. A median of 12 pills were prescribed. Patients with renal colic used the least opioids (total pills: median [interquartile range {IQR}] = 3 [1-7]; total MME: median [IQR] = 20 [10-50]); patients with back pain used the most (total pills: median [IQR] = 12 [7-16]; total MME: median [IQR] = 65 [47.5-100]); 92.5% of patients had leftover pills., Conclusions: In this sample, pill consumption varied by illness category; however, overall, patients were consuming low quantities of pills, and the majority had unused pills 10 days after their ED visit., (© 2020 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: To describe the development of an ED-based take-home naloxone (THN) program in which naloxone kits are dispensed directly to patients during ED discharge., Practice Description: Our THN program was carried out at an urban academic hospital in downtown Chicago, IL. The THN kits consisted of 3 vials of 0.4-mg naloxone and 3 sterile syringes and needles for intramuscular delivery. Any member of the ED team (e.g., physician, pharmacist, or nurse) could recommend naloxone dispensing for a patient; however only the treating ED physician served as the prescriber for record. The ED pharmacist provided bedside education on recognizing opioid overdose and administering naloxone. The naloxone kit was dispensed to the patient at no cost., Practice Innovation: This ED pharmacist-led naloxone dispensing model bypasses barriers to naloxone filling and ensures that patients walk out of the emergency department with naloxone in hand., Evaluation Methods: We report key metrics from the first 16 months of program implementation, including the number of ED visits for opioid overdose and THN kits dispensed. We further describe the key facilitators and barriers to program development., Results: Over 16 months, our emergency department had 669 unique visits for opioid overdose, and we dispensed 168 THN kits (10.5 per month). We are aware of at least 3 cases in which our THN kits were used to reverse opioid overdose. We faced key informational barriers to program development, such as a lack of knowledge regarding the allowability of ED medication dispensing, as well as financial barriers, such as the need to obtain a supply of naloxone. We also recognized the key facilitators of success, such as early engagement with hospital leadership., Conclusion: Implementing a successful THN program is possible in the ED setting, and individual hospital emergency departments seeking to build their own program may benefit from our report., (Copyright © 2020 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.)

Despite consensus recommendations from the American College of Emergency Physicians (ACEP), the Centers for Disease Control and Prevention, and the surgeon general to dispense naloxone to discharged ED patients at risk for opioid overdose, there remain numerous logistic, financial, and administrative barriers to implementing "take-home naloxone" programs at individual hospitals. This article describes the recent collective experience of 7 Chicago-area hospitals in implementing take-home naloxone programs. We highlight key barriers, such as hesitancy from hospital administrators, lack of familiarity with relevant rules and regulations in regard to medication dispensing, and inability to secure a supply of naloxone for dispensing. We also highlight common facilitators of success, such as early identification of a "C-suite" champion and the formation of a multidisciplinary team of program leaders. Finally, we provide recommendations that will assist emergency departments planning to implement their own take-home naloxone programs and will inform policymakers of specific needs that may facilitate dissemination of naloxone to the public., (Copyright © 2020 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Objective: To better understand patients' reasoning for keeping unused opioid pills., Methods: As part of a larger study, patients were asked their plans for their unused opioids. Responses were categorized as "dispose," "keep," and "don't know." Baseline characteristics were compared between the "keep" and "dispose" groups. Verbatim responses categorized as "keep" were analyzed qualitatively using a team-based inductive approach with constant comparison across cases., Results: One hundred patients planned to dispose of their pills; 117 planned to keep them. There were no differences in demographics between the groups. Among patients who planned to keep their pills, the mean age was 43 years and 47% were male. Analysis revealed four categories of patient responses: 1) plans to keep their pills "just in case," with reference to a medical condition (e.g., kidney stone); 2) plans to keep pills "just in case" without reference to any medical condition; 3) plans to dispose in delayed fashion (e.g., after pill expiration) or unsure of how to dispose; and 4) no identified plans, yet intended to keep pills. In this sample, there were no differences in characteristics of those reporting planning to keep vs dispose of pills; however, there were diverse reasons for keeping opioids., Conclusions: This manuscript describes a sample of patients who kept their unused opioids and presents qualitative data detailing their personal reasoning for keeping the unused pills. Awareness of the range of motivations underpinning this behavior may inform the development of tailored education and risk communication messages to improve opioid disposal., (© 2019 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Women in emergency medicine (EM) at all career stages report gender-specific obstacles to satisfaction and advancement. Programs that facilitate longitudinal mentoring, professional development, and networking may ameliorate these barriers., Methods: We designed and implemented a program for female residents, faculty, and alumnae from our EM training program to enhance social support, leadership training and professional mentorship opportunities. An anonymous, online survey was sent to participants at the end of the academic year, using a SWOT (strengths, weaknesses, opportunities, and threats) format. The survey collected free-text responses designed to evaluate the program., Results: Of 43 invited participants, 32 responded (74.4%). Eight themes emerged from the free-text responses and were grouped by SWOT domain. We identified four themes relating to the "strength" domain: 1) creating a dedicated space; 2) networking community; 3) building solidarity; and 4) providing forward guidance. Responses to the "weaknesses" and "threats" questions were combined due to overlapping codes and resulted in three themes: 5) barriers to participation; 6) the threat of poorly structured events lapsing into negativity; and 7) concerns about external optics. A final theme: 8) expansion of program scope was noted in the "opportunity" domain., Conclusion: This program evaluation of the Women's Night curriculum demonstrates it was a positive addition to the formal curriculum, providing longitudinal professional development opportunities. Sharing the strengths of the program, along with identified weaknesses, threats, and opportunities for advancement allows other departments to learn from this experience and implement similar models that use existing intellectual and social capital.

Objectives: Despite increased focus on opioid prescribing, little is known about the influence of prescription opioid medication information given to patients in the emergency department (ED). The study objective was to evaluate the effect of an Electronic Medication Complete Communication (EMC 2 ) Opioid Strategy on patients' safe use of opioids and knowledge about opioids., Methods: This was a three-arm prospective, randomized controlled pragmatic trial with randomization occurring at the physician level. Consecutive discharged patients at an urban academic ED (>88,000 visits) with new hydrocodone-acetaminophen prescriptions received one of three care pathways: 1) usual care, 2) EMC 2 intervention, or 3) EMC 2  + short message service (SMS) text messaging. The ED EMC 2 intervention triggered two patient-facing educational tools (MedSheet, literacy-appropriate prescription wording [Take-Wait-Stop]) and three provider-facing reminders to counsel (directed to ED physician, dispensing pharmacist, follow-up physician). Patients in the EMC 2  + SMS arm additionally received one text message/day for 1 week. Follow-up at 1 to 2 weeks assessed "demonstrated safe use" (primary outcome). Secondary outcomes including patient knowledge and actual safe use (via medication diaries) were assessed 2 to 4 days and 1 month following enrollment., Results: Among the 652 enrolled, 343 completed follow-up (57% women; mean ± SD age = 42 ± 14.0 years). Demonstrated safe opioid use occurred more often in the EMC 2 group (adjusted odds ratio [aOR] = 2.46, 95% confidence interval [CI] = 1.19 to 5.06), but not the EMC 2  + SMS group (aOR = 1.87, 95% CI = 0.90 to 3.90) compared with usual care. Neither intervention arm improved medication safe use as measured by medication diary data. Medication knowledge, measured by a 10-point composite knowledge score, was greater in the EMC 2  + SMS group (β = 0.57, 95% CI = 0.09 to 1.06) than usual care., Conclusions: The study found that the EMC 2 tools improved demonstrated safe dosing, but these benefits did not translate into actual use based on medication dairies. The text-messaging intervention did result in improved patient knowledge., (© 2019 by the Society for Academic Emergency Medicine.)

Background: The Accreditation Council for Graduate Medical Education Common Program Requirements effective 2017 state that programs and sponsoring institutions have the same responsibility to address well-being as they do other aspects of resident competence., Objectives: The authors sought to determine if the implementation of a multifaceted wellness curriculum improved resident burnout as measured by the Maslach Burnout Inventory (MBI)., Methods: We performed a multicenter educational interventional trial at 10 emergency medicine (EM) residencies. In February 2017, we administered the MBI at all sites. A year-long wellness curriculum was then introduced at five intervention sites while five control sites agreed not to introduce new wellness initiatives during the study period. The MBI was readministered in August 2017 and February 2018., Results: Of 523 potential respondents, 437 (83.5%) completed at least one MBI assessment. When burnout was assessed as a continuous variable, there was a statistically significant difference in the depersonalization component favoring the control sites at the baseline and final survey administrations. There was also a higher mean personal accomplishment score at the control sites at the second survey administration. However, when assessed as a dichotomous variable, there were no differences in global burnout between the groups at any survey administration and burnout scores did not change over time for either control or intervention sites., Conclusions: In this national study of EM residents, MBI scores remained stable over time and the introduction of a multifaceted wellness curriculum was not associated with changes in global burnout scores., (© 2019 by the Society for Academic Emergency Medicine.)

Objectives: To describe the frequency and risk of return visit to the emergency department (ED) by older adults after prescription of any of four potentially inappropriate medication (PIM) classes included in the 2015 Beers Criteria commonly used for the relief of acute pain in the ED., Design: Retrospective cohort study., Setting: Large urban academic ED from January 1, 2013, to December 31, 2015., Participants: Patients age 65 and older discharged from the ED with an initial pain score of 1 or higher (11 822 visits)., Measurements: Prescriptions for PIM classes were collected from the medical record: nonsteroidal anti-inflammatory drugs (NSAIDs), benzodiazepines, skeletal muscle relaxants, and opioids. The proportion of patients with ED returns within 9 days were compared by medication class and pain severity (mild, moderate, or severe). Multivariable logistic regression was performed for each pain category to determine adjusted odds ratios (aORs) of ED return., Results: Of 11 822 included patients, PIMs were prescribed in 3392 (28.7%): 2550 (21.6%) opioids, 826 (7.0%) NSAIDs, 277 (2.3%) benzodiazepines, and 68 (0.6%) nonbenzodiazepine skeletal muscle relaxants. Total 9-day ED returns were 1125 (9.5%): mild 7.0%, moderate 8.3%, and severe pain 11.7%. Opioids were not associated with more frequent ED returns for mild or moderate pain, and they were associated with less frequent ED returns for severe pain (9.2% vs 12.7%; p < .001; aOR 0.69; 95% confidence interval [CI] = 0.54-0.87). Benzodiazepines were associated with more frequent ED returns for patients with moderate pain (15.5% vs 8.2%; p < .01; aOR = 2.01; 95%CI = 1.10-3.70)., Conclusions: These results are consistent with recommendations to limit benzodiazepine prescriptions for older adults and that among older adults with severe pain, opioid prescribing is associated with less frequent ED visits within 9 days of discharge. However, this study was not designed to evaluate safety, adverse events, or other important patient-centered outcomes. J Am Geriatr Soc 67:719-725, 2019., (© 2019 The American Geriatrics Society.)

Background: The Maslach Burnout Inventory (MBI) is considered the "gold standard" for measuring burnout, encompassing 3 scales: emotional exhaustion, depersonalization, and personal accomplishment. Other well-being instruments have shown utility in various settings, and correlations between MBI and these instruments could provide evidence of relationships among key variables to guide well-being efforts., Objective: We explored correlations between the MBI and other well-being instruments., Methods: We fielded a multicenter survey of 9 emergency medicine (EM) residencies, administering the MBI and 4 published well-being instruments: a quality-of-life assessment, a work-life balance rating, an appraisal of career satisfaction, and the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire 2 question screen. Consistent with the Maslach definition, burnout was defined by high emotional exhaustion (> 26) and high depersonalization (> 12)., Results: Of 334 residents, 261 (78%) responded. Residents who reported lower quality of life had higher emotional exhaustion (ρ = -0.437, P  < .0001), higher depersonalization (ρ = -0.18, P  < .005), and lower personal accomplishment (ρ = 0.347, P  < .001). Residents who reported a negative work-life balance had emotional exhaustion ( P  < .001) and depersonalization ( P  < .009). Positive career satisfaction was associated with lower emotional exhaustion ( P  < .0001), lower depersonalization ( P  < .005), and higher personal accomplishment ( P  < .05). A positive depression screen was associated with higher emotional exhaustion, higher depersonalization, and lower personal achievement (all P  < .0001)., Conclusions: Our multicenter study of EM residents demonstrated that assessments using the MBI correlate with other well-being instruments., Competing Interests: Conflict of interest: The authors declare they have no competing interests.

Burnout, the triad of emotional exhaustion, depersonalization, and low personal accomplishment, begins early in medical education and the prevalence continues to increase over time among U.S. physicians. The Accreditation Council for Graduate Medical Education (ACGME) now requires that programs and sponsoring institutions have the same responsibility to address well-being as they do other aspects of resident competence. Yet, there are no studies published in the emergency medicine (EM) literature that discuss the development and institution of a formal wellness curriculum. The authors conducted a needs analysis among EM residents with the aim of creating a multifaceted 12-month wellness curriculum. The needs analysis determined that residents are not comfortable with their knowledge of wellness principles. In response, the authors developed a curriculum by integrating components of published non-EM wellness curricula and online academic wellness programs with commonly accepted domains of wellness. The curriculum was subsequently introduced at five EM residencies. This curriculum represents an example of successful multi-institution collaboration to meet an ACGME Common Program Requirement.

Background: Thousands of people die annually from prescription opioid overdoses; however there are few strategies to ensure patients receive medication risk information at the time of prescribing., Objectives: To compare the effectiveness of the Emergency Department (ED) Electronic Medication Complete Communication (EMC 2 ) Opioid Strategy (with and without text messaging) to promote safe medication use and improved patient knowledge as compared to usual care., Methods: The ED EMC 2 Opioid Strategy consists of 5 automated components to promote safe medication use: 1) physician reminder to counsel, 2) inbox message sent on to the patient's primary care physician, 3) pharmacist message on the prescription to counsel, 4) MedSheet supporting prescription information, and 5) patient-centered Take-Wait-Stop wording of prescription instructions. This strategy will be assessed both with and without the addition of text messages via a three-arm randomized trial. The study will take place at an urban academic ED (annual volume>85,000) in Chicago, IL. Patients being discharged with a new prescription for hydrocodone-acetaminophen will be enrolled and randomized (based on their prescribing physician). The primary outcome of the study is medication safe use as measured by a demonstrated dosing task. Additionally actual safe use, patient knowledge and provider counseling will be measured. Implementation fidelity as well as costs will be reported., Conclusions: The ED EMC 2 Opioid Strategy embeds a risk communication strategy into the electronic health record and promotes medication counseling with minimal workflow disruption. This trial will evaluate the strategy's effectiveness and implementation fidelity as compared to usual care., Trial Registration: This trial is registered on clinicaltrials.gov with identifier NCT02431793., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: Burnout is common among emergency medicine (EM) physicians, and it is prevalent even among EM trainees. Recently proposed Accreditation Council for Graduate Medical Education requirements encourage faculty to alert residency leadership when trainees display signs of burnout. It remains uncertain how trainees experiencing burnout can be reliably identified. We examined if EM faculty advisers at one institution can accurately predict burnout in their EM resident advisees., Methods: In this cross-sectional, exploratory study at a single institution, we measured EM trainee burnout using the Maslach Burnout Inventory through a confidential, electronic survey. We subsequently asked EM faculty to predict if their designated advisees were experiencing burnout through a separate confidential, electronic survey. Burnout results were dichotomized from each survey and compared using a 2 × 2 contingency table and Fisher's exact test., Results: Thirty-six of 54 (66.7%) eligible EM trainees completed the burnout assessment. Eleven of 19 (57.9%) eligible faculty advisers completed trainee burnout predictions, resulting in 30 of 54 (55.6%) trainees who completed the burnout assessment and had a faculty burnout prediction. Trainees reported an overall burnout rate of 70.0% (95% confidence interval [CI] = 53.6% to 86.4%). Cumulative faculty predictions of trainee burnout resulted in an overall burnout rate of 16.7% (95% CI = -5.3% to 38.7%). The sensitivity and specificity of faculty predictions of trainee burnout were 19.1% (95% CI = 5.5% to 41.9%) and 88.9% (95% CI = 51.8% to 99.7%), respectively. Faculty prediction of trainee burnout had a positive predictive value of 80.0% (95% CI = 28.4% to 99.5%) and a negative predictive value of 32.0% (95% CI = 15.0% to 53.5). The difference between trainees' reported rate of burnout and faculty predictions of trainee burnout was significant (p < 0.001)., Conclusion: Emergency medicine faculty prediction of trainee burnout was poor. Education on recognizing burnout and other methods of identifying trainee burnout may be necessary.

Background: Benzodiazepine-opioid combination therapy is potentially harmful due to the risk of synergistic respiratory depression, and the rate of death due to benzodiazepine-opioid overdose is increasing. Little is known about the prevalence and characteristics of benzodiazepine-opioid co-prescribing from the ED setting., Methods: Secondary analysis of data from the National Hospital Ambulatory Medical Care Survey, using sample weights to generate population estimates. The primary objective was to describe the annual prevalence of benzodiazepine-opioid co-prescribing from 2006 to 2012, using 95% confidence intervals (95% CI) to compare adjacent years. The secondary objective was to compare characteristics of ED encounters receiving a benzodiazepine-opioid co-prescription versus those receiving an opioid prescription alone, using a multivariable logistic regression., Results: The prevalence of benzodiazepine-opioid co-prescribing did not significantly change from 2006 to 2012. During this period, 2.7% (95% CI: 2.5-2.8%) of ED encounters prescribed an opioid were also prescribed a benzodiazepine. Relative to encounters receiving an opioid prescription alone, encounters receiving a co-prescription were more likely to represent a follow-up rather than initial visit (Odds Ratio [OR] 1.52), receive more medications (OR 1.41) and fewer procedures (OR 0.48) while in the ED, and more likely to have a diagnosis related to mental disorder (OR 20.60) or musculoskeletal problem (OR 3.71)., Conclusions: From 2006 to 2012, almost 3% of all ED encounters receiving an opioid prescription also received a benzodiazepine co-prescription. The odds of benzodiazepine-opioid co-prescribing were significantly higher in ED encounters representing a follow-up visit and in diagnoses relating to a mental disorder or musculoskeletal problem., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Recent guidelines recommend universal substance abuse screening for all trauma patients aged 12 years and older because brief interventions can help prevent future trauma. However, little is known about actual rates of screening in this setting., Methods: The Illinois State Trauma Registry was queried for severely injured patients from 1999 to 2009. Multivariate logistic regression was used to characterize, according to demographic and physiologic parameters, which patients were screened with blood alcohol and urine toxicology and which screened positive., Results: Of the 12,264 pediatric patients, 40% were tested for alcohol and 37% for drugs. Nine percent of patients screened positive for alcohol and 8% for drugs. Age strongly predicted positive tests, as did male sex. Black and Hispanic patients were screened for alcohol most frequently, but only Hispanics were more likely to test positive., Conclusion: Although current guidelines recommend screening all trauma patients 12 years and older, current practice falls far short of this goal., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Substance use among older adults is an increasing concern, with the prevalence of substance use in older populations expected to double in the next decade. Drug and alcohol use is associated with trauma risk and outcomes, but little is known about the specific risk for older trauma patients., Objectives: To evaluate the association between drug and alcohol use and trauma outcomes among adults aged 55 years and older., Methods: This retrospective observational study included older adults from the Illinois Trauma Registry between 1999 and 2009. Exclusion criteria were age younger than 55 years or absent date of birth, ethanol level, or urine drug screen (UDS). Alcohol intoxication was defined as ethanol level greater than 80 mg/dL. UDS was used to screen cocaine and marijuana use. Analyses, for both the alcohol and the marijuana/cocaine groups, compared outcomes for patients with negative vs. positive screens., Results: 21 320 patients were included in the alcohol analysis and 17 077 in the drug analysis. Compared to non-intoxicated patients, alcohol-intoxicated patients had significantly (p < 0.001) lower in-hospital mortality, decreased ICU admission, decreased intubation rate, and shorter hospital length of stay. Patients screening positive for cocaine or marijuana had significantly longer lengths of stay with increased ICU admission compared with those who screened negative., Conclusion: Among older trauma patients, this study shows significant associations with multiple trauma outcomes, including one between elevated ethanol concentrations and improved outcomes. Future research into the causes of these findings could inform the care of older trauma patients and aid in prevention of injuries.

Introduction: The use of synthetic drugs of abuse in the United States has grown in the last few years, with little information available on how much physicians know about these drugs and how they are treating patients using them. The objective of this study was to assess emergency physician (EP) knowledge of synthetic cannabinoids (SC)., Methods: A self-administered internet-based survey of resident and attending EPs at a large urban emergency department (ED) was administered to assess familiarity with the terms Spice or K2 and basic knowledge of SC, and to describe some practice patterns when managing SC intoxication in the ED., Results: Of the 83 physicians invited to participate, 73 (88%) completed surveys. The terms "Spice" and "K2" for SC were known to 25/73 (34%) and 36/73 (49%) of respondents. Knowledge of SC came most commonly (72%) from non-medical sources, with lay publications and the internet providing most respondents with information. Among those with previous knowledge of synthetic cannabinoids, 25% were not aware that SC are synthetic drugs, and 17% did not know they are chemically most similar to marijuana. Among all participants, 80% felt unprepared caring for a patient in the ED who had used synthetic cannabinoids., Conclusion: Clinically active EPs are unfamiliar with synthetic cannabinoids. Even those who stated they had heard of synthetic cannabinoids answered poorly on basic knowledge questions. More education is needed among EPs of all ages and levels of training on synthetic cannabinoids.