In patients with coma due to acute poisoning, withholding intubation improved clinical outcomes.

SOURCE CITATION: Freund Y, Viglino D, Cachanado M, et al. Effect of noninvasive airway management of comatose patients with acute poisoning: a randomized clinical trial. JAMA. 2023;330:2267-2274. 38019968.

Low-dose ketamine safely reduces acute pain in the ED with a more rapid and shorter effect than morphine.

SOURCE CITATION: Guo J, Zhao F, Bian J, et al. Low-dose ketamine versus morphine in the treatment of acute pain in the emergency department: a meta-analysis of 15 randomized controlled trials. Am J Emerg Med. 2024;76:140-149. 38071883.

A Critical Appraisal of AHRQ's "Diagnostic Errors" Report.

The Agency for Healthcare Research and Quality (AHRQ) report "Diagnostic Errors in the Emergency Department" generated significant mass media interest with negative implications for the safety of contemporary emergency care. The assumptions and methodology underlying this report are problematic, while multiple ongoing efforts to improve the quality and quantity of diagnostic research are missed, neglected, or ignored. The AHRQ report identifies reasonable target diseases for targeting diagnostic quality improvement efforts, as well as viable methods by which to measure any initiatives impact on diagnostic error. We note additional opportunities to improve the status quo by funding emergency department-based diagnostic research and healthcare system-level patient safety research and highlighting innovative approaches to diagnostic science within emergency medicine.

Medications for Opioid Use Disorder Do Help Patients.

Much of the focus on the current opioid crisis remains on how we arrived here and who is to blame. Despite having effective treatments for the management of patients with opioid use disorder (OUD), rates of overdose deaths continue to increase. As such, the focus needs to shift to increasing access to medications for OUD and better incorporation of harm reduction strategies to decrease not just the mortality but also the morbidity associated with OUD and other substance use disorders. Unfortunately, significant barriers rooted in misunderstanding and bias still limit access and prevent patients with OUD from seeking and staying in treatment. Until these are overcome and medical practice changes, both physicians and patients will continue to struggle to overcome this problem.

Consensus Recommendations on the Treatment of Opioid Use Disorder in the Emergency Department.

The treatment of opioid use disorder with buprenorphine and methadone reduces morbidity and mortality in patients with opioid use disorder. The initiation of buprenorphine in the emergency department (ED) has been associated with increased rates of outpatient treatment linkage and decreased drug use when compared to patients randomized to receive standard ED referral. As such, the ED has been increasingly recognized as a venue for the identification and initiation of treatment for opioid use disorder, but no formal American College of Emergency Physicians (ACEP) recommendations on the topic have previously been published. The ACEP convened a group of emergency physicians with expertise in clinical research, addiction, toxicology, and administration to review literature and develop consensus recommendations on the treatment of opioid use disorder in the ED. Based on literature review, clinical experience, and expert consensus, the group recommends that emergency physicians offer to initiate opioid use disorder treatment with buprenorphine in appropriate patients and provide direct linkage to ongoing treatment for patients with untreated opioid use disorder. These consensus recommendations include strategies for opioid use disorder treatment initiation and ED program implementation. They were approved by the ACEP board of directors in January 2021.

A Comparison of Medication for Opioid Use Disorder Treatment Strategies for Persons Who Inject Drugs With Invasive Bacterial and Fungal Infections.

BACKGROUND: Patients with opioid use disorder (OUD) are frequently admitted for invasive infections. Medications for OUD (MOUD) may improve outcomes in hospitalized patients. METHODS: In this retrospective cohort of 220 admissions to a tertiary care center for invasive infections due to OUD, we compared 4 MOUD treatment strategies: methadone, buprenorphine, methadone taper for detoxification, and no medication to determine whether there were differences in parenteral antibiotic completion and readmission rates. RESULTS: The MOUDs were associated with increased completion of parenteral antimicrobial therapy (64.08% vs 46.15%; odds ratio [OR] = 2.08; 95% CI, 1.23-3.61). On multivariate analysis, use of MOUD maintenance with either buprenorphine (OR = 0.38; 95% CI, .17-.85) or methadone maintenance (OR = 0.43; 95% CI, .20-.94) and continuation of MOUD on discharge (OR = 0.35; 95% CI, .18-.67) was associated with lower 90-day readmissions. In contrast, use of methadone for detoxification followed by tapering of the medication without continuation on discharge was not associated with decreased readmissions (OR = 1.87; 95% CI, .62-5.10). CONCLUSIONS: Long-term MOUDs, regardless of selection, are an integral component of care in patients hospitalized with OUD-related infections. Patients with OUD should have arrangements made for MOUDs to be continued after discharge, and MOUDs should not be discontinued before discharge.

Evaluation of Partial Oral Antibiotic Treatment for Persons Who Inject Drugs and Are Hospitalized With Invasive Infections.

BACKGROUND: Persons who inject drugs (PWID) are at risk of invasive infections; however, hospitalizations to treat these infections are frequently complicated by against medical advice (AMA) discharges. This study compared outcomes among PWID who (1) completed a full course of inpatient intravenous (IV) antibiotics, (2) received a partial course of IV antibiotics but were not prescribed any antibiotics on AMA discharge, and (3) received a partial course of IV antibiotics and were prescribed oral antibiotics on AMA discharge. METHODS: A retrospective, cohort study of PWID aged ≥18 years admitted to a tertiary referral center between 01/2016 and 07/2019, who received an infectious diseases consultation for an invasive bacterial or fungal infection. RESULTS: 293 PWID were included in the study. 90-day all-cause readmission rates were highest among PWID who did not receive oral antibiotic therapy on AMA discharge (n = 46, 68.7%), compared with inpatient IV (n = 43, 31.5%) and partial oral (n = 27, 32.5%) antibiotics. In a multivariate analysis, 90-day readmission risk was higher among PWID who did not receive oral antibiotic therapy on AMA discharge (adjusted hazard ratio [aHR], 2.32; 95% confidence interval [CI], 1.41-3.82) and not different among PWID prescribed oral antibiotic therapy on AMA discharge (aHR, .99; 95% CI, .62-1.62). Surgical source control (aHR, .57; 95% CI, .37-.87) and addiction medicine consultation (aHR, .57; 95% CI, .38-.86) were both associated with reduced readmissions. CONCLUSIONS: Our single-center study suggests access to oral antibiotic therapy for PWID who cannot complete prolonged inpatient IV antibiotic courses is beneficial.

Addiction Medicine Consultations Reduce Readmission Rates for Patients With Serious Infections From Opioid Use Disorder.

The opioid epidemic has increased hospital admissions for serious infections related to opioid abuse. Our findings demonstrate that addiction medicine consultation is associated with increased treatment for opioid use disorder (OUD), greater likelihood of completing antimicrobial therapy, and reduced readmission rates among patients with OUD and serious infections requiring hospitalization.

A Bridge to Nowhere? Challenging Outpatient Transitions of Care for Acute Pain Patients in the Opioid Epidemic Era.

Opioid misuse is reducing Americans' life expectancy, thereby catalyzing professional societies and legislators to action. Efforts to combat the opioid epidemic must work hand-in-hand with appropriate efforts to reduce the severity and duration of suffering. Pharmacologic analgesia is temporizing. Current opioid prescribing guidelines focus on reducing the frequency and quantity of narcotics prescribed, but lack attention to alleviation of the source of pain. Conditions eliciting acute pain sometimes require additional specialist management following discharge from the emergency department. Patients frequently lack timely access to these specialists, particularly if underinsured. This essay explores acute dental pain, extremity fractures, and back pain as three common examples whereby complex healthcare systems must efficiently adapt in order to serve the dual objectives of reducing the risk of opioid-related adverse consequences and minimizing the duration of patient suffering.

Resident Access to the St. Louis County Prescription Drug Monitoring Program: Why PDMPs Matter and How to Gain Access.

Prescription Drug Monitoring Programs (PDMPSs) permit physicians to determine whether patients obtained addictive substances from multiple physicians or pharmacies. In April 2017, the Saint Louis County Department of Public Health created its own PDMP. This manuscript evaluates evidence regarding the efficacy of PDMPs, in addition to discussing their impact on patient care and a provider's workflow. It also details how physicians can register to use the St. Louis County PDMP, Missouri's de-facto PDMP.

Is a Prehospital Treat and Release Protocol for Opioid Overdose Safe?

BACKGROUND: The current standards for domestic emergency medical services suggest that all patients suspected of opioid overdose be transported to the emergency department for evaluation and treatment. This includes patients who improve after naloxone administration in the field because of concerns for rebound toxicity. However, various emergency medical services systems release such patients at the scene after a 15- to 20-min observation period as long as they return to their baseline. OBJECTIVES: We sought to determine if a "treat and release" clinical pathway is safe in prehospital patients with suspected opioid overdose. RESULTS: Five studies were identified and critically appraised. From a pooled total of 3875 patients who refused transport to the emergency department after an opioid overdose, three patient deaths were attributed to rebound toxicity. These results imply that a "treat and release" policy might be safe with rare complications. A close review of these studies reveals several confounding factors that make extrapolation to our population limited. CONCLUSION: The existing literature suggests a "treat and release" policy for suspected prehospital opioid overdose might be safe, but additional research should be conducted in a prospective design.

The Opioid Crisis in Missouri: A Call to Action for Physicians, Legislators, and Society.

Opioid overdose deaths in the United States increased sharply over the last decade leading the President to declare a national emergency. The neurobiology of opioid addiction is explored in conjunction with the historical events preceding the current epidemic. A patient-centric perspective is provided along with rationale for contemporary Medical Assisted Therapy (MAT) options to safely reduce overdose deaths and other preventable consequences of prescription misuse and heroin abuse. A multidisciplinary medical provider approach is essential, in addition to legislative efforts to reduce current regulatory burdens that reduce access to MAT in many settings. This review introduces a new Missouri Medicine series intended to explore key concepts to simultaneously reduce opioid prescribing, while effectively managing acute and chronic pain across complex healthcare settings.