Evaluation of an emergency department buprenorphine induction and medication-assisted treatment referral program.

BACKGROUND: Emergency departments are struggling to manage the increasing number of patients seen for opioid use disorders and opioid overdose. With opioid overdose deaths rising at alarming rates, emergency physicians are beginning to induce patients with long-acting opioids such as buprenorphine and referring patients to outpatient medication-assisted treatment facilities. The objective of this study was to describe a pragmatic approach to buprenorphine induction, referral to treatment, and assess follow-up rates. METHODS: Single center, retrospective analysis of emergency department patients undergoing buprenorphine induction and referral to outpatient medication-assisted treatment. Patients were identified by an ongoing log of induced patients, between May 2017 and October 2018. The data is analyzed using descriptive statistics, with means and associated standard deviations, medians and interquartile ranges for continuous variables, and frequencies as percentages for categorical data. RESULTS: Overall, 219 patients were seen and induced with buprenorphine in the emergency department. Mean age was 35 years old (SD 10.3) and 56% were male. Intravenous opioids were most commonly abused at 75%. Our primary outcome of interest was the percentage of patients enrolled in MAT at 30 days, which occurred in 49.3% of our population. Patients were in moderate withdrawal based on initial COWS scores of 13.1(SD 5.8), and received mean total doses of 7.7 mg (SD 3.3). Median ED length of stay decreased by 40% between May 2017 and October 2018. CONCLUSION: Emergency department initiated buprenorphine induction using a structured pragmatic approach is effective at maintaining patients in medication-assisted therapy.

A confirmed case of agranulocytosis after use of cocaine contaminated with levamisole.

More than 2 million Americans use cocaine each month (National Survey on Drug Use and Health, Department of Health and Human Services: Substance Abuse and Mental Health Services Administration (SAMHSA) & Office of Applied Studies (OAS), Rockville, MD 2007). Starting in early 2003, South American cocaine cartels began to add levamisole, a pharmaceutical agent, to bulk cocaine prior to shipment to the USA (Valentino and Fuentecilla 2005). A dramatic increase in the prevalence of levamisole in cocaine was noted in early 2008. By October, 30% of cocaine bricks analyzed by the United States Drug Enforcement Administration contained levamisole (Casale et al. 2008). Exposure to levamisole can cause agranulocytosis (Amery and Bruynseels 1992). We report the first confirmed case of agranulocytosis associated with consumption of levamisole-contaminated cocaine in the USA. A previously healthy adult male presented to the emergency department with 5 days of mouth pain. He admitted to chronic active ethanol and crack cocaine abuse. Laboratory studies revealed severe neutropenia, with an absolute neutrophil count of 19 cells/mm³ (normal = 1,500-8,000 cells/mm³). A urine screen for drugs of abuse was positive for cocaine metabolites and opiates. Evaluation of a peripheral blood smear showed leukopenia with severe absolute neutropenia. A bone marrow biopsy revealed recently injured bone marrow showing early recovery. While in the hospital, the patient had little spontaneous bone marrow recovery. He received granulocyte colony-stimulating factor with improvement in peripheral white blood cell counts. The residue in the patient's crack pipe contained 10% levamisole. Subsequently, levamisole was detected in the patient's urine. Levamisole-associated agranulocytosis should be considered in the diagnosis of patients who present with neutropenia and a history or evidence of cocaine use.