Urine Drug Testing Among Patients Prescribed Long-Term Opioid Therapy: Patient and Clinician Factors.

INTRODUCTION: National guidelines recommend that patients with chronic noncancer pain prescribed long-term opioid therapy (LTOT) undergo periodic urine drug testing (UDT), yet UDT is performed inconsistently, and little evidence supports the utility of this approach. We examined patient and prescriber factors associated with UDT. METHODS: A 1-year retrospective cohort study of 5690 patients prescribed LTOT by 689 clinicians in a network of 13 primary care and specialty clinics. Negative binomial regression examined patient and prescriber factors associated with the number of tests completed, and logistic regression examined prescriber and practice level testing likelihood. Analyses were adjusted for patient and clinician characteristics and accounted for patient clustering within prescribers. RESULTS: A total of 2256 patients (39.6%) had UDT completed at least once. More UDT completion was associated with Black patient race and receipt of more opioid prescriptions, as well as with clinician testing compliance. CONCLUSIONS: UDT was relatively infrequent in patients prescribed LTOT and associated with patient factors not known to confer greater opioid-related risk, such as race. In addition, there was significant clinician-driven variation in UDT. Given the uncertain clinical utility of such testing, these findings signal the need for strategies to address potential biases in the use of UDT.

Buprenorphine Inductions via Transdermal Patches for Opioid Use Disorder in the Inpatient Setting.

Buprenorphine inductions traditionally require an opioid-free period due to the risk of precipitated opioid withdrawal. Hospitalized patients with opioid use disorder and concurrent acute pain may be eligible for buprenorphine therapy. However, effective buprenorphine induction strategies in this patient population have not been well established. Investigators sought to review the completion of a low dose induction protocol that does not require an opioid-free period prior to buprenorphine initiation. Hospitalized patients who completed a 7-day low dose induction protocol via buprenorphine transdermal patches October 2021 - March 2022 were examined via retrospective chart review (N = 7). All seven patients completed the induction and were discharged on sublingual buprenorphine. Low dose transdermal buprenorphine provides a reasonable strategy for hospitalized patients on full agonist opioid therapy or those who have failed conventional buprenorphine induction strategies. Reducing barriers such as opioid abstinence is key to combating opioid use disorder.

Bodybuilding supplements leading to copper toxicity, encephalopathy, fulminant hepatic failure and rhabdomyolysis.

Millions of people worldwide use nutritional and dietary supplements, such as vitamins and minerals. These and other performance-enhancing substances are also used by high school, college, and professional athletes, bodybuilders, and amateur sports enthusiasts. The constituents of these supplements and their metabolites may be harmful and not listed on the product label. We present a case report of a 32-year-old bodybuilder using myriad nutritional, performance-enhancing, and weight-loss supplements with life-threatening encephalopathy, hepatic failure, rhabdomyolysis, and copper toxicity mimicking Wilson's disease. Emergency physicians and nurses should be aware of these potential deleterious effects and inquire about supplement use by patients with unexplained multiorgan failure. Family, friends, or acquaintances should be asked to bring the actual products to the hospital for analysis.

Monitoring the corrected QT in the acute care setting: A comparison of the 12­lead ECG and bedside monitor.

INTRODUCTION: Prolongation of the QT interval is a well-recognized complication associated with many commonly used medications. Emergency Department monitoring of the corrected QT (QTc) both before and after medication administration is typically performed using the 12­lead electrocardiogram (ECG). The purpose of this study is to compare the QTc reported on the 12­lead ECG to that reported by single brand of bedside monitor. METHODS: A convenience sample of emergency department patients over the age of 18 undergoing bedside monitoring and who had an ECG ordered by their treating physician were enrolled. These patients underwent simultaneous ECG and monitor QTc calculation. The primary outcome of interest was the correlation between the monitor and ECG QTc. Secondary outcomes included ability of each method to identify patients with a QTc >500ms and the ability of each method to identify patients with a QTc <450ms. RESULTS: A total of 125 patients had simultaneous ECG and monitor QTc measurements recorded. There was moderate correlation between the monitor and ECG QTc (Pearson's correlation coefficient=0.55). The median difference between the ECG QTc and the monitor QTc (ECG QTc minus monitor QTc) was -7ms (IQR -23 to 11ms). CONCLUSION: We found that there was moderate correlation between the QTc reported on the 12 lead ECG and that reported by the bedside monitor. This correlation is not strong enough to support the use of the bedside monitor as a substitute for the 12­lead ECG when evaluating a patient's QTc.

Massive diltiazem and metoprolol overdose rescued with extracorporeal life support.

The management of overdoses of cardioactive medications in the emergency department can be challenging. The reversal of severe toxicity from one or more types of cardioactive medication may fail maximal medical therapies and require extreme invasive measures such as transvenous cardiac pacing and extracorporeal life support. We present a case of massive diltiazem and metoprolol overdose refractory to maximal medical therapy, including intravenous calcium, glucagon, vasopressors, high dose insulin, and lipid emulsion. The patient experienced refractory bradydysrhythmia that responded only to transvenous pacing. Extracorporeal life support was initiated and resulted in successful organ perfusion and complete recovery of the patient. This case highlights the potential utility of extracorporeal life support in cases of severe toxicity due to multiple cardioactive medications.

Amanita phalloides Mushroom Poisonings - Northern California, December 2016.

Amanita phalloides, colloquially known as the "death cap," belongs to the Phalloideae section of the Amanita family of mushrooms and is responsible for most deaths following ingestion of foraged mushrooms worldwide (1). On November 28, 2016, members of the Bay Area Mycological Society notified personnel at the California Poison Control System (CPCS) of an unusually large A. phalloides bloom in the greater San Francisco Bay Area, coincident with the abundant rainfall and recent warm weather. Five days later, CPCS received notification of the first human A. phalloides poisoning of the season. Over the following 2 weeks, CPCS was notified of an additional 13 cases of hepatotoxicity resulting from A. phalloides ingestion. In the past few years before this outbreak, CPCS received reports of only a few mushroom poisoning cases per year. A summary of 14 reported cases is presented here. Data extracted from patient medical charts revealed a pattern of delayed gastrointestinal manifestations of intoxication leading to dehydration and hepatotoxicity. Three patients received liver transplants and all but one recovered completely. The morbidity and potential lethality associated with A. phalloides ingestion are serious public health concerns and warrant medical provider education and dissemination of information cautioning against consuming foraged wild mushrooms.

Fatal Fentanyl: One Pill Can Kill.

OBJECTIVE: The current national opioid epidemic is a public health emergency. We have identified an outbreak of exaggerated opioid toxicity caused by fentanyl adulterated tablets purchased on the street as hydrocodone/acetaminophen. METHODS: Over an 8-day period in late March 2016, a total of 18 patients presented to our institution with exaggerated opioid toxicity. The patients provided a similar history: ingesting their "normal dose" of hydrocodone/acetaminophen tablets but with more pronounced symptoms. Toxicology testing and analysis was performed on serum, urine, and surrendered pills. RESULTS: One of the 18 patients died in hospital. Five patients underwent cardiopulmonary resuscitation, one required extracorporeal life support, three required intubation, and two received bag-valve-mask ventilation. One patient had recurrence of toxicity after 8 hours after naloxone discontinuation. Seventeen of 18 patients required boluses of naloxone, and four required prolonged naloxone infusions (26-39 hours). All 18 patients tested positive for fentanyl in the serum. Quantitative assays conducted in 13 of the sera revealed fentanyl concentrations of 7.9 to 162 ng/mL (mean = 52.9 ng/mL). Pill analysis revealed fentanyl amounts of 600-6,900 µg/pill. The pills are virtually indistinguishable from authentic hydrocodone/acetaminophen tablets and are similar in weight. To date, our county has reported 56 cases of fentanyl opioid toxicity, with 15 fatalities. In our institution, the outbreak has stressed the capabilities and resources of the emergency department and intensive care units. CONCLUSIONS: A serious outbreak of exaggerated opioid toxicity caused by fentanyl-adulterated tablets purchased on the street as hydrocodone/acetaminophen is under way in California. These patients required higher dosing and prolonged infusions of naloxone. Additionally, observation periods off naloxone were extended due to delayed, recurrent toxicity. The outbreak has serious ramifications for public health and safety, law enforcement, and healthcare facilities and resources.

The Changing Drug Culture: Medical and Recreational Marijuana.

The major psychoactive compounds in marijuana (cannabis) are cannabinoids, the most significant of which is delta-9-tetrahydrocannabinol. There are also two synthetic pharmaceutical cannabinoids, nabilone and dronabinol, available by prescription in the United States. The use of marijuana has increased in the United States with passage of medical marijuana laws in many states and legalization of recreational marijuana use in several states. In addition, the potency of marijuana has increased in recent years. Marijuana has been used for a variety of medical purposes, including management of nausea and vomiting, appetite and immunologic stimulation in patients with HIV infection and AIDS, glaucoma, neurologic disorders, and pain relief. Studies on the benefits of marijuana as a treatment for various conditions have been inconsistent, except for those on pain management. Marijuana has adverse effects, and has been associated with driving impairment, psychosis, dependence and withdrawal syndromes, hyperemesis, acute cardiac events, some cancers, and impaired lung function. As with studies on the benefits of marijuana, studies of adverse effects have yielded inconsistent results. Except for impaired driving and the occurrence of dependence and withdrawal syndromes, the adverse effects of marijuana use have not been fully studied.

The Changing Drug Culture: Emerging Drugs of Abuse and Legal Highs.

In recent years, there has been a large increase in the number of synthetic drugs used recreationally. One class of drugs is synthetic cannabinoids, which are sprayed onto herbal preparations and marketed under names such as K2 and spice. Others include amphetaminelike compounds, such as cathinones (eg, bath salts) and methylenedioxymethamphetamine (MDMA) (eg, ecstasy, Molly). New hallucinogens, such as Bromo-Dragonfly, and hallucinogens that have been used for centuries, such as Salvia divinorum, also are gaining popularity. Because these substances are sold labeled as not for human consumption and because the chemicals in them frequently change, they often are unregulated, and many users consider them legal, although they are not. Their use often goes undetected because testing for them is not included in routine drug screening. Nonetheless, these substances can be associated with significant toxicities, often because their concentrations are unpredictable. Adverse effects of synthetic cannabinoids include psychosis and other effects. Amphetaminelike drugs have stimulant effects and can cause hyponatremia and seizures. The new hallucinogens can cause serious vasoconstriction with ischemia. Clinicians, especially those working with adolescents and young adults (ie, the main users of these drugs), should be aware of these new substances and counsel patients about their adverse effects.

The Changing Drug Culture: Use and Misuse of Appearance- and Performance-Enhancing Drugs.

Awareness of the prevalence of the use of appearance- and performance-enhancing drugs (APEDs) is increasing. Users range from professional athletes and bodybuilders to amateurs and adolescents. Anabolic androgenic steroids (AASs) are the most widely used APEDs, typically for purposes of building muscle mass, in forms that include pills, injections, topical preparations, and transdermal systems. AASs are often used in combination with augmenting drugs taken to enhance androgen production and, for men, to decrease estrogen production. These include aromatase inhibitors, clomiphene, selective estrogen receptor modulators, and human chorionic gonadotropin. Other drugs used with the intention of improving athletic performance include human growth hormone, insulinlike growth factor 1, insulin, erythropoietin, stimulants, diuretics, levothyroxine, and gamma-hydroxybutyrate. Use of APEDs is increasing, with up to 5% of male and 2% of female college athletes using AASs and reports of a more than 20% usage rate among teenagers. Although many of these substances can increase muscle mass when combined with high levels of exercise and specific diets, it is not clear that they improve athletic performance. Furthermore, they are associated with a variety of serious adverse effects. AASs, in particular, can cause hepatotoxicity and acute cardiac events. Behavioral and psychiatric symptoms also can occur.

The Changing Drug Culture: Use and Misuse of Cognition-Enhancing Drugs.

There has been an increase in diagnoses of attention-deficit/hyperactivity disorder (ADHD), with approximately 9% of American children now diagnosed, and a concomitant increase in the use of stimulants (eg, amphetamines, methylphenidate) to manage ADHD. Nonstimulant drugs (eg, atomoxetine, guanfacine, clonidine) also are used, but most patients are treated with stimulants. All of these drugs are effective for management of ADHD, and, overall, use in childhood does not seem to increase the risk of substance abuse later in life. However, widespread use has resulted in prescription stimulants being diverted for nonmedical uses, particularly by high school and college students seeking cognitive enhancement for improved academic performance. Studies of ADHD drugs for improving cognition in patients without ADHD have mixed results, and any improvements appear to be modest and short-term. Other substances also are used for cognitive enhancement. Drugs for Alzheimer disease are being used for mild cognitive impairment, though there is no evidence that they are effective. Creatine may have mild cognition-enhancing properties, but study results often are confounded by the addition of exercise, which by itself is thought to improve cognition. There is no evidence that other supplements, such as vitamins and omega-3 fatty acids, improve cognitive function.

Dispatcher recognition of stroke using the National Academy Medical Priority Dispatch System.

BACKGROUND AND PURPOSE: Emergency medical dispatchers play an important role in optimizing stroke care if they are able to accurately identify calls regarding acute cerebrovascular disease. This study was undertaken to assess the diagnostic accuracy of the current national protocol guiding dispatcher questioning of 911 callers to identify stroke (QA Guide version 11.1 of the National Academy Medical Priority Dispatch System). METHODS: We identified all Los Angeles Fire Department paramedic transports of patients to University of California Los Angeles Medical Center during the 12-month period from January to December 2005 in a prospectively maintained database. Dispatcher-assigned Medical Priority Dispatch System codes for each of these patient transports were abstracted from the paramedic run sheets and compared to final hospital discharge diagnosis. RESULTS: Among 3474 transported patients, 96 (2.8%) had a final diagnosis of stroke or transient ischemic attack. Dispatchers assigned a code of potential stroke to 44.8% of patients with a final discharge diagnosis of stroke or TIA. Dispatcher identification of stroke showed a sensitivity of 0.41, specificity of 0.96, positive predictive value of 0.45, and negative predictive value of 0.95. CONCLUSIONS: Dispatcher recognition of stroke calls using the widely employed Medical Priority Dispatch System algorithm is suboptimal, with failure to identify more than half of stroke patients as likely stroke. Revisions to the current national dispatcher structured interview and symptom identification algorithm for stroke may facilitate more accurate recognition of stroke by emergency medical dispatchers.