Patient Perspectives on Seeking Emergency Care for Acute Low Back Pain and Access to Physical Therapy in the Emergency Department.

STUDY OBJECTIVE: Low back pain is a common reason for visiting the emergency department (ED), yet little is known about patient motivations for seeking emergency care. The purpose of this study was to explore patient perspectives on visiting the ED for low back pain to inform a more patient-centered approach to emergency care. METHODS: We conducted focus group discussions and individual interviews among patients visiting an urban academic ED for acute low back pain. We recruited participants from an ongoing prospective study of 101 patients receiving either ED-initiated physical therapy or usual care. We conducted discussions, and interviews using an a priori developed discussion guide. We audio recorded, transcribed, and iteratively content analyzed the data using a consensual qualitative approach until thematic saturation was reached. RESULTS: We conducted 4 focus group discussions among 18 participants (median age 46.5 years, 66.7% women, 61.1% Black) and individual interviews with 27 participants (median age 45 years, 55.6% women, 44.4% White). No new themes emerged during the fourth and final focus group. We identified 5 summary themes: (1) the decision to seek emergency care for low back pain is motivated by severe pain, resulting disability, and fears about a catastrophic diagnosis, (2) participants sought various goals from their ED visit but emphasized the primacy of pain control, (3) participants were reluctant to use pain medications but also acknowledged their benefit, (4) participants perceived a number of benefits from direct access to an ED physical therapist in the ED, and (5) participation in physical therapy ultimately facilitated recovery, but the pain was a barrier to performing exercises. CONCLUSIONS: These patient perspectives and resulting themes may be used to inform a more patient-centered emergency care experience and contextualize quantitative research findings on ED care for low back pain.

Feasibility of Emergency Department-based Fentanyl Test Strip Distribution.

OBJECTIVES: United States drug overdose deaths now overwhelmingly involve fentanyl and fentanyl analogs. The emergency department (ED) is an important setting to provide harm reduction for persons who use drugs, but ED-based fentanyl test strip distribution has not yet been described. METHODS: This is an observational study of patients with an opioid-related visit to an ED in downtown Chicago, Illinois. We offered fentanyl test strips alongside an existing take-home naloxone program and report on the number of patients who accepted fentanyl test strips. We assessed patient familiarity with fentanyl and fentanyl test strips during the index ED visit and attempted to contact patients 1 month after the ED visit to determine testing outcomes. RESULTS: We offered fentanyl test strips to 23 consecutive ED patients (mean age, 39.8 years; male, 73.9%) with an opioid-related ED visit (87.0% for opioid overdose). Sixteen patients (69.5%) had heard of fentanyl, and 2 (8.7%) had prior experience using fentanyl test strips. Eighteen patients (78.2%) accepted the fentanyl test strips, 2 of which left the test strips behind in the ED alongside their take-home naloxone kit. Of the 16 total patients who departed with fentanyl test strips, we were able to reach 3 (18.8%) by phone 1 month after their ED visit; 9 had disconnected or wrong numbers listed. All 3 patients reported a positive fentanyl test strip result; tested substances included heroin, alprazolam, and cocaine. CONCLUSIONS: This report demonstrates the feasibility and acceptability of ED fentanyl test strip distribution among patients with opioid-related ED visits.

Antibiotic and antitussive prescribing among urgent care and emergency department visits for respiratory diagnoses in a large health system.

Objective: Urgent care centers (UCs) commonly evaluate patients with respiratory infections, and patients increasingly prefer UCs to emergency departments (EDs) because of their customer-centric approach. The aim of this study is to describe antibiotic and opioid prescribing among UC and ED visits with respiratory diagnoses. Methods: This is a cross-sectional study of visits to 7 EDs and 6 UCs in the greater Chicago area. We included visits from July 1, 2017, to June 30, 2019, with a primary diagnosis of upper or lower respiratory infection. We describe the proportion of visits resulting in an antibiotic or antitussive prescription as well as the most frequently prescribed medications in these categories. We also describe the demographic and clinical characteristics of visits. Results: Of 9134 ED visits, 32.9% were prescribed an antibiotic and 14.4% an antitussive (6.6% opioid). Of 41,380 UC visits for respiratory diagnoses, 57.9% were prescribed an antibiotic and 25.0% an antitussive (9.3% opioid). The most frequently prescribed antibiotics among ED and UC visits were penicillins (36.6% and 44.5%, respectively) and macrolides (44.1% and 35.3%, respectively). The most commonly prescribed opioid was codeine (55.6% and 91.0%, respectively). Median waiting room time was 16 and 5 minutes for ED and UC visits, respectively; median length of stay was 178 and 41 minutes, respectively. Conclusions: Antibiotics and antitussives, including opioids, are frequently prescribed for ED and UC visits with non-bacterial respiratory diagnoses. These findings suggest greater attention to the appropriateness of antibiotic prescribing in both settings and the incorporation of specific guidance on codeine products in opioid-prescribing guidelines.

Impact of the COVID pandemic on emergency department CT utilization: where do we go from here?

PURPOSE: To analyze the impact of the coronavirus disease (COVID) pandemic on emergency department (ED) computed tomography (CT) utilization. METHODS: A retrospective observational study was conducted assessing seven hospitals' ED imaging volumes between Jan. 6, 2019, and Feb. 27, 2021. Weekly CT utilization is reported as CTs ordered per 100 ED visits. Utilization was ascertained in aggregate and by body area. Interrupted time series analysis was performed to assess significance of utilization change. Prespecified sensitivity analysis was performed for influenza-like or COVID-like illness (ILI/CLI). RESULTS: Weekly ED CT utilization increased from 35.9 CTs per 100 visits (95% confidence interval [95% CI] 35.8-36.1) to 41.8 per 100 visits (95% CI 41.7-42.0) in pre- and post-pandemic periods. Weekly ED CT chest utilization increased immediately following the pandemic declaration (+ 0.52 chest CTs per 100 ED visits, 95% CI 0.01-1.03, p < 0.05) and compared to pre-pandemic period (+ 0.02 per 100 ED visits, 95% CI 0.02-0.05, p < 0.02). For both CT abdomen/pelvis and CT head, there was neither an immediate effect (+ 0.34 CT-AP per 100 ED visits, 95% CI - 0.74 to 1.44, p = 0.89; - 0.42 CT-H per 100 ED visits, 95% CI - 1.53 to 0.70, p = 0.46) nor a change in weekly CT utilization (+ 0.03 CT-AP per 100 ED visits, 95% CI - 0.01 to 0.05, p = 0.09; + 0.03 CT-H per 100 ED visits, 95% CI - 0.01 to 0.06, p = 0.10).  CONCLUSION: These data may help formulate future strategies for resource utilization and imaging operations as we envision a future with COVID and other federal mandates affecting imaging utilization and appropriateness.

Embedded emergency department physical therapy versus usual care for acute low back pain: a protocol for the NEED-PT randomised trial.

INTRODUCTION: Low back pain is a common problem and a substantial source of morbidity and disability worldwide. Patients frequently visit the emergency department (ED) for low back pain, but many experience persistent symptoms at 3 months despite frequent receipt of opioids. Although physical therapy interventions have been demonstrated to improve patient functioning in the outpatient setting, no randomised trial has yet to evaluate physical therapy in the ED setting. METHODS AND ANALYSIS: This is a single-centre cluster-randomised trial of an embedded ED physical therapy intervention for acute low back pain. We used a covariate-constrained approach to randomise individual physicians (clusters) at an urban academic ED in Chicago, Illinois, USA, to receive, or not receive, an embedded physical therapist on their primary treatment team to evaluate all patients with low back pain. We will then enrol individual ED patients with acute low back pain and allocate them to the embedded physical therapy or usual care study arms, depending on the randomisation assignment of their treating physician. We will follow patients to a primary endpoint of 3 months and compare a primary outcome of change in PROMIS-Pain Interference score and secondary outcomes of change in modified Oswestry Disability Index score and patient-reported opioid use. Our primary approach will be a modified intention-to-treat analysis, whereby all participants who complete at least one follow-up data time point will be included in analyses, regardless of their or their physicians' adherence to their assigned study arm. ETHICS AND DISSEMINATION: This trial is funded by the US Agency for Healthcare Research and Quality (R01HS027426) and was approved by the Northwestern University Institutional Review Board. All physician and patient participants will give written informed consent to study participation. Trial results will be submitted for presentation at scientific meetings and for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov (NCT04921449).

Disparities by Sex and Race and Ethnicity in Death Rates Due to Opioid Overdose Among Adults 55 Years or Older, 1999 to 2019.

Importance: Rates of opioid overdose deaths are increasing for older adults. Less is known about these deaths compared with those of younger adults. Objective: To analyze rate variation among opioid overdose deaths in older adults by sex and by race and ethnicity over time. Design, Setting, and Participants: This 21-year longitudinal cross-sectional study of adults who died due to opioid overdose at 55 years or older stratified by sex and by race and ethnicity used data from the Multiple Cause of Death database from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research. The data include all opioid overdose deaths among this age group that occurred between January 1, 1999, and December 31, 2019 (N = 79 893). Exposures: Sex and racial and ethnic groups. Main Outcomes and Measures: Rates of opioid overdose deaths per 100 000 population by sex and by race and ethnicity for persons 55 years or older. Results: During the period 1999 to 2019, 79 893 US residents 55 years or older died due to an opioid overdose. Among these individuals, 79.97% were aged 55 to 64 years, and 58.98% were men. Annual numbers of deaths increased over time from 518 in 1999 to 10 292 in 2019. Annual rates of opioid overdose deaths per 100 000 persons 55 years or older increased over time and ranged from 0.90 in 1999 to 10.70 in 2019. Substantial variation by sex and by race and ethnicity was found. In 2013, rates among non-Hispanic Black men began to diverge from those of other demographic subgroups. By 2019, the opioid overdose fatality rate among non-Hispanic Black men 55 years or older was 40.03 per 100 000 population, 4 times greater than the overall opioid overdose fatality rate of 10.70 per 100 000 for persons of the same age. Conclusions and Relevance: In this longitudinal cross-sectional study of US adults who died due to opioid overdose, the burden of opioid overdose deaths among older adults since 2013 was most concentrated among non-Hispanic Black men. Deaths among non-Hispanic Black men were disproportionality represented in the overall increase in the rate of opioid overdose deaths among older adults. Further research is needed to inform policy and practice.

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

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

Opioid-related Emergency Department Visits During COVID-19 in a Large Health System.

OBJECTIVE: Multiple states have reported increases in opioid overdose deaths during the coronavirus disease 2019 (COVID-19) pandemic, however little is known about opioid-related presentations to the emergency department (ED). METHODS: This was a time series analysis of visits to 7 EDs in greater Chicago, Illinois from October 20, 2019 to July 25, 2020. We compared the number of ED visits for opioid-related diagnoses in the time period preceding the World Health Organization pandemic declaration (prepandemic period, October 20, 2019-July 3, 2020) to the time period following the World Health Organization declaration (pandemic period, March 8, 2020 to July 25, 2020) using a single-group interrupted time series analysis with Newey-West standard errors. We also present data on alcohol-related ED visits for comparison. RESULTS: We evaluated a total of 177,405 visits across the 7 EDs during the study period. The mean number of weekly ED visits in the prepandemic and pandemic periods was 4841 and 4029 weekly visits, respectively. In the interrupted time series analysis, there was no significant immediate effect of the pandemic start on opioid-related ED visits (-0.44 visits per 1000 ED visits, 95% CI -2.47 to 1.58, P = 0.66), however, there was a significant immediate effect of the pandemic start on alcohol-related ED visits (-4.1, 95% CI: -8.25 to -0.01, P < 0.05). CONCLUSIONS: Despite reductions in overall ED visit volumes and alcohol-related visits during COVID-19, the number of opioid-related visits was not significantly reduced during the early pandemic. These data reinforce the need to provide comprehensive treatment services for opioid use disorder during the co-occurring COVID-19 and opioid crises.

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

OBJECTIVES: Patient knowledge deficits related to opioid risks, including lack of knowledge regarding addiction, are well documented. Our objective was to characterize patients' perceptions of signs of addiction. METHODS: This study utilized data obtained as part of a larger interventional trial. Consecutively discharged English-speaking patients, age >17 years, at an urban academic emergency department, with a new opioid prescription were enrolled from July 2015 to August 2017. During a follow-up phone interview 7 to 14 days after discharge, participants were asked a single question, "What are the signs of addiction to pain medicine?" Verbatim transcribed answers were analyzed using a directed content analysis approach and double coding. These codes were then grouped into themes. RESULTS: There were 325 respondents, 57% female, mean age 43.8 years, 70.1% privately insured. Ten de novo codes were added to the 11 DSM-V criteria codes. Six themes were identified: (1) effort spent acquiring opioids, (2) emotional and physical changes related to opioid use, (3) opioid use that is "not needed, (4) increasing opioid use, (5) an emotional relationship with opioids, and (6) the inability to stop opioid use. CONCLUSIONS: Signs of addiction identified by opioid naive patients were similar to concepts identified in medical definitions. However, participants' understanding also included misconceptions, omissions, and conflated misuse behaviors with signs of addiction. Identifying these differences will help inform patient-provider risk communication, providing an opportunity for counseling and prevention.

Unintentional Opioid Overdose Death Characteristics in Illinois Before and During the COVID-19 Era, 2017 to 2020.

This cross-sectional study characterizes Illinois unintentional opioid overdose deaths from July 2017 through June 2020 using data from the Centers for Disease Control and Prevention State Unintentional Drug Overdose Reporting System.

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

OBJECTIVES: Recent guidelines advise limiting opioid prescriptions for acute pain to a three-day supply; however, scant literature quantifies opioid use patterns after an emergency department (ED) visit. We sought to describe opioid consumption patterns after an ED visit for acute pain. DESIGN: Descriptive study with data derived from a larger interventional study promoting safe opioid use after ED discharge. SETTING: Urban academic emergency department (>88,000 annual visits). SUBJECTS: Patients were eligible if age >17 years, not chronically using opioids, and newly prescribed hydrocodone-acetaminophen and were included in the analysis if they returned the completed 10-day medication diary. METHODS: Patient demographics and opioid consumption are reported. Opioid use is described in daily number of pills and daily morphine milligram equivalents (MME) both for the sample overall and by diagnosis. RESULTS: Two hundred sixty patients returned completed medication diaries (45 [17%] back pain, 52 [20%] renal colic, 54 [21%] fracture/dislocation, 40 [15%] musculoskeletal injury [nonfracture], and 69 [27%] "other"). The mean age (SD) was 45 (15) years, and 59% of the sample was female. A median of 12 pills were prescribed. Patients with renal colic used the least opioids (total pills: median [interquartile range {IQR}] = 3 [1-7]; total MME: median [IQR] = 20 [10-50]); patients with back pain used the most (total pills: median [IQR] = 12 [7-16]; total MME: median [IQR] = 65 [47.5-100]); 92.5% of patients had leftover pills. CONCLUSIONS: In this sample, pill consumption varied by illness category; however, overall, patients were consuming low quantities of pills, and the majority had unused pills 10 days after their ED visit.

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

OBJECTIVE: Low back pain accounts for nearly 4 million emergency department (ED) visits annually and is a significant source of disability. Physical therapy has been suggested as a potentially effective nonopioid treatment for low back pain; however, no studies to our knowledge have yet evaluated the emerging resource of ED-initiated physical therapy. The study objective was to compare patient-reported outcomes in patients receiving ED-initiated physical therapy and patients receiving usual care for acute low back pain. METHODS: This was a prospective observational study of ED patients receiving either physical therapy or usual care for acute low back pain from May 1, 2018, to May 24, 2019, at a single academic ED (>91,000 annual visits). The primary outcome was pain-related functioning, assessed with Oswestry Disability Index (ODI) and Patient-Reported Outcomes Measurement Information System pain interference (PROMIS-PI) scores. The secondary outcome was use of high-risk medications (opioids, benzodiazepines, and skeletal muscle relaxants). Outcomes were compared over 3 months using adjusted linear mixed and generalized estimating equation models. RESULTS: For 101 participants (43 receiving ED-initiated physical therapy and 58 receiving usual care), the median age was 40.5 years and 59% were women. Baseline outcome scores in the ED-initiated physical therapy group were higher than those in the usual care group (ODI = 51.1 vs 36.0; PROMIS-PI = 67.6 vs 62.7). Patients receiving ED-initiated physical therapy had greater improvements in both ODI and PROMIS-PI scores at the 3-month follow-up (ODI = -14.4 [95% CI = -23.0 to -5.7]; PROMIS-PI = -5.1 [95% CI = -9.9 to -0.4]) and lower use of high-risk medications (odds ratio = 0.05 [95% CI = 0.01 to 0.58]). CONCLUSION: In this single-center observational study, ED-initiated physical therapy for acute low back pain was associated with improvements in functioning and lower use of high-risk medications compared with usual care; the causality of these relationships remains to be explored. IMPACT: ED-initiated physical therapy is a promising therapy for acute low back pain that may reduce reliance on high-risk medications while improving patient-reported outcomes. LAY SUMMARY: Emergency department-initiated physical therapy for low back pain was associated with greater improvement in functioning and lower use of high-risk medications over 3 months.

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

OBJECTIVE: To describe the development of an ED-based take-home naloxone (THN) program in which naloxone kits are dispensed directly to patients during ED discharge. PRACTICE DESCRIPTION: Our THN program was carried out at an urban academic hospital in downtown Chicago, IL. The THN kits consisted of 3 vials of 0.4-mg naloxone and 3 sterile syringes and needles for intramuscular delivery. Any member of the ED team (e.g., physician, pharmacist, or nurse) could recommend naloxone dispensing for a patient; however only the treating ED physician served as the prescriber for record. The ED pharmacist provided bedside education on recognizing opioid overdose and administering naloxone. The naloxone kit was dispensed to the patient at no cost. PRACTICE INNOVATION: This ED pharmacist-led naloxone dispensing model bypasses barriers to naloxone filling and ensures that patients walk out of the emergency department with naloxone in hand. EVALUATION METHODS: We report key metrics from the first 16 months of program implementation, including the number of ED visits for opioid overdose and THN kits dispensed. We further describe the key facilitators and barriers to program development. RESULTS: Over 16 months, our emergency department had 669 unique visits for opioid overdose, and we dispensed 168 THN kits (10.5 per month). We are aware of at least 3 cases in which our THN kits were used to reverse opioid overdose. We faced key informational barriers to program development, such as a lack of knowledge regarding the allowability of ED medication dispensing, as well as financial barriers, such as the need to obtain a supply of naloxone. We also recognized the key facilitators of success, such as early engagement with hospital leadership. CONCLUSION: Implementing a successful THN program is possible in the ED setting, and individual hospital emergency departments seeking to build their own program may benefit from our report.