Factors Associated with Take Home Naloxone Refusal among Emergency Department Patients Participating in an Opioid Overdose Prevention Program.

BACKGROUND: Increasing the equitable distribution of take home naloxone (THN) may result in reduced deaths from opioid overdose (OD). OBJECTIVES: The primary study objective is to describe the demographic and clinical characteristics of emergency department (ED) patients who decline THN. The findings of this descriptive study may generate new hypotheses for successful THN distribution. METHODS: Retrospective chart review using prospectively collected program evaluation data from a single urban EDs Health Education THN database and electronic health record. Characteristics of participants who refused versus accepted THN were compared using Chi-square testing for categorical variables and t-tests for continuous variables. A multivariate model was built to assess associations of statistical and clinically relevant characteristics with THN refusal. RESULTS: A total of 711 ED patients were offered THN of which 334 (46%) declined. In unadjusted analysis, with the independent variable being refusal of the THN offer, being currently on medication for opioid use disorder (MOUD) was associated with a greater odds of refusal (OR 1.9, 95%CI 1.3-2.6) while any drug related overdose (OR 0.6, 95%CI 0.4-0.8) or being given a prescription for buprenorphine in the ED (OR 0.2, 95%CI 0.1-0.9) were both associated with a lower odds of refusal. CONCLUSIONS: Demographic characteristics did not differ between those who accept versus refuse THN. Patients already receiving MOUD were more likely to refuse THN while those starting MOUD in the ED were less likely to refuse THN. Further studies are needed to determine the root causes of patients' declination of THN and develop targeted interventions to address these causes.

Relationship of hepatitis C risk to hepatitis C test acceptance among adult patients participating in an ED hepatitis C screening programme.

BACKGROUND: It is possible that adult ED patients consider their hepatitis C virus (HCV) risk factor history when deciding whether to accept HCV screening. To help address this question, we examined whether self-reporting any HCV risk was more common among ED patients who agreed than who declined HCV screening. Among ED patients who agreed to HCV screening, we also assessed if self-reporting any HCV risk was more common among those whose HCV antibody (Ab) and HCV viral load (VL) test results were positive. METHODS: This study was conducted among adult patients ≥18 years old participating in a universal, ED-based HCV screening programme in New York City between 22 January 2019 and 9 April 2020. Participants were surveyed about their HCV risk factors. Differences in the frequencies of self-reporting any HCV risk were compared according to HCV screening acceptance and by HCV Ab and VL status. RESULTS: Of the 4658 ED patients surveyed, 2846 (61%) accepted and 1812 (39%) declined HCV screening. Among these participants, 38% reported at least one HCV risk factor, most commonly injection drug use. Self-reporting any HCV risk was not more common among those who accepted versus declined HCV screening (40% vs 37%, p<0.7) but was more common among those with HCV Ab positive versus negative test results (36% vs 6%, p<0.001) and HCV VL positive versus negative results (95% vs 5%, p<0.001). CONCLUSION: HCV risk factors were self-reported by more than one-third of ED patients but were not more commonly present among those who accepted HCV screening.

Nontargeted Hepatitis C Screening in an Urban Emergency Department in New York City.

BACKGROUND: Previously the Centers for Disease Control and Prevention (CDC) recommended targeted hepatitis C virus (HCV) screening for adults born between 1945 and 1965 and individuals with HCV risk factors. In April 2020, the CDC updated their recommendations to now include all individuals 18 years of age and older in settings with HCV prevalence > 0.1%. Few emergency departments (EDs) currently employ this nontargeted screening approach. OBJECTIVES: We examined how a shift from targeted to nontargeted screening might affect HCV case identification. We hypothesized that nontargeted screening could improve HCV case identification in our ED. METHODS: Retrospective review of prospectively collected nontargeted screening data from June 6, 2018 to June 5, 2019 in a large urban academic ED. Patients 18 years of age and older, triaged to the adult or pediatric ED and able to provide consent for HCV testing, were eligible for study inclusion. RESULTS: There were 83,864 ED visits and 40,282 unique patients deemed eligible for HCV testing. Testing occurred in 10,630 (26.4%) patients, of which 638 (6%) had positive HCV antibody (Ab+) tests and 214 (2%) had a positive viral load (VL+). Birth cohort-targeted screening would have identified 48% of the patients with Ab+ tests and 47% of those who were VL+. Risk-based targeted screening would increase the number of Ab+ patients to 67% and VL+ to 72%. CONCLUSIONS: Nontargeted ED-based HCV screening can identify a large number of patients with HCV infection. A shift from targeted to nontargeted screening may result in fewer missed infections but requires further study.