Take-Home Naloxone Program Implementation: Lessons Learned From Seven Chicago-Area Hospitals.

Despite consensus recommendations from the American College of Emergency Physicians (ACEP), the Centers for Disease Control and Prevention, and the surgeon general to dispense naloxone to discharged ED patients at risk for opioid overdose, there remain numerous logistic, financial, and administrative barriers to implementing "take-home naloxone" programs at individual hospitals. This article describes the recent collective experience of 7 Chicago-area hospitals in implementing take-home naloxone programs. We highlight key barriers, such as hesitancy from hospital administrators, lack of familiarity with relevant rules and regulations in regard to medication dispensing, and inability to secure a supply of naloxone for dispensing. We also highlight common facilitators of success, such as early identification of a "C-suite" champion and the formation of a multidisciplinary team of program leaders. Finally, we provide recommendations that will assist emergency departments planning to implement their own take-home naloxone programs and will inform policymakers of specific needs that may facilitate dissemination of naloxone to the public.

An outbreak of severe coagulopathy from synthetic cannabinoids tainted with Long-Acting anticoagulant rodenticides.

Objective: To describe a large regional poison center's experience managing an outbreak of long-acting anticoagulant rodenticide (LAAR) poisoning associated with synthetic cannabinoid (SC) use.Methods: This is a retrospective review of exposures reported to the Illinois Poison Center between March 10 and August 1, 2018. All cases coded as exposure to Δ9-tetrahydrocannabinol homologs were identified. Patients with suspected SC use, positive LAAR testing, and coagulopathy (signs or symptoms of bleeding or international normalized ratio [INR] > 2) were included. If confirmatory LAAR testing was performed and resulted as negative, the patient was excluded from this analysis. In the absence of LAAR testing, patients with suspected SC use, an INR >2, and no alternative explanation of coagulopathy were included. Suspected SC use was defined as use suspected by a member of the treating team or reported by the patient. Presenting signs and symptoms, laboratory findings, management, healthcare utilization, outcomes, and disposition of patients affected by this outbreak were reported.Results: One hundred seventy-eight cases met inclusion criteria. Most patients were male (73%) and young to middle-aged (median age 32, IQR 25-40). Most presented to hospitals in Peoria (35%) and Cook (31%) counties. Median hospitalization was three days (IQR 2-4). Eighty-eight percent of patients presented with an INR >10. Eighteen cases had qualitative anticoagulant testing, all of which were positive for brodifacoum. Other identified LAARs included difenacoum (10/18) and bromadiolone (1/18). Sixty-three percent of patients had back, flank or abdominal pain; 70% of patients presented with hematuria. One hundred six cases received IV vitamin K1; no adverse or anaphylactoid reactions were reported. Forty-one (22%) patients left AMA. Thirty-eight patients (21%) were re-hospitalized during the study period. Patients leaving AMA were 1.6 times more likely to be re-hospitalized than patients with other dispositions. Intracranial hemorrhage, present in 3% of total cases, was present in 4 of 5 fatalities.Conclusions: We describe an outbreak of multiple LAARs contaminating SCs. Patients presented with bleeding from varied sites, often required blood products, factor replacement, and high dose vitamin K1 for stabilization.