Fewer Opioids but More Benzodiazepines? Prescription Trends by Specialty in Response to the Implementation of Michigan's Opioid Laws.

OBJECTIVES: To characterize the effects of Michigan's controlled substance legislation on acute care prescriber behavior by specialty, in a single hospital system. DESIGN: A retrospective study of opioid and benzodiazepine prescription records from a hospital electronic medical record system between August 1, 2016, and March 31, 2019, in Detroit, Michigan. SETTING: Discharges from inpatient and emergency department visits. INTERVENTION: Evaluating the impact of implementation of state controlled substance legislation, comparing prescriptions by physicians before, upon, and after June 1, 2018, using regression discontinuity analysis. METHODS: Total daily prescriptions of opioids and total daily prescriptions of benzodiazepine by physicians in the hospital system. Prescriptions were converted to morphine and lorazepam equivalents for comparability. RESULTS: We find 38.5% (95% confidence interval [CI] : 74.1% - 2.9%) decrease of prescription in milligrams of opioid equivalents attributable to implementation of legislation. The main catalyst of the decrease was emergency medicine which experienced 63.9% (95% CI: 109.7%-18.0%) decrease in milligrams of opioid equivalent prescriptions, while surgery increased prescriptions. Though we do not find any statistically significant changes in prescriptions of milligram equivalent of benzodiazepines, we estimate 43.1% (95% CI: 82.6%-3.7%) decrease in count of these prescriptions, implying a significant increase in average dosage of prescriptions. CONCLUSIONS: The introduction of new regulatory requirements for the prescription of controlled substances led to a general decrease in morphine equivalent milligrams prescribed in most specialties, though it may have increased the dosage of benzodiazepine prescriptions. The change in prescription behavior could be motivated by regulatory hassle or by change in attitude towards opioid prescriptions and increased recognition of opioid use disorder.

PEARL: Pharmacy Education Applied to Resident Learners.

INTRODUCTION: Emergency medicine residents typically train with the support of emergency medicine pharmacists (EMP), but many EM residents will practice in post-graduation settings without EMP assistance. Therefore, a novel pharmacy curriculum for postgraduate year-1 (PGY-1) EMRs was developed, implemented, and assessed. METHODS: We performed a controlled study of 25 residents from two separate EM programs in Detroit, MI. One program was the control group and the other program was the intervention group. The primary outcome was pre- and post-curriculum knowledge assessment scores, and the secondary outcome was pre- and post-curriculum, self-perceived knowledge survey responses. We performed statistical analyses with Welch's t-test or the Mann-Whitney U test. RESULTS: The pre-curriculum assessment scores (41% ± 11; 41% ± 8.1; P = 0.96; mean ± SD) and average pre-curriculum survey responses (2.8 ± 0.92; 3.0 ± 0.60; P = 0.35) were not statistically different between the control and the intervention groups. The post-curriculum assessment scores (63% ± 14; 74% ± 8.3; P = 0.04) and the average post-curriculum survey responses (4.2 ± 0.61; 5.0 ± 0.74, P = 0.02) were statistically different. The increase from the pre- to post-curriculum assessment scores (24% ± 11; 33% ± 11; P = 0.05) was also significantly different. CONCLUSION: The implementation of a novel pharmacy curriculum for PGY-1 EM residents resulted in improved knowledge of and comfort with pharmaceuticals and therapeutics specific to EM practice. The impact on patient care and frequency of medical errors requires further investigation.

Increased Enoxaparin Dosing Requirements for Treatment of Deep Vein Thrombosis in a Severely Burned Patient: Case Report and Literature Review.

Dosing of enoxaparin for deep vein thrombosis (DVT) prophylaxis in acutely burned patients has been shown to result in anti-Xa levels below target range. We describe the first case report, to our knowledge, of a severely burned patient who, despite prophylactic dosing of enoxaparin 30 mg subcutaneously twice daily, developed an acute DVT that required high-dose enoxaparin (100 mg [1.5 mg/kg] subcutaneously every 8 hours) to maintain anti-Xa levels within the therapeutic range (0.6-1 IU/ml). Pharmacokinetic evaluations were performed using anti-Xa levels measured throughout the patient's hospital stay to validate the appropriateness of this high-dose regimen based on established therapeutic anti-Xa level ranges. These results suggest that routine anti-Xa level monitoring, regardless of enoxaparin dosing, is necessary for burn patients who are receiving enoxaparin given their hypermetabolic state following injury.

Evaluating the risk profile of quetiapine in treating delirium in the intensive care adult population: A retrospective review.

PURPOSE: Dosing regimens of quetiapine to treat delirium in critically ill patients are titrated to effect, and may utilize doses higher than previously reported. This study aimed to assess the safety of quetiapine for this indication. MATERIALS AND METHODS: A retrospective medical chart review was conducted, identifying 154 critically ill adults that were initiated on quetiapine to treat delirium and monitored for QTc prolongation. RESULTS: The median average daily dose was 150 mg (79-234) and median max dose was 225 mg (100-350). The overall range was 25-800 mg daily. The time to peak dose was 3 days (1-8). Patients with QTc prolongation were significantly older (age 54 ±â€¯11 vs 45 ±â€¯17 years (p = 0.002)) and with higher baseline QTc (454 ±â€¯33 vs 442 ±â€¯30 (p = 0.045)). Regression analysis revealed only dose as a significant factor (OR = 1.006 (1.003-1.009) (p < 0.001)). CONCLUSION: The dose of quetiapine has very little correlation with QTc and change from baseline. A small number of side effects were observed. Overall, titrating quickly to large doses of quetiapine is safe for treating delirium.