Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE-4): Alcohol use disorder and cannabinoid hyperemesis syndrome management in the emergency department.

The fourth Society for Academic Emergency Medicine (SAEM) Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE-4) is on the topic of the emergency department (ED) management of nonopioid use disorders and focuses on alcohol withdrawal syndrome (AWS), alcohol use disorder (AUD), and cannabinoid hyperemesis syndrome (CHS). The SAEM GRACE-4 Writing Team, composed of emergency physicians and experts in addiction medicine and patients with lived experience, applied the Grading of Recommendations Assessment Development and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding six priority questions for adult ED patients with AWS, AUD, and CHS. The SAEM GRACE-4 Writing Team reached the following recommendations: (1) in adult ED patients (over the age of 18) with moderate to severe AWS who are being admitted to hospital, we suggest using phenobarbital in addition to benzodiazepines compared to using benzodiazepines alone [low to very low certainty of evidence]; (2) in adult ED patients (over the age of 18) with AUD who desire alcohol cessation, we suggest a prescription for one anticraving medication [very low certainty of evidence]; (2a) in adult ED patients (over the age of 18) with AUD, we suggest naltrexone (compared to no prescription) to prevent return to heavy drinking [low certainty of evidence]; (2b) in adult ED patients (over the age of 18) with AUD and contraindications to naltrexone, we suggest acamprosate (compared to no prescription) to prevent return to heavy drinking and/or to reduce heavy drinking [low certainty of evidence]; (2c) in adult ED patients (over the age of 18) with AUD, we suggest gabapentin (compared to no prescription) for the management of AUD to reduce heavy drinking days and improve alcohol withdrawal symptoms [very low certainty of evidence]; (3a) in adult ED patients (over the age of 18) presenting to the ED with CHS we suggest the use of haloperidol or droperidol (in addition to usual care/serotonin antagonists, e.g., ondansetron) to help with symptom management [very low certainty of evidence]; and (3b) in adult ED patients (over the age of 18) presenting to the ED with CHS, we also suggest offering the use of topical capsaicin (in addition to usual care/serotonin antagonists, e.g., ondansetron) to help with symptom management [very low certainty of evidence].

Characteristics of women concordant and discordant for urine drug screens for cannabis exposure and self-reported cannabis use during pregnancy.

BACKGROUND: Increasing cannabis use among pregnant people and equivocal evidence linking prenatal cannabis exposure to adverse outcomes in offspring highlights the need to understand its potential impact on pregnancy and child outcomes. Assessing cannabis use during pregnancy remains a major challenge with potential influences of stigma on self-report as well as detection limitations of easily collected biological matrices. OBJECTIVE: This descriptive study examined the concordance between self-reported (SR) cannabis use and urine drug screen (UDS) detection of cannabis exposure during the first trimester of pregnancy and characterized concordant and discordant groups for sociodemographic factors, modes of use, secondhand exposure to cannabis and tobacco, and alcohol use and cotinine positivity. STUDY DESIGN: The Cannabis Use During Development and Early Life (CUDDEL) Study is an ongoing longitudinal study that recruits pregnant individuals presenting for obstetric care, who report lifetime cannabis use as well as using (n = 289) or not using cannabis (n = 169) during pregnancy. During the first trimester pregnancy visit, SR of cannabis use and a UDS for cannabis, other illicit drugs and nicotine are acquired from eligible participants, of whom 333 as of 05/01/2023 had both. RESULTS: Using available CUDDEL Study data on both SR and UDS (n = 333; age 26.6 ± 4.7; 88.6% Black; 45.4% below federal poverty threshold; 56.5% with paid employment; 89% with high school education; 22% first pregnancy; 12.3 ± 3.6 weeks gestation), we classified pregnant individuals with SR and UDS data into 4 groups based on concordance (k = 0.49 [95% C.I. 0.40-0.58]) between SR cannabis use and UDS cannabis detection during the first trimester: 1) SR+/UDS+ (n = 107); 2) SR-/UDS- (n = 142); 3) SR+/UDS- (n = 44); 4) SR-/UDS+ (n = 40). Those who were SR+/UDS- reported less frequent cannabis use and fewer hours under the influence of cannabis during their pregnancy. Those who were SR-/UDS+ were more likely to have joined the study at a lower gestational age with 62.5% reporting cannabis use during their pregnancy prior to being aware that they were pregnant. Of the 40 SR-/UDS+ women, 14 (i.e., 35%) reported past month secondhand exposure, or blunt usage. In the subset of individuals with SR and UDS available at trimester 2 (N = 160) and 3 (N = 140), concordant groups were mostly stable and > 50% of those in the discordant groups became concordant by the second trimester. Classifying individuals as exposed or not exposed who were SR+ and/or UDS+ resulted in minor changes in group status based on self-report at screening. CONCLUSION: Overall, there was moderate concordance between SR and UDS for cannabis use/exposure during pregnancy. Instances of SR+/UDS- discordancy may partially be attributable to lower levels of use that are not detected on UDS. SR-/UDS+ discordancy may arise from recent use prior to knowledge of pregnancy, extreme secondhand exposure, deception, and challenges with completing questionnaires. Acquiring both self-report and biological detection of cannabis use/exposure allows for the examination of convergent evidence. Classifying those who are SR+ and/or UDS+ as individuals who used cannabis during their first trimester after being aware of their pregnancy resulted in only a minor change in exposure status; thus, relying on self-report screening, at least in this population and within this sociocultural context likely provides an adequate approximation of cannabis use during pregnancy.

Incidence of and Factors Associated With Recurrent Firearm Injury Among Patients Presenting to St. Louis Trauma Centers, 2010 to 2019 : A Cohort Study.

BACKGROUND: Firearm injuries are a public health crisis in the United States. OBJECTIVE: To examine the incidence and factors associated with recurrent firearm injuries and death among patients presenting with an acute (index), nonfatal firearm injury. DESIGN: Multicenter, observational, cohort study. SETTING: Four adult and pediatric level I trauma hospitals in St. Louis, Missouri, 2010 to 2019. PARTICIPANTS: Consecutive adult and pediatric patients (n = 9553) presenting to a participating hospital with a nonfatal acute firearm injury. MEASUREMENTS: Data on firearm-injured patient demographics, hospital and diagnostic information, health insurance status, and death were collected from the St. Louis Region-Wide Hospital-Based Violence Intervention Program Data Repository. The Centers for Disease Control and Prevention (CDC) Social Vulnerability Index was used to characterize the social vulnerability of the census tracts of patients' residences. Analysis included descriptive statistics and time-to-event analyses estimating the probability of experiencing a recurrent firearm injury. RESULTS: We identified 10 293 acutely firearm-injured patients of whom 9553 survived the injury and comprised the analytic sample. Over a median follow-up of 3.5 years (IQR, 1.5 to 6.4 years), 1155 patients experienced a recurrent firearm injury including 5 firearm suicides and 149 fatal firearm injuries. Persons experiencing recurrent firearm injury were young (25.3 ± 9.5 years), predominantly male (93%), Black (96%), and uninsured (50%), and resided in high social vulnerability regions (65%). The estimated risk for firearm reinjury was 7% at 1 year and 17% at 8 years. LIMITATIONS: Limited data on comorbidities and patient-level social determinants of health. Inability to account for recurrent injuries presenting to nonstudy hospitals. CONCLUSION: Recurrent injury and death are frequent among survivors of firearm injury, particularly among patients from socially vulnerable areas. Our findings highlight the need for interventions to prevent recurrence. PRIMARY FUNDING SOURCE: Emergency Medicine Foundation-AFFIRM and Missouri Foundation for Health.

Benzonatate Overdose Presenting as Cardiac Arrest with Rapidly Narrowing QRS Interval.

INTRODUCTION: Benzonatate is a local anesthetic-like sodium channel antagonist that is widely prescribed as an antitussive. While it may be reasonable to assume that patients would present with a prolonged QRS interval following benzonatate overdose, the published literature does not support this. We report a case of a patient presenting following a benzonatate overdose with a prolonged QRS on her initial electrocardiograph (ECG) rhythm strip with rapid normalization of QRS duration. CASE REPORT: A 14-year-old girl presented in cardiac arrest following a benzonatate overdose. The patient was found in cardiac arrest within minutes of last being known well. Bystanders immediately provided cardiopulmonary resuscitation (CPR), and she was in asystole on emergency medical services (EMS) arrival. Return of spontaneous circulation (ROSC) was obtained following administration of intraosseous epinephrine and naloxone. EMS obtained an ECG rhythm strip following ROSC demonstrating a sinus rhythm with a QRS duration of 160 ms. Over the ensuing 30 minutes, there was progressive narrowing of the QRS. A 12-lead ECG obtained on arrival in the emergency department (ED) 44 minutes later demonstrated a QRS duration of 94 ms. Initially, EMS ECG rhythm strips were unavailable and an isolated benzonatate ingestion was considered less likely as ECG intervals were normal. Benzonatate exposure was later confirmed with a urine benzonatate concentration, which was 8.5 mcg/mL. The patient made a full recovery. DISCUSSION: Cases of pediatric benzonatate overdose with rapid development of cardiac arrest and full recovery have been previously reported. In this case, evidence of cardiac sodium channel blockade was demonstrated with a prolonged QRS interval on initial ECG rhythm strip analysis. However, unlike previous cases, rapid resolution of QRS prolongation occurred in this case. While transient QRS prolongation may be observed, finding a normal QRS interval should not discount the possibility of benzonatate overdose.

61-year-old woman • nausea • paresthesia • cold allodynia • Dx?

► Nausea ►Paresthesia ► Cold allodynia.

Patients With Serious Injection Drug Use-Related Infections who Experience Patient-Directed Discharges on Oral Antibiotics Have High Rates of Antibiotic Adherence but Require Multidisciplinary Outpatient Support for Retention in Care.

BACKGROUND: Persons who inject drugs (PWID) are frequently admitted for serious injection-related infections (SIRIs). Outcomes and adherence to oral antibiotics for PWID with patient-directed discharge (PDD) remain understudied. METHODS: We conducted a prospective multicenter bundled quality improvement project of PWID with SIRI at 3 hospitals in Missouri. All PWID with SIRI were offered multidisciplinary care while inpatient, including the option of addiction medicine consultation and medications for opioid use disorder (MOUD). All patients were offered oral antibiotics in the event of a PDD either at discharge or immediately after discharge through an infectious diseases telemedicine clinic. Additional support services included health coaches, a therapist, a case manager, free clinic follow-up, and medications in an outpatient bridge program. Patient demographics, comorbidities, 90-day readmissions, and substance use disorder clinic follow-up were compared between PWID with PDD on oral antibiotics and those who completed intravenous (IV) antibiotics using an as-treated approach. RESULTS: Of 166 PWID with SIRI, 61 completed IV antibiotics inpatient (37%), while 105 had a PDD on oral antibiotics (63%). There was no significant difference in 90-day readmission rates between groups (P = .819). For PWID with a PDD on oral antibiotics, 7.6% had documented nonadherence to antibiotics, 67% had documented adherence, and 23% were lost to follow-up. Factors protective against readmission included antibiotic and MOUD adherence, engagement with support team, and clinic follow-up. CONCLUSIONS: PWID with SIRI who experience a PDD should be provided with oral antibiotics. Multidisciplinary outpatient support services are needed for PWID with PDD on oral antibiotics.

Methadone vs. Buprenorphine for In-Hospital Initiation: Which Is Better for Outpatient Care Retention in Patients with Opioid Use Disorder?

INTRODUCTION: Currently, few hospitals provide medications for opioid use disorder (MOUD) to admitted patients with opioid use disorder (OUD). Data are needed to inform whether the choice of medication during hospitalization influences probability of retention in outpatient OUD treatment. METHODS: This was a retrospective cohort analysis of patients who received a medical toxicology consult for OUD. Medical records were reviewed to determine if patients received MOUD and were referred to Engaging Patients in Care Coordination (EPICC), a service that connects hospitalized patients with OUD to outpatient care. Patients were stratified by the last form of MOUD they received in the hospital (methadone verses buprenorphine); retention in outpatient treatment was measured at 2 weeks, 30 days, and 12 weeks. The log-rank test was used to determine the difference in probabilities of retention in the methadone and buprenorphine groups. An event was defined as drop-out from outpatient treatment. RESULTS: Of 267 total patients with medical toxicology consults for OUD, 155 received MOUD and referral to EPICC. One hundred six patients received buprenorphine and 46 received methadone. Three additional patients were excluded. The rate of retention in outpatient treatment for patients who received buprenorphine was 37%, 26%, and 13% and for patients who received methadone was 43%, 39%, and 35% at 2 weeks, 30 days, and 12 weeks, respectively. Methadone was associated with a statistically significant increased probability of retention in outpatient treatment as compared to buprenorphine (P < 0.01). CONCLUSION: Despite the limitations of this retrospective study, in hospitalized patients who received MOUD, the probability of retention in outpatient treatment was higher in patients receiving methadone compared to buprenorphine.

Value of Packaged Testing for Sexually Transmitted Infections for Persons who Inject Drugs Hospitalized With Serious Injection-Related Infections.

BACKGROUND: Persons who inject drugs (PWID) are frequently admitted for serious injection-related infections (SIRIs). PWID are also at risk for sexually transmitted infections (STIs). METHODS: We conducted a multicenter quality improvement project at 3 hospitals in Missouri. PWID with SIRI who received an infectious diseases consultation were prospectively identified and placed into an electronic database as part of a Centers for Disease Control and Prevention-funded quality improvement project. Baseline data were collected from 8/1/2019 to 1/30/2020. During the intervention period (2/1/2020-2/28/2021), infectious diseases physicians caring for patients received 2 interventions: (1) email reminders of best practice screening for HIV, viral hepatitis, and STIs; (2) access to a customized EPIC SmartPhrase that included checkboxes of orders to include in assessment and plan of consultation notes. STI screening rates were compared before and after the intervention. We then calculated odds ratios to evaluate for risk factors for STIs in the cohort. RESULTS: Three hundred ninety-four unique patients were included in the cohort. Initial screening rates were highest for hepatitis C (88%), followed by HIV (86%). The bundled intervention improved screening rates for all conditions and substantially improved screening rates for gonorrhea, chlamydia, and syphilis (30% vs 51%, 30% vs 51%, and 39 vs 60%, respectively; P < .001). Of patients who underwent screening, 16.9% were positive for at least 1 STI. In general, demographics were not strongly associated with STIs. CONCLUSIONS: PWID admitted for SIRI frequently have unrecognized STIs. Our bundled intervention improved STI screening rates, but additional interventions are needed to optimize screening.

Antithrombotic and Antiplatelet Drug Toxicity.

Anticoagulant and antiplatelet drugs target a specific portion of the coagulation cascade or the platelet activation and aggregation pathway. The primary toxicity associated with these agents is hemorrhage. Understanding the pharmacology of these drugs allows the treating clinician to choose the correct antidotal therapy. Reversal agents exist for some of these drugs; however, not all have proven patient-centered outcomes. The anticoagulants covered in this review are vitamin K antagonists, heparins, fondaparinux, hirudin derivatives, argatroban, oral factor Xa antagonists, and dabigatran. The antiplatelet agents reviewed are aspirin, adenosine diphosphate antagonists, dipyridamole, and glycoprotein IIb/IIIa antagonists. Additional notable toxicities are also reviewed.

Care cascade for patients with opioid use disorder and serious injection related infections.

OBJECTIVES: To define the care cascade for patients with serious injection drug use related infections (SIRI) in a tertiary hospital system and compare outcomes of those who did and did not participate in an opioid use disorder (OUD) treatment referral program. METHODS: The medical records of patients admitted with both OUD and SIRI including endocarditis, osteomyelitis, septic arthritis, epidural abscess, thrombophlebitis, myositis, bacteremia, and fungemia from 2016-2019 were retrospectively reviewed. Patient demographics, clinical covariates, 90-day readmission rates, and outcomes data were collected. We compared data from those who were successfully referred to outpatient care through Engaging Patients in Care Coordination (EPICC), a peer recovery specialist-run OUD treatment referral program, to those who did not receive outpatient referral. RESULTS: During the study period 334 persons who inject opioids were admitted with SIRI. Fourteen admitted patients died and were excluded from the analysis. The all-cause readmission rate was lower among patients referred to the EPICC program (18/76 [23.7%]) compared to those not referred to EPICC (100/244 [41.0%]) (OR 0.44; 95% CI 0.25 - 0.80). CONCLUSION: An OUD care cascade evaluation for patients with SIRI demonstrated that referral to peer recovery services with outpatient OUD treatment was associated with reduced 90-day readmission rate.

A Comparison of Medication for Opioid Use Disorder Treatment Strategies for Persons Who Inject Drugs With Invasive Bacterial and Fungal Infections.

BACKGROUND: Patients with opioid use disorder (OUD) are frequently admitted for invasive infections. Medications for OUD (MOUD) may improve outcomes in hospitalized patients. METHODS: In this retrospective cohort of 220 admissions to a tertiary care center for invasive infections due to OUD, we compared 4 MOUD treatment strategies: methadone, buprenorphine, methadone taper for detoxification, and no medication to determine whether there were differences in parenteral antibiotic completion and readmission rates. RESULTS: The MOUDs were associated with increased completion of parenteral antimicrobial therapy (64.08% vs 46.15%; odds ratio [OR] = 2.08; 95% CI, 1.23-3.61). On multivariate analysis, use of MOUD maintenance with either buprenorphine (OR = 0.38; 95% CI, .17-.85) or methadone maintenance (OR = 0.43; 95% CI, .20-.94) and continuation of MOUD on discharge (OR = 0.35; 95% CI, .18-.67) was associated with lower 90-day readmissions. In contrast, use of methadone for detoxification followed by tapering of the medication without continuation on discharge was not associated with decreased readmissions (OR = 1.87; 95% CI, .62-5.10). CONCLUSIONS: Long-term MOUDs, regardless of selection, are an integral component of care in patients hospitalized with OUD-related infections. Patients with OUD should have arrangements made for MOUDs to be continued after discharge, and MOUDs should not be discontinued before discharge.

Evaluation of Partial Oral Antibiotic Treatment for Persons Who Inject Drugs and Are Hospitalized With Invasive Infections.

BACKGROUND: Persons who inject drugs (PWID) are at risk of invasive infections; however, hospitalizations to treat these infections are frequently complicated by against medical advice (AMA) discharges. This study compared outcomes among PWID who (1) completed a full course of inpatient intravenous (IV) antibiotics, (2) received a partial course of IV antibiotics but were not prescribed any antibiotics on AMA discharge, and (3) received a partial course of IV antibiotics and were prescribed oral antibiotics on AMA discharge. METHODS: A retrospective, cohort study of PWID aged ≥18 years admitted to a tertiary referral center between 01/2016 and 07/2019, who received an infectious diseases consultation for an invasive bacterial or fungal infection. RESULTS: 293 PWID were included in the study. 90-day all-cause readmission rates were highest among PWID who did not receive oral antibiotic therapy on AMA discharge (n = 46, 68.7%), compared with inpatient IV (n = 43, 31.5%) and partial oral (n = 27, 32.5%) antibiotics. In a multivariate analysis, 90-day readmission risk was higher among PWID who did not receive oral antibiotic therapy on AMA discharge (adjusted hazard ratio [aHR], 2.32; 95% confidence interval [CI], 1.41-3.82) and not different among PWID prescribed oral antibiotic therapy on AMA discharge (aHR, .99; 95% CI, .62-1.62). Surgical source control (aHR, .57; 95% CI, .37-.87) and addiction medicine consultation (aHR, .57; 95% CI, .38-.86) were both associated with reduced readmissions. CONCLUSIONS: Our single-center study suggests access to oral antibiotic therapy for PWID who cannot complete prolonged inpatient IV antibiotic courses is beneficial.