Publications by authors named "Rachel Haroz"

11 Publications

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Buprenorphine use and disparities in access among emergency department patients with opioid use disorder: A cross-sectional study.

J Subst Abuse Treat 2021 Apr 20;130:108405. Epub 2021 Apr 20.

Cooper Medical School of Rowan University, 401 Broadway, Camden, NJ 08103, United States of America; Cooper University Hospital, Department of Emergency Medicine, Keleman 152, 1 Cooper Plaza, Camden, NJ 08103, United States of America. Electronic address:

Background: Buprenorphine, a partial mu-opioid agonist and kappa-opioid antagonist, is an approved treatment for opioid use disorder (OUD). Studies demonstrate that buprenorphine decreases cravings for other opioids, effectively ameliorates withdrawal symptoms, and decreases opioid overdose and mortality. However, buprenorphine remains under-utilized. Despite its low potential for misuse, research has reported wide use of non-prescribed buprenorphine, seemingly for its effectiveness in treating withdrawal and helping to maintain sobriety. We designed our study to describe patient experiences with both prescribed and non-prescribed buprenorphine usage and to identify potential disparities in buprenorphine access within a high-risk population of patients with OUD.

Methods: This was a cross-sectional study conducted in the emergency department (ED) of a large inner-city university hospital from January 15, 2015, through April 30, 2018. Patients were eligible to participate in the study if they presented with opioid intoxication or after an opioid overdose and were 18 years of age or older. Research assistants administered surveys after the ED team deemed an eligible patient to be clinically sober.

Results: The study enrolled 423 patients. Most patients in this study were white (59.8%) and male (77.5%), with a mean age of 37.5 years. A majority of patients (58.4%) had Medicaid insurance. Of those, 15.8% had previously been on medication for opioid use disorder (MOUD) with methadone, and 16.3% received outpatient buprenorphine. Most (72.8%, 95% CI 68.6-77.0%) respondents reported having used buprenorphine at one point. Of the participants reporting prior buprenorphine use, 15.5% had either traded, shared, or sold their buprenorphine in the past. Patients who obtained non-prescribed buprenorphine generally purchased it from a dealer, took only 8 mg at a time, and paid $10 per dose. Of those patients with a history of using buprenorphine, only 3.2% reported taking buprenorphine for euphoric effects, though 45.5% of participants declined to provide a specific reason for using the drug. Patients younger than 40 were more likely than those older than 40 to have taken buprenorphine in the past (81% vs 60%, p < 0.001). Further, white patients were more likely than nonwhite patients to have both used (42% vs 31%) and been prescribed buprenorphine (46% vs 25%, p < 0.001).

Discussion: Familiarity with buprenorphine is high among patients with OUD, and our data show that there is a strong demand among these patients for access to legal buprenorphine-based treatment programs. However, a variety of issues hamper access to this medication. Most patients in our study reported having been to an in-patient detox or rehabilitation program, yet only 16% of patients participated in a buprenorphine-based program. Furthermore, less than half of patients surveyed (37%) received a prescription for buprenorphine, and few participants reported taking buprenorphine for euphoric effects. Our findings suggest that a major barrier exists in legally obtaining buprenorphine for treatment of OUD, and that there appear to be racial and other disparities in buprenorphine prescribing, further limiting access to patients. Buprenorphine access needs to be expanded to satisfy the unmet need for appropriate treatment of those struggling with OUD, with particular attention to older and nonwhite patients.
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http://dx.doi.org/10.1016/j.jsat.2021.108405DOI Listing
April 2021

The Genomics of Opioid Addiction Longitudinal Study (GOALS): study design for a prospective evaluation of genetic and non-genetic factors for development of and recovery from opioid use disorder.

BMC Med Genomics 2021 01 7;14(1):16. Epub 2021 Jan 7.

Cooper University Health Care, 1 Cooper Plaza, Camden, NJ, 08103, USA.

Background: The opioid use disorder and overdose crisis in the United States affects public health as well as social and economic welfare. While several genetic and non-genetic risk factors for opioid use disorder have been identified, many of the genetic associations have not been independently replicated, and it is not well understood how these factors interact. This study is designed to evaluate relationships among these factors prospectively to develop future interventions to help prevent or treat opioid use disorder.

Methods: The Genomics of Opioid Addiction Longitudinal Study (GOALS) is a prospective observational study assessing the interplay of genetic and non-genetic by collecting comprehensive genetic and non-genetic information on 400 participants receiving medication for opioid use disorder. Participants will be assessed at four time points over 1 year. A saliva sample will be collected for large-scale genetic data analyses. Non-genetic assessments include validated surveys measuring addiction severity, depression, anxiety, and adverse childhood experiences, as well as treatment outcomes such as urine toxicology results, visit frequency, and number of pre and post-treatment overdoses extracted from electronic medical records.

Discussion: We will use these complex data to investigate the relative contributions of genetic and non-genetic risk factors to opioid use disorder and related treatment outcomes.
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http://dx.doi.org/10.1186/s12920-020-00837-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7792024PMC
January 2021

Buprenorphine Field Initiation of ReScue Treatment by Emergency Medical Services (Bupe FIRST EMS): A Case Series.

Prehosp Emerg Care 2021 Mar-Apr;25(2):289-293. Epub 2020 May 4.

The opioid epidemic is currently a leading health crisis in the United States, and evidence supports Medication for Opioid Use Disorder (MOUD) as the most effective treatment (2). In our EMS system we are observing an ever increasing number of patients who, due to refusing transport after naloxone rescue, represent an access void at the point of overdose. We present a case series to illustrate a new treatment paradigm utilizing front line EMS paramedic units and high dose buprenorphine to treat withdrawal symptoms with next day bridge to long term care. The three patients described are exemplary cases, meant to represent overall characteristics of the intervention prior to complete data collection. Each patient was revived from opioid overdose with naloxone. Paramedics then treated each patient with 16 mg of buprenorphine to relieve and prevent withdrawal symptoms. Patients were provided with outpatient follow up irrespective of ED transport. To the best of our knowledge, this is the first EMS agency in the United States providing MOUD in the prehospital setting at the point of overdose. This innovative program provides EMS with education and tools to promote patient engagement. While still in its infancy, this approach utilizes existing EMS resources to bring MOUD to the prehospital setting, offering a new avenue to long term care. Opioid, buprenorphine, emergency medical services, medication assisted therapy, naloxone, overdose.
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http://dx.doi.org/10.1080/10903127.2020.1747579DOI Listing
June 2021

Epidemiology of opioid-related visits to US Emergency Departments, 1999-2013: A retrospective study from the NHAMCS (National Hospital Ambulatory Medical Care Survey).

Am J Emerg Med 2020 01 31;38(1):23-27. Epub 2019 Mar 31.

Cooper Medical School of Rowan University, Department of Emergency Medicine, One Cooper Plaza, Camden, NJ, United States of America.

Goals: To characterize the epidemiology of opioid-related visits to United States (US) emergency departments (EDs) and describe trends in opioid-related visits over time.

Design: Retrospective cohort study CASES: The National Hospital Ambulatory Care Survey (NHAMCS) was used to identify opioid-related ED visits between 1999 and 2013.

Measurements: The NHAMCS is an annual, weighted, multi-stage survey which allows for the study of ambulatory care services within a nationally representative sample of US hospitals. We used ICD-9 codes to identify ED visits related to opioid use and abuse. We applied visit weights calculated by NHAMCS to generate nation-wide estimates regarding the overall prevalence of opioid-related visits, and demographic characteristics of these patients. We report trends with respect to opioid-related visits and ED resource utilization between 1999 and 2013.

Results: 1072 visits were included, representing 2,731,000 nation-wide opioid-related ED encounters between 1999 and 2013. During this time, opioid-related ED visits increased from 125,000 in 1999 to over 300,000 visits in 2013. Between 1999-2001 and 2011-2013 opioid-related visits increased by 170%. Greater numbers of such visits occurred across nearly all demographic groups, and all regions of the US. Weighted visits among women increased by 250% between these time periods. Over these periods, opioid-related ED visits resulting in hospital admission increased by over 240%. The proportion of ED visits that were related to opioids doubled from 1999 (0.12%) to 2013 (0.25%).

Conclusions: Opioid-related ED encounters and resource utilization both rose substantially between 1999 and 2013, with consistent increases across a broad spectrum of demographic groups.
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http://dx.doi.org/10.1016/j.ajem.2019.03.052DOI Listing
January 2020

Elective Naloxone-Induced Opioid Withdrawal for Rapid Initiation of Medication-Assisted Treatment of Opioid Use Disorder.

Ann Emerg Med 2019 09 14;74(3):430-432. Epub 2019 Feb 14.

Cooper University Hospital Emergency Department, Camden, NJ.

We present a case of elective naloxone-induced opioid withdrawal followed by buprenorphine rescue to initiate opioid use disorder treatment in the emergency department. This strategy may represent a safe alternative to prescribing buprenorphine for outpatient initiation, a method that puts the patient at risk for complications of unmonitored opioid withdrawal, including relapse. After confirmation that the naloxone-induced withdrawal was adequately treated with buprenorphine, the patient was discharged with prescribed buprenorphine to follow up in an addiction medicine clinic, where he was treated 2 days later.
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http://dx.doi.org/10.1016/j.annemergmed.2019.01.006DOI Listing
September 2019

Comparison between buprenorphine provider availability and opioid deaths among US counties.

J Subst Abuse Treat 2018 10 20;93:19-25. Epub 2018 Jul 20.

Cooper Medical School of Rowan University, Department of Emergency Medicine, One Cooper Plaza, Camden, NJ 08103, USA. Electronic address:

Background: Buprenorphine is an effective medication for the treatment of opioid addiction, but current barriers to buprenorphine access limit treatment availability for many patients. We identify and characterize regions within the United States (US) with poor buprenorphine access relative to the observed burden of overdose deaths.

Methods: This cross sectional study includes US county-level data on the number of available buprenorphine providers (Substance Abuse and Mental Health Services Administration Buprenorphine Treatment Practitioner Locator) and the number of opioid-related overdose deaths between 2013 and 2015 (Centers for Disease Control and Prevention WONDER Database). Counties with fewer than 10 deaths during this time period were excluded to maintain patient privacy. Population-adjusted county death rates and provider availability were compared to identify locations with high disease burdens and limited buprenorphine access. The presence of significant clustering across the dataset was evaluated using Global Moran's I and zones of significant spatial clusters and anomalies were identified using Local Indicator of Spatial Autocorrelation.

Results: County data were available for 846 counties from 49 states and the District of Columbia, comprising 83% of the US population. The median number of opioid overdose deaths per county was 20.0 deaths per 100,000 residents (interquartile range 13.4-29.9, range 2.9 to 108.8). The number of buprenorphine providers per 100,000 county residents ranged from 0 to 45, with a median of 5.9 (interquartile range 3.2 to 9.5). Global Moran's I analysis yielded significant clustering in the distribution of both providers and deaths, with notable significant clusters of higher than average providers and deaths in the Northeast, and scattered mismatched regions of lower-than-average providers and higher-than-average deaths across the Southern, Midwestern, and Western US. Graphical analysis of buprenorphine provider availability and overdose burden reveals limited treatment access relative to overdose deaths throughout much of the Midwestern and Southern US.

Conclusions: Substantial county-level imbalances between the availability of buprenorphine providers and the burden of opioid overdose deaths are present within the US.
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http://dx.doi.org/10.1016/j.jsat.2018.07.008DOI Listing
October 2018

When Hydromorphone Is Not Working, Try Loratadine: An Emergency Department Case of Loratadine as Abortive Therapy for Severe Pegfilgrastim-Induced Bone Pain.

J Emerg Med 2017 Feb 14;52(2):e29-e31. Epub 2016 Oct 14.

Department of Emergency Medicine, Medical Toxicology, Cooper University Hospital, Camden, New Jersey; Cooper Medical School of Rowan University, Medical Toxicology, Cooper University Hospital, Camden, New Jersey.

Background: Intractable bone pain is a notorious adverse effect of granulocyte-colony stimulating factors (G-CSFs), such as pegfilgrastim and filgrastim, which are given to help prevent neutropenia in patients who are undergoing chemotherapy. G-CSF-induced bone pain is surprisingly common and often refractory to treatment with conventional analgesics.

Case Report: This article describes an emergency department case of opiate and nonsteroidal anti-inflammatory drug-resistant pegfilgrastim-induced bone pain that was successfully alleviated with 10 mg of oral loratadine, allowing for discharge home. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case suggests that loratadine may be an easy to implement, safe, and effective therapy in the emergency department management of intractable bone pain caused by G-CSF use. Emergency physicians should be aware that loratadine may successfully relieve otherwise intractable G-CSF-induced bone pain and allow for discharge home.
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http://dx.doi.org/10.1016/j.jemermed.2016.08.018DOI Listing
February 2017

Limb-threatening Deep Venous Thrombosis Complicating Warfarin Reversal with Three-factor Prothrombin Complex Concentrate: A Case Report.

J Emerg Med 2016 Jan 24;50(1):28-31. Epub 2015 Oct 24.

Department of Emergency Medicine, Cooper University Hospital, Camden, New Jersey.

Background: Three- and four-factor prothrombin complex concentrates (PCC) are gaining popularity for acute reversal of vitamin K antagonist-associated bleeding. Although acute thrombosis after PCC administration has been described, it seems to be rare.

Case Report: An 83-year-old woman on warfarin for history of deep venous thrombosis (DVT) presented to the Emergency Department with life-threatening gastrointestinal bleeding, requiring urgent PCC administration. After stabilization, she subsequently developed a new limb-threatening upper-extremity DVT. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: As PCC therapy gains popularity for reversal of anticoagulant-induced bleeding in urgent bleeding scenarios, the emergency physician must be aware of the complications of PCC administration, including new limb-threatening DVT.
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http://dx.doi.org/10.1016/j.jemermed.2015.02.053DOI Listing
January 2016

Use and efficacy of nebulized naloxone in patients with suspected opioid intoxication.

Am J Emerg Med 2013 Mar 21;31(3):585-8. Epub 2013 Jan 21.

Department of Emergency Medicine, Cooper Medical School of Rowan University, Camden, NJ 08103, USA.

Objective: To describe the use and efficacy of nebulized naloxone in patients with suspected opioid intoxication.

Methods: This was an observational study conducted at an inner city emergency department. Patients were eligible if they had self-reported or suspected opioid intoxication and a spontaneous respiratory rate ≥6 breaths/minute. Nebulized naloxone (2 mg in 3 mL normal saline) was administered through a standard face mask at the discretion of the treating physician. Structured data collection included demographics, vital signs pre and post naloxone administration and adverse events. The primary outcome was level of consciousness, which was recorded pre and 15 minutes postnaloxone administration using the Glasgow Coma Scale (GCS) and the Richmond Agitation Sedation Scale (RASS).

Results: Of the 73 patients who presented with suspected opioid intoxication and were given naloxone over the study period, 26 were initially treated with nebulized naloxone. After nebulized naloxone administration, median GCS improved from 11 [interquartile range (IQR) 3.5] to 13 (IQR, 2.5), P = .001. Median RASS improved from -3.0 (IQR, -1.0) to -2.0 (IQR, -1.5), P < .0001. Need for supplemental oxygen decreased from 81% to 50%, P = .03. Vital signs did not differ pre/post therapy. There were few adverse effects from nebulized naloxone administration: 12% experienced moderate-severe agitation, 8% were diaphoretic and none vomited. Eleven required subsequent administrations of naloxone, nine of whom self-reported using either heroin, methadone or both. Of these, 5 underwent urine drug screening and all 5 tested positive for either opiates or methadone.

Conclusions: Nebulized naloxone was well-tolerated and led to a reduction in the need for supplemental oxygen as well as improved median GCS and RASS scores in patients with suspected opioid intoxication.
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http://dx.doi.org/10.1016/j.ajem.2012.10.004DOI Listing
March 2013

New drugs of abuse in North America.

Clin Lab Med 2006 Mar;26(1):147-64, ix

Department of Emergency Medicine, Cooper Hospital University Medical Center, Camden, NJ 08103, USA.

The term "drugs of abuse" usually brings to mind traditional street drugs, such as cocaine, heroin, marijuana, and methamphetamine. The drug scene, however, is constantly evolving. As various law enforcement agencies pursue and dismantle distribution and pro-duction organizations of the usual drugs of abuse, dealers and users are turning to less known, more accessible, and often currently licit substances. The widespread growth of the Internet with its vast distribution of information has increased the accessibility ofa host of substances and facilitated synthesis and production of various substances by individuals. This article discusses several new and emerging abused substances, including new synthetic variations, plants, and pharmaceuticals diverted for abuse.
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http://dx.doi.org/10.1016/j.cll.2006.01.008DOI Listing
March 2006

Emerging drugs of abuse.

Med Clin North Am 2005 Nov;89(6):1259-76

Department of Emergency Medicine, Drexel University College of Medicine, Medical College of Pennsylvania Hospital, Philadelphia, PA 19129-1191, USA.

Several new and emerging substances are being diverted for abuse. Most of these emerging abused substances do not cause traditional drug screens to turn positive. The health effects of these substances have not yet been fully elucidated. Health care providers should be aware of the existence of these new abused substances.
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http://dx.doi.org/10.1016/j.mcna.2005.06.008DOI Listing
November 2005
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