Publications by authors named "Michael S Lyons"

80 Publications

Development and Validation of a Model to Predict Posttraumatic Stress Disorder and Major Depression After a Motor Vehicle Collision.

JAMA Psychiatry 2021 Sep 1. Epub 2021 Sep 1.

Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville.

Importance: A substantial proportion of the 40 million people in the US who present to emergency departments (EDs) each year after traumatic events develop posttraumatic stress disorder (PTSD) or major depressive episode (MDE). Accurately identifying patients at high risk in the ED would facilitate the targeting of preventive interventions.

Objectives: To develop and validate a prediction tool based on ED reports after a motor vehicle collision to predict PTSD or MDE 3 months later.

Design, Setting, And Participants: The Advancing Understanding of Recovery After Trauma (AURORA) study is a longitudinal study that examined adverse posttraumatic neuropsychiatric sequalae among patients who presented to 28 US urban EDs in the immediate aftermath of a traumatic experience. Enrollment began on September 25, 2017. The 1003 patients considered in this diagnostic/prognostic report completed 3-month assessments by January 31, 2020. Each patient received a baseline ED assessment along with follow-up self-report surveys 2 weeks, 8 weeks, and 3 months later. An ensemble machine learning method was used to predict 3-month PTSD or MDE from baseline information. Data analysis was performed from November 1, 2020, to May 31, 2021.

Main Outcomes And Measures: The PTSD Checklist for DSM-5 was used to assess PTSD and the Patient Reported Outcomes Measurement Information System Depression Short-Form 8b to assess MDE.

Results: A total of 1003 patients (median [interquartile range] age, 34.5 [24-43] years; 715 [weighted 67.9%] female; 100 [weighted 10.7%] Hispanic, 537 [weighted 52.7%] non-Hispanic Black, 324 [weighted 32.2%] non-Hispanic White, and 42 [weighted 4.4%] of non-Hispanic other race or ethnicity were included in this study. A total of 274 patients (weighted 26.6%) met criteria for 3-month PTSD or MDE. An ensemble machine learning model restricted to 30 predictors estimated in a training sample (patients from the Northeast or Midwest) had good prediction accuracy (mean [SE] area under the curve [AUC], 0.815 [0.031]) and calibration (mean [SE] integrated calibration index, 0.040 [0.002]; mean [SE] expected calibration error, 0.039 [0.002]) in an independent test sample (patients from the South). Patients in the top 30% of predicted risk accounted for 65% of all 3-month PTSD or MDE, with a mean (SE) positive predictive value of 58.2% (6.4%) among these patients at high risk. The model had good consistency across regions of the country in terms of both AUC (mean [SE], 0.789 [0.025] using the Northeast as the test sample and 0.809 [0.023] using the Midwest as the test sample) and calibration (mean [SE] integrated calibration index, 0.048 [0.003] using the Northeast as the test sample and 0.024 [0.001] using the Midwest as the test sample; mean [SE] expected calibration error, 0.034 [0.003] using the Northeast as the test sample and 0.025 [0.001] using the Midwest as the test sample). The most important predictors in terms of Shapley Additive Explanations values were symptoms of anxiety sensitivity and depressive disposition, psychological distress in the 30 days before motor vehicle collision, and peritraumatic psychosomatic symptoms.

Conclusions And Relevance: The results of this study suggest that a short set of questions feasible to administer in an ED can predict 3-month PTSD or MDE with good AUC, calibration, and geographic consistency. Patients at high risk can be identified in the ED for targeting if cost-effective preventive interventions are developed.
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http://dx.doi.org/10.1001/jamapsychiatry.2021.2427DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8411364PMC
September 2021

Missed HIV diagnoses when screening only emergency department patients who have blood samples obtained for other clinical purposes.

Am J Emerg Med 2021 Jul 21;50:102-105. Epub 2021 Jul 21.

Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA. Electronic address:

Objective: Emergency departments (EDs) are highly valued settings for HIV screening. Most large-volume ED HIV screening programs have attenuated operational barriers by screening only ED patients who already have a blood sample available for other clinical reasons. Our objective was to estimate the proportion of HIV positive patients who are missed when an ED excludes patients for whom HIV screening would be the only indication to obtain a blood sample.

Methods: This cross-sectional analysis used existing electronic records of patients seen between 2017 and 2019 by an urban, academic ED and its HIV screening program, which includes patients regardless of whether they receive other ED blood testing. The primary outcome was the proportion of patients tested by the screening program who were newly diagnosed with HIV (Sample 1) for whom HIV screening would be the only indication for venipuncture. We secondarily 1) estimate the proportion of ED patients who received venipuncture using a representative sample of consecutively approached participants which prospectively recorded whether patients had blood obtained or intravenous catheter placement during usual ED care (Sample 2) and 2) report patient characteristics including HIV risk factors for those with and without ED venipuncture for both groups.

Results: Of 41 persons newly diagnosed with HIV by the ED screening program (Sample 1), 13 (31.7%, 95%CI 18.6-48.2) did not undergo venipuncture for any reason other than their HIV test. The proportion of ED visits without a venipuncture (Sample 2) was 44.2% (95% CI 41.9-46.6). Patient characteristics were similar for both groups.

Conclusions: Screening only those patients with a blood sample already available or easily obtainable due to usual ED care, misses many opportunities for earlier HIV diagnosis. Innovation in research, policy, and practice is needed to overcome still unaddressed barriers to ED HIV screening when HIV screening is the only indication for collection of a biological sample.
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http://dx.doi.org/10.1016/j.ajem.2021.07.031DOI Listing
July 2021

Comparison of HIV Screening Strategies in the Emergency Department: A Randomized Clinical Trial.

JAMA Netw Open 2021 Jul 1;4(7):e2117763. Epub 2021 Jul 1.

Denver Public Health, Denver, Colorado.

Importance: The National HIV Strategic Plan for the US recommends HIV screening in emergency departments (EDs). The most effective approach to ED-based HIV screening remains unknown.

Objective: To compare strategies for HIV screening when integrated into usual ED practice.

Design, Setting, And Participants: This randomized clinical trial included patients visiting EDs at 4 US urban hospitals between April 2014 and January 2016. Patients included were ages 16 years or older, not critically ill or mentally altered, not known to have an HIV positive status, and with an anticipated length of stay 30 minutes or longer. Data were analyzed through March 2021.

Interventions: Consecutive patients underwent concealed randomization to either nontargeted screening, enhanced targeted screening using a quantitative HIV risk prediction tool, or traditional targeted screening as adapted from the Centers for Disease Control and Prevention. Screening was integrated into clinical practice using opt-out consent and fourth-generation antigen-antibody assays.

Main Outcomes And Measures: New HIV diagnoses using intention-to-treat analysis, absolute differences, and risk ratios (RRs).

Results: A total of 76 561 patient visits were randomized; median (interquartile range) age was 40 (28-54) years, 34 807 patients (51.2%) were women, and 26 776 (39.4%) were Black, 22 131 (32.6%) non-Hispanic White, and 14 542 (21.4%) Hispanic. A total of 25 469 were randomized to nontargeted screening; 25 453, enhanced targeted screening; and 25 639, traditional targeted screening. Of the nontargeted group, 6744 participants (26.5%) completed testing and 10 (0.15%) were newly diagnosed; of the enhanced targeted group, 13 883 participants (54.5%) met risk criteria, 4488 (32.3%) completed testing, and 7 (0.16%) were newly diagnosed; and of the traditional targeted group, 7099 participants (27.7%) met risk criteria, 3173 (44.7%) completed testing, and 7 (0.22%) were newly diagnosed. When compared with nontargeted screening, targeted strategies were not associated with a higher rate of new diagnoses (enhanced targeted and traditional targeted combined: difference, -0.01%; 95% CI, -0.04% to 0.02%; RR, 0.7; 95% CI, 0.30 to 1.56; P = .38; and enhanced targeted only: difference, -0.01%; 95% CI, -0.04% to 0.02%; RR, 0.70; 95% CI, 0.27 to 1.84; P = .47).

Conclusions And Relevance: Targeted HIV screening was not superior to nontargeted HIV screening in the ED. Nontargeted screening resulted in significantly more tests performed, although all strategies identified relatively low numbers of new HIV diagnoses.

Trial Registration: ClinicalTrials.gov Identifier: NCT01781949.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.17763DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8314142PMC
July 2021

Incidence of opioid use disorder in the year after discharge from an emergency department encounter.

J Am Coll Emerg Physicians Open 2021 Jun 22;2(3):e12476. Epub 2021 Jun 22.

University of Cincinnati College of Medicine Department of Emergency Medicine Cincinnati Ohio USA.

Objective: Therapeutic opioid exposure is associated with long-term use. How much later use is due to opioid use disorder (OUD) and the incidence of OUD without preceding therapeutic exposure are unknown. We preliminarily explored the association between emergency department opioid prescriptions and subsequent OUD.

Methods: This retrospective cohort study queried electronic health records for discharged adult patients in the year before (2014) and after (2016) their first encounter in 2015 at either of 2 EDs in a Midwestern healthcare system. OUD was defined by diagnosis codes and prescription history. Patients with OUD history before the index encounter were excluded. We report OUD incidence within 1 year, with time to first indicator of OUD among those with a repeat health system encounter post index using a Cox proportional hazards model. Secondary outcomes were sources of therapeutic opioid exposure and frequency of risk factors associated with OUD among those who developed OUD.

Results: Of the 49,904 unique, adult ED patients without history of OUD, 669 (1.3%; 95% CI, 1.2-1.4) had health records indicating OUD within 12 months. The proportion of ED patients with OUD at 12 months was 1.5% (95% CI, 1.2-1.9) if prescribed an opioid at index and 1.3% (95% CI, 1.2-1.4) if not. Of the 669 who developed OUD, 80 (12.0%) were prescribed an opioid at the index ED visit, 54 (8%) received an opioid prescription at a subsequent ED visit, and median time to OUD was 4.5 months (interquartile range 1.6-7.6, range 0.0-11.9). When controlling for demographics, mental health, and prior opioid prescriptions, there was no difference in OUD incidence between patients who did or did not receive an initial ED opioid prescription (HR, 1.1; 95% CI, 0.9-1.4).

Conclusions: A small but meaningful proportion of the ED population will develop OUD within 1 year even without ED opioid prescription. Though we found no association between ED opioid prescription and later OUD, further study is warranted given the complexity factors influencing OUD incidence, ongoing ED opioid exposure, and limitations inherent to this study design.
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http://dx.doi.org/10.1002/emp2.12476DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8219283PMC
June 2021

COVID-19 and beyond: Lessons learned from emergency department HIV screening for population-based screening in healthcare settings.

J Am Coll Emerg Physicians Open 2021 Jun 22;2(3):e12468. Epub 2021 Jun 22.

Department of Emergency Medicine University of Cincinnati College of Medicine Cincinnati Ohio USA.

Emergency departments (EDs) have played a major role in the science and practice of HIV population screening. After decades of experience, EDs have demonstrated the capacity to provide testing and linkage to care to large volumes of patients, particularly those who do not otherwise engage the healthcare system. Efforts to expand ED HIV screening in the United States have been accelerated by a collaborative national network of emergency physicians and other stakeholders called EMTIDE (Emergency Medicine Transmissible Infectious Diseases and Epidemics). As the COVID-19 pandemic evolves, EDs nationwide are being tasked with diagnosing and managing COVID-19 in a myriad of capacities, adopting varied approaches based in part on know-how, local disease trends, and the supply chain. The objective of this article is to broadly summarize the lessons learned from decades of ED HIV screening and provide guidance for many analogous issues and challenges in population screening for COVID-19. Over time, and with the accumulated experience from other epidemics, ED screening should develop into an overarching discipline in which the disease in question may vary, but the efficiency of response is increased by prior knowledge and understanding.
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http://dx.doi.org/10.1002/emp2.12468DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8219288PMC
June 2021

Emergency Nurse Perceptions of Pain and Opioids in the Emergency Department.

Pain Manag Nurs 2021 Jun 4. Epub 2021 Jun 4.

Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio; Center for Addiction Research, University of Cincinnati College of Medicine, Cincinnati, Ohio.

The opioid crisis is a national health emergency with immense morbidity, mortality, and socioeconomic cost. Emergency department (ED) pain management is tightly linked to the issue of opioid use disorder (OUD), because opioid exposure is necessary for development of OUD. Emergency nurses are on the frontlines of this complex problem, yet little, if any, attention has been paid to the role they play in the prevention and management of either pain or OUD in this unique and important setting. A framework that conceptualizes and optimizes emergency nurses as change agents in the opioid epidemic is urgently needed. While ED pain management and OUD prevention is dependent on the entire care team, this innovative study qualitatively characterizes emergency nurse perceptions of pain management, OUD prevention, and their potential role in each. Content analysis produced 14 categories that were clustered into two themes, "nurses influence ED pain management" and "adjustments in ED pain management", and an overarching message that "pain management depends on the care team." By generating a more comprehensive and nuanced understanding of the role played by emergency nurses, our findings provide essential insights into potential interventions and frameworks.
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http://dx.doi.org/10.1016/j.pmn.2021.05.003DOI Listing
June 2021

Evaluation of tobacco screening and counseling in a large, midwestern pediatric emergency department.

Tob Prev Cessat 2021 25;7:39. Epub 2021 May 25.

Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, College of Medicine, University of Cincinnati, Cincinnati, United States.

Introduction: The study objective was to assess tobacco screening and cessation counseling practices of pediatric emergency department (PED) and urgent care (UC) nurses and physicians, and factors associated with these practices. Secondarily, we assessed factors associated with performing tobacco smoke exposure reduction and tobacco cessation counseling.

Methods: We conducted a cross-sectional survey of 30 PED/UC nurses and physicians working at one large, urban, Midwestern children's hospital. Measures included current practices of performing the 5 As of tobacco counseling (Ask, Advise, Assess, Assist, Arrange), and attitude and practice factors that may influence practices.

Results: Overall, 90.0% of participants had not received recent tobacco counseling training, 73.3% were unaware of the 5 As, and 63.3% did not have a standardized, routine screening system to identify patients exposed to secondhand smoke. The majority of participants reported that they: asked about patients' secondhand smoke exposure status (70.0%) and parents' tobacco use status (53.3%), and advised parental smokers to not smoke around their child (70.0%) and to quit smoking (50%). One in five participants reported they assessed smokers' interest in quitting smoking, and 16.7% talked with smokers about cessation techniques and tactics; of these, 10% referred/enrolled smokers to the Tobacco Quitline or cessation program, and 6.7% made a quit plan or recommended nicotine replacement therapy medication.

Conclusions: Key findings identified are the need for professional tobacco counseling training, standardizing efforts during visits, and emphasizing pediatric patients' potential health benefits. This information will be used for developing a PED/ UC-based parental tobacco cessation and child tobacco smoke exposure reduction intervention.
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http://dx.doi.org/10.18332/tpc/134751DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8145199PMC
May 2021

HIV detection by an emergency department HIV screening program during a regional outbreak among people who inject drugs.

PLoS One 2021 18;16(5):e0251756. Epub 2021 May 18.

Department of Emergency Medicine, University of Cincinnati Medical Center, Cincinnati, OH, United States of America.

Objective: Multiple HIV outbreaks among persons who inject drugs (PWID) have occurred in the US since 2015. Emergency departments (EDs), recognized as essential venues for HIV screening, may play a unique role in identifying undiagnosed HIV among PWID, who frequently present for complications of injection drug use (IDU). Our objective was to describe changes in HIV diagnoses among PWID detected by an ED HIV screening program and estimate the program's contribution to HIV diagnoses among PWID county-wide during the emergence of a regional HIV outbreak.

Methods: This was a retrospective study of electronically queried clinical records from an urban, safety-net ED's HIV screening program and publicly available HIV surveillance data for its surrounding county, Hamilton County, Ohio. Outcomes included the change in number of HIV diagnoses and the ED's contribution to case identification county-wide, overall and for PWID during 2014-2018.

Results: During 2014-2018, the annual number of HIV diagnoses made by the ED program increased from 20 to 42 overall, and from 1 to 18 for PWID. We estimated that the ED contributed 18% of HIV diagnoses in the county and 22% of diagnoses among PWID.

Conclusions: The ED program contributed 1 in 5 new HIV diagnoses among PWID county-wide, further illustrating the importance of ED HIV screening programs in identifying undiagnosed HIV infections. In areas experiencing increasing IDU, HIV screening in EDs can provide an early indication of increasing HIV diagnoses among PWID and can substantially contribute to case-finding during an HIV outbreak.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0251756PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8130938PMC
May 2021

Estimated proportion of an urban academic emergency department patient population eligible for HIV preexposure prophylaxis.

Am J Emerg Med 2021 May 4;48:198-202. Epub 2021 May 4.

University of Cincinnati, Department of Emergency Medicine, Cincinnati, OH, USA; Center for Addiction Research, University of Cincinnati College of Medicine, Cincinnati, OH, USA. Electronic address:

Objective: Pre-exposure prophylaxis (PrEP) is a highly effective but underutilized method of HIV prevention. Emergency departments (EDs) have access to at-risk populations meeting CDC eligibility criteria for PrEP. Characterizing this population could help motivate, develop, and implement ED interventions to promote PrEP uptake.

Methods: This cross-sectional study explored the proportion of patients from an urban, academic ED who met CDC 2017 PrEP eligibility criteria using three existing datasets that mimic patient selection strategies for HIV screening: 1) study of consecutively approached ED patients from 2008 to 2009 (analogous to non-targeted screening), 2) patients of the ED's HIV screening program in 2017 (analogous to risk-targeted screening), and 3) electronic health record (EHR) diagnostic codes in 2017 (analogous to EHR selected screening). The primary outcome was the proportion eligible for PrEP referral. Secondary outcomes included proportion by risk group: men who have sex with men (MSM), heterosexual men and women (HMW), and persons who inject drugs (PWID).

Results: The proportion eligible for PrEP was: 568/1970 (28.8%, 95% CI: 26.9-30.9) for consecutively approached patients, 552/3884 (14%, 95% CI: 13-15) for risk-targeted patients, and 605/66287 (0.9%, 95% CI: 0.8-1.0) for EHR diagnoses of all patients. For the two datasets with behavioral risk information, the proportion eligible was: MSM 1-2%, HMW 12-28%, and PWID 1-4%.

Conclusions: A large subgroup of this ED population was eligible for PrEP referral. EDs are a compelling setting for development and implementation of HIV prevention interventions to assist in national efforts to expand PrEP.
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http://dx.doi.org/10.1016/j.ajem.2021.04.087DOI Listing
May 2021

Variation in Participation in Nurse-Driven Emergency Department Hepatitis C Screening.

Adv Emerg Nurs J 2021 Apr-Jun 01;43(2):138-144

Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio (Drs Lane, Lyons, and Punches and Ms Ancona); and University of Cincinnati College of Nursing, Cincinnati, Ohio (Punches).

Emergency departments (EDs) are an important potential site for public health screening programs, although implementation of such programs can be challenging. Potential barriers include system-level issues (e.g., funding and time pressures) and individual provider-level issues (e.g., awareness and acceptance). This cross-sectional evaluation of a nurse-driven, triage-based hepatitis C virus (HCV) screening program in an urban, academic ED assessed variation in nurse participation from April to November 2017. For this program, electronic health record (EHR) prompts for HCV screening were integrated into nurses' triage workflow. Process measures evaluating HCV screening participation were abstracted from the EHR for all ED encounters with patient year of birth between 1945 and 1965. Registered nurses who routinely worked in triage and were full-time employees throughout the study period were included for analysis. The primary outcome was the proportion of eligible ED encounters with completed HCV screening, by nurse. Of 14,375 ED encounters, 3,375 (23.5%, 95% confidence interval [CI]: 22.8, 24.2) had completed HCV screening and 1,408 (9.8%, 95% CI: 3.9, 10.3) had HCV screening EHR sections opened by the triage nurse but closed without action; the remainder of encounters had no activity in HCV screening EHR sections. Among the 93 eligible nurses, 22 nurses (24%, 95% CI: 16, 34) completed HCV screening for more than 70% of encounters, whereas 10 nurses (11%, 95% CI: 6, 19) never completed HCV screening. The proportion of eligible encounters with completed HCV screening was 11.0% higher (95% CI: 9.8, 12.6) for encounters seen between 7 a.m. and 7 p.m. than between 7 p.m. and 7 a.m. (27.5% and 16.3%, respectively). In conclusion, wide variation in individual nurse participation in HCV screening suggests individual-level barriers are a more significant barrier to ED screening than previously recognized. Implementation research should expand beyond questions of resource availability and procedural streamlining to evaluate and address staff knowledge, beliefs, attitudes, and motivation.
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http://dx.doi.org/10.1097/TME.0000000000000349DOI Listing
September 2021

The synthetic opioid fentanyl enhances viral replication in vitro.

PLoS One 2021 14;16(4):e0249581. Epub 2021 Apr 14.

Division of Digestive Diseases, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, United States of America.

The US is in the midst of a major drug epidemic fueled in large part by the widespread recreational use of synthetic opioids such as fentanyl. Persons with opioid use disorder are at significant risk for transmission of injection-associated infections such as hepatitis B virus (HBV) and hepatitis C virus (HCV). Commonly abused substances may antagonize immune responses and promote viral replication. However, the impact of synthetic opioids on virus replication has not been well explored. Thus, we evaluated the impact of fentanyl and carfentanil using in vitro systems that replicate infectious viruses. Fentanyl was used in cell lines replicating HBV or HCV at concentrations of 1 ng, 100 ng, and 10 ug. Viral protein synthesis was quantified by ELISA, while apoptosis and cell death were measured by M30 or MTT assays, respectively. HCV replicative fitness was evaluated in a luciferase-based system. RNAseq was performed to evaluate cellular gene regulation in the presence of fentanyl. Low dose fentanyl had no impact on HCV replication in Huh7.5JFH1 hepatocytes; however, higher doses significantly enhanced HCV replication. Similarly, a dose-dependent increase in HCV replicative fitness was observed in the presence of fentanyl. In the HepG2.2.15 hepatocyte cell line, fentanyl caused a dose-dependent increase in HBV replication, although only a higher doses than for HCV. Addition of fentanyl resulted in significant apoptosis in both hepatocyte cell lines. Cell death was minimal at low drug concentrations. RNAseq identified a number of hepatocyte genes that were differentially regulated by fentanyl, including those related to apoptosis, the antiviral / interferon response, chemokine signaling, and NFκB signaling. Collectively, these data suggest that synthetic opioids promote viral replication but may have distinct effects depending on the drug dose and the viral target. As higher viral loads are associated with pathogenesis and virus transmission, additional research is essential to an enhanced understanding of opioid-virus pathogenesis and for the development of new and optimized treatment strategies.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0249581PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8046189PMC
September 2021

Healthcare resources attributable to child tobacco smoke exposure.

PLoS One 2021 23;16(2):e0247179. Epub 2021 Feb 23.

Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, College of Medicine, University of Cincinnati, Cincinnati, Ohio, United States of America.

Background: Tobacco smoke exposure (TSE) places an economic toll on the U.S. healthcare system. There is a gap in the literature on pediatric emergency department (ED) and urgent care related healthcare costs and utilization specific to tobacco smoke-exposed patients. The objectives were to assess pediatric ED visits, urgent care visits and hospital admissions longitudinally, and baseline visit costs among tobacco smoke-exposed children (TSE group) relative to unexposed children (non-TSE group).

Methods And Findings: We conducted a retrospective study using electronic medical records of 380 children ages 0-17 years in the TSE group compared to 1,140 in the non-TSE group propensity score matched via nearest neighbor search by child age, sex, race, and ethnicity. Linear and Poisson regression models were used. Overall, children had a mean of 0.19 (SE = 0.01) repeat visits within 30-days, and 0.69 (SE = 0.04) pediatric ED visits and 0.87 (SE = 0.03) urgent care visits over 12-months following their baseline visit. The percent of children with ≥ 1 urgent care visit was higher among the TSE group (52.4%) than the non-TSE group (45.1%, p = 0.01). Children in the TSE group (M = $1,136.97, SE = 76.44) had higher baseline pediatric ED visit costs than the non-TSE group (M = $1,018.96, SE = 125.51, p = 0.01). Overall, children had 0.08 (SE = 0.01) hospital admissions over 12-months, and the TSE group (M = 0.12, SE = 0.02) had higher mean admissions than the non-TSE group (M = 0.06, SE = 0.01, p = 0.02). The child TSE group was at 1.85 times increased risk of having hospital admissions (95% CI = 1.23, 2.79, p = 0.003) than the non-TSE group.

Conclusions: Tobacco smoke-exposed children had higher urgent care utilization and hospital admissions over 12-months, and higher pediatric ED costs at baseline. Pediatric ED visits, urgent care visits, and hospitalizations may be opportune times for initiating tobacco control interventions, which may result in reductions of preventable acute care visits.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0247179PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7901732PMC
August 2021

Emergency department patients with untreated opioid use disorder: A comparison of those seeking versus not seeking referral to substance use treatment.

Drug Alcohol Depend 2021 02 26;219:108428. Epub 2020 Nov 26.

Yale School of Medicine, Department of Emergency Medicine, New Haven, CT, USA; Yale Program in Addiction Medicine, New Haven, CT, USA.

BACKGROUND Little is known regarding the sociodemographic and clinical characteristics of emergency department (ED) patients with untreated opioid use disorder (OUD) and the relationship of those characteristics with whether they were seeking a referral to substance use treatment at the time of their ED visit. METHODS Using data collected from 2/2017-1/2019 from participants enrolled in Project ED Health (CTN-0069), we conducted a cross-sectional analysis of patients with untreated moderate to severe OUD presenting to one of four EDs in Baltimore, New York City, Cincinnati, or Seattle. Sociodemographic and clinical correlates, and International Classification of Diseases Tenth Revision (ICD-10) diagnosis codes related to opioid withdrawal, injection-related infection, other substance use, overdose, and OUD of those seeking and not seeking a referral to substance use treatment on presentation were compared using univariate analyses. RESULTS Among 394 study participants, 15.2 % (60/394) came to the ED seeking a referral to substance use treatment. No differences in age, gender, education, health insurance status or housing stability were detected between those seeking and not seeking referral to substance use treatment. Those seeking a referral to substance use treatment were less likely to have urine toxicology testing positive for amphetamine [17 % (10/60) vs 31 % (104/334), p = 0.023] and methamphetamine [23 % (14/60) vs 40 % (132/334), p = 0.017] compared to those not seeking a referral. CONCLUSION Most patients with untreated OUD seen in the EDs were not seeking a referral to substance use treatment. Active identification, treatment initiation, and coding may improve ED efforts to address untreated OUD.
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http://dx.doi.org/10.1016/j.drugalcdep.2020.108428DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8110210PMC
February 2021

Naloxone provision to emergency department patients recognized as high-risk for opioid use disorder.

Am J Emerg Med 2021 02 11;40:173-176. Epub 2020 Nov 11.

Dept. of Emergency Medicine, Univ. of Cincinnati College of Medicine, Cincinnati, OH, United States of America. Electronic address:

Introduction: Patients with opioid use disorder (OUD) are at increased risk for overdose and death. Clinical practice guidelines and professional organization policy statements recommend providing naloxone to patients at risk for overdose. We sought to characterize fidelity to naloxone practice recommendations in a cohort of Emergency Department (ED) patients in whom opioid use disorder was suspected by the treating physician.

Methods: This single-center cross-sectional study evaluated electronic health records from an urban academic ED with 73,000 annual encounters in a region with a high prevalence of OUD. Patients ≥18 years old with encounters from January 1, 2018 to November 30, 2019 were included if discharged from the ED and either administered buprenorphine in the ED or referred to outpatient substance use treatment. The primary outcome measure was the percentage of included patients provided naloxone (take-home or prescription). We used random effects multivariable logistic regression (accounting for multiple patient encounters) to estimate the odds ratio (OR) for receiving naloxone.

Results: Of 1036 eligible patient encounters, 320 resulted in naloxone provision (30.9%, 95% CI: 28.1-33.8). Naloxone provision occurred for 33.6% (95% CI 30.5-36.7) of 900 patients referred to outpatient substance use treatment without ED buprenorphine administration, 10.6% (95% CI 5.0-19.2) of 85 patients administered buprenorphine and not referred to outpatient substance use treatment, and 17.6% (95% CI 8.4-30.9) of 51 patients administered buprenorphine and referred to outpatient treatment. After controlling for age, sex, race, and prior provision of naloxone, the administration of buprenorphine was associated with a 94% lower odds (aOR = 0.06 [95% CI 0.011-0.33]) for naloxone provision compared to those only referred to outpatient treatment.

Conclusion: A majority of ED patients who received an intervention targeted at OUD, in an ED where take-home naloxone is freely available, did not receive either take-home naloxone or a prescription for naloxone at discharge. Patients receiving buprenorphine were less likely to receive naloxone than patients only referred to outpatient treatment. These data suggest barriers other than recognition of potential OUD and naloxone availability impact provision of naloxone and argue for a treatment "bundle" as a conceptual model for care of ED patients with suspected OUD.
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http://dx.doi.org/10.1016/j.ajem.2020.10.061DOI Listing
February 2021

Clarifying the volume of estimated need for public health and prevention services within an emergency department population.

J Am Coll Emerg Physicians Open 2020 Oct 23;1(5):845-851. Epub 2020 Jul 23.

Department of Emergency Medicine University of Cincinnati College of Medicine Cincinnati Ohio USA.

Objectives: Emergency departments (EDs) are called to implement public health and prevention initiatives, such as infectious disease screening. The perception that ED resources are insufficient is a primary barrier. Resource needs are generally conceptualized in terms of total number of ED encounters, without formal calculation of the number of encounters for which a service is required. We illustrate potential differences in the estimated volume of service need relative to ED census using the examples of HIV and hepatitis C (HCV) screening.

Methods: This cross-sectional analysis adjusted the proportion of ED encounters in which patients are eligible for HIV and HCV screening according to a cascade of successively more restrictive patient selection criteria, presuming full implementation of each criterion. Parameter estimates for the proportion satisfying each selection criterion were derived from the electronic health records of an urban academic facility and its ED HIV and HCV screening program during 2 time periods. The primary outcome was the estimated reduction in proportion of ED visits eligible for screening after application of the entire cascade.

Results: There were 76,104 ED encounters during the study period. Applying all selection criteria reduced the number of required screens by 97.1% (95% confidence interval, 97.0-97.2) for HIV and 86.1% (95% confidence interval, 85.9-86.3) for HCV.

Conclusions: Using the example of HIV and HCV screening, the application of eligibility metrics reduces the volume of service need to a smaller, more feasible number than estimates from ED census alone. This approach might be useful for clarifying perceived service need and guiding operational planning.
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http://dx.doi.org/10.1002/emp2.12168DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7593451PMC
October 2020

Evaluation of low-intensity initiatives to improve linkage to care for emergency department patients with opioid use disorder.

Am J Emerg Med 2020 11 7;38(11):2391-2394. Epub 2020 Sep 7.

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

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http://dx.doi.org/10.1016/j.ajem.2020.09.007DOI Listing
November 2020

Evaluation of a personally-tailored opioid overdose prevention education and naloxone distribution intervention to promote harm reduction and treatment readiness in individuals actively using illicit opioids.

Drug Alcohol Depend 2020 11 31;216:108265. Epub 2020 Aug 31.

Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH 45229, USA; Center for Addiction Research, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH 45267, USA.

Background: Opioid overdose prevention education and naloxone distribution (OEND) programs include information on general risk factors, overdose recognition, and naloxone utilization. This study evaluated a personally-tailored OEND (PTOEND) intervention designed to promote harm reduction and treatment readiness for illicit opioid users by also including education about personal overdose-risk factors and medication for opioid use disorder (MOUD).

Method: A secondary analysis of a randomized controlled trial testing a Peer recovery support service (PRSS) intervention, relative to Control, in adult illicit opioid users reporting treatment for an overdose in the prior 6 months. PTOEND, a 30-minute computer-guided intervention, was administered by a research assistant at the randomization visit to all participants (N = 80). Participants completed a telephone visit 3 weeks post-randomization (n = 74) to assess changes in opioid overdose/MOUD knowledge and treatment readiness. Participants completed in-person visits at 3 (n = 66), 6 (n = 58), and 12 (n = 44) months post-randomization to assess illicit opioid use and naloxone utilization (all time points) and overdose-risk behaviors (12 months). We conducted pre-post analyses of the impact of PTOEND controlling for the PRSS effect.

Results: PTOEND increased knowledge of overdose (79.8% to 81.5%, p < 0.05) and MOUD (66.9% to 75.0%, p < 0.01) and decreased perceived treatment barriers (2.1 to 1.9, p < 0.01); desire to quit all substances increased (7.2 to 7.8, p = 0.05). Self-reported opioid use was significantly decreased at each follow-up (all p < 0.01). Self-reported overdose-risk behaviors decreased significantly (6.2 to 2.4, p < 0.01). A majority of participants (65 %) reported naloxone utilization.

Conclusions: PTOEND may be effective for promoting harm reduction and treatment readiness.
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http://dx.doi.org/10.1016/j.drugalcdep.2020.108265DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7458095PMC
November 2020

A brief telephone-delivered peer intervention to encourage enrollment in medication for opioid use disorder in individuals surviving an opioid overdose: Results from a randomized pilot trial.

Drug Alcohol Depend 2020 11 1;216:108270. Epub 2020 Sep 1.

Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH, 45229, USA; Center for Addiction Research, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH 45267, USA.

Background: Medication for opioid use disorder (MOUD) can decrease the risk of opioid overdose (OOD) in individuals with opioid use disorder. Peer recovery support services (PRSS) are increasingly used to promote MOUD engagement but evidence of their efficacy is limited. This study's objective was to evaluate a single 20-minute telephone-delivered PRSS intervention for increasing MOUD enrollment and decreasing recurring OODs.

Method: This single-site, randomized controlled pilot trial enrolled adults, primarily recruited from a syringe service program, with an opioid-positive urine drug screen (UDS) reporting having been treated for an OOD within the past 6 months. Participants (N = 80) were randomized to PRSS (n = 40) or Control (n = 40) condition with all participants receiving personally-tailored OOD education and naloxone. Outcome measures obtained at 3 (n = 66), 6 (n = 58), and 12 (n = 44) months post-randomization included verified MOUD enrollment (primary), self-reported OOD, and opioid use assessed by self-report and UDS.

Results: Through 12-month follow-up, 32.5 % of PRSS, compared to 17.5 % of Control participants enrolled in MOUD (X = 2.4, p = 0.12; odds ratio = 2.27 (0.79-6.49)). PRSS participants were significantly less likely to have experienced an OOD through 12-month follow-up (12.5 % of PRSS participants, 32.5 % of Control, p = 0.03). No significant treatment effect was found for opioid use through 12-month follow-up as measured by either opioid-positive UDSs or self-reported past month opioid use days. Based on self-report, PRSS had good acceptability for both the interventionists and participants.

Conclusions: The results suggest that further development and testing of this PRSS telephone intervention to encourage MOUD enrollment and reduce OOD may be warranted.
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http://dx.doi.org/10.1016/j.drugalcdep.2020.108270DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7462596PMC
November 2020

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

Emergency Nurse Perceptions of Naloxone Distribution in the Emergency Department.

J Emerg Nurs 2020 Sep;46(5):675-681.e1

Introduction: Emergency department encounters are an opportunity to distribute naloxone kits to patients at risk of opioid overdose. Several programs cite mixed uptake and implementation barriers including staff education and burden. Emergency nurses can facilitate many approaches to naloxone distribution (eg, prescription, overdose education, dispensing take-home naloxone). To evaluate acceptance, we investigated nurse perceptions about take-home naloxone, describing potential barriers to program implementation.

Methods: This qualitative study enrolled 17 emergency nurses from an urban trauma center emergency department and affiliated community emergency department. During the study period, nurses in both sites could distribute take-home naloxone kits stocked in the medication dispensing system. We conducted 12 individual, in-depth interviews and 3 distinct focus groups involving 12 nurses in aggregate. A semistructured interview guide was used with a range of topics surrounding pain management, addiction, opioid overdose, and emergency care. We employed conventional content analysis to enable thematic analysis of transcripts.

Results: Six component themes emerged as part of the overarching theme "mixed feelings about naloxone-morally distressing." One positive theme identified naloxone as an opportunity for discussion. Negative themes included (1) Addiction is a choice, why can't we help other diseases? It's unfair; (2) Providing naloxone enables and condones the behavior; (3) Emergency departments cannot treat social issues; (4) Patients can't give it to themselves; it's wasting money; and (5) Moral distress.

Discussion: Perceptions and moral distress may be a barrier to ED-based take-home naloxone programs. Development of interventions targeting naloxone misperceptions and addiction stigma should be a goal of expanded implementation efforts.
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http://dx.doi.org/10.1016/j.jen.2020.05.006DOI Listing
September 2020

Use of Amphetamine-Type Stimulants Among Emergency Department Patients With Untreated Opioid Use Disorder.

Ann Emerg Med 2020 12 8;76(6):782-787. Epub 2020 Aug 8.

Yale School of Medicine, Department of Emergency Medicine, New Haven, CT; Yale School of Public Health, New Haven, CT.

Study Objective: Concurrent use of amphetamine-type stimulants among individuals with opioid use disorder can exacerbate social and medical harms, including overdose risk. The study evaluated rates of amphetamine-type stimulant use among patients with untreated opioid use disorder presenting at emergency departments in Baltimore, MD; New York, NY; Cincinnati, OH; and Seattle, WA.

Methods: Emergency department (ED) patients with untreated opioid use disorder (N=396) and enrolled between February 2017 and January 2019 in a multisite hybrid type III implementation science study were evaluated for concurrent amphetamine-type stimulant use. Individuals with urine tests positive for methamphetamine, amphetamine, or both were compared with amphetamine-type stimulant-negative patients.

Results: Overall, 38% of patients (150/396) were amphetamine-type stimulant positive; none reported receiving prescribed amphetamine or methamphetamine medications. Amphetamine-type stimulant-positive versus -negative patients were younger: mean age was 36 years (SD 10 years) versus 40 years (SD 12 years), 69% (104/150) versus 46% (114/246) were white, 65% (98/150) versus 54% (132/246) were unemployed, 67% (101/150) versus 49 (121/246) had unstable housing, 47% (71/150) versus 25% (61/245) reported an incarceration during 1 year before study admission, 60% (77/128) versus 45% (87/195) were hepatitis C positive, 79% (118/150) versus 47% (115/245) reported drug injection during 1 month before the study admission, and 42% (62/149) versus 29% (70/244) presented to the ED for an injury. Lower proportions of amphetamine-type stimulant-positive patients had cocaine-positive urine test results (33% [50/150] versus 52% [129/246]) and reported seeking treatment for substance use problems as a reason for their ED visit (10% [14/148] versus 19% [46/246]). All comparisons were statistically significant at P<.05 with the false discovery rate correction.

Conclusion: Amphetamine-type stimulant use among ED patients with untreated opioid use disorder was associated with distinct sociodemographic, social, and health factors. Improved ED-based screening, intervention, and referral protocols for patients with opioid use disorder and amphetamine-type stimulant use are needed.
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http://dx.doi.org/10.1016/j.annemergmed.2020.06.046DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8048036PMC
December 2020

Identifying ED patients with previous abnormal HIV or hepatitis C test results who may require additional services.

Am J Emerg Med 2020 09 11;38(9):1831-1833. Epub 2020 May 11.

University of Cincinnati College of Medicine, Department of Emergency Medicine, Medical Sciences Building Room 1654, 231 Albert Sabin Way, PO Box 670769, Cincinnati, OH 45267-0769, United States of America. Electronic address:

Objectives: Routine emergency department (ED) HIV or HCV screening may inadvertently capture patients already diagnosed but does not specifically prioritize identification of this group. Our objective was to preliminarily estimate the volume of this distinct group in our ED population through a pilot electronic health record (EHR) build that identified all patients with indications of HIV or HCV in their EHR at time of ED presentation.

Methods: Cross-sectional study of an urban, academic ED's HIV/HCV program for previously diagnosed patients August 2017-July 2018. Prevention program staff, alerted by the EHR, reviewed records and interviewed patients to determine if confirmatory testing or linkage to care was needed. Primary outcome was total proportion of ED patients for whom the EHR generated an alert. Secondary outcome was the proportion of patients assessed by program staff who required confirmatory testing or linkage to HIV/HCV medical care.

Results: There were 65,374 ED encounters with 5238 (8.0%, 95% CI: 7.8%-8.2%) EHR alerts. Of these, 3741 were assessed by program staff, with 798 (21%, 95% CI: 20%-23%) requiring HIV/HCV confirmatory testing or linkage to care services, 163 (20%) for HIV, 551 (69%) for HCV, and 84 (11%) for both HIV and HCV services.

Conclusions: Patients with existing indication of HIV or HCV infection in need of confirmatory testing or linkage to care were common in this ED. EDs should prioritize identifying this population, outside of routine screening, and intervene similarly regardless of whether the patient is newly or previously diagnosed.
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http://dx.doi.org/10.1016/j.ajem.2020.05.020DOI Listing
September 2020

Child tobacco smoke exposure and healthcare resource utilization patterns.

Pediatr Res 2020 10 6;88(4):571-579. Epub 2020 Jun 6.

Cincinnati Children's Hospital Medical Center, Division of Emergency Medicine, College of Medicine, University of Cincinnati, 3333 Burnet Avenue, MLC 2008, Cincinnati, OH, 45229, USA.

Background: The objective was to examine the relationship between healthcare resource utilization patterns in tobacco smoke-exposed children (TSE group) compared with unexposed children (non-TSE group).

Methods: We matched 380 children in the TSE group with 1140 children in the non-TSE group based on child age, sex, race, and ethnicity using propensity scores. Healthcare resource utilization variables included respiratory-related procedures, diagnostic testing, disposition, and medications. Logistic and linear regression models were built.

Results: Child mean age was 4.9 (SD = 0.1) years, 50.5% were female, 55.5% black, and 73.2% had public insurance/self-pay. Compared to the non-TSE group, the TSE group was at increased odds to have the following performed/obtained: nasal bulb suctioning, infectious diagnostic tests, laboratory tests, and radiologic tests. The TSE group was more likely to be admitted to the hospital, and more likely to receive steroids and intravenous fluids during their visit. Among asthmatics, the TSE group was more likely to receive steroids, albuterol, or ipratropium alone, or a combination of all three medications during their visit, and be prescribed albuterol alone or steroids and albuterol.

Conclusion: Tobacco smoke-exposed children are more likely to have higher resource utilization patterns, highlighting the importance of screening and providing TSE prevention and remediation interventions.

Impact: Tobacco smoke exposure may affect the healthcare resource utilization patterns of children. Evidence is lacking concerning these associations among the highly vulnerable pediatric emergency department patient population. This study examined the association between tobacco smoke exposure and healthcare resource utilization patterns among pediatric emergency department patients. Tobacco smoke exposure increased the risk of pediatric patients having respiratory-related procedures, respiratory-related and non-respiratory-related testing, medications administered during the pediatric emergency department visit, and medications prescribed for home administration. Tobacco smoke-exposed patients were more likely to be admitted to the hospital compared to unexposed patients.
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http://dx.doi.org/10.1038/s41390-020-0997-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7529841PMC
October 2020

Barriers and Facilitators to Clinician Readiness to Provide Emergency Department-Initiated Buprenorphine.

JAMA Netw Open 2020 05 1;3(5):e204561. Epub 2020 May 1.

Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut.

Importance: Treatment of opioid use disorder (OUD) with buprenorphine decreases opioid use and prevents morbidity and mortality. Emergency departments (EDs) are an important setting for buprenorphine initiation for patients with untreated OUD; however, readiness varies among ED clinicians.

Objective: To characterize barriers and facilitators of readiness to initiate buprenorphine for the treatment of OUD in the ED and identify opportunities to promote readiness across multiple clinician types.

Design, Setting, And Participants: Using data collected from April 1, 2018, to January 11, 2019, this mixed-methods formative evaluation grounded in the Promoting Action on Research Implementation in Health Services framework included 4 geographically diverse academic EDs. Attending physicians (n = 113), residents (n = 107), and advanced practice clinicians (APCs) (n = 48) completed surveys electronically distributed to all ED clinicians (n = 396). A subset of participants (n = 74) also participated in 1 of 11 focus group discussions. Data were analyzed from June 1, 2018, to February 22, 2020.

Main Outcomes And Measures: Clinician readiness to initiate buprenorphine and provide referral for ongoing treatment for patients with OUD treated in the ED was assessed using a visual analog scale. Responders (268 of 396 [67.7%]) were dichotomized as less ready (scores 0-6) or most ready (scores 7-10). An ED-adapted Organizational Readiness to Change Assessment (ORCA) and 11 focus groups were used to assess ratings and perspectives on evidence and context-related factors to promote ED-initiated buprenorphine with referral for ongoing treatment, respectively.

Results: Among the 268 survey respondents (153 of 260 were men [58.8%], with a mean [SD] of 7.1 [9.8] years since completing formal training), 56 (20.9%) indicated readiness to initiate buprenorphine for ED patients with OUD. Nine of 258 (3.5%) reported Drug Addiction Treatment Act of 2000 training completion. Compared with those who were less ready, clinicians who were most ready to initiate buprenorphine had higher mean scores across all ORCA Evidence subscales (3.50 [95% CI, 3.35-3.65] to 4.33 [95% CI, 4.13-4.53] vs 3.11 [95% CI, 3.03-3.20] to 3.60 [95% CI, 3.49-3.70]; P < .001) and on the Slack Resources of the ORCA Context subscales (3.32 [95% CI, 3.08-3.55] vs 3.0 [95% CI, 2.87-3.12]; P = .02). Barriers to ED-initiated buprenorphine included lack of training and experience in treating OUD with buprenorphine, concerns about ability to link to ongoing care, and competing needs and priorities for ED time and resources. Facilitators to ED-initiated buprenorphine included receiving education and training, development of local departmental protocols, and receiving feedback on patient experiences and gaps in quality of care.

Conclusions And Relevance: Only a few ED clinicians had a high level of readiness to initiate buprenorphine; however, many expressed a willingness to learn with sufficient supports. Efforts to promote adoption of ED-initiated buprenorphine will require clinician and system-level changes.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.4561DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7215257PMC
May 2020

Exploring Current Stereotypes and Norms Impacting Sexual Partner HIV-Status Communication.

Health Commun 2020 10 30;35(11):1376-1385. Epub 2019 Jun 30.

Department of Emergency Medicine, University of Cincinnati.

This study sought to explore HIV-related stereotypes and norms that impact HIV-status communication with potential sexual partners. A series of focus groups and in-depth interviews were conducted (N = 59) with HIV-positive and HIV-negative MSM (75%) and Heterosexuals (25%). Findings indicate that HIV stereotypes and stigma remain as barriers to HIV-status discussion. Differences also emerged across groups: 1) HIV-negative MSM were more likely to report engaging in HIV-status communication, 2) HIV-positive MSM described inconsistent HIV-status communication and reported concealing their status at times, and 3) Heterosexuals reported being least likely to engage in HIV-status communication; often using the blanket question "Are you clean?" to encompass all STIs and avoiding direct HIV-status discussion. Overall, findings indicate that many HIV stereotypes and stigma-related communication norms persist that discourage discussion of sexual partners' HIV-status prior to sexual activity.
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http://dx.doi.org/10.1080/10410236.2019.1636340DOI Listing
October 2020

Synthetic Opioid Use and Common Injection-associated Viruses: Expanding the Translational Research Agenda.

Curr HIV Res 2019 ;17(2):94-101

Department of Emergency Medicine, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267, United States.

The US is in the midst of a major epidemic of opioid addiction and related comorbidities. People with opioid use disorder (OUD) are at significant risk for transmission of several blood-borne pathogens including the human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV). Commonly abused opioids and their receptors promote viral replication and virus-mediated pathology. However, most studies demonstrating an adverse effect of drugs of abuse have been conducted in vitro, the specific effects of synthetic opioids on viral replication have been poorly characterized, and the evaluation of opioid-virus interactions in clinically relevant populations is rare. Rigorous characterization of the interactions among synthetic opioids, host cells, and common injection-associated viral infections will require an interdisciplinary research approach and translational studies conducted on humans. Such research promises to improve clinical management paradigms for difficult-to-treat populations, facilitate rational public health policies given severely strained resources, and reveal additional pathways for novel target-specific therapeutic interventions. This mini-review examines the published literature on the effects of opioids on HIV, HBV, and HCV pathogenesis and proposes a series of scientific questions and considerations to establish a translational research agenda focused on opioid-virus interactions.
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http://dx.doi.org/10.2174/1570162X17666190618154534DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6756949PMC
February 2020

Emergency Physicians' Perception of Barriers and Facilitators for Adopting an Opioid Prescribing Guideline in Ohio: A Qualitative Interview Study.

J Emerg Med 2019 Jan 17;56(1):15-22. Epub 2018 Oct 17.

Ohio Department of Health, Columbus, Ohio.

Background: Ohio has the fifth highest rate of prescription opioid overdose deaths in the United States. One strategy implemented to address this concern is a state-wide opioid prescribing guideline in the emergency department (ED).

Objective: Our aim was to explore emergency physicians' perceptions on barriers and strategies for the Ohio ED opioid prescribing guideline.

Methods: Semi-structured interviews with emergency physicians in Ohio were conducted from October to December 2016. Emergency physicians were recruited through the American College of Emergency Physicians Ohio State Chapter. The interview guide explored issues related to the implementation of the guidelines. Interview data were transcribed and thematically analyzed and coded using a scheme of inductively determined labels.

Results: In total, we conducted 20 interviews. Of these, 11 were also the ED medical director at their institution. Main themes we identified were: 1) increased organizational responsibility, 2) improved prescription drug monitoring program (PDMP) integration, 3) concerns regarding patient satisfaction scores, and 4) increased patient involvement. In addition, some physicians wanted the guidelines to contain more clinical information and be worded more strongly against opioid prescribing. Emergency physicians felt patient satisfaction scores were perceived to negatively impact opioid prescribing guidelines, as they may encourage physicians to prescribe opioids. Furthermore, some participants reported that this is compounded if the emergency physicians' income was linked to their patient satisfaction score.

Conclusions: Emergency physicians interviewed generally supported the state-wide opioid prescribing guideline but felt hospitals needed to take additional organizational responsibility for addressing inappropriate opioid prescribing.
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http://dx.doi.org/10.1016/j.jemermed.2018.09.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6549497PMC
January 2019

Statewide cross-sectional survey of emergency departments' adoption and implementation of the Ohio opioid prescribing guidelines and opioid prescribing practices.

BMJ Open 2018 06 30;8(6):e020477. Epub 2018 Jun 30.

Ohio Department of Health, Columbus, Ohio, USA.

Study Objective: To evaluate the implementation of the Ohio Emergency and Acute Care Facility Opioids and Other Controlled Substances Prescribing Guidelines and their perceived impact on local policies and practice.

Methods: The study design was a cross-sectional survey of emergency department (ED) medical directors, or appropriate person identified by the hospital, perception of the impact of the Ohio ED Opioid Prescribing Guidelines on their departments practice. All hospitals with an ED in Ohio were contacted throughout October and November 2016. Distribution followed Dillman's Tailored Design Method, augmented with telephone recruitment. Hospital chief executive officers were contacted when necessary to encourage ED participation. Descriptive statistics were used to assess the impact of opioid prescribing policies on prescribing practices.

Results: A 92% response rate was obtained (150/163 EDs). In total, 112 (75%) of the respondents stated that their ED has an opioid prescribing policy, is adopting one or is implementing prescribing guidelines without a specific policy. Of these 112 EDs, 81 (72%) based their policy on the Ohio ED Opioid Prescribing Guidelines. The majority of respondents strongly agreed/agreed that the prescribing guidelines have increased the use of the prescription drug monitoring programme (86%) and have reduced inappropriate opioid prescribing (71%).

Conclusion: This study showed that the Ohio ED Opioid Prescribing Guidelines have been widely disseminated and that the majority of EDs in Ohio are using them to develop local policies. The majority of respondents believed that the Ohio opioid prescribing guidelines reduced inappropriate opioid prescribing. However, prescribing practices still varied greatly between EDs.
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http://dx.doi.org/10.1136/bmjopen-2017-020477DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6042556PMC
June 2018

Impact of a low intensity and broadly inclusive ED care coordination intervention on linkage to primary care and ED utilization.

Am J Emerg Med 2018 12 5;36(12):2219-2224. Epub 2018 Apr 5.

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

Objective: We aim to evaluate the effectiveness of a broadly inclusive, comparatively low intensity intervention linking ED patients to a primary care home.

Methods: This retrospective cohort study evaluated ED patients referred for primary care linkage in a large, urban, academic ED. A care coordination specialist performed a brief interview to gauge access barriers and provide a clinic referral with optional scheduling assistance. Data were abstracted from program records and the electronic medical record. The primary outcome was the proportion of referred individuals who attended at least one primary care appointment. Secondary outcomes included return ED encounters within one year, and factors associated with linkage outcomes.

Results: There were 2142 referrals made for 2064 patients; 1688/2142 accepted assistance. Linkage was successful for 1059/1688 (63%, CI95 60% to 65%). Among patients accepting assistance, those without successful linkage were younger (41 vs 45years, difference 3years, CI95 2 to 3), more often male (62% vs 55%,difference 7%, CI95 2% to 12%), and less likely to have a chronic medical condition (37% vs 45%, difference 8%; CI95 3% to 12%) or to have had an appointment scheduled within two weeks (26% vs 33%, difference 7%, CI95 2% to 12%). Insurance status and self-reported barriers to care were not associated with linkage success. Patterns of subsequent ED use were similar, regardless of referral status or linkage outcome.

Conclusion: Low intensity, broadly inclusive, ED care coordination linked nearly 50% of patients referred for intervention, and two-thirds of willing participants, with a primary care home.
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http://dx.doi.org/10.1016/j.ajem.2018.04.005DOI Listing
December 2018
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