Publications by authors named "Lewis Nelson"

321 Publications

Consensus Recommendations on the Treatment of Opioid Use Disorder in the Emergency Department.

Ann Emerg Med 2021 Jun 22. Epub 2021 Jun 22.

Department of Emergency Medicine, Yale School of Medicine, New Haven, CT.

The treatment of opioid use disorder with buprenorphine and methadone reduces morbidity and mortality in patients with opioid use disorder. The initiation of buprenorphine in the emergency department (ED) has been associated with increased rates of outpatient treatment linkage and decreased drug use when compared to patients randomized to receive standard ED referral. As such, the ED has been increasingly recognized as a venue for the identification and initiation of treatment for opioid use disorder, but no formal American College of Emergency Physicians (ACEP) recommendations on the topic have previously been published. The ACEP convened a group of emergency physicians with expertise in clinical research, addiction, toxicology, and administration to review literature and develop consensus recommendations on the treatment of opioid use disorder in the ED. Based on literature review, clinical experience, and expert consensus, the group recommends that emergency physicians offer to initiate opioid use disorder treatment with buprenorphine in appropriate patients and provide direct linkage to ongoing treatment for patients with untreated opioid use disorder. These consensus recommendations include strategies for opioid use disorder treatment initiation and ED program implementation. They were approved by the ACEP board of directors in January 2021.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.annemergmed.2021.04.023DOI Listing
June 2021

Illicit drug packet ingestion and the ASGE clinical guideline on removal of foreign bodies.

Gastrointest Endosc 2021 07;94(1):205

Department of Emergency Medicine, New Jersey Poison Information and Education System, Rutgers New Jersey Medical School, Newark, New Jersey, USA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.gie.2020.12.052DOI Listing
July 2021

The impact of adherence to a guideline for minimizing opioid use for treatment of pain in an urban emergency department.

Am J Emerg Med 2021 Jun 1;49:104-109. Epub 2021 Jun 1.

Rutgers New Jersey Medical School, Department of Emergency Medicine, Newark, NJ, USA.

Introduction: The opioid epidemic has significantly evolved over the last three decades. The initiation and continuation of prescription opioids for pain control were one of the primary contributors, across different medical settings. The emergency department (ED) is typically the first place patients go to for management of acute pain, and often where opioid naïve patients first become exposed to opioids. In 2018, the ED of University Hospital located in Newark, NJ implemented a pain guideline to ensure that patients are not unnecessarily exposed to opioids. The goal of our study was to determine whether provider adherence was successful in reducing opioid administration.

Methods: We conducted a retrospective review of pharmacy records of patients treated for pain in the ED within the time frame January 1, 2017 and December 31, 2019. We analyzed the change in our practice by comparing the amount of opioid and non-opioid medications administered and the number of patients administered each type, as well as the change in our utilization of specific medications. The t-test or the χ test were used as applicable.

Results: There were decreases in the mean number of opioid doses administered in 2017 (1273) compared to 2019 (498; p = 0.027). There was an increase in non-opioid analgesics administered, (mean 2017: 1817, mean 2019: 2432.5, p = 0.018). There was also an increase in the proportion of patients given non-opioid analgesics (mean 2017: 22%, mean 2019: 28%, p < 0.0001). There were increases in administrations of acetaminophen (40% to 52%) and ibuprofen (30% to 35.1%), and decreases in administrations of hydromorphone (2.5% to 0.03%), morphine (11.5% to 5.6%), oxycodone (10.6% to 5.3%), and tramadol (5.7% to 1.9%) (all p < 0.0001).

Discussion: A guideline that emphasizes the use of non-opioid analgesics first line treatment for acute pain can be effective for reducing opioid administration in the ED. Through the use of our guideline, we reduced the number of patients who have received opioid analgesics and, at the same time, increased non-opioid analgesic administration. Future studies should explore readmission rates, duration of pain relief in patients managed with non-opioid versus opioid analgesics, and perception of relief through the use of satisfaction scores.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ajem.2021.05.056DOI Listing
June 2021

The impact of adherence to a guideline for minimizing opioid use for treatment of pain in an urban emergency department.

Am J Emerg Med 2021 Jun 1;49:104-109. Epub 2021 Jun 1.

Rutgers New Jersey Medical School, Department of Emergency Medicine, Newark, NJ, USA.

Introduction: The opioid epidemic has significantly evolved over the last three decades. The initiation and continuation of prescription opioids for pain control were one of the primary contributors, across different medical settings. The emergency department (ED) is typically the first place patients go to for management of acute pain, and often where opioid naïve patients first become exposed to opioids. In 2018, the ED of University Hospital located in Newark, NJ implemented a pain guideline to ensure that patients are not unnecessarily exposed to opioids. The goal of our study was to determine whether provider adherence was successful in reducing opioid administration.

Methods: We conducted a retrospective review of pharmacy records of patients treated for pain in the ED within the time frame January 1, 2017 and December 31, 2019. We analyzed the change in our practice by comparing the amount of opioid and non-opioid medications administered and the number of patients administered each type, as well as the change in our utilization of specific medications. The t-test or the χ test were used as applicable.

Results: There were decreases in the mean number of opioid doses administered in 2017 (1273) compared to 2019 (498; p = 0.027). There was an increase in non-opioid analgesics administered, (mean 2017: 1817, mean 2019: 2432.5, p = 0.018). There was also an increase in the proportion of patients given non-opioid analgesics (mean 2017: 22%, mean 2019: 28%, p < 0.0001). There were increases in administrations of acetaminophen (40% to 52%) and ibuprofen (30% to 35.1%), and decreases in administrations of hydromorphone (2.5% to 0.03%), morphine (11.5% to 5.6%), oxycodone (10.6% to 5.3%), and tramadol (5.7% to 1.9%) (all p < 0.0001).

Discussion: A guideline that emphasizes the use of non-opioid analgesics first line treatment for acute pain can be effective for reducing opioid administration in the ED. Through the use of our guideline, we reduced the number of patients who have received opioid analgesics and, at the same time, increased non-opioid analgesic administration. Future studies should explore readmission rates, duration of pain relief in patients managed with non-opioid versus opioid analgesics, and perception of relief through the use of satisfaction scores.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ajem.2021.05.056DOI Listing
June 2021

Trends in visits related to drug use adverse effects in an urban ED during COVID-19.

Am J Emerg Med 2021 Apr 27. Epub 2021 Apr 27.

Rutgers New Jersey Medical School, Department of Emergency Medicine, Newark, NJ, USA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ajem.2021.04.067DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8076727PMC
April 2021

The Impact of the Parenteral Opioid Medication Shortages on Opioid Utilization Practices in the Emergency Department of Two University Hospitals.

J Med Toxicol 2021 Apr 27. Epub 2021 Apr 27.

University of Pennsylvania, Philadelphia, USA.

Introduction: Both opioid and non-opioid analgesics are commonly utilized in treating acute and chronic pain in the emergency department (ED). Opioid stewardship efforts have focused on judicious opioid use and opioid alternatives as first-line analgesics. Parenteral opioid formulations have been impacted by periodic shortages creating the opportunity for a natural experiment to observe how emergency clinician prescribing behavior may be impacted. We investigated the change in analgesic practice related to a period of parenteral opioid shortage at two large urban, academic medical centers.

Methods: A retrospective review of pharmacy administration data from two academic urban EDs was performed looking at time periods before, during, and after resolution of the parenteral opioid shortage. The data were analyzed by medication, dose, time, number of doses, and oral morphine milligram equivalents (MME) administered per patient.

Results: The percentage of patients who received any opioid among ED visits decreased during the shortage period and did not return to pre-shortage levels after the shortage ended: 11.5% pre, 8.5% during (p=0.01), 7.2% post (NS; p=0.18). The number of doses of either oral or IV opioid doses administered during the shortage decreased significantly: 8.7% pre, 5.6% during (p=0.02) for PO, and 13.7% pre, 9.0% during (p=0.004) for IV, and neither changed during recovery from the shortage. The percentage of patients receiving non-opioid analgesics rose from 30.5% before to 45.8% (p=0.004) after the shortage. Among patients who received opioids, the MME per patient did not change across the time periods: 11.5% before, 11.2% during, 12.7% post.

Conclusions: A period of restricted opioid use due to parenteral opioid shortages led to less opioid use overall and fewer patients treated with opioids, yet no significant change in opioid MME administered per patient requiring opioids. Overall, the shift in opioid prescribing during the parenteral opioid shortage appeared to be sustained in the post-shortage period.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s13181-021-00842-7DOI Listing
April 2021

The Poison Center as a pandemic response: establishment and characteristics of a COVID-19 hotline through the New Jersey Poison Center.

Clin Toxicol (Phila) 2021 Mar 31:1-6. Epub 2021 Mar 31.

Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA.

Background: Poison Centers are uniquely positioned to respond to an unprecedented public health threat such as the COVID-19 pandemic, as fully operational 24-h hotlines already staffed with healthcare professionals.

Methods: On January 27, 2020 the New Jersey Poison Information and Education System (NJPIES) agreed to operate the New Jersey Coronavirus Hotline. Call patterns, subject matter, and staffing and infrastructure strategies that were implemented to meet the demand are described. In addition, a sample of 1500 individual calls were collected and analyzed in an endeavor to describe call times, call days, area from which the call originated, callers to the hotline, primary language of the caller, and why a call was placed to the hotline. Binomial regression analysis was utilized in an attempt to identify significant patterns.

Results: Since the inception of the hotline through October 31, NJPIES responded to 57,579 calls for COVID-19 information. Most calls (68.7%) were regarding testing for COVID-19 and for general questions/symptoms. Call types varied when they were analyzed by time of day with calls for general questions/symptoms and where to get tested for COVID-19 showing a significant association for the early morning hours, how to obtain test results being significantly associated with the afternoon hours, and how to renew or obtain a medical license showing a significant association to the evening hours. We additionally noted that specific call types became significant when analyzed on a week-to-week basis and as specific events, like the enactment of the CARES Act of 2020, occurred.

Conclusion: Although not the traditional role of a regional Poison Control Center, pandemic response synergizes with the workflow of this hotline because the infrastructure, staffing, and healthcare expertise are already present. Poison centers can rapidly adapt through scaling and process change to meet the needs of the public during times of public health threats.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1080/15563650.2021.1905163DOI Listing
March 2021

The Poison Center as a pandemic response: establishment and characteristics of a COVID-19 hotline through the New Jersey Poison Center.

Clin Toxicol (Phila) 2021 Mar 31:1-6. Epub 2021 Mar 31.

Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA.

Background: Poison Centers are uniquely positioned to respond to an unprecedented public health threat such as the COVID-19 pandemic, as fully operational 24-h hotlines already staffed with healthcare professionals.

Methods: On January 27, 2020 the New Jersey Poison Information and Education System (NJPIES) agreed to operate the New Jersey Coronavirus Hotline. Call patterns, subject matter, and staffing and infrastructure strategies that were implemented to meet the demand are described. In addition, a sample of 1500 individual calls were collected and analyzed in an endeavor to describe call times, call days, area from which the call originated, callers to the hotline, primary language of the caller, and why a call was placed to the hotline. Binomial regression analysis was utilized in an attempt to identify significant patterns.

Results: Since the inception of the hotline through October 31, NJPIES responded to 57,579 calls for COVID-19 information. Most calls (68.7%) were regarding testing for COVID-19 and for general questions/symptoms. Call types varied when they were analyzed by time of day with calls for general questions/symptoms and where to get tested for COVID-19 showing a significant association for the early morning hours, how to obtain test results being significantly associated with the afternoon hours, and how to renew or obtain a medical license showing a significant association to the evening hours. We additionally noted that specific call types became significant when analyzed on a week-to-week basis and as specific events, like the enactment of the CARES Act of 2020, occurred.

Conclusion: Although not the traditional role of a regional Poison Control Center, pandemic response synergizes with the workflow of this hotline because the infrastructure, staffing, and healthcare expertise are already present. Poison centers can rapidly adapt through scaling and process change to meet the needs of the public during times of public health threats.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1080/15563650.2021.1905163DOI Listing
March 2021

The Vice Chair Position in Emergency Medicine Deserves Continued Support.

AEM Educ Train 2021 Jan 12;5(1):145-146. Epub 2020 Mar 12.

Department of Emergency Medicine Rutgers New Jersey Medical School Newark NJ United States.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/aet2.10441DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7821056PMC
January 2021

Levamisole-a Toxic Adulterant in Illicit Drug Preparations: a Review.

Ther Drug Monit 2021 04;43(2):221-228

NMS Labs, Horsham, Pennsylvania.

Abstract: Discovered in the 1960s, the common anthelminthic levamisole has seen widespread use in veterinary applications. Its use rapidly expanded thereafter to include human medical treatments for a variety of acute and chronic disorders. Because of reports of severe adverse effects, the US Food and Drug Administration withdrew levamisole's approval for human use in 2000; however, medical options outside the United States and illicit options worldwide allow continued accessibility to levamisole. The compound is rapidly metabolized in the body, with at least 2 known active metabolites. Levamisole has a broad range of immunomodulatory effects, including both stimulatory and inhibitory effects on immune responses. It is generally well tolerated at therapeutic concentrations, although a variety of autoimmune-related adverse effects have been reported, including agranulocytosis, leukopenia, purpura, and visible necrotized skin tissue. Individuals with levamisole-compromised immune systems are more susceptible to infections, including COVID-19. Since the early 2000's, levamisole has been frequently used as an adulterating agent in illicit street drugs, especially cocaine, fentanyl, and heroin. Although its prevalence has varied over time and geographically, levamisole has been detected in up to 79% of the street supply of cocaine at levels up to 74% by weight. Its presence in illicit drug markets also raises concern over the potential for exposure of children and neonates, although this is supported by only limited anecdotal evidence. Levamisole is not currently included in routine drug testing panels, although a variety of confirmatory testing techniques exist across a range of antemortem and postmortem specimen options. Because of its varying presence in illicit drug markets, both the medical and forensic communities need to be aware of levamisole and its potential impact on toxicological investigations.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/FTD.0000000000000851DOI Listing
April 2021

Comment on Comparison of rates of opioid withdrawal symptoms and reversal of opioid toxicity in patients treated with two naloxone dosing regimens.

Clin Toxicol (Phila) 2021 01 6;59(1):79-80. Epub 2020 Nov 6.

Department of Emergency Medicine, Director, Division of Medical Toxicology, Rutgers New Jersey Medical School, Chief of Service, Emergency Department, University Hospital of Newark, Senior Consultant New Jersey Poison Information and Education System.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1080/15563650.2020.1838536DOI Listing
January 2021

Carbon tetrachloride poisoning from an antique fire extinguisher.

Am J Emerg Med 2020 10 24;38(10):2139-2141. Epub 2020 Jul 24.

Rutgers New Jersey Medical School, Newark, NJ, United States of America; New Jersey Poison Information and Education System, Newark, NJ, United States of America.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ajem.2020.07.052DOI Listing
October 2020

Executive Summary of the American Society of Addiction Medicine (ASAM) Clinical Practice Guideline on Alcohol Withdrawal Management.

J Addict Med 2020 Sep/Oct;14(5):376-392

American Society of Addiction Medicine, North Bethesda, MD.

: The American Society of Addiction Medicine (ASAM) Clinical Practice Guideline on Alcohol Withdrawal Management provides guidance on the identification and management of alcohol withdrawal in adults with varying degrees of syndrome severity. The guideline addresses both ambulatory and inpatient care and considers special patient populations. The Guideline was primarily developed following the RAND/UCLA Appropriateness Method (RAM), a process to determine the appropriateness of a set of clinical procedures. This process included a review of gray and empirical literature published between January 2012 and October 2017. Nineteen existing guidelines, 112 reviews, and 150 research studies were used to develop draft guideline statements that were assessed by a panel of physicians experienced in withdrawal management and representing a diverse range of settings and patient populations. Recommendations were included in the Guideline where consensus on appropriate clinical practice was identified by the panel. Areas where additional research would provide valuable information for determining best practices were highlighted.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/ADM.0000000000000732DOI Listing
June 2021

A theoretical framework and nomenclature to characterize the iatrogenic contribution of therapeutic opioid exposure to opioid induced hyperalgesia, physical dependence, and opioid use disorder.

Am J Drug Alcohol Abuse 2020 11 8;46(6):671-683. Epub 2020 Sep 8.

Department of Emergency Medicine, University of Cincinnati College of Medicine , Cincinnati, OH, USA.

Opioid use, misuse, and risky use contribute to a critically important and complex crisis in current healthcare. Consequences of long-term opioid use, including opioid induced hyperalgesia, physical dependence, and opioid use disorder, can be considered iatrogenic, or partially iatrogenic, in cases where therapeutic opioid exposures were contributory. Research investigation and presumptive clinical action are needed to attenuate the iatrogenic component of the opioid crisis; treatment of individuals already suffering from opioid use disorder will not prevent incident cases. This work will be challenged by a remarkably high degree of complexity involving myriad and highly variable factors along the continuum from initial opioid exposure to long-term opioid use. An organized view of this complex problem should accelerate the pace of innovation and facilitate clinical implementation of research findings. Herein, we propose a theoretical framework and modern nomenclature for characterizing therapeutic opioid exposure and the degree to which it contributes iatrogenically to adverse outcomes. In doing so, we separate the role of exposure from other factors contributing to long-term opioid use, clarify the relationship between opioid exposure and outcomes, emphasize that exposure source is an important consideration for health services research and practice in the areas of pain treatment and opioid prevention, and recommend terminology necessary to quantify therapeutic opioid exposure separately from nonmedical exposure.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1080/00952990.2020.1778713DOI Listing
November 2020

Emergency department patients' perceptions of the efficacy and safety of opioid analgesics.

J Opioid Manag 2020 Jul/Aug;16(4):239-246

Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, New Jersey.

Introduction: Emergency department (ED) providers are on the forefront of the prescription drug crisis and understand-ing patient's perceptions of opioids may allow physicians to better address misconceptions. The aim was to determine the perceptions of ED patients regarding the efficacy and safety of opioid analgesics.

Methods: Cross-sectional study of a convenience sample of adults at a single urban academic ED. Patients completed a tablet-based survey regarding the efficacy and safety of opioid analgesics.

Results: Of the 715 subjects, the sample was predominantly black (80.4 percent), female (59.2 percent), and aged 18-59 years (76.8 percent). The majority (70.1 percent) of respondents reported pain as the reason for visit. Seventy-two percent had previously taken an opioid primarily for acute pain, found them effective for pain (88.2 percent), and would be willing to do so again (62.7 percent). Adverse effects made patients less likely to use them again (OR 0.703, [0.659-0.751]). Gender and age did not affect perceptions of efficacy and safety, but certain racial groups did (OR 1.08, [1.02 to 1.14], p < 0.05). Knowing someone who used opioids in a nonmedical manner did not impact willingness to use opioids. Many (54 percent) believed opioids to be as safe as nonopioid alternatives. The majority (78 percent) consid-ered prescription opioid abuse a public health problem, however underestimated the number of annual opioid-related deaths.

Conclusion: The majority of ED patients had used opioids and considered the prescription drug crisis a public health problem. Through personal use or media coverage, the majority of participants considered opioids safe, even compared to nonopioid alternatives. Better understanding these viewpoints may improve patient-physician communication about analgesic treatment.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5055/jom.2020.0577DOI Listing
October 2020

Pain Score, Opioid Administration, and Delirium: A Confounded Relationship.

Acad Emerg Med 2021 01 1;28(1):144. Epub 2020 Sep 1.

Department of Emergency Medicine, Rutgers NJMS, Newark, NJ, USA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/acem.14109DOI Listing
January 2021

Opioid Overdose Deaths with Buprenorphine Detected in Postmortem Toxicology: a Retrospective Analysis.

J Med Toxicol 2021 01 9;17(1):10-15. Epub 2020 Jul 9.

Department of Epidemiology, Brown University School of Public Health, 121 South Main St, Box G-S-121-2, Providence, RI, 02912, USA.

Background: Buprenorphine is a unique μ-opioid receptor partial agonist with avid receptor binding, nominal euphoric reward, and a ceiling effect on sedation and respiratory depression. Despite a pharmacologic profile that enhances safety, cases of fatal opioid overdose with buprenorphine on postmortem toxicology are reported, but details of these cases in the literature are limited.

Methods: A retrospective review of opioid-involved drug overdose fatalities in Rhode Island (RI) from 2016 to 2018 using the RI Department of Health State Unintentional Drug Overdose Reporting System (SUDORS) database. Deaths with buprenorphine on toxicology testing versus opioid-involved overdose deaths without buprenorphine were compared to assess the type and number of co-exposures.

Results: Of 534 opioid-involved deaths, 29 (5.4%) included buprenorphine and/or norbuprenorphine on toxicology. Most frequent co-exposures are as follows: fentanyl (75.9%), norfentanyl (72.4%), cocaine (41.4%), benzoylecgonine (41.4%), cannabinoids (31.0%), ethanol (31.0%), levamisole (31.0%), and free morphine (31.0%). An average number of co-exposures for fatalities with buprenorphine were 9.24 versus 6.68 in those without buprenorphine. In one case buprenorphine was the only drug listed to cause death; all other fatalities with buprenorphine on toxicology reported additional drugs contributing to death.

Conclusion: Decedents with buprenorphine detected on toxicology testing commonly had documented polysubstance use. Although data are limited, buprenorphine may provide some risk mitigation against full agonist opioid overdose including fentanyl. Further work should explore the use of postmortem concentrations of buprenorphine, norbuprenorphine, and other opioid metabolites to determine the role of buprenorphine in fatal overdose pharmacology.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s13181-020-00795-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7785599PMC
January 2021

ACMT Position Statement: Off-Label Prescribing during COVID-19 Pandemic.

J Med Toxicol 2020 Jul 4;16(3):342-345. Epub 2020 Jun 4.

Berman Institute of Bioethics, Johns Hopkins University School of Medicine, Baltimore, MD, USA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s13181-020-00784-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7272106PMC
July 2020

Opioid-Associated Hearing Loss: A 20-Year Review from the New Jersey Poison Center.

J Med Toxicol 2020 10 28;16(4):416-422. Epub 2020 May 28.

New Jersey Poison Information and Education System, Newark, NJ, USA.

Background: Opioid-associated ototoxicity is a known complication of opioid exposure, although the mechanism remains unclear. While historically most closely linked to heroin and oxycodone, evolving reports suggest that it may be a class effect of opioids. However, the evidence is limited to case reports.

Methods: A retrospective review of the New Jersey Poison Center records (ToxiCALL®) identified cases that included both hearing loss and recent opioid exposure between January 1, 1999, and September 21, 2018.

Results: Forty-one cases were identified, mean age 29.4 years, 51% (n = 21) were male. Reported heroin exposures comprised 51% (n = 22), 18 of which were heroin alone. The next most commonly cited opioids were oxycodone (n = 7), methadone, (n = 4), and tramadol (n = 3). Hearing loss was described as tinnitus in 24% of cases, hypoacusis in 37% of cases, deafness in 29% of cases, and mixed tinnitus/hypoacusis in 10% of cases. Only 34% (n = 14) of cases were associated with a potential hypoxic event. Of the cases that documented resolution data, 21% (n = 4 of 19) reported no improvement at time of hospital discharge.

Discussion: Opioid-associated ototoxicity appears to be a hypoxia-independent adverse effect since most of the reported cases did not involve a known contributory hypoxic event. It occurs with a wide array of opioids, which supports an opioid receptor-mediated mechanism. The ototoxic effect may be self-limited in many patients.

Conclusion: Opioid-associated ototoxicity was most commonly associated with heroin exposure and appeared independent of hypoxic events. Further investigation that clarifies the risk factors and long-term outcomes is needed.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s13181-020-00785-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7554281PMC
October 2020

Position Paper: Recommendations for the Investigation, Diagnosis, and Certification of Deaths Related to Opioid and Other Drugs.

Am J Forensic Med Pathol 2020 Sep;41(3):152-159

Laboratory Quality Assurance and Proficiency Program, RTI International, Research Triangle Park, NC.

The National Association of Medical Examiners convened an expert panel to update the association's evidence-based recommendations for investigating and certifying deaths associated with opioids and other misused substances to improve death certificate and mortality data for public health surveillance. The recommendations are as follows:1. Autopsy provides the best information on a decedent's medical condition for optimal interpretation of toxicology results, circumstances surrounding death, medical history, and scene findings. The panel considers autopsy an essential component of investigating apparent overdose deaths.2. Scene investigation includes reconciling prescription information and medication counts. Investigators should note drug paraphernalia or other evidence of using intoxicating substances.3. Retain blood, urine, and vitreous humor whenever available. Blood from the iliofemoral vein is preferable to blood from more central sites.4. A toxicological panel should be comprehensive, including potent depressant, stimulant, and antidepressant medications. Detecting novel substances present in the community may require special testing.5. When death is attributed to a drug or combination of drugs (as cause or contributing factor), the certifier should list the drugs by generic name in the autopsy report and death certificate.6. The best classification for manner of death in an overdose without any apparent intent of self-harm is "accident."
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/PAF.0000000000000550DOI Listing
September 2020

Primum Non Nocere: Even a Little High Is Still High.

Acad Emerg Med 2020 11 31;27(11):1209-1211. Epub 2020 May 31.

Department of Emergency Medicine, Division of Medical Toxicology, Rutgers New Jersey Medical School, Newark, NJ, USA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/acem.14008DOI Listing
November 2020

American Board of Emergency Medicine Report on Residency and Fellowship Training Information (2019-2020).

Ann Emerg Med 2020 05;75(5):648-667

The American Board of Emergency Medicine gathers extensive background information on Accreditation Council for Graduate Medical Education (ACGME)-accredited emergency medicine residency and fellowship programs, as well as the residents and fellows training in those programs. We present the 2020 annual report on the status of physicians training in ACGME-accredited emergency medicine training programs in the United States.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.annemergmed.2020.03.012DOI Listing
May 2020

Intravenous Acetaminophen and Hydromorphone: The Bad and the Ugly of Emergency Department Pain Management.

Acad Emerg Med 2020 08 22;27(8):793-794. Epub 2020 May 22.

Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/acem.13990DOI Listing
August 2020

ACMT Position Statement on Prescription Drug Shortages.

J Med Toxicol 2020 07 15;16(3):349-351. Epub 2020 Apr 15.

Johns Hopkins University School of Medicine, Baltimore, MD, USA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s13181-020-00775-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7320088PMC
July 2020

Opioid Deprescribing in Emergency Medicine-A Tool in an Expanding Toolkit.

JAMA Netw Open 2020 03 2;3(3):e201129. Epub 2020 Mar 2.

Department of Emergency Medicine, Center for Addiction Medicine and Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamanetworkopen.2020.1129DOI Listing
March 2020

The rising cost of commonly used emergency department medications (2006-15).

Am J Emerg Med 2021 04 13;42:137-142. Epub 2020 Feb 13.

US Acute Care Solutions, Canton, OH, United States of America.

Objective: We determine how aggregate costs have changed for commonly used emergency department (ED) medications, and assess drivers of cost increases.

Methods: Using the National Hospital Ambulatory Medical Care Survey (NHAMCS), we identified the top 150 ED medications administered and prescribed at discharge in 2015. We used average wholesale prices (AWP) for each year from 2006 to 15 from the Red Book (Truven Health Analytics Inc.). Average wholesale price per patient (AWPP) was calculated by dividing AWP by drug uses. This was then multiplied by the total drug administrations or prescriptions to estimate the total cost in a given the year. All prices were converted to 2015 dollars.

Results: Aggregate costs of drugs administered in the ED increased from $688.7 million in 2006 to $882.4 million in 2015. For discharge prescriptions, aggregate costs increased from $2.031 billion in 2006 to $4.572 billion in 2015. AWPP for drugs administered in the ED in 2015 was 14.5% higher than in 2006 and 24.3% higher at discharge. The largest absolute increase in AWPP for drugs administered was for glucagon, which increased from $111 in 2006 to $235 in 2015. The largest AWPP increase at discharge was for epinephrine auto-injector, which increased from $124 in 2006 and to $481 in 2015.

Conclusion: Over the course of the study period, the aggregate costs of the most common medications administered in the ED increased by 28% while the costs of medications prescribed at discharge increased 125%.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ajem.2020.02.010DOI Listing
April 2021
-->