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1.
BMJ ; 377: e069271, 2022 06 27.
Article in English | MEDLINE | ID: covidwho-1909708

ABSTRACT

OBJECTIVE: To determine the effect of a user centered clinical decision support tool versus usual care on rates of initiation of buprenorphine in the routine emergency care of individuals with opioid use disorder. DESIGN: Pragmatic cluster randomized controlled trial (EMBED). SETTING: 18 emergency department clusters across five healthcare systems in five states representing the north east, south east, and western regions of the US, ranging from community hospitals to tertiary care centers, using either the Epic or Cerner electronic health record platform. PARTICIPANTS: 599 attending emergency physicians caring for 5047 adult patients presenting with opioid use disorder. INTERVENTION: A user centered, physician facing clinical decision support system seamlessly integrated into user workflows in the electronic health record to support initiating buprenorphine in the emergency department by helping clinicians to diagnose opioid use disorder, assess the severity of withdrawal, motivate patients to accept treatment, and complete electronic health record tasks by automating clinical and after visit documentation, order entry, prescribing, and referral. MAIN OUTCOME MEASURES: Rate of initiation of buprenorphine (administration or prescription of buprenorphine) in the emergency department among patients with opioid use disorder. Secondary implementation outcomes were measured with the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework. RESULTS: 1 413 693 visits to the emergency department (775 873 in the intervention arm and 637 820 in the usual care arm) from November 2019 to May 2021 were assessed for eligibility, resulting in 5047 patients with opioid use disorder (2787 intervention arm, 2260 usual care arm) under the care of 599 attending physicians (340 intervention arm, 259 usual care arm) for analysis. Buprenorphine was initiated in 347 (12.5%) patients in the intervention arm and in 271 (12.0%) patients in the usual care arm (adjusted generalized estimating equations odds ratio 1.22, 95% confidence interval 0.61 to 2.43, P=0.58). Buprenorphine was initiated at least once by 151 (44.4%) physicians in the intervention arm and by 88 (34.0%) in the usual care arm (1.83, 1.16 to 2.89, P=0.01). CONCLUSIONS: User centered clinical decision support did not increase patient level rates of initiating buprenorphine in the emergency department. Although streamlining and automating electronic health record workflows can potentially increase adoption of complex, unfamiliar evidence based practices, more interventions are needed to look at other barriers to the treatment of addiction and increase the rate of initiating buprenorphine in the emergency department in patients with opioid use disorder. TRIAL REGISTRATION: ClinicalTrials.gov NCT03658642.


Subject(s)
Buprenorphine , Decision Support Systems, Clinical , Opioid-Related Disorders , Adult , Buprenorphine/therapeutic use , Emergency Service, Hospital , Humans , Narcotic Antagonists/therapeutic use , Opiate Substitution Treatment/methods , Opioid-Related Disorders/drug therapy
2.
PLoS One ; 17(1): e0262136, 2022.
Article in English | MEDLINE | ID: covidwho-1622352

ABSTRACT

BACKGROUND: As the emergency department (ED) has evolved into the de-facto site of care for a variety of substance use disorder (SUD) presentations, trends in ED utilization are an essential public health surveillance tool. Changes in ED visit patterns during the COVID-19 pandemic may reflect changes in access to outpatient treatment, changes in SUD incidence, or the unintended effects of public policy to mitigate COVID-19. We use a national emergency medicine registry to describe and characterize trends in ED visitation for SUDs since 2019. METHODS: We included all ED visits identified in a national emergency medicine clinical quality registry, which included 174 sites across 33 states with data from January 2019 through June 2021. We defined SUD using ED visit diagnosis codes including: opioid overdose and opioid use disorder (OUD), alcohol use disorders (AUD), and other SUD. To characterize changes in ED utilization, we plotted the 3-week moving average ratio of visit counts in 2020 and 2021 as compared to visit counts in 2019. FINDINGS: While overall ED visits declined in the early pandemic period and had not returned to 2019 baseline by June 2021, ED visit counts for SUD demonstrated smaller declines in March and April of 2020, so that the proportion of overall ED visits that were for SUD increased. Furthermore, in the second half of 2020, ED visits for SUD returned to baseline, and increased above baseline for OUD ever since May 2020. CONCLUSIONS: We observe distinct patterns in ED visitation for SUDs over the course of the COVID-19 pandemic, particularly for OUD for which ED visitation barely declined and now exceeds previous baselines. These trends likely demonstrate the essential role of hospital-based EDs in providing 24/7/365 care for people with SUDs and mental health conditions. Allocation of resources must be directed towards the ED as a de-facto safety net for populations in crisis.


Subject(s)
Ambulatory Care/statistics & numerical data , COVID-19/psychology , Emergency Service, Hospital/statistics & numerical data , Mental Disorders/psychology , Mental Health/statistics & numerical data , Substance-Related Disorders/psychology , Humans , Pandemics/statistics & numerical data
4.
Ann Emerg Med ; 79(2): 158-167, 2022 02.
Article in English | MEDLINE | ID: covidwho-1265634

ABSTRACT

STUDY OBJECTIVE: People with opioid use disorder are vulnerable to disruptions in access to addiction treatment and social support during the COVID-19 pandemic. Our study objective was to understand changes in emergency department (ED) utilization following a nonfatal opioid overdose during COVID-19 compared to historical controls in 6 healthcare systems across the United States. METHODS: Opioid overdoses were retrospectively identified among adult visits to 25 EDs in Alabama, Colorado, Connecticut, North Carolina, Massachusetts, and Rhode Island from January 2018 to December 2020. Overdose visit counts and rates per 100 all-cause ED visits during the COVID-19 pandemic were compared with the levels predicted based on 2018 and 2019 visits using graphical analysis and an epidemiologic outbreak detection cumulative sum algorithm. RESULTS: Overdose visit counts increased by 10.5% (n=3486; 95% confidence interval [CI] 4.18% to 17.0%) in 2020 compared with the counts in 2018 and 2019 (n=3020 and n=3285, respectively), despite a 14% decline in all-cause ED visits. Opioid overdose rates increased by 28.5% (95% CI 23.3% to 34.0%) from 0.25 per 100 ED visits in 2018 to 2019 to 0.32 per 100 ED visits in 2020. Although all 6 studied health care systems experienced overdose ED visit rates more than the 95th percentile prediction in 6 or more weeks of 2020 (compared with 2.6 weeks as expected by chance), 2 health care systems experienced sustained outbreaks during the COVID-19 pandemic. CONCLUSION: Despite decreases in ED visits for other medical emergencies, the numbers and rates of opioid overdose-related ED visits in 6 health care systems increased during 2020, suggesting a widespread increase in opioid-related complications during the COVID-19 pandemic. Expanded community- and hospital-based interventions are needed to support people with opioid use disorder and save lives during the COVID-19 pandemic.


Subject(s)
COVID-19/epidemiology , Delivery of Health Care/statistics & numerical data , Emergency Service, Hospital/statistics & numerical data , Facilities and Services Utilization/statistics & numerical data , Health Services Accessibility/statistics & numerical data , Opiate Overdose/therapy , Adult , Cross-Sectional Studies , Humans , Pandemics , Retrospective Studies , SARS-CoV-2 , United States/epidemiology
5.
EClinicalMedicine ; 32: 100741, 2021 Feb.
Article in English | MEDLINE | ID: covidwho-1071273

ABSTRACT

BACKGROUND: Suicides by any method, plus 'nonsuicide' fatalities from drug self-intoxication (estimated from selected forensically undetermined and 'accidental' deaths), together represent self-injury mortality (SIM)-fatalities due to mental disorders or distress. SIM is especially important to examine given frequent undercounting of suicides amongst drug overdose deaths. We report suicide and SIM trends in the United States of America (US) during 1999-2018, portray interstate rate trends, and examine spatiotemporal (spacetime) diffusion or spread of the drug self-intoxication component of SIM, with attention to potential for differential suicide misclassification. METHODS: For this state-based, cross-sectional, panel time series, we used de-identified manner and underlying cause-of-death data for the 50 states and District of Columbia (DC) from CDC's Wide-ranging Online Data for Epidemiologic Research. Procedures comprised joinpoint regression to describe national trends; Spearman's rank-order correlation coefficient to assess interstate SIM and suicide rate congruence; and spacetime hierarchical modelling of the 'nonsuicide' SIM component. FINDINGS: The national annual average percentage change over the observation period in the SIM rate was 4.3% (95% CI: 3.3%, 5.4%; p<0.001) versus 1.8% (95% CI: 1.6%, 2.0%; p<0.001) for the suicide rate. By 2017/2018, all states except Nebraska (19.9) posted a SIM rate of at least 21.0 deaths per 100,000 population-the floor of the rate range for the top 5 ranking states in 1999/2000. The rank-order correlation coefficient for SIM and suicide rates was 0.82 (p<0.001) in 1999/2000 versus 0.34 (p = 0.02) by 2017/2018. Seven states in the West posted a ≥ 5.0% reduction in their standardised mortality ratios of 'nonsuicide' drug fatalities, relative to the national ratio, and 6 states from the other 3 major regions a >6.0% increase (p<0.05). INTERPRETATION: Depiction of rising SIM trends across states and major regions unmasks a burgeoning national mental health crisis. Geographic variation is plausibly a partial product of local heterogeneity in toxic drug availability and the quality of medicolegal death investigations. Like COVID-19, the nation will only be able to prevent SIM by responding with collective, comprehensive, systemic approaches. Injury surveillance and prevention, mental health, and societal well-being are poorly served by the continuing segregation of substance use disorders from other mental disorders in clinical medicine and public health practice. FUNDING: This study was partially funded by the National Centre for Injury Prevention and Control, US Centers for Disease Control and Prevention (R49CE002093) and the US National Institute on Drug Abuse (1UM1DA049412-01; 1R21DA046521-01A1).

6.
J Addict Med ; 14(6): e369-e371, 2020 12.
Article in English | MEDLINE | ID: covidwho-1020284

ABSTRACT

OBJECTIVES: The COVID-19 epidemic in the United States has hit in the midst of the opioid overdose crisis. Emergency medical services (EMS) clinicians may limit their use of intranasal naloxone due to concerns of novel coronavirus infection. We sought to determine changes in overdose events and naloxone administration practices by EMS clinicians. METHODS: Between April 29, 2020 and May 15, 2020, we surveyed directors of EMS fellowship programs across the US about how overdose events and naloxone administration practices had changed in their catchment areas since March 2020. RESULTS: Based on 60 respondents across all regions of the country, one fifth of surveyed communities have experienced an increase in opioid overdoses and events during which naloxone was administered, and 40% have experienced a decrease. The findings varied by region of the country. Eighteen percent of respondents have discouraged or prohibited the use of intranasal naloxone with 10% encouraging the use of intramuscular naloxone. CONCLUSIONS: These findings may provide insight into changes in opioid overdose mortality during this time and assist in future disaster planning.


Subject(s)
Coronavirus Infections/epidemiology , Emergency Medical Services/statistics & numerical data , Naloxone/therapeutic use , Narcotic Antagonists/therapeutic use , Pneumonia, Viral/epidemiology , Analgesics, Opioid/toxicity , COVID-19 , Coronavirus Infections/prevention & control , Drug Overdose/drug therapy , Drug Overdose/mortality , Humans , Infection Control , Naloxone/administration & dosage , Narcotic Antagonists/administration & dosage , Nasal Sprays , Pandemics/prevention & control , Pneumonia, Viral/prevention & control , Surveys and Questionnaires , United States/epidemiology
7.
JAMA Intern Med ; 180(10): 1328-1333, 2020 10 01.
Article in English | MEDLINE | ID: covidwho-693393

ABSTRACT

Importance: As coronavirus disease 2019 (COVID-19) spread throughout the US in the early months of 2020, acute care delivery changed to accommodate an influx of patients with a highly contagious infection about which little was known. Objective: To examine trends in emergency department (ED) visits and visits that led to hospitalizations covering a 4-month period leading up to and during the COVID-19 outbreak in the US. Design, Setting, and Participants: This retrospective, observational, cross-sectional study of 24 EDs in 5 large health care systems in Colorado (n = 4), Connecticut (n = 5), Massachusetts (n = 5), New York (n = 5), and North Carolina (n = 5) examined daily ED visit and hospital admission rates from January 1 to April 30, 2020, in relation to national and the 5 states' COVID-19 case counts. Exposures: Time (day) as a continuous variable. Main Outcomes and Measures: Daily counts of ED visits, hospital admissions, and COVID-19 cases. Results: A total of 24 EDs were studied. The annual ED volume before the COVID-19 pandemic ranged from 13 000 to 115 000 visits per year; the decrease in ED visits ranged from 41.5% in Colorado to 63.5% in New York. The weeks with the most rapid rates of decrease in visits were in March 2020, which corresponded with national public health messaging about COVID-19. Hospital admission rates from the ED were stable until new COVID-19 case rates began to increase locally; the largest relative increase in admission rates was 149.0% in New York, followed by 51.7% in Massachusetts, 36.2% in Connecticut, 29.4% in Colorado, and 22.0% in North Carolina. Conclusions and Relevance: From January through April 2020, as the COVID-19 pandemic intensified in the US, temporal associations were observed with a decrease in ED visits and an increase in hospital admission rates in 5 health care systems in 5 states. These findings suggest that practitioners and public health officials should emphasize the importance of visiting the ED during the COVID-19 pandemic for serious symptoms, illnesses, and injuries that cannot be managed in other settings.


Subject(s)
Coronavirus Infections , Delivery of Health Care/trends , Emergency Service, Hospital , Hospitalization/statistics & numerical data , Infection Control , Pandemics , Pneumonia, Viral , Adult , Betacoronavirus , COVID-19 , Coronavirus Infections/epidemiology , Coronavirus Infections/therapy , Cross-Sectional Studies , Emergency Service, Hospital/organization & administration , Emergency Service, Hospital/trends , Female , Humans , Infection Control/methods , Infection Control/organization & administration , Male , Organizational Innovation , Pandemics/prevention & control , Pandemics/statistics & numerical data , Pneumonia, Viral/epidemiology , Pneumonia, Viral/therapy , Retrospective Studies , SARS-CoV-2 , United States/epidemiology
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