Fentanyl, etizolam, and beyond: A feasibility study of a community partnership using handheld Raman spectrometry to identify substances in the local illicit drug supply.

Background: The United States is currently experiencing an unprecedented rise in fatal drug overdoses, which is in part due to the arrival of fentanyl, fentanyl analogs, and other synthetic drugs into the illicit drug supply. Traditional urine drug testing is often unable to detect fentanyl analogs and other novel synthetic drugs, which places physicians and first responders in the difficult position of treating patients who are intoxicated with or overdosing on unknown substances. Design and methods: We report, as a feasibility study, the development of a novel program to use a handheld Raman spectrometry device in our hospital's Emergency Department to surveil our local illicit drug supply in terms of what substances are being sold and used. Results: Using our novel program, we were able to detect 27 substances in our illicit drug supply over a 10 month period, including fentanyl analogues. We shared, through our local opioid safety coalition, real-time information to first responders, substance use treatment programs, and physicians about the novel substances we detected using the handheld Raman spectrometer. Conclusions: A community partnership of using handheld Raman spectrometry in our hospital's Emergency Department was successful in providing information to health care providers about novel substances in our illicit drug market. Additionally, the implementation of this program improved collaboration between local health care providers and local law enforcement.

Atraumatic Back Pain Due to Quadratus Lumborum Spasm Treated by Physical Therapy with Manual Trigger Point Therapy in the Emergency Department.

Manual trigger point therapy is effective for treating myofascial pain, yet it is not frequently used in emergency department (ED) settings. A 42-year-old female presented to the ED with atraumatic back pain. Her pain was thought to be myofascial, and we obtained a physical therapy consultation. Diagnosing the patient with quadratus lumborum spasm, the physical therapist treated her in the ED using manual trigger point therapy, and completely relieved her pain without requiring any medications. Manual trigger point therapy can provide non-opioid pain relief in ED patients, and physical therapists can apply this technique effectively in the ED.

Transcutaneous Electrical Nerve Stimulation (TENS) in the Emergency Department for Pain Relief: A Preliminary Study of Feasibility and Efficacy.

INTRODUCTION: Given the high rates of opioid addiction and overdose in the United States, non-opioid means of treating pain are increasingly needed. Transcutaneous electrical nerve stimulation (TENS) therapy is an effective non-opioid modality for treating pain, but has not yet been routinely used in emergency department (ED) settings. In this study we asked the following questions: Are TENS units a feasible treatment for pain in the ED? How effective are TENS units for the management of pain in a general ED population? METHODS: At our institution, we performed a pilot study using TENS units for pain. Patients in the ED were given, at the discretion of the ED provider, TENS units for the treatment of pain. Patients could be included for acute or chronic pain on whatever part of the body that was safe to use with TENS. RESULTS: A chart review of patients receiving TENS units in the ED (n=110) revealed that TENS was useful in relieving pain, along with other treatments, in 99% of cases. When surveyed, 83% of patients reported a functional improvement while using the TENS, and 100% of patients would recommend a TENS unit to a family or friend. When surveyed, 100% of ED staff observed that TENS units were effective in treating pain for patients, and 97% would want to use them if they themselves were patients. CONCLUSION: Overall, in this small pilot study, TENS units appeared to be effective in our ED for reducing pain, when added to standard treatment. Additional studies are needed to determine which conditions are most responsive to TENS therapy, and the magnitude of pain reduction when used alone.

Case Management Reduces Length of Stay, Charges, and Testing in Emergency Department Frequent Users.

INTRODUCTION: Case management is an effective, short-term means to reduce emergency department (ED) visits in frequent users of the ED. This study sought to determine the effectiveness of case management on frequent ED users, in terms of reducing ED and hospital length of stay (LOS), accrued costs, and utilization of diagnostic tests. METHODS: The study consisted of a retrospective chart review of ED and inpatient visits in our hospital's ED case management program, comparing patient visits made in the one year prior to enrollment in the program, to the visits made in the one year after enrollment in the program. We examined the LOS, use of diagnostic testing, and monetary charges incurred by these patients one year prior and one year after enrollment into case management. RESULTS: The study consisted of 158 patients in case management. Comparing the one year prior to enrollment to the one year after enrollment, ED visits decreased by 49%, inpatient admissions decreased by 39%, the use of computed tomography imaging decreased 41%, the use of ultrasound imaging decreased 52%, and the use of radiographs decreased 38%. LOS in the ED and for inpatient admissions decreased by 39%, reducing total LOS for these patients by 178 days. ED and hospital charges incurred by these patients decreased by 5.8 million dollars, a 41% reduction. All differences were statistically significant. CONCLUSION: Case management for frequent users of the ED is an effective method to reduce patient visits, the use of diagnostic testing, length of stay, and cost within our institution.

The Efficacy of Case Management on Emergency Department Frequent Users: An Eight-Year Observational Study.

BACKGROUND: Case management is an effective short-term means to reduce Emergency Department (ED) visits in frequent users of the ED. OBJECTIVES: Our study aimed to assess the long-term efficacy of intensive case management in frequent users of the ED. METHODS: This was an observational study of ED usage conducted at a community hospital that has an ED case management program in which frequent users of the ED are enrolled and provided with intensive care management to reduce ED use. RESULTS: We identified 199 patients that were enrolled for 6 or more years. Patients averaged 16 visits per person per year in the year prior to enrollment. Patients averaged the following number of visits per person per year after enrollment: year 1 (7.1), year 2 (4.1), year 3 (3.1), year 4 (3.3), year 5 (3.1), year 6 (2.0), year 7 (2.1), and year 8 (1.9), all statistically significant compared to the year prior to enrollment. Twenty-nine patients, despite case management, continued their frequent use, and required a revision to their plan of care. Five patients required a second revision to their plan of care secondary to recurrent ED usage. Persistent use despite case management was primarily due to prescription medication misuse and chronic pain. CONCLUSION: Case management of ED frequent users seems to be an effective means to reduce ED usage in both the short and long term. Patients with prescription drug misuse or chronic pain may continue to demonstrate frequent use despite case management, and may require revisions to their plan of care.

New Initiative Slashes Opioid Prescriptions, Boosts Community Response.

The Community Hospital of Monterey Peninsula (CHOMP) has spearheaded a multiagency collaborative that has been successful at more than halving the prescriptions for narcotics in the region and trimming ED visits among frequent users. Known as "Prescribe Safe," the approach can be credited, in part, with nudging emergency providers to view addiction as a disease and to reevaluate their role in linking patients with needed treatment. Under its recurrent visitors program, emergency providers at CHOMP reject the term "drug seeking," instead focusing on addressing the underlying reasons for a patient's addiction problem. A centerpiece of the Prescribe Safe initiative is county-wide implementation of pain management protocols for the ED, coupled with provider and patient education initiatives about these guidelines and why they are important. Physician leaders of the Prescribe Safe initiative note that networking with community partners has produced alliances with law enforcement on drug take back events and a more effective response to drug diversion and prescription forgery. By making safety the ultimate goal of the initiative, patient provider conflict over prescribing choices has been minimized.

Quantifying drug-seeking behavior: a case control study.

BACKGROUND: Drug-seeking behavior (DSB) is common in the Emergency Department (ED), yet the literature describing DSB in the ED consists predominantly of anecdotal evidence. STUDY OBJECTIVES: To perform a case-control study examining the relative frequency of DSB in suspected drug-seeking patients as compared to all ED patients. METHODS: We performed a retrospective chart review of 152 drug-seeking patients and of age- and gender-matched controls, noting which of the following behaviors were exhibited during a 1-year period: reporting a non-narcotic allergy, requesting addictive medications by name, requesting a medication refill, reporting lost or stolen medication, three or more ED visits complaining of pain in different body parts, reporting 10 out of 10 pain, reporting > 10 out of 10 pain, three or more ED visits within 7 days, reporting being out of medication, requesting medications parenterally, and presenting with a chief complaint of headache, back pain, or dental pain. RESULTS: The odds ratios for each studied behavior being used by drug seeking patients as compared to controls were: non-narcotic allergy: 3.4, medication by name: 26.3, medication refill: 19.2, lost or stolen medication: 14.1, three or more pain related visits in different parts of the body: 29.3, 10 out of 10 pain: 13.9, three visits in 7 days: 30.8, out of medication: 26.9, headache: 10.9, back pain: 13.6, and dental pain: 6.3. Zero patients in the control group complained of greater than 10-out-of-10 pain or requested medication parenterally, resulting in a calculated odds ratio of infinity for these two behaviors. CONCLUSIONS: Requesting parenteral medication and reporting greater than ten out of ten pain were most predictive of drug-seeking, while reporting a non-narcotic allergy was less predictive of drug-seeking than other behaviors.

How Frequently are "Classic" Drug-Seeking Behaviors Used by Drug-Seeking Patients in the Emergency Department?

INTRODUCTION: Drug-seeking behavior (DSB) in the emergency department (ED) is a very common problem, yet there has been little quantitative study to date of such behavior. The goal of this study was to assess the frequency with which drug seeking patients in the ED use classic drug seeking behaviors to obtain prescription medication. METHODS: We performed a retrospective chart review on patients in an ED case management program for DSB. We reviewed all visits by patients in the program that occurred during a 1-year period, and recorded the frequency of the following behaviors: complaining of headache, complaining of back pain, complaining of dental pain, requesting medication by name, requesting a refill of medication, reporting medications as having been lost or stolen, reporting 10/10 pain, reporting greater than 10/10 pain, reporting being out of medication, and requesting medication parenterally. These behaviors were chosen because they are described as "classic" for DSB in the existing literature. RESULTS: We studied 178 patients from the case management program, who made 2,486 visits in 1 year. The frequency of each behavior was: headache 21.7%, back pain 20.8%, dental pain 1.8%, medication by name 15.2%, requesting refill 7.0%, lost or stolen medication 0.6%, pain 10/10 29.1%, pain greater than 10/10 1.8%, out of medication 9.5%, and requesting parenteral medication 4.3%. Patients averaged 1.1 behaviors per visit. CONCLUSION: Drug-seeking patients appear to exhibit "classically" described drug-seeking behaviors with only low to moderate frequency. Reliance on historical features may be inadequate when trying to assess whether or not a patient is drug-seeking.

Narcotic bowel syndrome.

BACKGROUND: Narcotic bowel syndrome is characterized by chronic or recurrent abdominal pain associated with escalating doses of narcotic pain medications. It may occur in as many as 4% of all patients taking opiates, and yet few physicians are aware that the syndrome exists. OBJECTIVES: The objectives of this case report are to raise awareness of narcotic bowel syndrome among emergency physicians, as well as review the clinical features, diagnosis, pathophysiology, and emergency department (ED) management of the syndrome. CASE REPORT: We report a case of narcotic bowel syndrome diagnosed in a 24-year-old woman after > 1 year of ED visits for recurrent abdominal pain of unknown origin. CONCLUSIONS: It is particularly important for emergency physicians to be familiar with this syndrome, as many patients with narcotic bowel syndrome seek evaluation and treatment in the ED. Although the diagnosis is unlikely to be made in the ED, timely referral for evaluation of this syndrome may help patients to receive definitive treatment for their recurrent and chronic pain.

Emergency department frequent user: pilot study of intensive case management to reduce visits and computed tomography.

OBJECTIVE: Emergency department (ED) frequent users account for a large number of annual ED visits and often receive radiological studies as a part of their evaluation. We report a pilot study of a case management program for ED frequent users to reduce ED usage and radiation exposure. METHODS: This observational retrospective study was performed at a community hospital ED. Between May 2006 and April 2008, 96 patients were enrolled in a case management program and were followed through November 2008. The case management program consisted of a multi-disciplinary team of physicians, nurses, social services and specialists in pain management and behavioral health. Patients were enrolled if they had five or more visits to the ED in the previous month, if a concern about a patient's ED use was raised by staff, or if they were identified by the California prescription monitoring program. Case management addressed specific patient issues and assisted with receiving consistent outpatient care. The number of ED visits per patient and the number of radiological studies at each of these visits was recorded. When reviewing data for analysis, we used the number of total images in all computed tomography (CT) scans during the given time period. RESULTS: In the six months prior to enrollment, patients averaged 2.3 ED visits per patient per month. In the six months after enrollment, patients averaged 0.6 ED visits per patient per month (P<0.0001), and all visits after enrollment up to November 2008 averaged 0.4 visits per patient per month (P<0.0001). In the six months prior to enrollment, these patients averaged 25.6 CT images per patient per month. In the six months after enrollment, patients averaged 10.2 CT images per patient per month (P=0.001), and all CT images after enrollment up to November 2008 averaged 8.1 CT images per patient per month (P=0.0001). This represents a decrease in ED use by 83% and a decrease in radiation exposure by 67%. CONCLUSION: Case management can significantly reduce ED use by frequent users, and can also decrease radiation exposure from diagnostic imaging.

Graphical literacy: the quality of graphs in a large-circulation journal.

STUDY OBJECTIVES: We sought to characterize the quantity and quality of graphs in the Journal of American Medicine (JAMA), contrasting articles published in 1999 with those published in 2000 after the addition of a dedicated tables and figures editor. We also sought to compare the quality of graphs in JAMA with the quality of graphs in Annals of Emergency Medicine. METHODS: Two reviewers independently assessed all graphs in original research articles from 12 randomly chosen issues of JAMA, 6 each from 1999 and 2000, using a standardized abstraction form. We noted graph type, clarity, and completeness and identified internal discrepancies. We examined the graphs and articles to observe discrepancies with text, to observe efficiency of graph presentation, and to determine whether the graph portrayed unaggregated data. Results were compared with results from a previously published study of graphs from 18 consecutive issues of Annals of Emergency Medicine beginning in January 1998. RESULTS: The 12 JAMA issues contained 56 research articles, with 64 graphs in the 37 articles that had graphs (28 in 27 1999 articles, 36 in 29 2000 articles). Simple bar or point charts (63%) predominated. We rarely encountered internal errors (8%), contradictions with text (3%), numeric distortion (6%), lack of visual clarity (5%), nonstandard graphing conventions (11%), or extraneous decoration (0%). Graphs generally defined all symbols (98%), but 31% were not self-explanatory; that is, despite knowing the study's design and reading the figure's legend, we could not unambiguously interpret the graph. Fourteen percent contained redundancies. Graphs infrequently portrayed by-subject data (9%) or advanced features (15%) such as pairing, symbolic dimensionality, or small multiples. Forty-eight percent (21/44) of graphs did not illustrate the underlying distribution, 48% (26/54) did not depict important covariates, and 67% (14/21) did not portray pairing inherent in the data. There were no differences between 1999 and 2000 graphs, although we noted more graphs in the 2000 issues. Graph quality was similar in Annals of Emergency Medicine and JAMA, but graphs were more common in the original research articles in JAMA. Although univariate displays predominated in both publications, there were more bivariate displays in Annals of Emergency Medicine but fewer advanced graphic features. CONCLUSION: The graphs in JAMA were similar to those in Annals of Emergency Medicine and, although generally clear and without errors, often failed to depict detailed data. Authors and editors could improve data presentations by incorporating graphic formats that depict stratified, detailed data.