Publications by authors named "Howard S Kim"

33 Publications

Perceptions of Signs of Addiction Among Opioid Naive Patients Prescribed Opioids in the Emergency Department.

J Addict Med 2021 Feb 5. Epub 2021 Feb 5.

Department of Emergency Medicine, Northwestern University, Chicago, IL (PTS, PML, HSK, DMM); Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University, Chicago, IL (KAC, LAO, LMC, MSW); Department of Emergency Medicine, University of Texas Southwestern, Dallas, TX (DMC).

Objectives: Patient knowledge deficits related to opioid risks, including lack of knowledge regarding addiction, are well documented. Our objective was to characterize patients' perceptions of signs of addiction.

Methods: This study utilized data obtained as part of a larger interventional trial. Consecutively discharged English-speaking patients, age >17 years, at an urban academic emergency department, with a new opioid prescription were enrolled from July 2015 to August 2017. During a follow-up phone interview 7 to 14 days after discharge, participants were asked a single question, "What are the signs of addiction to pain medicine?" Verbatim transcribed answers were analyzed using a directed content analysis approach and double coding. These codes were then grouped into themes.

Results: There were 325 respondents, 57% female, mean age 43.8 years, 70.1% privately insured. Ten de novo codes were added to the 11 DSM-V criteria codes. Six themes were identified: (1) effort spent acquiring opioids, (2) emotional and physical changes related to opioid use, (3) opioid use that is "not needed, (4) increasing opioid use, (5) an emotional relationship with opioids, and (6) the inability to stop opioid use.

Conclusions: Signs of addiction identified by opioid naive patients were similar to concepts identified in medical definitions. However, participants' understanding also included misconceptions, omissions, and conflated misuse behaviors with signs of addiction. Identifying these differences will help inform patient-provider risk communication, providing an opportunity for counseling and prevention.
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http://dx.doi.org/10.1097/ADM.0000000000000806DOI Listing
February 2021

Take-Home Naloxone and the Need for a Publicly Funded Naloxone Supply.

J Addict Med 2021 Feb 1. Epub 2021 Feb 1.

Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (HSK); Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, IL (HSK); Department of Emergency Medicine, Cook County Health, Chicago, IL (SEA); Toxikon Consortium, Chicago, IL (SEA).

The opioid crisis continues to exact a heavy toll on the United States, and overdose deaths have only increased during the current global pandemic. One effective intervention to reduce overdose deaths is to distribute the opioid antagonist naloxone directly to persons actively using opioids (ie, "take-home naloxone"), especially at touchpoints with the potential for significant impact such as emergency departments and jails. A number of hospital emergency departments have recently sought to implement individual take-home naloxone programs; however, programmatic success has been inconsistent due primarily to the inability to secure reliable funding for a naloxone supply. In this commentary, we establish the argument for a publicly funded naloxone supply to support take-home naloxone distribution in emergency department settings. We posit that the complex billing and reimbursement system for medication dispensing is impossibly burdensome during emergency care for an acute opioid overdose, and that the mounting death toll from this public health crisis demands a strong commitment to harm reduction. A publicly financed naloxone supply would demonstrate this commitment and make a measurable impact in saving lives. Ultimately, provision of naloxone should be coupled with other comprehensive treatment services and medications for opioid use disorder to meaningfully reduce harms associated with opioid use.
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http://dx.doi.org/10.1097/ADM.0000000000000821DOI Listing
February 2021

A Prospective Observational Study of Emergency Department-Initiated Physical Therapy for Acute Low Back Pain.

Phys Ther 2021 Mar;101(3)

Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.

Objective: Low back pain accounts for nearly 4 million emergency department (ED) visits annually and is a significant source of disability. Physical therapy has been suggested as a potentially effective nonopioid treatment for low back pain; however, no studies to our knowledge have yet evaluated the emerging resource of ED-initiated physical therapy. The study objective was to compare patient-reported outcomes in patients receiving ED-initiated physical therapy and patients receiving usual care for acute low back pain.

Methods: This was a prospective observational study of ED patients receiving either physical therapy or usual care for acute low back pain from May 1, 2018, to May 24, 2019, at a single academic ED (>91,000 annual visits). The primary outcome was pain-related functioning, assessed with Oswestry Disability Index (ODI) and Patient-Reported Outcomes Measurement Information System pain interference (PROMIS-PI) scores. The secondary outcome was use of high-risk medications (opioids, benzodiazepines, and skeletal muscle relaxants). Outcomes were compared over 3 months using adjusted linear mixed and generalized estimating equation models.

Results: For 101 participants (43 receiving ED-initiated physical therapy and 58 receiving usual care), the median age was 40.5 years and 59% were women. Baseline outcome scores in the ED-initiated physical therapy group were higher than those in the usual care group (ODI = 51.1 vs 36.0; PROMIS-PI = 67.6 vs 62.7). Patients receiving ED-initiated physical therapy had greater improvements in both ODI and PROMIS-PI scores at the 3-month follow-up (ODI = -14.4 [95% CI = -23.0 to -5.7]; PROMIS-PI = -5.1 [95% CI = -9.9 to -0.4]) and lower use of high-risk medications (odds ratio = 0.05 [95% CI = 0.01 to 0.58]).

Conclusion: In this single-center observational study, ED-initiated physical therapy for acute low back pain was associated with improvements in functioning and lower use of high-risk medications compared with usual care; the causality of these relationships remains to be explored.

Impact: ED-initiated physical therapy is a promising therapy for acute low back pain that may reduce reliance on high-risk medications while improving patient-reported outcomes.

Lay Summary: Emergency department-initiated physical therapy for low back pain was associated with greater improvement in functioning and lower use of high-risk medications over 3 months.
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http://dx.doi.org/10.1093/ptj/pzaa219DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7970627PMC
March 2021

Emergency Department Visits for Serious Diagnoses During the COVID-19 Pandemic.

Acad Emerg Med 2020 09 17;27(9):910-913. Epub 2020 Aug 17.

From the, Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.

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http://dx.doi.org/10.1111/acem.14099DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7436489PMC
September 2020

Development of a take-home naloxone program at an urban academic emergency department.

J Am Pharm Assoc (2003) 2020 Nov - Dec;60(6):e324-e331. Epub 2020 Jul 18.

Objective: To describe the development of an ED-based take-home naloxone (THN) program in which naloxone kits are dispensed directly to patients during ED discharge.

Practice Description: Our THN program was carried out at an urban academic hospital in downtown Chicago, IL. The THN kits consisted of 3 vials of 0.4-mg naloxone and 3 sterile syringes and needles for intramuscular delivery. Any member of the ED team (e.g., physician, pharmacist, or nurse) could recommend naloxone dispensing for a patient; however only the treating ED physician served as the prescriber for record. The ED pharmacist provided bedside education on recognizing opioid overdose and administering naloxone. The naloxone kit was dispensed to the patient at no cost.

Practice Innovation: This ED pharmacist-led naloxone dispensing model bypasses barriers to naloxone filling and ensures that patients walk out of the emergency department with naloxone in hand.

Evaluation Methods: We report key metrics from the first 16 months of program implementation, including the number of ED visits for opioid overdose and THN kits dispensed. We further describe the key facilitators and barriers to program development.

Results: Over 16 months, our emergency department had 669 unique visits for opioid overdose, and we dispensed 168 THN kits (10.5 per month). We are aware of at least 3 cases in which our THN kits were used to reverse opioid overdose. We faced key informational barriers to program development, such as a lack of knowledge regarding the allowability of ED medication dispensing, as well as financial barriers, such as the need to obtain a supply of naloxone. We also recognized the key facilitators of success, such as early engagement with hospital leadership.

Conclusion: Implementing a successful THN program is possible in the ED setting, and individual hospital emergency departments seeking to build their own program may benefit from our report.
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http://dx.doi.org/10.1016/j.japh.2020.06.017DOI Listing
July 2020

Emergency department operations in a large health system during COVID-19.

Am J Emerg Med 2021 Mar 2;41:241-243. Epub 2020 Jun 2.

Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, 211 East Ontario St., Suite #200, Chicago, IL 60611, United States of America. Electronic address:

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http://dx.doi.org/10.1016/j.ajem.2020.05.097DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7264938PMC
March 2021

Overcoming Barriers to Prescribing Buprenorphine in the Emergency Department.

JAMA Netw Open 2020 05 1;3(5):e204996. Epub 2020 May 1.

Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, Rhode Island.

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http://dx.doi.org/10.1001/jamanetworkopen.2020.4996DOI Listing
May 2020

Take-Home Naloxone Program Implementation: Lessons Learned From Seven Chicago-Area Hospitals.

Ann Emerg Med 2020 09 30;76(3):318-327. Epub 2020 Mar 30.

Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL. Electronic address:

Despite consensus recommendations from the American College of Emergency Physicians (ACEP), the Centers for Disease Control and Prevention, and the surgeon general to dispense naloxone to discharged ED patients at risk for opioid overdose, there remain numerous logistic, financial, and administrative barriers to implementing "take-home naloxone" programs at individual hospitals. This article describes the recent collective experience of 7 Chicago-area hospitals in implementing take-home naloxone programs. We highlight key barriers, such as hesitancy from hospital administrators, lack of familiarity with relevant rules and regulations in regard to medication dispensing, and inability to secure a supply of naloxone for dispensing. We also highlight common facilitators of success, such as early identification of a "C-suite" champion and the formation of a multidisciplinary team of program leaders. Finally, we provide recommendations that will assist emergency departments planning to implement their own take-home naloxone programs and will inform policymakers of specific needs that may facilitate dissemination of naloxone to the public.
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http://dx.doi.org/10.1016/j.annemergmed.2020.02.013DOI Listing
September 2020

Patient-Reported Opioid Pill Consumption After an ED Visit: How Many Pills Are People Using?

Pain Med 2021 Feb;22(2):292-302

Department of Emergency Medicine, University of Texas Southwestern, Dallas, Texas, USA.

Objectives: Recent guidelines advise limiting opioid prescriptions for acute pain to a three-day supply; however, scant literature quantifies opioid use patterns after an emergency department (ED) visit. We sought to describe opioid consumption patterns after an ED visit for acute pain.

Design: Descriptive study with data derived from a larger interventional study promoting safe opioid use after ED discharge.

Setting: Urban academic emergency department (>88,000 annual visits).

Subjects: Patients were eligible if age >17 years, not chronically using opioids, and newly prescribed hydrocodone-acetaminophen and were included in the analysis if they returned the completed 10-day medication diary.

Methods: Patient demographics and opioid consumption are reported. Opioid use is described in daily number of pills and daily morphine milligram equivalents (MME) both for the sample overall and by diagnosis.

Results: Two hundred sixty patients returned completed medication diaries (45 [17%] back pain, 52 [20%] renal colic, 54 [21%] fracture/dislocation, 40 [15%] musculoskeletal injury [nonfracture], and 69 [27%] "other"). The mean age (SD) was 45 (15) years, and 59% of the sample was female. A median of 12 pills were prescribed. Patients with renal colic used the least opioids (total pills: median [interquartile range {IQR}] = 3 [1-7]; total MME: median [IQR] = 20 [10-50]); patients with back pain used the most (total pills: median [IQR] = 12 [7-16]; total MME: median [IQR] = 65 [47.5-100]); 92.5% of patients had leftover pills.

Conclusions: In this sample, pill consumption varied by illness category; however, overall, patients were consuming low quantities of pills, and the majority had unused pills 10 days after their ED visit.
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http://dx.doi.org/10.1093/pm/pnaa048DOI Listing
February 2021

Patient-reported Outcome Measures in Emergency Care Research: A Primer for Researchers, Peer Reviewers, and Readers.

Acad Emerg Med 2020 05 5;27(5):403-418. Epub 2020 Feb 5.

Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL.

Patient-reported outcomes (PROs) are of increasing importance in clinical research because they capture patients' experience with well-being, illness, and their interactions with health care. Because PROs tend to focus on specific symptoms (e.g., pain, anxiety) or general assessments of patient functioning and quality of life that offer unique advantages compared to traditional clinical outcomes (e.g., mortality, emergency department revisits), emergency care researchers may benefit from incorporation of PRO measures into their research design as a primary or secondary outcome. Patients may also benefit from the ability of PROs to inform clinical practice and facilitate patient decision making, as PROs are obtained directly from the lived experience of other patients with similar conditions or health status. This review article introduces and defines key terminology relating to PROs, discusses reasons for utilizing PROs in clinical research, outlines basic psychometric and practical assessments that can be used to select a specific PRO measure, and highlights examples of commonly utilized PRO measures in emergency care research.
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http://dx.doi.org/10.1111/acem.13918DOI Listing
May 2020

Women's Night in Emergency Medicine Mentorship Program: A SWOT Analysis.

West J Emerg Med 2019 Dec 18;21(1):37-41. Epub 2019 Dec 18.

Northwestern University, Feinberg School of Medicine, Department of Emergency Medicine, Chicago, Illinois.

Introduction: Women in emergency medicine (EM) at all career stages report gender-specific obstacles to satisfaction and advancement. Programs that facilitate longitudinal mentoring, professional development, and networking may ameliorate these barriers.

Methods: We designed and implemented a program for female residents, faculty, and alumnae from our EM training program to enhance social support, leadership training and professional mentorship opportunities. An anonymous, online survey was sent to participants at the end of the academic year, using a SWOT (strengths, weaknesses, opportunities, and threats) format. The survey collected free-text responses designed to evaluate the program.

Results: Of 43 invited participants, 32 responded (74.4%). Eight themes emerged from the free-text responses and were grouped by SWOT domain. We identified four themes relating to the "strength" domain: 1) creating a dedicated space; 2) networking community; 3) building solidarity; and 4) providing forward guidance. Responses to the "weaknesses" and "threats" questions were combined due to overlapping codes and resulted in three themes: 5) barriers to participation; 6) the threat of poorly structured events lapsing into negativity; and 7) concerns about external optics. A final theme: 8) expansion of program scope was noted in the "opportunity" domain.

Conclusion: This program evaluation of the Women's Night curriculum demonstrates it was a positive addition to the formal curriculum, providing longitudinal professional development opportunities. Sharing the strengths of the program, along with identified weaknesses, threats, and opportunities for advancement allows other departments to learn from this experience and implement similar models that use existing intellectual and social capital.
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http://dx.doi.org/10.5811/westjem.2019.11.44433DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6948687PMC
December 2019

A Multifaceted Intervention to Improve Patient Knowledge and Safe Use of Opioids: Results of the ED EMC Randomized Controlled Trial.

Acad Emerg Med 2019 12 19;26(12):1311-1325. Epub 2019 Nov 19.

Division of General Internal Medicine and Geriatrics, Northwestern University, Chicago, IL.

Objectives: Despite increased focus on opioid prescribing, little is known about the influence of prescription opioid medication information given to patients in the emergency department (ED). The study objective was to evaluate the effect of an Electronic Medication Complete Communication (EMC ) Opioid Strategy on patients' safe use of opioids and knowledge about opioids.

Methods: This was a three-arm prospective, randomized controlled pragmatic trial with randomization occurring at the physician level. Consecutive discharged patients at an urban academic ED (>88,000 visits) with new hydrocodone-acetaminophen prescriptions received one of three care pathways: 1) usual care, 2) EMC intervention, or 3) EMC  + short message service (SMS) text messaging. The ED EMC intervention triggered two patient-facing educational tools (MedSheet, literacy-appropriate prescription wording [Take-Wait-Stop]) and three provider-facing reminders to counsel (directed to ED physician, dispensing pharmacist, follow-up physician). Patients in the EMC  + SMS arm additionally received one text message/day for 1 week. Follow-up at 1 to 2 weeks assessed "demonstrated safe use" (primary outcome). Secondary outcomes including patient knowledge and actual safe use (via medication diaries) were assessed 2 to 4 days and 1 month following enrollment.

Results: Among the 652 enrolled, 343 completed follow-up (57% women; mean ± SD age = 42 ± 14.0 years). Demonstrated safe opioid use occurred more often in the EMC group (adjusted odds ratio [aOR] = 2.46, 95% confidence interval [CI] = 1.19 to 5.06), but not the EMC  + SMS group (aOR = 1.87, 95% CI = 0.90 to 3.90) compared with usual care. Neither intervention arm improved medication safe use as measured by medication diary data. Medication knowledge, measured by a 10-point composite knowledge score, was greater in the EMC  + SMS group (β = 0.57, 95% CI = 0.09 to 1.06) than usual care.

Conclusions: The study found that the EMC tools improved demonstrated safe dosing, but these benefits did not translate into actual use based on medication dairies. The text-messaging intervention did result in improved patient knowledge.
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http://dx.doi.org/10.1111/acem.13860DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6901720PMC
December 2019

A Quality Improvement Initiative Featuring Peer-Comparison Prescribing Feedback Reduces Emergency Department Opioid Prescribing.

Jt Comm J Qual Patient Saf 2019 10 2;45(10):669-679. Epub 2019 Sep 2.

Background: Opioid prescribing in the United States nearly tripled from 1999 to 2015, and opioid overdose deaths doubled in the same time frame. Emergency departments (EDs) may play a pivotal role in the opioid epidemic as a source of first-time opioid exposure; however, many prescribers are generally unaware of their prescribing behaviors relative to their peers.

Methods: All 117 ED prescribers at an urban academic medical center were provided with regular feedback on individual rates of opioid prescribing relative to their de-identified peers. To evaluate the effect of this intervention on the departmental rate of opioid prescribing, a statistical process control (SPC) chart was created to identify special cause variation, and an interrupted time series analysis was conducted to evaluate the immediate effect of the intervention and any change in the postintervention trend due to the intervention.

Results: The aggregate opioid prescribing rate in the preintervention period was 8.6% (95% confidence interval [CI]: 8.3%-8.9%), while the aggregate postintervention prescribing rate was 5.8% (95% CI: 5.5%-6.1%). The SPC chart revealed special cause variation in both the pre- and postintervention periods, with an overall downtrend of opioid prescribing rates across the evaluation period and flattening of rates in the final four blocks. Interrupted time series analysis demonstrated a significant immediate downward effect of the intervention and a nonsignificant additional decrease in postintervention trend.

Conclusion: Implementation of peer-comparison opioid prescribing feedback was associated with a significant immediate reduction in the rate of ED discharge opioid prescribing.
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http://dx.doi.org/10.1016/j.jcjq.2019.07.008DOI Listing
October 2019

Reply to Comment on Potentially Inappropriate Medication Prescriptions for Older Adults With Painful Conditions and Association With Return Emergency Department Visits.

J Am Geriatr Soc 2019 07 7;67(7):1532-1533. Epub 2019 May 7.

The Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois.

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http://dx.doi.org/10.1111/jgs.15973DOI Listing
July 2019

Who Is Keeping Their Unused Opioids and Why?

Pain Med 2020 01;21(1):84-91

Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois.

Objective: To better understand patients' reasoning for keeping unused opioid pills.

Methods: As part of a larger study, patients were asked their plans for their unused opioids. Responses were categorized as "dispose," "keep," and "don't know." Baseline characteristics were compared between the "keep" and "dispose" groups. Verbatim responses categorized as "keep" were analyzed qualitatively using a team-based inductive approach with constant comparison across cases.

Results: One hundred patients planned to dispose of their pills; 117 planned to keep them. There were no differences in demographics between the groups. Among patients who planned to keep their pills, the mean age was 43 years and 47% were male. Analysis revealed four categories of patient responses: 1) plans to keep their pills "just in case," with reference to a medical condition (e.g., kidney stone); 2) plans to keep pills "just in case" without reference to any medical condition; 3) plans to dispose in delayed fashion (e.g., after pill expiration) or unsure of how to dispose; and 4) no identified plans, yet intended to keep pills. In this sample, there were no differences in characteristics of those reporting planning to keep vs dispose of pills; however, there were diverse reasons for keeping opioids.

Conclusions: This manuscript describes a sample of patients who kept their unused opioids and presents qualitative data detailing their personal reasoning for keeping the unused pills. Awareness of the range of motivations underpinning this behavior may inform the development of tailored education and risk communication messages to improve opioid disposal.
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http://dx.doi.org/10.1093/pm/pnz025DOI Listing
January 2020

Potentially Inappropriate Medication Prescriptions for Older Adults with Painful Conditions and Association with Return Emergency Department Visits.

J Am Geriatr Soc 2019 04 27;67(4):719-725. Epub 2019 Jan 27.

Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois.

Objectives: To describe the frequency and risk of return visit to the emergency department (ED) by older adults after prescription of any of four potentially inappropriate medication (PIM) classes included in the 2015 Beers Criteria commonly used for the relief of acute pain in the ED.

Design: Retrospective cohort study.

Setting: Large urban academic ED from January 1, 2013, to December 31, 2015.

Participants: Patients age 65 and older discharged from the ED with an initial pain score of 1 or higher (11 822 visits).

Measurements: Prescriptions for PIM classes were collected from the medical record: nonsteroidal anti-inflammatory drugs (NSAIDs), benzodiazepines, skeletal muscle relaxants, and opioids. The proportion of patients with ED returns within 9 days were compared by medication class and pain severity (mild, moderate, or severe). Multivariable logistic regression was performed for each pain category to determine adjusted odds ratios (aORs) of ED return.

Results: Of 11 822 included patients, PIMs were prescribed in 3392 (28.7%): 2550 (21.6%) opioids, 826 (7.0%) NSAIDs, 277 (2.3%) benzodiazepines, and 68 (0.6%) nonbenzodiazepine skeletal muscle relaxants. Total 9-day ED returns were 1125 (9.5%): mild 7.0%, moderate 8.3%, and severe pain 11.7%. Opioids were not associated with more frequent ED returns for mild or moderate pain, and they were associated with less frequent ED returns for severe pain (9.2% vs 12.7%; p < .001; aOR 0.69; 95% confidence interval [CI] = 0.54-0.87). Benzodiazepines were associated with more frequent ED returns for patients with moderate pain (15.5% vs 8.2%; p < .01; aOR = 2.01; 95%CI = 1.10-3.70).

Conclusions: These results are consistent with recommendations to limit benzodiazepine prescriptions for older adults and that among older adults with severe pain, opioid prescribing is associated with less frequent ED visits within 9 days of discharge. However, this study was not designed to evaluate safety, adverse events, or other important patient-centered outcomes. J Am Geriatr Soc 67:719-725, 2019.
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http://dx.doi.org/10.1111/jgs.15722DOI Listing
April 2019

A comparison of analgesic prescribing among ED back and neck pain visits receiving physical therapy versus usual care.

Am J Emerg Med 2019 07 23;37(7):1322-1326. Epub 2018 Oct 23.

Department of Communication Studies, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America; Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America.

Objective: Physical therapy (PT) is commonly cited as a non-opioid pain strategy, and previous studies indicate PT reduces opioid utilization in outpatients with back pain. No study has yet examined whether PT is associated with lower analgesic prescribing in the ED setting.

Methods: This was a retrospective cohort study of discharged ED visits with a primary ICD-10 diagnosis relating to back or neck pain from 10/1/15 to 2/21/17 at an urban academic ED. Visits receiving a PT evaluation were matched with same-date visits receiving usual care. We compared the primary outcomes of opioid and benzodiazepine prescribing between the two cohorts using chi-squared test and multivariable logistic regression.

Results: 74 ED visits received PT during the study period; these visits were matched with 390 same-date visits receiving usual care. Opioid prescribing among ED-PT visits was not significantly higher compared to usual care visits on both unadjusted analysis (50% vs 42%, p = 0.19) and adjusted analysis (adjOR 1.05, 95% CI 0.48-2.28). However, benzodiazepine prescribing among ED-PT visits was significantly higher than usual care visits on both unadjusted (45% vs 23%, p < 0.001) and adjusted analysis (adjOR 3.65, 95% CI 1.50-8.83).

Conclusions: In this single center study, ED back and neck pain visits receiving PT were no less likely to receive an opioid prescription and were more likely to receive a benzodiazepine than visits receiving usual care. Although prior studies demonstrate that PT may reduce opioid utilization in the subsequent year, these results indicate that analgesic prescribing is not reduced at the initial ED encounter.
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http://dx.doi.org/10.1016/j.ajem.2018.10.009DOI Listing
July 2019

Physical therapy in the emergency department: A new opportunity for collaborative care.

Am J Emerg Med 2018 08 24;36(8):1492-1496. Epub 2018 May 24.

Department of Physical Therapy and Athletic Training, Northern Arizona University, Flagstaff, AZ, United States.

Emergency department-initiated physical therapy (ED PT) is an emerging resource in the United States, with the number of ED PT programs in the United States growing rapidly over the last decade. In this collaborative model of care, physical therapists are consulted by the treating ED physician to assist in the evaluation and treatment of a number of movement and functional disorders, such as low back pain, peripheral vertigo, and various gait disturbances. Patients receiving ED PT benefit from the physical therapist's expertise in musculoskeletal and vestibular conditions and from the individualized attention provided in a typical bedside evaluation and treatment session, which includes education on expected symptom trajectory, recommendations for activity modulation, and facilitated outpatient follow-up. Early data suggest that both physicians and patients view ED PT services favorably, and that ED PT is associated with improvement of several important clinical and operational outcomes. Hospital systems interested in building their own ED PT program may benefit from the key steps outlined in this review, as well as a summary of the typical clinical volumes and practice patterns encountered at existing programs around the country.
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http://dx.doi.org/10.1016/j.ajem.2018.05.053DOI Listing
August 2018

Emergency Department Provider Perspectives on Benzodiazepine-Opioid Coprescribing: A Qualitative Study.

Acad Emerg Med 2018 01 19;25(1):15-24. Epub 2017 Sep 19.

Department of Communication Studies, Northwestern University Feinberg School of Medicine, Chicago, IL.

Objective: Benzodiazepines and opioids are prescribed simultaneously (i.e., "coprescribed") in many clinical settings, despite guidelines advising against this practice and mounting evidence that concomitant use of both medications increases overdose risk. This study sought to characterize the contexts in which benzodiazepine-opioid coprescribing occurs and providers' reasons for coprescribing.

Methods: We conducted focus groups with emergency department (ED) providers (resident and attending physicians, advanced practice providers, and pharmacists) from three hospitals using semistructured interviews to elicit perspectives on benzodiazepine-opioid coprescribing. Discussions were audio-recorded and transcribed. We performed qualitative content analysis of the resulting transcripts using a consensual qualitative research approach, aiming to identify priority categories that describe the phenomenon of benzodiazepine-opioid coprescribing.

Results: Participants acknowledged coprescribing rarely and reluctantly and often provided specific discharge instructions when coprescribing. The decision to coprescribe is multifactorial, often isolated to specific clinical and situational contexts (e.g., low back pain, failed solitary opioid therapy) and strongly influenced by a provider's beliefs about the efficacy of combination therapy. The decision to coprescribe is further influenced by a self-imposed pressure to escalate care or avoid hospital admission. When considering potential interventions to reduce the incidence of coprescribing, participants opposed computerized alerts but were supportive of a pharmacist-assisted intervention. Many providers found the process of participating in peer discussions on prescribing habits to be beneficial.

Conclusions: In this qualitative study of ED providers, we found that benzodiazepine-opioid coprescribing occurs in specific clinical and situational contexts, such as the treatment of low back pain or failed solitary opioid therapy. The decision to coprescribe is strongly influenced by a provider's beliefs and by self-imposed pressure to escalate care or avoid admission.
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http://dx.doi.org/10.1111/acem.13273DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5764790PMC
January 2018

Unresponsive Male.

Ann Emerg Med 2017 May;69(5):552-561

Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; Medical Toxicology, Toxikon Consortium, Cook County Stroger Hospital, Chicago, IL.

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http://dx.doi.org/10.1016/j.annemergmed.2016.03.022DOI Listing
May 2017

Benzodiazepine-opioid co-prescribing in a national probability sample of ED encounters.

Am J Emerg Med 2017 Mar 2;35(3):458-464. Epub 2016 Dec 2.

Department of Communication Studies, Northwestern University Feinberg School of Medicine, Chicago, IL, United States.

Background: Benzodiazepine-opioid combination therapy is potentially harmful due to the risk of synergistic respiratory depression, and the rate of death due to benzodiazepine-opioid overdose is increasing. Little is known about the prevalence and characteristics of benzodiazepine-opioid co-prescribing from the ED setting.

Methods: Secondary analysis of data from the National Hospital Ambulatory Medical Care Survey, using sample weights to generate population estimates. The primary objective was to describe the annual prevalence of benzodiazepine-opioid co-prescribing from 2006 to 2012, using 95% confidence intervals (95% CI) to compare adjacent years. The secondary objective was to compare characteristics of ED encounters receiving a benzodiazepine-opioid co-prescription versus those receiving an opioid prescription alone, using a multivariable logistic regression.

Results: The prevalence of benzodiazepine-opioid co-prescribing did not significantly change from 2006 to 2012. During this period, 2.7% (95% CI: 2.5-2.8%) of ED encounters prescribed an opioid were also prescribed a benzodiazepine. Relative to encounters receiving an opioid prescription alone, encounters receiving a co-prescription were more likely to represent a follow-up rather than initial visit (Odds Ratio [OR] 1.52), receive more medications (OR 1.41) and fewer procedures (OR 0.48) while in the ED, and more likely to have a diagnosis related to mental disorder (OR 20.60) or musculoskeletal problem (OR 3.71).

Conclusions: From 2006 to 2012, almost 3% of all ED encounters receiving an opioid prescription also received a benzodiazepine co-prescription. The odds of benzodiazepine-opioid co-prescribing were significantly higher in ED encounters representing a follow-up visit and in diagnoses relating to a mental disorder or musculoskeletal problem.
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http://dx.doi.org/10.1016/j.ajem.2016.11.054DOI Listing
March 2017

ED opioid prescribing is not associated with higher patient satisfaction scores.

Am J Emerg Med 2016 Oct 21;34(10):2032-2034. Epub 2016 Jul 21.

Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL.

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http://dx.doi.org/10.1016/j.ajem.2016.07.033DOI Listing
October 2016

A Case of Recalcitrant Urinary Tract Infection.

J Emerg Med 2016 Sep 2;51(3):e61-2. Epub 2016 Jul 2.

Department of Emergency Medicine, Denver Health Medical Center, Denver, Colorado.

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http://dx.doi.org/10.1016/j.jemermed.2016.06.004DOI Listing
September 2016

Opioid prescription fill rates after emergency department discharge.

Am J Health Syst Pharm 2016 Jun;73(12):902-7

Department of Emergency Medicine, School of Medicine, University of Colorado, Aurora, CORocky Mountain Poison and Drug Center, Denver, CO.

Purpose: Opioid prescription fill rates and the time to fill after emergency department (ED) discharge were studied.

Methods: Data were evaluated for all patients discharged from the ED between September 1, 2011, who were February 1, 2012, who were diagnosed with one of the following: dental pain, jaw pain, flank pain, abdominal pain, pelvic pain, back pain, neck pain, knee pain, headache, fracture, or sprain. Clinical information was abstracted via computer algorithm, and prescription filling within 100 days of prescription writing was determined by cross-referencing patient demographics with the state prescription drug monitoring program. Logistic regression analysis and a Cox proportional hazards model were used to determine if any clinical and demographic characteristics were associated with fill rates or the time to fill, respectively.

Results: Of the 2243 patients who received an opioid prescription at ED discharge, 1775 (79%) filled it, with a median time to fill of 0 days. On adjusted analysis, characteristics associated with filling the opioid prescriptions included Caucasian race, being insured by the federal government or through a state indigent assistance program, a chief complaint of back pain, and a history of filling an opioid prescription within the past year. No characteristics were predictive of a prolonged time to filling.

Conclusion: One in five patients who received an opioid prescription at discharge from an urban academic ED did not fill it. Several factors may be associated with a greater likelihood of filling, such as insurance status and history of filling an opioid prescription within the past year.
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http://dx.doi.org/10.2146/ajhp150528DOI Listing
June 2016

Patients are aware of risks of opioid dependence, yet note poor communication from providers about pain and pain management.

Evid Based Nurs 2016 07 23;19(3):88. Epub 2016 Mar 23.

Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, US.

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http://dx.doi.org/10.1136/eb-2016-102310DOI Listing
July 2016

Colorado Cannabis Legalization and Its Effect on Emergency Care.

Ann Emerg Med 2016 07 24;68(1):71-5. Epub 2016 Feb 24.

Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, and Rocky Mountain Poison and Drug Center, Denver, CO.

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http://dx.doi.org/10.1016/j.annemergmed.2016.01.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4939797PMC
July 2016

CYP2C19 drug-drug and drug-gene interactions in ED patients.

Am J Emerg Med 2016 Feb 9;34(2):245-9. Epub 2015 Nov 9.

University of Colorado Department of Emergency Medicine, 12401 E 17th Ave, Aurora, CO, 80045; Denver Health Residency in Emergency Medicine, 770 Bannock St, Denver, CO, 80204; University of Colorado School of Medicine, 12401 E 17th Ave, Aurora, CO, 80045; Skaggs School of Pharmacy and Pharmaceutical Sciences, 12401 E 17th Ave, Aurora, CO, 80045; Rocky Mountain Poison & Drug Center, 990 Bannock St, Denver, CO, 80204. Electronic address:

Background: CYP450 polymorphisms result in variable rates of drug metabolism. CYP drug-drug interactions can contribute to altered drug effectiveness and safety.

Study Objectives: The primary objective was to determine the percentage of emergency department (ED) patients with cytochrome 2C19 (CYP2C19) drug-drug interactions. The secondary objective was to determine the prevalence of CYP2C19 polymorphisms in a US ED population.

Methods: We conducted a prospective observational study in an urban academic ED with 72,000 annual visits. Drug ingestion histories for the 48 hours preceding ED visit were obtained; each drug was coded as CYP2C19 substrate, inhibitor, inducer, or not CYP2C19 dependent. Ten percent of patients were randomized to undergo CYP2C19 genotyping using the Roche Amplichip.

Results: A total of 502 patients were included; 61% were female, 65% were white, and median age was 39 years (interquartile range, 22-53). One hundred thirty-one (26.1%) patients had taken at least 1 CYP2C19-dependent home drug. Eighteen (13.7%) patients who were already taking a CYP2C19-dependent drug were given or prescribed a CYP2C19-dependent drug while in the ED. Among the 53 patients genotyped, 52 (98%) were extensive metabolizers and 1 was a poor metabolizer.

Conclusions: In a population of ED patients, more than a quarter had taken a CYP2C19-dependent drug in the preceding 48 hours, but few were given or prescribed another CYP2C19-dependent drug in the ED. On genotyping analysis, CYP2C19 polymorphisms were uncommon in our cohort. We conclude that changing prescribing practice due to CYP2C19 drug-drug interaction or genotype is unlikely to be useful in most US ED populations.
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http://dx.doi.org/10.1016/j.ajem.2015.10.055DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4878122PMC
February 2016

Cyclic vomiting presentations following marijuana liberalization in Colorado.

Acad Emerg Med 2015 Jun 22;22(6):694-9. Epub 2015 Apr 22.

Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO.

Objectives: Case reports have described a syndrome of cyclic vomiting associated with chronic marijuana use, termed cannabinoid hyperemesis syndrome. The primary objective was to determine the prevalence of patients presenting with cyclic vomiting before and after the liberalization of medical marijuana in Colorado in 2009. The secondary objective was to describe the odds of marijuana use among cyclic vomiting visits in these same time periods.

Methods: This was a cross-sectional study of cyclic vomiting visits to the emergency department (ED) before and after marijuana liberalization. ED visits with International Classification of Diseases, ninth revision, coding for cyclic vomiting or that met diagnostic criteria for cyclic vomiting by the Rome III criteria were included.

Results: The authors reviewed 2,574 visits and identified 36 patients diagnosed with cyclic vomiting over 128 visits. The prevalence of cyclic vomiting visits increased from 41 per 113,262 ED visits to 87 per 125,095 ED visits after marijuana liberalization, corresponding to a prevalence ratio of 1.92 (95% confidence interval [CI] = 1.33 to 2.79). Patients with cyclic vomiting in the postliberalization period were more likely to have marijuana use documented than patients in the preliberalization period (odds ratio = 3.59, 95% CI = 1.44 to 9.00).

Conclusions: The prevalence of cyclic vomiting presentations nearly doubled after the liberalization of medical marijuana. Patients presenting with cyclic vomiting in the postliberalization period were more likely to endorse marijuana use, although it is unclear whether this was secondary to increased marijuana use, more accurate marijuana reporting, or both.
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http://dx.doi.org/10.1111/acem.12655DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4469074PMC
June 2015

Carbohydrate restriction and lactate transporter inhibition in a mouse xenograft model of human prostate cancer.

BJU Int 2012 Oct 6;110(7):1062-9. Epub 2012 Mar 6.

Division of Urologic Surgery, Department of Surgery and the Duke Prostate Center, Duke University School of Medicine, Durham, NC 27710, USA.

Unlabelled: What's known on the subject? and What does the study add? It is known that both lactate inhibition and carbohydrate restriction inhibit tumour growth. What is unknown is whether the two work synergistically together. This study adds that though the combination of lactate inhibition and carbohydrate restriction did not synergistically slow tumour growth in our model, we confirmed that carbohydrate restriction started after tumour inoculation slowed tumour growth. Moreover, lactate inhibition resulted in changes in the tumour microenvironment that may have implications for future metabolic targeting of prostate cancer growth.

Objective: To determine if a no-carbohydrate ketogenic diet (NCKD) and lactate transporter inhibition can exert a synergistic effect on delaying prostate tumour growth in a xenograft mouse model of human prostate cancer.

Materials And Methods: 120 nude athymic male mice (aged 6-8 weeks) were injected s.c. in the flank with 1.0 × 10(5) LAPC-4 prostate cancer cells. • Mice were randomized to one of four treatment groups: Western diet (WD, 35% fat, 16% protein, 49% carbohydrate) and vehicle (Veh) treatment; WD and mono-carboxylate transporter-1 (MCT1) inhibition via α-cyano-4-hydroxycinnamate (CHC) delivered through a mini osmotic pump; NCKD (84% fat, 16% protein, 0% carbohydrate) plus Veh; or NCKD and MCT1 inhibition. • Mice were fed and weighed three times per week and feed was adjusted to maintain similar body weights. • Tumour size was measured twice weekly and the combined effect of treatment was tested via Kruskal-Wallis analysis of all four groups. Independent effects of treatment (NCKD vs WD and CHC vs Veh) on tumour volume were tested using linear regression analysis. • All mice were killed on Day 53 (conclusion of pump ejection), and serum and tumour sections were analysed for various markers. Again, combined and independent effects of treatment were tested using Kruskal-Wallis and linear regression analysis, respectively.

Results: There were no significant differences in tumour volumes among the four groups (P= 0.09). • When testing the independent effects of treatment, NCKD was significantly associated with lower tumour volumes at the end of the experiment (P= 0.026), while CHC administration was not (P= 0.981). However, CHC was associated with increased necrotic fraction (P < 0.001).

Conclusions: Differences in tumour volumes were observed only in comparisons between mice fed a NCKD and mice fed a WD. • MCT1 inhibition did not have a significant effect on tumour volume, although it was associated with increased necrotic fraction.
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http://dx.doi.org/10.1111/j.1464-410X.2012.10971.xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3371292PMC
October 2012