Drug-Related Emergency Department Visits Research Articles

Associations between short-term ambient temperature exposure and emergency department visits for amphetamine, cocaine, and opioid use in California from 2005 to 2019

Substance use disorder is a growing public health challenge in the United States. People who use drugs may be more vulnerable to ambient heat due to the effects of drugs on thermoregulation and their risk environment. There have been limited population-based studies of ambient temperature and drug-related morbidity. We examined short-term associations between daily ambient temperature and emergency department (ED) visits for use or overdose of amphetamine, cocaine and opioids in California during the period 2005 to 2019. Daily ZIP code-level maximum, mean, and minimum temperature exposures were derived from 1-km data Daymet products. A time-stratified case-crossover design was used to estimate cumulative non-linear associations of daily temperature for lag days 0 to 3. Stratified analyses by patient sex, race, and ethnicity were also conducted. The study included over 3.4 million drug-related ED visits. We found positive associations between daily temperature and ED visits for all outcomes examined. An increase in daily mean temperature from the 50th to the 95th percentile was associated with ED visits for amphetamine use (OR = 1.072, 95% CI: 1.058, 1.086), cocaine use (OR = 1.044, 95% CI: 1.021, 1.068 and opioid use (OR = 1.041, 95% CI: 1.025, 1.057). Stronger positive associations were also observed for overdose: amphetamine overdose (OR = 1.150, 95% CI: 1.085, 1.218), cocaine overdose (OR = 1.159, 95% CI: 1.053, 1.276), and opioid overdose (OR = 1.079, 95% CI: 1.054, 1.106). In summary, people who use stimulants and opioids may be a subpopulation sensitive to short-term higher ambient temperature. Mitigating heat exposure can be considered in harm reduction strategies in response to the substance use epidemic and global climate change.

A prospective intervention study to identify drug-related emergency department visits comparing a standard care group and a pharmaceutical care group.

Adverse drug reactions impose a major burden. Those adverse drug reactions might lead to hospitalization but are often not correctly identified in the emergency department (ED). Clinical pharmacists, although not routinely implemented, can help identify adverse drug reactions. The primary objective was to examine the drug association of ED visits in a pharmaceutical group with a clinical pharmacist integrated in the ED team compared with a standard group without additional support. This prospective intervention study was performed in the ED of a tertiary care university hospital in Leipzig, Germany. Patients who were ≥50 years old were included. From 1 March 2020 to May 31, 2020 patients were enrolled in the standard group. From 1 March 2021 to 31 May 2021, the pharmaceutical group was enrolled. The clinical pharmacist supported the ED team with patient´s detailed medication history and medication analysis. In both groups, patients were evaluated whether their ED visit was drug-related. The number of identified drug-related ED presentations were compared between the two groups. Interventions performed on adverse drug reaction management, causative drugs and patient characteristics were evaluated. A total of 798 patients were enrolled in the standard group and 827 patients in the pharmaceutical group. Patients whose ED visit was drug-related had a median age of 77 years [(Q25-Q75) 63.5-83.5] and took 7 [(Q25-Q75) 5-8] drugs in standard group. In the pharmaceutical group median age was 78 years [(Q25-Q75) 66-83] and number of drugs taken was 9 [(Q25-Q75) 5.25-11]. 31 (3.9%) drug-related ED visits were identified in the standard group compared to 104 (12.6%) in the pharmaceutical group (OR 3.56; 95% CI 2.35-5.38). An intervention on the patient's pharmacotherapy was performed in 16 drug-related ED visits in standard group compared to 77 in the pharmaceutical group. In this study the implementation of a clinical pharmacist was associated with improved identification of drug-related ED visits. Discontinuations of causal medications and dose reductions were significantly higher in the pharmaceutical group compared to the standard care group.

Which Adverse Events and Which Drugs Are Implicated in Drug-Related Hospital Admissions? A Systematic Review and Meta-Analysis.

Adverse drug events (ADEs) and adverse drug reactions (ADRs) are leading causes of iatrogenic injury, which can result in emergency department (ED) visits or admissions to inpatient wards. The aim of this systematic review and meta-analysis was to provide up-to-date estimates of the prevalence of (preventable) drug-related ED visits and hospital admissions, as well as the type and prevalence of implicated ADRs/ADEs and drugs. A literature search of studies published between January 2012 and December 2021 was performed in PubMed, Medline, EMBASE, Cochrane Library, and Web of Science. Retrospective and prospective observational studies investigating acute admissions to EDs or inpatient wards due to ADRs or ADEs in the general population were included. Meta-analyses of prevalence rates were conducted using generalized linear mixed models (GLMM) with the random-effect method. Seventeen studies reporting ADRs and/or ADEs were eligible for inclusion. The prevalence rates of ADR- and ADE-related admissions to EDs or inpatient wards were estimated at 8.3% ([95% CI, 6.4-10.7%]) and 13.9% ([95% CI, 8.1-22.8%]), respectively, of which almost half (ADRs: 44.7% [95% CI: 28.1; 62.4]) and more than two thirds (ADEs: 71.0% [95% CI, 65.9-75.6%]) had been classified as at least possibly preventable. The ADR categories most frequently implicated in ADR-related admissions were gastrointestinal disorders, electrolyte disturbances, bleeding events, and renal and urinary disorders. Nervous system drugs were found to be the most commonly implicated drug groups, followed by cardiovascular and antithrombotic agents. Our findings demonstrate that ADR-related admissions to EDs and inpatient wards still represent a major and often preventable health care problem. In comparison to previous systematic reviews, cardiovascular and antithrombotic drugs remain common causes of drug-related admissions, while nervous system drugs appear to have become more commonly implicated. These developments may be considered in future efforts to improve medication safety in primary care.

Drug-related emergency department visits: prevalence and risk factors

The study aimed to investigate the prevalence of drug-related emergency department (ED) visits and associated risk factors. This retrospective cohort study was conducted in the ED, Diakonhjemmet Hospital, Oslo, Norway. From April 2017 to May 2018, 402 patients allocated to the intervention group in a randomized controlled trial were included in this sub-study. During their ED visit, these patients received medication reconciliation and medication review conducted by study pharmacists, in addition to standard care. Retrospectively, an interdisciplinary team assessed the reconciled drug list and identified drug-related issues alongside demographics, final diagnosis, and laboratory tests for all patients to determine whether their ED visit was drug-related. The study population’s median age was 67 years (IQR 27, range 19–96), and patients used a median of 4 regular drugs (IQR 6, range 0–19). In total, 79 (19.7%) patients had a drug-related ED visits, and identified risk factors were increasing age, increasing number of regular drugs and medical referral reason. Adverse effects (72.2%) and non-adherence (16.5%) were the most common causes of drug-related ED visits. Antithrombotic agents were most frequently involved in drug-related ED visits, while immunosuppressants had the highest relative frequency. Only 11.4% of the identified drug-related ED visits were documented by physicians during ED/hospital stay. In the investigated population, 19.7% had a drug-related ED visit, indicating that drug-related ED visits are a major concern. If not recognized and handled, this could be a threat against patient safety. Identified risk factors can be used to identify patients in need of additional attention regarding their drug list during the ED visit.

Development and Validation of a Trigger Tool for Identifying Drug-Related Emergency Department Visits.

There are various trigger tools for detecting adverse drug events (ADEs), however, a drug-related emergency department (ED) visit trigger tool (DrEDTT) has not yet been developed. We aimed to develop and validate a DrEDTT with a multi-center cohort. In this cross-sectional study, we developed the DrEDTT consisting of 28 triggers through a comprehensive literature review and three phase expert group discussion. Next, we evaluated the performance of the DrEDTT by applying it to relevant medical records retrieved from four hospitals from January 2016 to June 2016. Two experts performed an in-depth chart review of a 25% of random sample of trigger flagged and unflagged ED visits and a true ADE was determined through causality assessment. Among 66,564 patients who visited the ED for reasons other than traffic accident and trauma during the study period, at least one trigger was found in 21,268 (32.0%) patients. A total of 959 true ADE cases (5.8%) were identified from a randomly selected 25% of ED visit cases. The overall positive predictive value was 14.0% (range: 8.3–66.7%). Sensitivity and specificity of DrEDTT were 77.7% and 70.4%, respectively. In conclusion, this newly developed trigger tool might be helpful to detect ADE-related ED visits.

COCAINE-INDUCED THROMBOTIC STORM

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Cocaine is associated with a wide array of complications through a number of different mechanisms. Although majority of cocaine related morbidity has been attributed to complications in arterial vasculature, the deleterious impact of venous complications appears to be largely unrepresented in current literature as well as clinical practice despite emerging evidence of the high prevalence and annual incidence of DVT in illicit drug users CASE PRESENTATION: 27-year-old previously healthy male presented to the ED with new onset difficulty speaking and facial droop hours after using cocaine. He was afebrile with vitals 98.5 °F, BP 142/97, HR 94 and RR 16. Examination was remarkable for expressive aphasia and right facial droop with no other focal neurological finding. CT scan of head showed thrombosed left MCA with infarct in left frontal lobe and basal ganglia. Labs were significant for a troponin of 14 md/dl and CK-MB 34. CBC and metabolic panel were unremarkable. Urine toxicology was positive for cocaine and opiates. EKG showed T wave inversion with ST depression in V1-V4 II and aVF. CTA of chest revealed bilateral segmental and subsegmental PE without any acute pulmonary disease. CTA of head and neck showed complete abrupt occlusion of proximal left internal carotid artery with distal reconstitution at the segment M1 of MCA and an intraluminal thrombus in the M1 segment. A doppler of lower extremities revealed deep venous thrombosis in left peroneal and posterior tibial veins. An ECHO failed to reveal an intracardiac shunt precluding the possibility of paradoxical thrombosis. He was continued on heparin for 10 days before being switched to Xarelto. He experienced improvement in word finding ability and is currently in rehab. Hypercoagulability work-up including prothrombin gene mutation, factor V Leiden deficiency, APLA and anti-thrombin deficiency was negative. DISCUSSION: This case illustrates an uncharacteristic presentation of cocaine-related widespread thrombotic cascade involving both arterial and venous circulations causing significant morbidity. The complex pathophysiology of widespread prothrombotic state caused by cocaine includes endothelial damage promoting increase of fibrinogen and Von Willebrand factor to platelet aggregation and clot formation. It is important to identify the impact cocaine induced venous thrombosis can mount, especially in the form of potentially fatal complications like pulmonary embolism. CONCLUSIONS: Although recent studies have focused on increased incidence and prevalence of venous thrombosis in setting of cocaine abuse, ours is the first case of documented pulmonary embolism caused by cocaine related venous thrombosis. Further studies are needed to identify patients at higher risk for this complication like rare thrombotic disorders Reference #1: 1. Substance Abuse and Mental Health Services Administration, Drug Abuse Warning Network, 2011: National Estimates of Drug-Related Emergency Department Visits. HHS Publication No. (SMA) 13-4760, DAWN Series D-39. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013. Reference #2: Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality (formerly the Office of Applied Studies). The DAWN Report: Highlights of the 2009 Drug Abuse Warning Network (DAWN) Findings on Drug-Related Emergency Department Visits. Rockville, MD, December 28, 2010. Reference #3: . Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. Drug Abuse Warning Network: Detailed Tables: National Estimates, Drug-Related Emergency Department Visits for 2004–2009. Rockville, MD, December 28, 2010. DISCLOSURES: no disclosure on file for Erika Cappelluti; No relevant relationships by Manish Kumar, source=Web Response No relevant relationships by Alain Rizkallah, source=Web Response No relevant relationships by Nihar Shah, source=Web Response No relevant relationships by Toishi Sharma, source=Web Response

P097: The characteristics and effectiveness of interventions targeting chronic pain patients in the emergency department: A systematic review and meta-analysis

Introduction: Patients with chronic non-cancer pain (CNCP) and opioid-use disorders make up a category of patients who present a challenge to emergency department (ED) providers and healthcare administrators. Their conditions predispose them to frequent ED utilization. This problem has been compounded by a worsening opioid epidemic that has rendered clinicians apprehensive about how they approach pain care. A systematic review has not yet been performed to inform the management of CNCP patients in the ED. As such, the purpose of this project was to identify and describe the effectiveness of interventions to reduce ED visits for high-utilizers with CNCP. Methods: Included participants were high-utilizers presenting with CNCP. All study designs were eligible for inclusion if they examined an intervention aimed at reducing ED utilization. The outcomes of interest were the number of ED visits as well as the amount and type of opioids prescribed in the ED and after discharge. We searched Medline, EMBASE, CINAHL, CENTRAL, SCOPUS, Web of Science, and the grey literature from inception to June 16, 2018. Two independent investigators assessed articles for inclusion following PRISMA guidelines. Risk of bias will be assessed using the Cochrane ROBINS-I and RoB 2 tools for non-randomized and randomized trials, respectively. Results: Following review, 14 of the 5,018 identified articles were included for analysis. These articles assessed a total of 1,670 patients from both urban and rural settings. Interventions included pain protocols or policies (n = 5), individualized care plans (n = 5), ED care coordination (n = 2), a chronic pain management pathway (n = 1), and a behavioural health intervention (n = 1). Intervention effects trended towards the reduction of both ED visits and opioid prescriptions. The meta-analysis is in progress. Conclusion: Preliminary results suggest that interventions aimed at high-utilizers with CNCP can reduce ED visits and ED opioid prescription. ED opioid-restriction policies that sought to disincentivize drug-related ED visits were most successful, especially when accompanied by an electronic medical record (EMR) alert to ensure consistent application of the policy by all clinicians and administrators involved in the care of these patients. This review was limited by inconsistencies in the definition of ‘high-utilizer’ and by the lack of high-powered randomized studies.

When DAWN went dark: Can the Nationwide Emergency Department Sample (NEDS) fill the surveillance gap left by the discontinued Drug Abuse Warning Network (DAWN)?

BackgroundThis study assessed whether the Nationwide Emergency Department Sample (NEDS) could reliably fill the national drug surveillance gap caused by the discontinuation of the Drug Abuse Warning Network (DAWN). MethodsEstimates of the drug-related emergency department (ED) visits derived from DAWN (2004–2011) and NEDS (2006–2013). Estimates of the underlying reason for the drug-related ED visit, patient characteristics, and the specific drugs involved were compared for 2011, the most recent overlapping data year in DAWN and NEDS. Trends in ED visits for major drugs of abuse were then compared over the period 2004–2013. ResultsIn 2011, DAWN and NEDS produced statistically similar estimates of the overall number of drug-related ED visits (5.1 vs. 4.9 million) and those involving drug misuse or abuse (2.65 vs. 2.77 million). Among the latter, estimates by gender, age group, and patient disposition were generally consistent across data systems, suggesting that NEDS and DAWN samples draw from a similar population. Main analyses reveal statistically similar estimates across data systems in both levels and trends for cocaine, amphetamines, and narcotic pain relievers. In contrast, the number of ED visits for sedatives and heroin was significantly undercounted in NEDS, whereas marijuana-related ED visits were undercounted in DAWN. ConclusionsThis study demonstrates the utility of NEDS for conducting post-DAWN drug surveillance. Because NEDS cannot provide targeted surveillance of certain established (e.g., heroin) and emerging (e.g., fentanyl) drugs, however, it is critical that a data system that employs medical record-based reviews be implemented to augment the known weaknesses of NEDS.

Clinical Implications

HomeHypertensionVol. 71, No. 4Clinical Implications Free AccessIn BriefPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessIn BriefPDF/EPUBClinical Implications Originally published1 Apr 2018https://doi.org/10.1161/HYPERTENSIONAHA.118.10969Hypertension. 2018;71:539Socioeconomic Status and Hypertension in Africa (p 577)Download figureDownload PowerPointSystemic hypertension is a rapidly growing epidemic in Africa. Our study represents the first multination report on socioeconomic status and uncontrolled hypertension from Sub-Saharan Africa. Our results demonstrate the overall strikingly high proportion of uncontrolled blood pressure in low- and middle-income countries (77.4%), of which 61.7% had hypertension of grade 2 or 3. We further observed that the rate and severity (hypertension grade) of uncontrolled hypertension was proportional to individual wealth. This was observed in low-income but not middle-income countries, suggesting that the combination of individual poverty with a poor health system is particularly detrimental to achieving the goal of adequate blood pressure control. Hypertension is probably the easiest chronic noncommunicable disease to treat because blood pressure measurement for diagnosis and monitoring is simple, drug regimens are mainly once daily and inexpensive, and treatments generally do not need laboratory monitoring. According to World Health Organization estimations, the African region has the highest prevalence world rate of hypertension, afflicting 46% of the adult population aged ≥25 years. With >9 million deaths from hypertension worldwide each year, the potential effect of improved treatment of hypertension, particularly if combined with population-wide measures, would be substantial. Strategies for improving hypertension control in Sub-Saharan Africa should focus on people belonging to the lowest wealth groups with a particular focus on those living in low-income countries.Antifibrotic Effects of Finerenone (p 599)Download figureDownload PowerPointIn this study, we demonstrate that the new nonsteroidal mineralocorticoid receptor antagonist finerenone prevents cardiac fibrosis and improves global longitudinal strain parameters in a mouse model of early subendocardial damage. In addition, we identify a new pharmacological mechanism of selective mineralocorticoid receptor modulation which distinguishes nonsteroidal mineralocorticoid receptor antagonists from steroidal mineralocorticoid receptor antagonists based on selective mineralocorticoid receptor–cofactor binding. It has been shown previously by other groups that finerenone also exerts antifibrotic action in the kidney. The efficacy and safety of finerenone in patients with type 2 diabetes mellitus and the clinical diagnosis of diabetic kidney disease is currently being investigated in 2 large phase 3 outcome trials in patients with diabetic kidney disease (FIGARO-DKD [Efficacy and Safety of Finerenone in Subjects With Type 2 Diabetes Mellitus and the Clinical Diagnosis of Diabetic Kidney Disease], URL: http://www.clinicaltrials.gov. Unique identifier: NCT02545049; FIDELIO-DKD [Efficacy and Safety of Finerenone in Subjects With Type 2 Diabetes Mellitus and Diabetic Kidney Disease], URL: http://www.clinicaltrials.gov. Unique identifier: NCT02540993). FIGARO-DKD is a 6400 patient trial that will examine the time to the first occurrence of the composite end point of cardiovascular death and nonfatal cardiovascular events, whereas FIDELIO-DKD is a 4800 patient trial that will compare the effects of finerenone versus placebo on the time to the first occurrence of the composite end point of kidney failure, decrease of estimated glomerular filtration rate ≥40% from baseline, or renal death. The marked cardiorenal antifibrotic effects of finerenone shown in our study and by others are likely to be substantial for finerenone’s clinical effects currently tested in these trials.MiR-30c-5p Pathway in Cocaine-Induced Hypertension (p 752)Download figureDownload PowerPointThe use of cocaine remains the leading cause for all illicit drug-related emergency department visits, with the majority of these visits resulting from cardiovascular complaints, including chest pain. Cocaine exposure has short-term effects on the cardiovascular system, such as increasing blood pressure and inducing arrhythmias, but also negatively impacts long-term cardiovascular health by increasing the risk for hypertension, aortic stiffness, and atherosclerosis. It is well-known that cocaine inhibits catecholamine reuptake at sympathetic nerve terminals, stimulates central sympathetic outflow, and increases the sensitivity of adrenergic nerve endings to norepinephrine. It has been assumed that these cocaine-associated sympathetic nervous system effects are wholly responsible for hypertension and other cardiovascular effects resulting from cocaine exposure. However, recent studies have suggested that other mechanisms may be governing the effects of cocaine on the cardiovascular system. To better understand the molecular mechanisms underlying cocaine-induced cardiovascular toxicities, we analyzed microRNAs whose expression was altered in mouse aortas in response to cocaine exposure. We have identified a key pathway, the miR-30c–Me1 (malic enzyme 1) axis, that is involved in regulating reactive oxygen species levels, crucial factors in the pathogenesis of hypertension, vascular aging, and atherosclerosis. Inhibition of this pathway suppresses cocaine-induced elevation of blood pressure and augmentation of aortic stiffness in mice, providing new molecular targets for the development of therapeutic strategies as well as the rationale for the use of an antioxidant, such as N-acetylcysteine, to treat cocaine-associated cardiovascular toxicities. Previous Back to top Next FiguresReferencesRelatedDetails April 2018Vol 71, Issue 4 Advertisement Article InformationMetrics © 2018 American Heart Association, Inc.https://doi.org/10.1161/HYPERTENSIONAHA.118.10969 Originally publishedApril 1, 2018 PDF download Advertisement

Developing Syndromic Surveillance to Monitor and Respond to Adverse Health Events Related to Psychoactive Substance Use: Methods and Applications.

Recent increases in drug overdose deaths, both in New York City and nationally, highlight the need for timely data on psychoactive drug-related morbidity. We developed drug syndrome definitions for syndromic surveillance to monitor drug-related emergency department (ED) visits in real time. We used 2012 archived syndromic surveillance data from New York City hospitals to develop definitions for psychoactive drug-related syndromes. The dataset contained ED visit-level information that included patients' chief complaints, dates of visits, ZIP codes of residence, discharge diagnoses, and dispositions. After manually reviewing chief complaints, we developed a classification scheme comprising 3 categories (overdose, drug mention, and drug abuse/misuse), which we used to define 25 psychoactive drug syndromes. From July 2013 through December 2015, the New York City Department of Health and Mental Hygiene performed daily syndromic surveillance of psychoactive drug-related ED visits using the 25 syndrome definitions. Syndromic surveillance triggered 4 public health investigations, supported 8 other public health investigations that had been triggered by other mechanisms, and resulted in the identification of 5 psychoactive drug-related outbreaks. Syndromic surveillance also identified a substantial increase in synthetic cannabinoid-related visits (from an average of 3 per week in January 2014 to >300 per week in July 2015) and an increase in heroin overdose visits (from 80 to 171 in the first 3 quarters of 2012 and 2014, respectively) in a single neighborhood. Syndromic surveillance using these novel definitions enabled monitoring of trends in psychoactive drug-related morbidity, initiation and support of public health investigations, and targeting of interventions. Health departments can refine these definitions for their jurisdictions using the described methods and integrate them into existing syndromic surveillance systems.

Factors Associated with Drug-Related Emergency Department Visits at a Teaching Hospital in Malaysia

Adverse drug events (ADEs) are a significant health problem globally, with the emergency department (ED) being an important environment for the detection of ADEs. Data regarding drug-related visits to the ED in Malaysia are currently limited. The aim of this study was to determine factors associated with prescription drug-related ED visits at a teaching hospital. A case-control study was conducted on patients who visited the ED of Hospital Universiti Sains Malaysia over a 7-week period between December 2014 and January 2015. A visit to the ED was considered drug-related if the chief presenting complaint was related to prescription drug use. Data were collected by interviewing patients, and also from the patient’s medical record. Multiple logistic regression was applied to determine the risk factors. Overall, 144 physician-identified patients with drug-related ED visits were considered as cases and 288 patients with non-drug-related complaints were selected as controls. Independent risk factors identified for drug-related ED visits were female sex (adjusted odds ratio [OR] 1.7, 95% confidence interval [CI] 1.03–2.71), currently taking regular medication (OR 3.4, 95% CI 1.87–6.05), concurrent comorbidity (OR 2.3, 95% CI 1.28–4.10), a history of drug allergy (OR 5.36, 95% CI 2.30–12.48), and recent hospital admission (OR 2.85, 95% CI 1.23–4.10). Independent risk factors were also associated with the following health problems: diabetes mellitus (OR 6.83, 95% CI 3.30–14.12), central nervous system disorders (OR 9.42, 95% CI 3.08–14.12), and cardiovascular disorders (OR 2.5, 95% CI 1.25–4.79). The determinants of a drug-related ED visit at a teaching hospital are multifactorial. Interventions to prevent future occurrences should focus on those patients at risk.

Emergency Department Visits for Adverse Drug Reactions Involving Alcohol: United States, 2005 to 2011

Alcohol consumption may interfere with absorption, distribution, metabolism, and excretion of medications and increase risk of adverse drug reactions (ADR). Studies report increasing prescription medication use over time, with many U.S. drinkers using alcohol-interactive medication. This study identified trends in incidence of U.S. emergency department (ED) visits for ADR with alcohol involvement (ADR-A), compared characteristics and disposition between ADR-A visits and ADR visits without alcohol involvement (ADR-NA), and examined frequency of implicated medications in such visits for 2005 to 2011. ADR visits were identified through the Drug Abuse Warning Network, a national surveillance system monitoring drug-related ED visits. Analysis accounted for sampling design effects and sampling weights. Estimates are presented for totals (ages 12+), age group, and/or sex. Trends were assessed by joinpoint log-linear regression. Differences between ADR-A and ADR-NA visits were compared using two-tailed Rao-Scott chi-square tests. From 2005 to 2011, incidence of ADR-A visits increased for males and females ages 21 to 34 and females ages 55+. An average of 25,303 ADR-A visits ages 12+ occurred annually. Compared with ADR-NA visits, ADR-A visits were more likely to involve males, patients ages 21 to 54, and 2+ implicated drugs. Alcohol involvement increased odds of more serious outcomes from ADR visits. Central nervous system (CNS) agents were the most common medications in ADR-A visits (59.1%), with nearly half being analgesics (mainly opioid). About 13.8% of ADR-A visits involved psychotherapeutic agents, including antidepressants. Besides CNS and psychotherapeutic agents, ADR-A visits involved a higher percentage of genitourinary-tract agents (mainly for impotence) than ADR-NA visits. Sex and age variations were observed with certain implicated medications. ED visits for alcohol-drug interactions can be prevented by avoiding alcohol when taking alcohol-interactive medications. Our results underscore the need for healthcare professionals to routinely ask patients about alcohol consumption and warn of ADR risks before prescribing and dispensing alcohol-interactive medications.

Prevalence of Drug-Related Emergency Department Visits at a Teaching Hospital in Malaysia.

BackgroundData on the prevalence of adverse drug event (ADE)-related emergency department (ED) visits in developing countries are limited. Malaysia is located in South-East Asia, and, to our knowledge, no information exists on ADE-related ED visits.ObjectiveThe objective of this study was to determine the prevalence, preventability, severity, and outcome of drug-related ED visits.MethodologyA cross-sectional study was conducted in consenting patients who visited the ED of Hospital Universiti Sains Malaysia over a 6-week period. The ED physician on duty determined whether or not the visit was drug related according to set criteria. Other relevant information was extracted from the patient’s medical folder by a clinical pharmacist.ResultsOf the 434 consenting patients, 133 (30.6 %; 95 % confidence interval [CI] 26–35 %) visits were determined to be ADE related; 55.5 % were considered preventable, 11.3 % possibly preventable, and 33.1 % not preventable. Severity was classed as mild in 1.5 %, moderate in 67.7 %, and severe in 30.8 %. The most common ADEs reported were drug therapeutic failure (55.6 %) and adverse drug reactions (32.3 %). The most frequently implicated drugs were antidiabetics (n = 31; 23.3 %), antihypertensives (n = 28; 21.1 %), antibiotics (n = 13; 9.8 %), and anti-asthmatics (n = 11; 8.3 %). A total of 93 patients (69.9 %) were admitted to the ED for observation, 25 (18.8 %) were discharged immediately after consultation, and 15 (11.3 %) were admitted to the ward through the ED.ConclusionThe prevalence of ADE-related ED visits was high; more than one-half of the events were considered preventable and one-third was classed as severe. As such, preventive measures will minimize future occurrences and increase patient safety.

Identifying Patients With Problematic Drug Use in the Emergency Department: Results of a Multisite Study

Drug-related emergency department (ED) visits have steadily increased, with substance users relying heavily on the ED for medical care. The present study aims to identify clinical correlates of problematic drug use that would facilitate identification of ED patients in need of substance use treatment. Using previously validated tests, 15,224 adult ED patients across 6 academic institutions were prescreened for drug use as part of a large randomized prospective trial. Data for 3,240 participants who reported drug use in the past 30 days were included. Self-reported variables related to demographics, substance use, and ED visit were examined to determine their correlative value for problematic drug use. Of the 3,240 patients, 2,084 (64.3%) met criteria for problematic drug use (Drug Abuse Screening Test score ≥ 3). Age greater than or equal to 30 years, tobacco smoking, daily or binge alcohol drinking, daily drug use, primary noncannabis drug use, resource-intense ED triage level, and perceived drug-relatedness of ED visit were highly correlated with problematic drug use. Among primary cannabis users, correlates of problematic drug use were age younger than 30 years, tobacco smoking, binge drinking, daily drug use, and perceived relatedness of the ED visit to drug use. Clinical correlates of drug use problems may assist the identification of ED patients who would benefit from comprehensive screening, intervention, and referral to treatment. A clinical decision rule is proposed. The correlation between problematic drug use and resource-intense ED triage levels suggests that ED-based efforts to reduce the unmet need for substance use treatment may help decrease overall health care costs.

Physician Attitudes and Perceived Barriers to Prescribing Nasal Naloxone Rescue Kits in the Emergency Department

Currently, nasal naloxone rescue kits (NNRK) are distributed through detoxification centers and needle exchange programs to opioid users and those likely to witness an overdose in the community. Given the high rate of drug-related emergency department (ED) visits, the ED is an underutilized arena for preventing deaths due to overdose. The study objectives were to assess ED provider attitudes towards NNRK prescriptions and distribution, and to examine barriers and willingness to prescribe NNRKs in the ED.

Drug - related emergency department visits by elderly patients presenting with non-specific complaints

BackgroundSince drug-related emergency department (ED) visits are common among older adults, the objectives of our study were to identify the frequency of drug-related problems (DRPs) among patients presenting to the ED with non-specific complaints (NSC), such as generalized weakness and to evaluate responsible drug classes.MethodsDelayed type cross-sectional diagnostic study with a prospective 30 day follow-up in the ED of the University Hospital Basel, Switzerland. From May 2007 until April 2009, all non-trauma patients presenting to the ED with an Emergency Severity Index (ESI) of 2 or 3 were screened and included, if they presented with non-specific complaints. After having obtained complete 30-day follow-up, two outcome assessors reviewed all available information, judged whether the initial presentation was a DRP and compared their judgment with the initial ED diagnosis. Acute morbidity (“serious condition”) was allocated to individual cases according to predefined criteria.ResultsThe study population consisted of 633 patients with NSC. Median age was 81 years (IQR 72/87), and the mean Charlson comorbidity index was 2.5 (IQR 1/4). DRPs were identified in 77 of the 633 cases (12.2%). At the initial assessment, only 40% of the DRPs were correctly identified. 64 of the 77 identified DRPs (83%) fulfilled the criteria “serious condition”. Polypharmacy and certain drug classes (thiazides, antidepressants, benzodiazepines, anticonvulsants) were associated with DRPs.ConclusionElderly patients with non-specific complaints need to be screened systematically for drug-related problems.Trial RegistrationClinicalTrials.gov: NCT00920491

Trends in Alcohol- and Drug-Related Emergency Department and Primary Care Visits: Data From Four U.S. National Surveys (1995–2010)

The purpose of this study was to update trends in alcohol- and drug-related emergency department and primary care visits over the last 15 years in the United States. A trend analysis was conducted on substance-related health services visits, based on self-reported alcohol or other drug use within 6 hours before an injury and/or illness event, from four National Alcohol Surveys: 1995, 2000, 2005, and 2010. A significant upward trend was found from 1995 to 2010 in alcohol-related emergency department visits but not in alcohol-related primary care visits. The odds of an alcohol-related emergency department visit doubled between 1995 and 2010 (odds ratio = 2.36). No significant trend was found in either drug-related emergency department or drug-related primary care visits between 1995 and 2010. These data suggest that alcohol-related emergency department visits have increased significantly over the past 15 years, whereas drug-related emergency department visits may have stabilized. These findings underscore the opportunity provided by the emergency department for screening and brief intervention for alcohol-related problems and suggest that Healthy People 2010 objectives calling for a reduction in substance-related emergency department visits were not realized. Thus, it might be prudent to adjust Healthy People 2020 objectives accordingly.

Do Emergency Physicians Attribute Drug-Related Emergency Department Visits to Medication-Related Problems?

Adverse drug events represent the most common cause of preventable nonsurgical adverse events in medicine but may remain undetected. Our objective is to determine the proportion of drug-related visits emergency physicians attribute to medication-related problems. This prospective observational study enrolled adults presenting to a tertiary care emergency department (ED) during 12 weeks. Drug-related visits were defined as ED visits caused by adverse drug events. The definition of adverse drug event was varied to examine both narrow and broad adverse drug event classification systems. Clinical pharmacists evaluated all patients for drug-related visits, using standardized assessment algorithms, and then followed patients until hospital discharge. Interrater agreement for the clinical pharmacist diagnosis of drug-related visit was assessed. Emergency physicians, blinded to the clinical pharmacist opinion, were interviewed at the end of each shift to determine whether they attributed the visit to a medication-related problem. An independent committee reviewed and adjudicated all cases in which the emergency physicians' and clinical pharmacists' assessments were discordant, or either the emergency physician or clinical pharmacist was uncertain. The primary outcome was the proportion of drug-related visits attributed to a medication-related problem by emergency physicians. Nine hundred forty-four patients were enrolled, of whom 44 patients received a diagnosis of the narrowest definition of an adverse drug event, an adverse drug reaction (4.7%; 95% confidence interval [CI] 3.5% to 6.2%). Twenty-seven of these were categorized as medication-related by emergency physicians (61.4%; 95% CI 46.5% to 74.3%), 10 were categorized as uncertain (22.7%; 95% CI 12.9% to 37.1%), and 7 categorized as a non-medication-related problem (15.9%; 95% CI 8.0% to 29.5%). Seventy-eight patients (8.3%; 95% CI 6.7% to 10.2%) received a diagnosis of an adverse drug event caused by an adverse drug reaction, a drug interaction, drug withdrawal, a medication error, or noncompliance. Emergency physicians attributed 49 of these to a medication-related problem (62.8%; 95% CI 51.7% to 72.7%), were uncertain about 15 (19.2%; 95% CI 12.0% to 29.4%), and attributed 14 to non-medication-related problems (17.9%; 95% CI 11.0% to 27.9%). Twenty-five of 29 (86.2%; 95% CI 69.3% to 94.4%) adverse drug events not considered medication related by emergency physicians were rated at least moderate in severity. A significant proportion of drug-related visits are not deemed medication related by emergency physicians. Drug-related visits not attributed to medication-related problems by emergency physicians may be missed in ongoing outpatient adverse drug event surveillance programs intended to develop strategies to enhance drug safety. Further research is needed to determine what the effect may be of not attributing adverse drug events to medication-related problems.

The Silver Tsunami is Coming: Will Pharmacy Be Swept Away with the Tide?

It's been called the silver tsunami, the age wave, the geriatric imperative, among others. It is the aging baby boomers and the first of this cohort turns 65 years old in 2011. From a health care perspective, the numbers are scary. Seventy-six million boomers will enter the fragmented, under funded health care arena for older people. Today the elderly constitute 12% of the US population and use approximately 35% of all medications. Medication use will likely grow with increased use of multiple medications to treat illnesses and increase longevity. Over the next 20 years, 1 in every 5 Americans will be over 65 years of age, and even more important, the 85-plus cohort will expand to 15 million over the next 40 years—about the same length of time that our recent graduates will be in practice. This raises the question: Are our graduates able to provide excellent care to the ever increasing older population? Older people, particularly those more than 85 years old, utilize massive healthcare dollars, have the poorest outcomes from adverse drug events (ADEs), and often receive inadequate, inappropriate, or poorly managed medication therapy. The incidence of avoidable adverse outcomes from drug therapy in older people is shameful. For example, 28% of ADEs in ambulatory geriatric patients are deemed preventable; even more shocking, 50% of the life-threatening and fatal ADEs are preventable.1 Why aren't they being prevented? Who's responsible for prevention? The main causes of these preventable ADEs include prescribing inappropriate medications, wrong dosing, and inferior monitoring. Poor patient adherence and lack of patient education account for more than 20% of preventable ADEs1—clearly a pharmacist intervention opportunity. In older adults the incidence of emergency department visits as a consequence of ADEs increases with age and accounts for 25% of all ADE-related emergency department visits.2 Improper therapeutic monitoring is a major cause for these visits, and approximately 50% of seniors with drug-related emergency department visits are hospitalized as a result of their ADE, highlighting the vulnerability of older people using medications.2 Given these and other alarming data, what is going to happen over the next 20 years when our population is 20% geriatric? Will pharmacists be on the front lines rendering better care in the future than what is currently being provided? The Institute of Medicine's 2008 report, Retooling for an Aging America: Building the Health Care Workforce, makes the case that “the geriatric competence of virtually all members of the health care workforce needs to be improved through significant enhancements in the educational curricula and training programs.”3 Like most health disciplines, pharmacy education is woefully inadequate in geriatrics. Few US colleges and schools of pharmacy mandate a geriatric-focused advanced practice experience, although most schools offer this as an elective.4,5 In addition, few pharmacy schools have a required geriatrics course or module and integrate geriatrics into other coursework.4,5 The quantity and success of integration is unknown, but less than half of all schools of pharmacy have a full-time geriatric pharmacy specialist.5 Geriatric pharmacy practice is much more than applying pharmacokinetic principles based on age-related altered renal function. Although this is important, age-related changes in pharmacodynamics are far more important, as these changes extensively contribute to the unnecessary high rate of ADEs in older people. There are geriatric pharmacotherapy doctrines that all pharmacists must know. But other nonpharmacologic knowledge and competencies must be learned by our students, including overcoming communication barriers that are frequently encountered in geriatrics; being able to work with community-based aging networks; working within social and economic constraints; continuum of care issues; and geriatric assessment to recognize common but unusual presentations of ADEs and geriatric syndromes. Our students must develop good interpersonal skills to work with other care providers, as the practice of geriatric medicine is interdisciplinary. Now is the time for faculties to assess their curriculum to determine whether they are adequately preparing their graduates for the silver tsunami. With the number of older people in the United States almost doubling to 70 million by 2030, if we don't address the shortfall in geriatric education today, pharmacists will not be part of interdisciplinary teams caring for seniors. As all health disciplines will not have sufficient numbers to care for our growing elderly population, we have an opportunity to fill a void by having pharmacists be responsible for medication therapy management in seniors. It won't be easy, as we do not have sufficient numbers of pharmacists with specialized training in geriatrics to serve as faculty. The academy must work towards funding more postdoctoral training programs and mid-career develop awards and help retool practicing pharmacists to meet the demand that will soon be upon us. The profession of pharmacy will suffer greatly if we wait too long to improve geriatric pharmacy education. If we don't prepare for the silver tsunami, we will be swept away with the tide.

Trends in Alcohol- and Drug-Related ED and Primary Care Visits: Data from Three U.S. National Surveys (1995–2005)

Objective: To evaluate trends in alcohol- and drug-related emergency department (ED) and primary care visits over the previous decade. Method: A trend analysis was conducted on substance-related health services visit data, based on self-reported drinking or drug use within six hours prior to an injury or illness event, from the 1995, 2000, and 2005 National Alcohol Surveys. Results: Although an upward trend was observed in alcohol-related ED visits from 1995 to 2005, this increase was not significant. A significant trend was found for drug-related ED visits from. 6% in 1995 to 3.7% in 2005 (p <. 01). In multiple logistic regression, year of survey (2000 vs. 1995) was positively predictive of drug-related ED visits, controlling for gender, age, ethnicity, and health insurance coverage; however, year of survey (2005 vs. 2000) was not significant. Conclusion: These data suggest that drug-related ED visits are continuing to increase, although the increase has not been as substantial between 2000 and 2005 as that which was observed between 1995 and 2000 and highlight the opportunity provided by the ED and primary care settings for screening and brief intervention for substance-related problems. These findings also suggest that Healthy People 2010 objectives calling for a reduction in substance-related visits may not be reached.