Applying Project ECHO (Extension for Community Health Care Outcomes) to improve addiction care in rural emergency departments.

Background: Advancements in research and legislation have improved emergency provider ability to treat opioid use disorder (OUD), but dissemination into rural emergency departments (EDs) is limited. Project Extension for Community Healthcare Outcomes (ECHO) allows community generalists to learn from specialists through telementoring. We aimed to use ECHO to facilitate knowledge translation, increase confidence, and change behavior of rural ED providers treating patients with OUD. Methods: Stakeholder interviews were conducted with rural ED providers. A group of ED addiction experts created an ECHO curriculum with eight OUD topics. ED health professionals were recruited and completed pre/post surveys centered around knowledge and comfort with treating OUD in the ED, with focus on clinical practice and stigma. Following the ECHO model, sessions included a 20-min didactic followed by two cases presented by participants, with discussion facilitated by faculty. Results: Twenty-seven participants registered; seven attended ≥75% of sessions and completed both surveys. Of the seven, three were physicians, two advanced practice providers, one nurse, and one clinical pharmacist. Eight 1-hour sessions were conducted in two cohorts between January and December 2021. On a 5-point Likert scale, respondents on average agreed with questions evaluating acceptability (mean ± SD 3.96 ± 0.64), appropriateness (mean ± SD 4.18 ± 1.18), and feasibility (mean ± SD 4.00 ± 1.17). Participants had a 1.09-point increase (paired t-test = 2.43, p = 0.05) on 7-point Likert-scale questions measuring self-efficacy and a 0.13-point change (paired t-test = 2.64, p = 0.04) on 4-point Likert scale questions measuring stigmatizing attitudes (reduction of attitudes). A total of 71% (5/7) reported changes in clinical practice and 57% (4/7) in departmental protocols after participation. Conclusions: Our ED OUD ECHO course successfully created a model for rural ED providers to learn from ED addiction experts. It was well received and impacted self-reported provider stigmatizing attitudes, patient-facing behavior, and departmental initiatives. Recruitment was challenging and participation was limited. Future efforts will target maximizing recruitment.

Mushroom for Improvement Case Report: The Importance of Involving Mycologists.

A case of acute cholecystitis following giant puffball mushroom ingestion is described. A 64-year-old male ingested what was presumed to be a puffball mushroom, developed epigastric pain several hours later, and went to the emergency department. Patient blood work yielded elevated liver enzymes and bilirubin levels, with no change in coagulation studies. A mycologist associated with our regional poison center confirmed the mushroom to be a giant puffball mushroom which is recognized as a non-poisonous mushroom. After identification of the mushroom and recognition that it was unlikely the cause of the elevated liver enzymes, the workup was expanded, and the patient was found to have acute cholecystitis on imaging. This case highlights the added value of incorporating mycologists when the mushroom in question is available. Topics: Toxicology, mycology, poison control/center, puffball mushroom, Calvatia, Lycoperdon.

Opioid-related overdose deaths by race and neighborhood economic hardship in Chicago.

Compared to national findings, Chicago has both a higher rate of opioid-related overdose death and a markedly different distribution by demographics. The Chicago Department of Public Health analyzed fatal overdoses by level of neighborhood economic hardship. The highest rate of opioid-related deaths occurred in neighborhoods with high economic hardship (36.9 per 100,000 population) compared to medium- (20.5) and low- (12.3) hardship neighborhoods. However, these patterns were not consistent across racial/Hispanic ethnicity subgroups. These data support the need to consider the role of racism and other structural, social, and economic factors when designing interventions to reduce opioid-related overdose deaths.

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.

A cross-sectional analysis of fentanyl analog exposures among living patients.

Background: Synthetic opioids, including fentanyl analogs, contribute to an increasing proportion of opioid-related deaths. Highly potent analogs pose an increased risk for fatal overdose. The prevalence of fentanyl analog exposures in patients with known opioid exposure is unknown.Objective: The purpose of this study was to determine the exposure prevalence for fentanyl analogs in living patients with positive urine screens for opiates or fentanyl.Methods: This was a cross-sectional analysis of urine high performance liquid chromatography/tandem mass spectroscopy (HPLC-MS/MS) results from patients with a positive urine screen for opiates or fentanyl at a large public healthcare system in Chicago, Illinois. Samples with positive screens were non-continuously tested by HPLC-MS/MS for 5 selected months in 2018 and 2019.Results: A total of 219 urine samples which screened positive for fentanyl or opiates underwent HPLC-MS/MS testing. At least one fentanyl analog was detected in 65.3% (n = 143) of samples with 26.0% (n = 57) testing positive for multiple analogs. The most common analogs, intermediates, or metabolites were: 4-ANPP (n = 131); 2-furanylfentanyl (n = 22); acryl fentanyl (n = 21); butyrylfentanyl (n = 15); cyclopropylfentanyl (n = 15); and carfentanil (n = 13). Of samples which screened positive for fentanyl (n = 188), 70.2% (132) tested positive for at least one fentanyl analog. Of samples which screened negative for fentanyl but positive for opiates (n = 31), 35.5% (n = 11) tested positive for fentanyl analogsConclusion: Fentanyl analog exposure is common in patients with positive urine screens for fentanyl or opiates. Screening living patient samples for synthetic opioids has future toxicosurveillance implications and these data underscore the increased risks from illicit opioid use.

Severe Vitamin K-dependent Coagulopathy from Rodenticide-contaminated Synthetic Cannabinoids: Emergency Department Presentations.

INTRODUCTION: Synthetic cannabinoids are a rapidly expanding subset of designer drugs widely available in the United States since 2008. In Illinois during the spring of 2018, over 160 documented cases of bleeding and prolonged coagulopathy occurred secondary to contaminated synthetic cannabinoids. METHODS: We conducted a retrospective cohort study consisting of 38 patients to describe the initial emergency department (ED) presentation, diagnosis, and treatment. RESULTS: Through serum testing we found that three long-acting anticoagulant rodenticides (LAAR) were detected in patients who had inhaled these tainted products: brodifacoum, difenacoum, and bromodialone. DISCUSSION: This study encompasses the largest ED presentation of LAAR poisoning via the inhalational route known to date. CONCLUSION: The emergency physician should be aware of the potential for tainted coingestants as the cause of undifferentiated coagulopathy.

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.

Effect of positive urine fentanyl screen on attitudes toward heroin use.

BACKGROUND: It is unknown if targeted risk reduction counseling in the health care setting, after documented exposure to fentanyl, can affect behavior change to reduce risks and increase utilization of evidence-based overdose prevention strategies. METHODS: We conducted a retrospective analysis of results (7/2018-6/2019) from questionnaire-facilitated counseling by recovery coaches in the emergency department (ED) and primary care settings following disclosure of a urine toxicology positive for fentanyl. RESULTS: Seventy-five percent of N = 101 respondents were neither aware of nor expecting fentanyl in their substances of use. Fifty-three (70 %) of those initially unaware answered that learning about exposure to and the risks from fentanyl changed their thoughts about reducing or abstaining from use. A greater proportion of patients seen in the ED expressed desire to stop or reduce opioid use as compared to ambulatory clinic patients (91 % vs. 46 %, p < 0.001). Of those not already engaged in treatment, 18 % and 15 % were interested in medication and behavioural health treatment, respectively, and each of them indicated a change in thought based on the counseling. Forty-five percent of individuals not yet receiving naloxone endorsed interest in receiving it, and 22 % of all respondents were somewhat or very interested in access to safe consumption sites. CONCLUSION: This study suggests a novel clinical utility in toxicology screens to inform behavior in the setting of illicit fentanyl exposure. In addition to linkages to evidence-based treatment, linkages to harm-mitigating strategies associated with ongoing substance use may be critical to a comprehensive overdose prevention strategy in the clinical setting.

The Public Health Response to a Large Poisoning Outbreak Involving an Illicit Substance: Synthetic Cannabinoids Contaminated With a Long-Acting Anticoagulant Rodenticide, Illinois, March-July, 2018.

During March-July 2018, the Illinois Department of Public Health responded to an acute outbreak of severe coagulopathy among patients with recent synthetic cannabinoid use. Toxicological testing indicated that cases were exposed to brodifacoum, a long-acting anticoagulant rodenticide. A total of 174 confirmed and probable cases, including 5 deaths, were linked to this outbreak. On the basis of the experience of responding to this complex outbreak, we recommend several steps for consideration to improve health department preparation for acute outbreaks involving illicit substances including strengthening communication between public health and law enforcement agencies, reviewing legal authority to investigate noninfectious acute disease outbreaks, continuing strong partnerships with state poison control centers, partnering with substance abuse and mental health agencies to provide services to patients, and determining health department ability to rapidly enter into public-private partnership agreements.

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.

Treatment of acute naloxone-precipitated opioid withdrawal with buprenorphine.

Naloxone is a frequently utilized and effective treatment to reverse the life-threatening effects of illicit opioid intoxication. Excessive naloxone dosing in these circumstances, however, may lead to naloxone-precipitated opioid withdrawal in individuals with opioid dependence. Buprenorphine, a partial mu-opioid agonist, is increasingly utilized in the Emergency Department (ED) for the treatment of opioid withdrawal syndrome but little is known regarding its utility in cases of naloxone-precipitated opioid withdrawal. We report a case of naloxone-precipitated opioid withdrawal that was effectively treated with sublingual buprenorphine. An older male was brought into the ED with signs and symptoms of opioid toxicity that was successfully treated with pre-hospital naloxone by Emergency Medical Services. He had a clinical opioid withdrawal scale (COWS) or 10 with abdominal cramping and unintentional defecation. After a discussion of treatment options and possible adverse effects with the patient, the decision was made to administer 4 mg/1 mg of sublingual buprenorphine/naloxone film. The patient reported a rapid improvement in symptoms and at 30 min posttreatment, his COWS was 4. His COWS decreased to 3 at 1 h and this was sustained for 4 h of observation. The patient was subsequently discharged to a treatment facility for opioid use disorder. This case highlights the potential of buprenorphine as a treatment modality for acute naloxone-precipitated opioid withdrawal. Due to the risks of worsening or sustained buprenorphine-precipitated opioid withdrawal, further research is warranted to identify patients who may benefit from this therapy.

Prescribing Associated with High-Risk Opioid Exposures Among Non-cancer Chronic Users of Opioid Analgesics: a Social Network Analysis.

BACKGROUND: The continued rise in fatalities from opioid analgesics despite a steady decline in the number of individual prescriptions directing ≥ 90 morphine milligram equivalents (MME)/day may be explained by patient exposures to redundant prescriptions from multiple prescribers. OBJECTIVES: We evaluated prescribers' specialty and social network characteristics associated with high-risk opioid exposures resulting from single-prescriber high-daily dose prescriptions or multi-prescriber discoordination. DESIGN: Retrospective cohort study. PARTICIPANTS: A cohort of prescribers with opioid analgesic prescription claims for non-cancer chronic opioid users in an Illinois Medicaid managed care program in 2015-2016. MAIN MEASURES: Per prescriber rates of single-prescriber high-daily-dose prescriptions or multi-prescriber discoordination. KEY RESULTS: For 2280 beneficiaries, 36,798 opioid prescription claims were submitted by 3532 prescribers. Compared to 3% of prescriptions (involving 6% of prescribers and 7% of beneficiaries) that directed ≥ 90 MME/day, discoordination accounted for a greater share of high-risk exposures-13% of prescriptions (involving 23% of prescribers and 24% of beneficiaries). The following specialties were at highest risk of discoordinated prescribing compared to internal medicine: dental (incident rate ratio (95% confidence interval) 5.9 (4.6, 7.5)), emergency medicine (4.7 (3.8, 5.8)), and surgical subspecialties (4.2 (3.0, 5.8)). Social network analysis identified 2 small interconnected prescriber communities of high-volume pain management specialists, and 3 sparsely connected groups of predominantly low-volume primary care or emergency medicine clinicians. Using multivariate models, we found that the sparsely connected sociometric positions were a risk factor for high-risk exposures. CONCLUSION: Low-volume prescribers in the social network's periphery were at greater risk of intended or discoordinated prescribing than interconnected high-volume prescribers. Interventions addressing discoordination among low-volume opioid prescribers in non-integrated practices should be a priority. Demands for enhanced functionality and integration of Prescription Drug Monitoring Programs or referrals to specialized multidisciplinary pain management centers are potential policy implications.

Health Care Utilization of Opioid Overdose Decedents with No Opioid Analgesic Prescription History.

Opioid overprescribing is a major driver of the current opioid overdose epidemic. However, annual opioid prescribing in the USA dropped from 782 to 640 morphine milligram equivalents per capita between 2010 and 2015, while opioid overdose deaths increased by 63%. To better understand the role of prescription opioids and health care utilization prior to opioid-related overdose, we analyzed the death records of decedents who died of an opioid overdose in Illinois in 2016 and linked to any existing controlled substance monitoring program (CSMP) and emergency department (ED) or hospital discharge records. We found that of the 1893 opioid-related overdoses, 573 (30.2%) decedents had not filled an opioid analgesic prescription within the 6 years prior to death. Decedents without an opioid prescription were more likely to be black (33.3% vs 20.2%, p < .001), Hispanic (16.3% vs 8.8%, p < .001), and Chicago residents (46.8% vs 25.6%, p < .001) than decedents with at least one filled opioid prescription. Decedents who did not fill an opioid prescription were less likely to die of an overdose involving prescribed opioids (7.3% vs 19.5%, p < .001) and more likely to fatally overdose on heroin (63% vs 50.4%, p < .001) or fentanyl/fentanyl analogues (50.3% vs 41.8%, p = .001). Between 2012 and the time of death, decedents without an opioid prescription had fewer emergency department admissions (2.5 ± 4.2 vs 10.6 ± 15.8, p < .001), were less likely to receive an opioid use disorder diagnosis (41.3% vs 47.5%, p = .052), and were less likely to be prescribed buprenorphine for opioid use disorder treatment (3.3% vs 8.6%, p < .001). Public health interventions have often focused on opioid prescribing and the use of CSMPs as the core preventive measures to address the opioid crisis. We identified a subset of individuals in Illinois who may not be impacted by such interventions. Additional research is needed to understand what strategies may be successful among high-risk populations that have limited opioid analgesic prescription history and low health care utilization.

Syndrome surveillance of fentanyl-laced heroin outbreaks: Utilization of EMS, Medical Examiner and Poison Center databases.

OBJECTIVE: Describe surveillance data from three existing surveillance systems during an unexpected fentanyl outbreak in a large metropolitan area. METHODS: We performed a retrospective analysis of three data sets: Chicago Fire Department EMS, Cook County Medical Examiner, and Illinois Poison Center. Each included data from January 1, 2015 through December 31, 2015. EMS data included all EMS responses in Chicago, Illinois, for suspected opioid overdose in which naloxone was administered and EMS personnel documented other criteria indicative of opioid overdose. Medical Examiner data included all deaths in Cook County, Illinois, related to heroin, fentanyl or both. Illinois Poison Center data included all calls in Chicago, Illinois, related to fentanyl, heroin, and other prescription opioids. Descriptive statistics using Microsoft Excel® were used to analyze the data and create figures. RESULTS: We identified a spike in opioid-related EMS responses during an 11-day period from September 30-October 10, 2015. Medical Examiner data showed an increase in both fentanyl and mixed fentanyl/heroin related deaths during the months of September and October, 2015 (375% and 550% above the median, respectively.) Illinois Poison Center data showed no significant increase in heroin, fentanyl, or other opioid-related calls during September and October 2015. CONCLUSION: Our data suggests that EMS data is an effective real-time surveillance mechanism for changes in the rate of opioid overdoses. Medical Examiner's data was found to be valuable for confirmation of EMS surveillance data and identification of specific intoxicants. Poison Center data did not correlate with EMS or Medical Examiner data.

Comparison of High-Fidelity Medical Simulation to Short-Answer Written Examination in the Assessment of Emergency Medicine Residents in Medical Toxicology.

We compared high-fidelity medical simulation to short-answer written examination in the assessment of emergency medicine residents (EMR) on a month-long medical toxicology rotation. Knowledge-based assessment tools using cases of an aspirin overdose and a tricyclic antidepressant overdose were used to assess all consecutive rotating EMR (n=53). Assessment by simulation had similar accuracy and precision but higher satisfaction rates when compared to written examination. Incorporating simulation into the ABEM certifying examination warrants further study.