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1.
Am J Emerg Med ; 51: 331-337, 2021 Nov 09.
Artigo em Inglês | MEDLINE | ID: mdl-34800906

RESUMO

STUDY OBJECTIVE: Emergency departments (ED) are critical touchpoints for encounters among patients with opioid use disorder (OUD), but implementation of ED initiated treatment and harm reduction programs has lagged. We describe national patient, visit and hospital-level characteristics of ED OUD visits and characterize EDs with high rates of OUD visits in order to inform policies to optimize ED OUD care. METHODS: We conducted a descriptive, cross-sectional study with the 2017 Nationwide Emergency Department Sample (NEDS) from the Healthcare Cost and Utilization Project, using diagnostic and mechanism of injury codes from ICD-10 to identify OUD related visits. NEDS weights were applied to generate national estimates. We evaluated ED visit and clinical characteristics of all OUD encounters. We categorized hospitals into quartiles by rate of visits for OUD per 1000 ED visits and described the visit, clinical, and hospital characteristics across the four quartiles. RESULTS: In 2017, the weighted national estimate for OUD visits was 1,507,550. Overdoses accounted for 295,954. (19.6%) of visits. OUD visit rates were over 8× times higher among EDs in the highest quartile of OUD visit rate (22.9 per 1000 total ED visits) compared with EDs in the lowest quartile of OUD visit rate (2.7 per 1000 ED visits). Over three fifths (64.2%) of all OUD visits nationwide were seen by the hospitals in the highest quartile of OUD visit rate. These hospitals were predominantly in metropolitan areas (86.2%), over half were teaching hospitals (51.7%), and less than a quarter (23.3%) were Level 1 or Level 2 trauma centers. CONCLUSION: Targeting initial efforts of OUD care programs to high OUD visit rate EDs could improve care for a large portion of OUD patients utilizing emergency care.

2.
Drug Alcohol Depend ; 227: 108994, 2021 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-34482038

RESUMO

INTRO: Understanding sex differences in toxicological etiologies of opioid-related drug overdose death could inform future sex- and gender-specific approaches to prevention and treatment. METHODS: A retrospective review of accidental or undetermined opioid-involved overdose deaths in Rhode Island 2016-2019 was performed using the Rhode Island Department of Health State Unintentional Drug Overdose Reporting System (SUDORS) database. Decedent toxicology data was linked with state Prescription Drug Monitoring Program (PDMP) records. RESULTS: Of 766 cases in the analytical sample, 568 cases were in men (74.2%) and 198 cases were in women (25.6%). Median age was 40.0 years for males and 42.0 years for females. Statistically significant sex-differences in drug exposures were found. Compared to men, women were more likely have exposure to benzodiazepine, antipsychotic, and antidepressant drug classes and less likely to have fentanyl and alcohol co-exposure. No sex differences were found in cocaine and amphetamine exposure. Female decedents were more likely than male decedents to have a prescription for benzodiazepines or opioids in the 30 days before death (40% vs 21%). The proportion of decedents with a benzodiazepine on post-mortem toxicology testing in combination with a benzodiazepine prescription (p < 0.001) or an opioid prescription (p = 0.005) was over two times higher in women than men. CONCLUSION: Higher rates of controlled substance prescription prior to death and prescription drug co-exposures suggest that female opioid-involved drug overdose decedents are often in contact with the health care system immediately preceding their death, presenting the opportunity to create patient-centric approaches for prevention, harm reduction, and substance use treatment.


Assuntos
Overdose de Drogas , Overdose de Opiáceos , Adulto , Analgésicos Opioides , Overdose de Drogas/epidemiologia , Feminino , Fentanila , Humanos , Masculino , Estudos Retrospectivos , Caracteres Sexuais
4.
JAMA Netw Open ; 4(7): e2118801, 2021 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-34323984

RESUMO

Importance: Although racial disparities in acute pain control are well established, the role of patient analgesic preference and the factors associated with these disparities remain unclear. Objective: To characterize racial disparities in opioid prescribing for acute pain after accounting for patient preference and to test the hypothesis that racial disparities may be mitigated by giving clinicians additional information about their patients' treatment preferences and risk of opioid misuse. Design, Setting, and Participants: This study is a secondary analysis of data collected from Life STORRIED (Life Stories for Opioid Risk Reduction in the ED), a multicenter randomized clinical trial conducted between June 2017 and August 2019 in the emergency departments (EDs) of 4 academic medical centers. Participants included 1302 patients aged 18 to 70 years who presented to the ED with ureter colic or musculoskeletal back and/or neck pain. Interventions: The treatment arm was randomized to receive a patient-facing intervention (not examined in this secondary analysis) and a clinician-facing intervention that consisted of a form containing information about each patient's analgesic treatment preference and risk of opioid misuse. Main Outcomes and Measures: Concordance between patient preference for opioid-containing treatment (assessed before ED discharge) and receipt of an opioid prescription at ED discharge. Results: Among 1302 participants in the Life STORRIED clinical trial, 1012 patients had complete demographic and treatment preference data available and were included in this secondary analysis. Of those, 563 patients (55.6%) self-identified as female, with a mean (SD) age of 40.8 (14.1) years. A total of 455 patients (45.0%) identified as White, 384 patients (37.9%) identified as Black, and 173 patients (17.1%) identified as other races. After controlling for demographic characteristics and clinical features, Black patients had lower odds than White patients of receiving a prescription for opioid medication at ED discharge (odds ratio [OR], 0.42; 95% CI, 0.27-0.65). When patients who did and did not prefer opioids were considered separately, Black patients continued to have lower odds of being discharged with a prescription for opioids compared with White patients (among those who preferred opioids: OR, 0.43 [95% CI, 0.24-0.77]; among those who did not prefer opioids: OR, 0.45 [95% CI, 0.23-0.89]). These disparities were not eliminated in the treatment arm, in which clinicians were given additional data about their patients' treatment preferences and risk of opioid misuse. Conclusions and Relevance: In this secondary analysis of data from a randomized clinical trial, Black patients received different acute pain management than White patients after patient preference was accounted for. These disparities remained after clinicians were given additional patient-level data, suggesting that a lack of patient information may not be associated with opioid prescribing disparities. Trial Registration: ClinicalTrials.gov Identifier: NCT03134092.

5.
JAMIA Open ; 4(2): ooab042, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-34169232

RESUMO

Objective: Biomedical research involving social media data is gradually moving from population-level to targeted, cohort-level data analysis. Though crucial for biomedical studies, social media user's demographic information (eg, gender) is often not explicitly known from profiles. Here, we present an automatic gender classification system for social media and we illustrate how gender information can be incorporated into a social media-based health-related study. Materials and Methods: We used a large Twitter dataset composed of public, gender-labeled users (Dataset-1) for training and evaluating the gender detection pipeline. We experimented with machine learning algorithms including support vector machines (SVMs) and deep-learning models, and public packages including M3. We considered users' information including profile and tweets for classification. We also developed a meta-classifier ensemble that strategically uses the predicted scores from the classifiers. We then applied the best-performing pipeline to Twitter users who have self-reported nonmedical use of prescription medications (Dataset-2) to assess the system's utility. Results and Discussion: We collected 67 181 and 176 683 users for Dataset-1 and Dataset-2, respectively. A meta-classifier involving SVM and M3 performed the best (Dataset-1 accuracy: 94.4% [95% confidence interval: 94.0-94.8%]; Dataset-2: 94.4% [95% confidence interval: 92.0-96.6%]). Including automatically classified information in the analyses of Dataset-2 revealed gender-specific trends-proportions of females closely resemble data from the National Survey of Drug Use and Health 2018 (tranquilizers: 0.50 vs 0.50; stimulants: 0.50 vs 0.45), and the overdose Emergency Room Visit due to Opioids by Nationwide Emergency Department Sample (pain relievers: 0.38 vs 0.37). Conclusion: Our publicly available, automated gender detection pipeline may aid cohort-specific social media data analyses (https://bitbucket.org/sarkerlab/gender-detection-for-public).

6.
Am J Emerg Med ; 47: 154-157, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-33812332

RESUMO

OBJECTIVE: To determine the rate at which commercially-insured patients fill prescriptions for naloxone after an opioid-related ED encounter as well as patient characteristics associated with obtaining naloxone. METHODS: This is a retrospective cohort study of adult patients discharged from the ED following treatment for an opioid-related condition from 2016 to 2018 using a commercial insurance claims database (Optum Clinformatics® Data Mart). The primary outcome was a pharmacy claim for naloxone in the 30 days following the ED encounter. A multivariable logistic regression model examined the association of patient characteristics with filled naloxone prescriptions, and predictive margins were used to report adjusted probabilities with 95% confidence intervals. RESULTS: 21,700 patients had opioid-related ED encounters during the study period, of which 1743 (8.0%) had encounters for heroin overdose, 8825 (40.7%) for overdose due to other opioids, 5400 (24.9%) for withdrawal, and 5732 (26.4%) for other opioid use disorder conditions. 230 patients (1.1%) filled a prescription for naloxone within 30 days. Patients with heroin overdose (2.6%; 95%CI 1.7 to 3.4), recent prescriptions for opioid analgesics (1.4%; 95%CI 1.1 to 1.7), recent prescriptions for buprenorphine (1.9%; 95%CI 1.0 to 2.9), and naloxone prescriptions in the prior year (3.3%; 95%CI 1.8 to 4.8) were more likely to obtain naloxone. The rate was significantly higher in 2018 [1.9% (95%CI 1.5 to 2.2)] as compared to 0.4% (95%CI 0.3 to 0.6) in 2016. CONCLUSIONS: Few patients use insurance to obtain naloxone by prescription following opioid-related ED encounters. Clinical and policy interventions should expand distribution of this life-saving medication in the ED.


Assuntos
Overdose de Drogas/epidemiologia , Prescrições de Medicamentos/estatística & dados numéricos , Naloxona/uso terapêutico , Antagonistas de Entorpecentes/uso terapêutico , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Síndrome de Abstinência a Substâncias/epidemiologia , Adulto , Bases de Dados Factuais , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Seguro Saúde/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Adulto Jovem
7.
Clin Toxicol (Phila) ; 59(11): 982-991, 2021 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-33821724

RESUMO

BACKGROUND: According to the latest medical evidence, Methadone and buprenorphine-naloxone (Suboxone®) are effective treatments for opioid use disorder (OUD). While the evidence basis for the use of these medications is favorable, less is known about the perceptions of the general public about them. OBJECTIVE: This study aimed to use Twitter to assess the public perceptions about methadone and buprenorphine-naloxone, and to compare their discussion contents based on themes/topics, subthemes, and sentiment. METHODS: We conducted a descriptive analysis of a small and automatic analysis of a large volume of microposts ("tweets") that mentioned "methadone" or "suboxone". In the manual analysis, we categorized the tweets into themes and subthemes, as well as by sentiment and personal experience, and compared the information posted about these two medications. We performed automatic topic modeling and sentiment analysis over large volumes of posts and compared the outputs to those from the manual analyses. RESULTS: We manually analyzed 900 tweets, most of which related to access (15.3% for methadone; 14.3% for buprenorphine-naloxone), stigma (17.0%; 15.5%), and OUD treatment (12.8%; 15.6%). Only a small proportion of tweets (16.4% for Suboxone® and 9.3% for methadone) expressed positive sentiments about the medications, with few tweets describing personal experiences. Tweets mentioning both medications primarily discussed MOUD broadly, rather than comparing the two medications directly. Automatic topic modeling revealed topics from the larger dataset that corresponded closely to the manually identified themes, but sentiment analysis did not reveal any notable differences in chatter regarding the two medications. CONCLUSIONS: Twitter content about methadone and Suboxone® is similar, with the same major themes and similar sub-themes. Despite the proven effectiveness of these medications, there was little dialogue related to their benefits or efficacy in the treatment of OUD. Perceptions of these medications may contribute to their underutilization in combatting OUDs.


Assuntos
Analgésicos Opioides/uso terapêutico , Combinação Buprenorfina e Naloxona/uso terapêutico , Metadona/uso terapêutico , Antagonistas de Entorpecentes/uso terapêutico , Tratamento de Substituição de Opiáceos , Transtornos Relacionados ao Uso de Opioides/reabilitação , Opinião Pública , Mídias Sociais , Analgésicos Opioides/efeitos adversos , Combinação Buprenorfina e Naloxona/efeitos adversos , Humanos , Metadona/efeitos adversos , Antagonistas de Entorpecentes/efeitos adversos , Processamento de Linguagem Natural , Tratamento de Substituição de Opiáceos/efeitos adversos
8.
J Med Toxicol ; 17(4): 372-377, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-33905078

RESUMO

INTRODUCTION: Both opioid and non-opioid analgesics are commonly utilized in treating acute and chronic pain in the emergency department (ED). Opioid stewardship efforts have focused on judicious opioid use and opioid alternatives as first-line analgesics. Parenteral opioid formulations have been impacted by periodic shortages creating the opportunity for a natural experiment to observe how emergency clinician prescribing behavior may be impacted. We investigated the change in analgesic practice related to a period of parenteral opioid shortage at two large urban, academic medical centers. METHODS: A retrospective review of pharmacy administration data from two academic urban EDs was performed looking at time periods before, during, and after resolution of the parenteral opioid shortage. The data were analyzed by medication, dose, time, number of doses, and oral morphine milligram equivalents (MME) administered per patient. RESULTS: The percentage of patients who received any opioid among ED visits decreased during the shortage period and did not return to pre-shortage levels after the shortage ended: 11.5% pre, 8.5% during (p=0.01), 7.2% post (NS; p=0.18). The number of doses of either oral or IV opioid doses administered during the shortage decreased significantly: 8.7% pre, 5.6% during (p=0.02) for PO, and 13.7% pre, 9.0% during (p=0.004) for IV, and neither changed during recovery from the shortage. The percentage of patients receiving non-opioid analgesics rose from 30.5% before to 45.8% (p=0.004) after the shortage. Among patients who received opioids, the MME per patient did not change across the time periods: 11.5% before, 11.2% during, 12.7% post. CONCLUSIONS: A period of restricted opioid use due to parenteral opioid shortages led to less opioid use overall and fewer patients treated with opioids, yet no significant change in opioid MME administered per patient requiring opioids. Overall, the shift in opioid prescribing during the parenteral opioid shortage appeared to be sustained in the post-shortage period.

9.
Contemp Clin Trials ; 104: 106359, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33737199

RESUMO

ED-INNOVATION (Emergency Department-INitiated bupreNOrphine VAlidaTION) is a Hybrid Type-1 Implementation-Effectiveness multisite emergency department (ED) study funded through The Helping to End Addiction Long-termSM Initiative, or NIH HEAL InitiativeSM efforts to increase access to medications for opioid use disorder (OUD). We use components of Implementation Facilitation to enhance adoption of ED-initiated buprenorphine (BUP) at approximately 30 sites. Subsequently we compare the effectiveness of two BUP formulations, sublingual (SL-BUP) and 7-day extended-release injectable (CAM2038, XR-BUP) in a randomized clinical trial (RCT) of approximately 2000 patients with OUD on the primary outcome of engagement in formal addiction treatment at 7 days. Secondary outcomes assessed at 7 and 30 days include self-reported opioid use, craving and satisfaction, health service utilization, overdose events, and engagement in formal addiction treatment (30 days) and receipt of medications for OUD (at 7 and 30 days). A sample size of 1000 per group provides 90% power at the 2-sided significance level to detect a difference in the primary outcome of 8% and accommodates a 15% dropout rate. We will compare the cost effectiveness of the two treatments on the primary outcome using the incremental cost-effectiveness ratio. We will also conduct an ancillary study in approximately 75 patients experiencing minimal to no opioid withdrawal who will undergo XR-BUP initiation. If the ancillary study demonstrates safety, we will expand the eligibility criteria for the RCT to include individuals with minimal to no opioid withdrawal. The results of these studies will inform implementation of ED-initiated BUP in diverse EDs which has the potential to improve treatment access.


Assuntos
Buprenorfina , Transtornos Relacionados ao Uso de Opioides , Buprenorfina/uso terapêutico , Preparações de Ação Retardada/uso terapêutico , Serviço Hospitalar de Emergência , Humanos , Antagonistas de Entorpecentes/uso terapêutico , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico
10.
Acad Med ; 2021 Feb 02.
Artigo em Inglês | MEDLINE | ID: mdl-33538477

RESUMO

In the face of an ongoing opioid crisis in the United States, persistent treatment gaps exist for vulnerable populations. Among the 3 Food and Drug Administration-approved medications used to treat opioid use disorder, many patients prefer buprenorphine. But physicians are currently required to register with the Drug Enforcement Administration and complete 8 hours of qualifying training before they can receive a waiver to prescribe buprenorphine to their patients. In this article, the authors summarize the evolution of buprenorphine waiver training in undergraduate medical education and outline 2 potential paths to increase buprenorphine treatment capacity going forward: the curriculum change approach and the training module approach. As part of the 2018 Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act, the Substance Abuse and Mental Health Services Administration has provided funding for medical schools to adapt their curricula to meet waiver-training requirements. To date, however, only one school has had its curriculum approved for this purpose. Additionally, recent political efforts have been directed at eliminating aspects of the waiver training requirement and creating a more direct path to integrating waiver qualification into undergraduate medical education. Other medical schools have adopted a more pragmatic approach involving the integration of existing online, in-person, and hybrid waiver-qualifying training modules into the curricula, generally for fourth-year students. This training module approach can be more rapidly, broadly, and cost-effectively implemented than the curriculum change approach. It can also be easily integrated into the online medical curricula that schools developed in response to the COVID-19 pandemic. Ultimately both curricular changes and support for student completion of existing training modules should be pursued in concert, but focus should not be single-mindedly on the former at the expense of the latter.

11.
Psychiatr Serv ; 72(9): 1048-1056, 2021 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-33593105

RESUMO

OBJECTIVE: In 2019, Pennsylvania established a voluntary financial incentive program designed to increase the engagement in addiction treatment for Medicaid patients with opioid use disorder after emergency department (ED) encounters. In this qualitative study involving hospital leaders, the authors examined decisions leading to participation in this program as well as barriers and facilitators that influenced its implementation. METHODS: Twenty semistructured interviews were conducted with leaders from a diverse sample of hospitals and health systems across Pennsylvania. Interviews were planned and analyzed following the Consolidated Framework for Implementation Research. An iterative approach was used to analyze the interviews and determine key themes and patterns regarding implementation of this policy initiative in hospitals. RESULTS: The authors identified six key themes that reflected barriers and facilitators to hospital participation in the program. Participation in the program was facilitated by community partners capable of arranging outpatient treatment for opioid use disorder, incentive payments focusing hospital leadership on opioid treatment pathways, multidisciplinary planning, and flexibility in adapting pathways for local needs. Barriers to program participation concerned the implementation of buprenorphine prescribing and the measurement of treatment outcomes. CONCLUSIONS: A financial incentive policy encouraged hospitals to enact rapid system and practice changes to support treatment for opioid use disorder, although challenges remained in implementing evidence-based treatment-specifically, initiation of buprenorphine-for patients visiting the ED. Analysis of treatment outcomes is needed to further evaluate this policy initiative, but new delivery and payment models may improve systems to treat patients who have an opioid use disorder.


Assuntos
Buprenorfina , Transtornos Relacionados ao Uso de Opioides , Serviço Hospitalar de Emergência , Humanos , Motivação , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Políticas , Estados Unidos
12.
BMC Med Inform Decis Mak ; 21(1): 27, 2021 01 26.
Artigo em Inglês | MEDLINE | ID: mdl-33499852

RESUMO

BACKGROUND: Prescription medication (PM) misuse/abuse has emerged as a national crisis in the United States, and social media has been suggested as a potential resource for performing active monitoring. However, automating a social media-based monitoring system is challenging-requiring advanced natural language processing (NLP) and machine learning methods. In this paper, we describe the development and evaluation of automatic text classification models for detecting self-reports of PM abuse from Twitter. METHODS: We experimented with state-of-the-art bi-directional transformer-based language models, which utilize tweet-level representations that enable transfer learning (e.g., BERT, RoBERTa, XLNet, AlBERT, and DistilBERT), proposed fusion-based approaches, and compared the developed models with several traditional machine learning, including deep learning, approaches. Using a public dataset, we evaluated the performances of the classifiers on their abilities to classify the non-majority "abuse/misuse" class. RESULTS: Our proposed fusion-based model performs significantly better than the best traditional model (F1-score [95% CI]: 0.67 [0.64-0.69] vs. 0.45 [0.42-0.48]). We illustrate, via experimentation using varying training set sizes, that the transformer-based models are more stable and require less annotated data compared to the other models. The significant improvements achieved by our best-performing classification model over past approaches makes it suitable for automated continuous monitoring of nonmedical PM use from Twitter. CONCLUSIONS: BERT, BERT-like and fusion-based models outperform traditional machine learning and deep learning models, achieving substantial improvements over many years of past research on the topic of prescription medication misuse/abuse classification from social media, which had been shown to be a complex task due to the unique ways in which information about nonmedical use is presented. Several challenges associated with the lack of context and the nature of social media language need to be overcome to further improve BERT and BERT-like models. These experimental driven challenges are represented as potential future research directions.


Assuntos
Medicamentos sob Prescrição , Mídias Sociais , Humanos , Aprendizado de Máquina , Processamento de Linguagem Natural , Prescrições
13.
J Addict Med ; 15(1): 49-54, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-32541363

RESUMO

OBJECTIVES: We performed a descriptive analysis of patient and treatment characteristics in premature discharges "against medical advice" (AMA) in a cohort of patients with opioid-related hospitalizations. METHODS: We abstracted data from 1152 opioid related hospitalizations of 928 adult patients in a large academic health system. Using electronic health record data, hospitalizations were categorized as AMA or conventional discharge (CD). To determine differences between AMA and CD regarding treatment characteristics, Fisher exact test, t tests, ANOVA, and logistic regression were performed. RESULTS: 74 / 1152 (6%) of opioid-related hospitalizations were discharged AMA. Hospitalizations that resulted in AMA discharge had shorter median length of stay (AMA vs CD 3.5 vs 5.5 days, P < 0.001) and received fewer of any type of opioid agonist treatment (AMA vs CD 73% vs 84%, P = 0.03). Although the number of hospitalizations in which methadone was administered did not differ between the AMA and CD groups, hospitalizations that resulted in AMA had more dose reductions and lesser quantities of methadone overall before discharge. Buprenorphine use was low overall in AMA and CD (0% and 2.1%, respectively). CONCLUSION: In this sample of opioid related hospitalizations, admissions that resulted in AMA discharge had fewer opioid agonist administrations and lower methadone dosing. These findings support efforts to initiate opioid agonist therapy during hospital admissions, and further studies should determine whether this practice mitigates AMA discharges.


Assuntos
Analgésicos Opioides , Alta do Paciente , Adulto , Analgésicos Opioides/efeitos adversos , Hospitalização , Humanos , Estudos Retrospectivos , Fatores de Risco , Recusa do Paciente ao Tratamento
14.
J Med Toxicol ; 17(1): 10-15, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32648229

RESUMO

BACKGROUND: Buprenorphine is a unique µ-opioid receptor partial agonist with avid receptor binding, nominal euphoric reward, and a ceiling effect on sedation and respiratory depression. Despite a pharmacologic profile that enhances safety, cases of fatal opioid overdose with buprenorphine on postmortem toxicology are reported, but details of these cases in the literature are limited. METHODS: A retrospective review of opioid-involved drug overdose fatalities in Rhode Island (RI) from 2016 to 2018 using the RI Department of Health State Unintentional Drug Overdose Reporting System (SUDORS) database. Deaths with buprenorphine on toxicology testing versus opioid-involved overdose deaths without buprenorphine were compared to assess the type and number of co-exposures. RESULTS: Of 534 opioid-involved deaths, 29 (5.4%) included buprenorphine and/or norbuprenorphine on toxicology. Most frequent co-exposures are as follows: fentanyl (75.9%), norfentanyl (72.4%), cocaine (41.4%), benzoylecgonine (41.4%), cannabinoids (31.0%), ethanol (31.0%), levamisole (31.0%), and free morphine (31.0%). An average number of co-exposures for fatalities with buprenorphine were 9.24 versus 6.68 in those without buprenorphine. In one case buprenorphine was the only drug listed to cause death; all other fatalities with buprenorphine on toxicology reported additional drugs contributing to death. CONCLUSION: Decedents with buprenorphine detected on toxicology testing commonly had documented polysubstance use. Although data are limited, buprenorphine may provide some risk mitigation against full agonist opioid overdose including fentanyl. Further work should explore the use of postmortem concentrations of buprenorphine, norbuprenorphine, and other opioid metabolites to determine the role of buprenorphine in fatal overdose pharmacology.

15.
Comput Biol Med ; 129: 104132, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33290931

RESUMO

BACKGROUND: Opioid misuse (OM) is a major health problem in the United States, and can lead to addiction and fatal overdose. We sought to employ natural language processing (NLP) and machine learning to categorize Twitter chatter based on the motive of OM. MATERIALS AND METHODS: We collected data from Twitter using opioid-related keywords, and manually annotated 6988 tweets into three classes-No-OM, Pain-related-OM, and Recreational-OM-with the No-OM class representing tweets indicating no use/misuse, and the Pain-related misuse and Recreational-misuse classes representing misuse for pain or recreation/addiction. We trained and evaluated multi-class classifiers, and performed term-level k-means clustering to assess whether there were terms closely associated with the three classes. RESULTS: On a held-out test set of 1677 tweets, a transformer-based classifier (XLNet) achieved the best performance with F1-score of 0.71 for the Pain-misuse class, and 0.79 for the Recreational-misuse class. Macro- and micro-averaged F1-scores over all classes were 0.82 and 0.92, respectively. Content-analysis using clustering revealed distinct clusters of terms associated with each class. DISCUSSION: While some past studies have attempted to automatically detect opioid misuse, none have further characterized the motive for misuse. Our multi-class classification approach using XLNet showed promising performance, including in detecting the subtle differences between pain-related and recreation-related misuse. The distinct clustering of class-specific keywords may help conduct targeted data collection, overcoming under-representation of minority classes. CONCLUSION: Machine learning can help identify pain-related and recreational-related OM contents on Twitter to potentially enable the study of the characteristics of individuals exhibiting such behavior.


Assuntos
Transtornos Relacionados ao Uso de Opioides , Mídias Sociais , Analgésicos Opioides/efeitos adversos , Humanos , Aprendizado de Máquina , Processamento de Linguagem Natural , Estados Unidos
16.
Am J Drug Alcohol Abuse ; 46(6): 671-683, 2020 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-32897113

RESUMO

Opioid use, misuse, and risky use contribute to a critically important and complex crisis in current healthcare. Consequences of long-term opioid use, including opioid induced hyperalgesia, physical dependence, and opioid use disorder, can be considered iatrogenic, or partially iatrogenic, in cases where therapeutic opioid exposures were contributory. Research investigation and presumptive clinical action are needed to attenuate the iatrogenic component of the opioid crisis; treatment of individuals already suffering from opioid use disorder will not prevent incident cases. This work will be challenged by a remarkably high degree of complexity involving myriad and highly variable factors along the continuum from initial opioid exposure to long-term opioid use. An organized view of this complex problem should accelerate the pace of innovation and facilitate clinical implementation of research findings. Herein, we propose a theoretical framework and modern nomenclature for characterizing therapeutic opioid exposure and the degree to which it contributes iatrogenically to adverse outcomes. In doing so, we separate the role of exposure from other factors contributing to long-term opioid use, clarify the relationship between opioid exposure and outcomes, emphasize that exposure source is an important consideration for health services research and practice in the areas of pain treatment and opioid prevention, and recommend terminology necessary to quantify therapeutic opioid exposure separately from nonmedical exposure.


Assuntos
Analgésicos Opioides/efeitos adversos , Hiperalgesia/induzido quimicamente , Transtornos Relacionados ao Uso de Opioides/etiologia , Terminologia como Assunto , Humanos , Doença Iatrogênica , Modelos Teóricos
17.
JMIR Res Protoc ; 9(9): e19496, 2020 Sep 24.
Artigo em Inglês | MEDLINE | ID: mdl-32969832

RESUMO

BACKGROUND: Prescription opioid misuse in the United States is a devastating public health crisis; many chronic opioid users were originally prescribed this class of medication for acute pain. Video narrative-enhanced risk communication may improve patient outcomes, such as knowledge of opioid risk and opioid use behaviors after an episode of acute pain. OBJECTIVE: Our objective is to assess the effect of probabilistic and narrative-enhanced opioid risk communication on patient-reported outcomes, including knowledge, opioid use, and patient preferences, for patients who present to emergency departments with back pain and kidney stone pain. METHODS: This is a multisite randomized controlled trial. Patients presenting to the acute care facilities of four geographically and ethnically diverse US hospital centers with acute renal colic pain or musculoskeletal back and/or neck pain are eligible for this randomized controlled trial. A control group of patients receiving general risk information is compared to two intervention groups: one receiving the risk information sheet plus an individualized, visual probabilistic Opioid Risk Tool (ORT) and another receiving the risk information sheet plus a video narrative-enhanced probabilistic ORT. We will study the effect of probabilistic and narrative-enhanced opioid risk communication on the following: risk awareness and recall at 14 days postenrollment, reduced use or preferences for opioids after the emergency department episode, and alignment with patient preference and provider prescription. To assess these outcomes, we administer baseline patient surveys during acute care admission and follow-up surveys at predetermined times during the 3 months after discharge. RESULTS: A total of 1302 patients were enrolled over 24 months. The mean age of the participants was 40 years (SD 14), 692 out of 1302 (53.15%) were female, 556 out of 1302 (42.70%) were White, 498 out of 1302 (38.25%) were Black, 1002 out of 1302 (76.96%) had back pain, and 334 out of 1302 (25.65%) were at medium or high risk. Demographics and ORT scores were equally distributed across arms. CONCLUSIONS: This study seeks to assess the potential clinical role of narrative-enhanced, risk-informed communication for acute pain management in acute care settings. This paper outlines the protocol used to implement the study and highlights crucial methodological, statistical, and stakeholder involvement as well as dissemination considerations. TRIAL REGISTRATION: ClinicalTrials.gov NCT03134092; https://clinicaltrials.gov/ct2/show/NCT03134092. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/19496.

18.
J Opioid Manag ; 16(4): 239-246, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32885831

RESUMO

INTRODUCTION: Emergency department (ED) providers are on the forefront of the prescription drug crisis and understand-ing patient's perceptions of opioids may allow physicians to better address misconceptions. The aim was to determine the perceptions of ED patients regarding the efficacy and safety of opioid analgesics. METHODS: Cross-sectional study of a convenience sample of adults at a single urban academic ED. Patients completed a tablet-based survey regarding the efficacy and safety of opioid analgesics. RESULTS: Of the 715 subjects, the sample was predominantly black (80.4 percent), female (59.2 percent), and aged 18-59 years (76.8 percent). The majority (70.1 percent) of respondents reported pain as the reason for visit. Seventy-two percent had previously taken an opioid primarily for acute pain, found them effective for pain (88.2 percent), and would be willing to do so again (62.7 percent). Adverse effects made patients less likely to use them again (OR 0.703, [0.659-0.751]). Gender and age did not affect perceptions of efficacy and safety, but certain racial groups did (OR 1.08, [1.02 to 1.14], p < 0.05). Knowing someone who used opioids in a nonmedical manner did not impact willingness to use opioids. Many (54 percent) believed opioids to be as safe as nonopioid alternatives. The majority (78 percent) consid-ered prescription opioid abuse a public health problem, however underestimated the number of annual opioid-related deaths. CONCLUSION: The majority of ED patients had used opioids and considered the prescription drug crisis a public health problem. Through personal use or media coverage, the majority of participants considered opioids safe, even compared to nonopioid alternatives. Better understanding these viewpoints may improve patient-physician communication about analgesic treatment.


Assuntos
Dor Aguda , Analgésicos não Narcóticos , Serviço Hospitalar de Emergência , Adolescente , Adulto , Analgésicos não Narcóticos/efeitos adversos , Analgésicos Opioides , Estudos Transversais , Feminino , Humanos , Pessoa de Meia-Idade , Padrões de Prática Médica , Adulto Jovem
19.
Ann Emerg Med ; 76(2): 206-214, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32376089

RESUMO

STUDY OBJECTIVE: Emergency department (ED) initiation of buprenorphine for patients with opioid use disorder increases treatment engagement but remains an uncommon practice. One important barrier to ED-initiated buprenorphine is the additional training requirement (X waiver). Our objective is to evaluate the influence of a financial incentive program on emergency physician completion of X-waiver training. Secondary objectives are to evaluate the program's effect on buprenorphine prescribing and to explore physician attitudes toward the incentive. METHODS: We conducted a prospective, observational cohort study set in 3 urban academic EDs before and after implementation of a financial incentive program providing $750 for completion of X-waiver training. We describe program participation as well as rates of buprenorphine prescribing per opioid use disorder-related encounter before and after the intervention period, using electronic health record data. We also completed a postintervention physician survey assessing attitudes about the incentive program. RESULTS: Overall, 89% of eligible emergency physicians (56/63) completed the X-waiver training during the 6-week incentive period. In the 5 months after the incentive, buprenorphine prescribing per opioid use disorder-related encounter increased from 0.5% to 16% (Δ 15%; 95% confidence interval 10.6% to 19.9%), with substantial variability across sites (range 8% to 22% of opioid use disorder-related encounters). In a postintervention survey, 67% of participating physicians indicated that they would have completed the training for a lower amount. CONCLUSION: A financial incentive paying approximately half the clinical rate was effective in promoting emergency physician X-waiver training. The effect on ED-based buprenorphine prescribing was positive but variable across sites, and likely dependent on the availability of additional supports.


Assuntos
Analgésicos Opioides/uso terapêutico , Buprenorfina/uso terapêutico , Medicina de Emergência/educação , Motivação , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Certificação , Humanos , Tratamento de Substituição de Opiáceos , Estudos Prospectivos
20.
J Addict Med ; 14(4): e6-e7, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32404651

RESUMO

: The COVID19 crisis has created many additional challenges for patients with opioid use disorder, including those seeking treatment with medications for OUD. Some of these challenges include closure of substance use treatment clinics, focus of emergency departments on COVID-19 patients, social distancing and shelter in place orders affecting mental health, bystander overdose rescue, threats to income and supply of substances for people who use drugs. While the initial changes in regulation allowing buprenorphine prescribing by telehealth are welcomed by providers and patients, many additional innovations are required to ensure that additional vulnerabilities and hurdles created by this pandemic scenario do not further fan the flames of the opioid epidemic.


Assuntos
Infecções por Coronavirus , Acesso aos Serviços de Saúde/organização & administração , Controle de Infecções/organização & administração , Antagonistas de Entorpecentes/uso terapêutico , Tratamento de Substituição de Opiáceos/métodos , Transtornos Relacionados ao Uso de Opioides , Pandemias , Pneumonia Viral , Betacoronavirus , COVID-19 , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/prevenção & controle , Humanos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Transtornos Relacionados ao Uso de Opioides/psicologia , Inovação Organizacional , Pandemias/prevenção & controle , Pneumonia Viral/epidemiologia , Pneumonia Viral/prevenção & controle , SARS-CoV-2 , Telemedicina/organização & administração , Estados Unidos
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