Drug-related Emergency Department Research Articles

Understanding adverse drug-related emergency department visits: development of a conceptual model through a systematic review.

Background:The burden of adverse drug event (ADE)-related emergency department (ED) visits is increasing despite several preventive measures. The objective of this paper was to develop and validate a conceptual model for a better understanding of ADE-related ED visits and to guide the design and implementation of effective interventions.Methods:The development of the model involved a systematic review of the literature using PubMed and Embase databases. Studies reporting the risk factors associated with ADE-related ED visits were included. The methodological qualities of the included studies were assessed using the Mixed Methods Appraisal Tool (MMAT). The model was mapped and validated using face and content validity by an expert panel. Deficiencies and targeted interventions were identified, and steps for the design and implementation were recommended.Results:The literature search generated 1361 articles, of which 38 were included in the review; 41 risk factors associated with ADE-related ED visits were identified. All factors were mapped, and the model was validated through face and content validity. The model consisted of six concepts related to sociodemographic factors, clinical factors, ADE-related to ED visits, ADE while in the ED, outcomes, and consequences. Interventions could be targeted at the factors identified in each concept to prevent ADE-related ED burden.Conclusion:A conceptual model to guide the successful design and implementation of strategies to prevent ADE-related ED visits and the occurrence of ADE at ED was developed. Clinicians should take these factors into consideration to prevent untoward events, especially when treating high-risk patients.

The challenges of researching drug-related emergency department presentations using reviews of medical charts.

Health research through review of medical charts is a useful way to understand presentations related to the effects and burden of illness, disease and substance misuse. However, the design and methods used in studies can affect their validity and reliability. It is therefore vital to ensure a strong study design and to use appropriate methodologies. To highlight some of the challenges nurse researchers face when designing and conducting research using reviews of medical charts. This paper provides an approach for conducting research using retrospective reviews of charts and potential solutions to inherent challenges involved in such reviews. Using a systematic and scientific approach can maximise the benefits, minimise the limitations, and improve the rigour and impact of nursing research. This paper advances methodological discourse about the challenges inherent when using medical charts for data collection. Despite the inherent challenges, medical charts are an important source of information about injury, disease and substance misuse. Nursing staff may face challenges when conducting research using patient medical charts. The quality of data abstracted from medical charts is affected by the data abstraction process used as well as the quality and accuracy of clinical documentation.

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.

Gender Differences in Emergency Department Visits and Detox Referrals for Illicit and Nonmedical Use of Opioids.

IntroductionVisits to the emergency department (ED) for use of illicit drugs and opioids have increased in the past decade. In the ED, little is known about how gender may play a role in drug-related visits and referrals to treatment. This study performs gender-based comparison analyses of drug-related ED visits nationwide.MethodsWe performed a cross-sectional analysis with data collected from 2004 to 2011 by the Drug Abuse Warning Network (DAWN). All data were coded to capture major drug categories and opioids. We used logistic regression models to find associations between gender and odds of referral to treatment programs. A second set of models were controlled for patient “seeking detox,” or patient explicitly requesting for detox referral.ResultsOf the 27.9 million ED visits related to drug use in the DAWN database, visits by men were 2.69 times more likely to involve illicit drugs than visits by women (95% CI [2.56, 2.80]). Men were more likely than women to be referred to detox programs for any illicit drugs (OR 1.12, 95% CI [1.02–1.22]), for each of the major illicit drugs (e.g., cocaine: OR 1.27, 95% CI [1.15–1.40]), and for prescription opioids (OR 1.30, 95% CI [1.17–1.43]). This significant association prevailed after controlling for “seeking detox.”ConclusionWomen are less likely to receive referrals to detox programs than men when presenting to the ED regardless of whether they are “seeking detox.” Future research may help determine the cause for this gender-based difference and its significance for healthcare costs and health outcomes.

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.

Do drug seizures predict drug-related emergency department presentations or arrests for drug use and possession?

BackgroundDirect evidence of the effect of drug seizures on drug use and drug-related harm is fairly sparse. The aim of this study was to see whether seizures of heroin, cocaine and ATS predict the number of people arrested for use and possession of these drugs and the number overdosing on them. MethodWe examined the effect of seizure frequency and seizure weight on arrests for drug use and possession and on the frequency of drug overdose with autoregressive distributed lag (ARDL) models. Granger causality tests were used to test for simultaneity. ResultsOver the short term (i.e. up to 4 months), increases in the intensity of high-level drug law enforcement (as measured by seizure weight and frequency) directed at ATS, cocaine and heroin did not appear to have any suppression effect on emergency department (ED) presentations relating to ATS, cocaine and heroin, or on arrests for use and/or possession of these drugs. A significant negative contemporaneous relationship was found between the heroin seizure weight and arrests for use and/or possession of heroin. However no evidence emerged of a contemporaneous or lagged relationship between heroin seizures and heroin ED presentations. ConclusionThe balance of evidence suggests that, in the Australian context, increases in the monthly seizure frequency and quantity of ATS, cocaine and heroin are signals of increased rather than reduced supply.

Is levorphanol a better option than methadone?

Methadone has been a stalwart pharmacologic option for the management of opioid drug dependence for many years. It substitutes for opioid agonists and possesses certain pharmacokinetic properties that confer characteristics preferable to those of other opioids for this application. Methadone is likewise used as an option for the treatment of pain, particularly chronic pain. It has a spectrum of pharmacodynamic activity, including contributions from non-opioid components, that translates to its specific clinical attributes as an analgesic. Unfortunately, basic science studies and accumulated clinical experience with methadone have revealed some undesirable, and even worrisome, features, including issues of safety. The benefit/risk ratio of methadone might be acceptable if there was no better alternative, but neither its pharmacokinetic nor pharmacodynamic properties are unique to methadone. We review the basic and clinical pharmacology of methadone and suggest that levorphanol should receive attention as a possible alternative. Unlike methadone, levorphanol is a more potent NMDA antagonist, possesses a higher affinity for DOR and KOR, has a shorter plasma half-life yet longer duration of action, has no CYP450 interactions or QTc prolongation risk, can be a viable option in the elderly, palliative care, and SCI patients, requires little to no need for co-administration of adjuvant analgesics, and has potentially a lower risk of drug-related Emergency Department visits compared to other opioids.

Cocaine, Marijuana, Hypertension and Cardiovascular Effects

Cocaine is used by more than 14 million people worldwide, about 0.3 percent of the global population age is 15 to 64 years. After alcohol, cocaine is the most common cause of acute drug-related emergency department visits in the United States. Cocaine consumption is more frequently associated with acute cardiovascular illness. Cocaine stimulates α1, α2, β1 and β2 adrenergic receptors through increased levels of norepinephrine and a lesser extent epinephrine. The cardiovascular effects of cocaine are thought to be similar and regardless to the route of consumption. An acute coronary syndrome is the most common cardiac problem including myocardial ischemia and infarction even in young persons without atherosclerosis, aortic dissection and rupture, arrhythmias, ventricular tachycardia and fibrillation, asystole and finally sudden death. Other cardiovascular effects that caused by cocaine include coronary artery aneurysm, palpitation, sinus tachycardia, increased systemic vascular resistance and hypertension crisis, left ventricular hypertrophy, myocarditis, cardiomyopathy, myocardial fibrosis, bundle branch block, heart block, supraventricular arrhythmia, accelerated atherosclerosis, hypotension, bradycardia and infective endocarditis among intravenous users.Cocaine by three mechanisms cause ischemia: 1. increased myocardial oxygen demand, 2. decreased coronary blood flow due to coronary artery vasoconstriction and spasm and 3. Coronary artery thrombosis via activation of platelets, stimulation of platelet aggregation and potentiation of thromboxane production.

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.

Stimulants and the Lung

Illicit stimulants, such as cocaine, amphetamine, and their derivatives (e.g., "ecstasy"), continue to exact heavy toll on health care in both developed and developing countries. The US Department of Health and Human Service reported over one million illicit drug-related emergency department visits in 2010, which was higher than any of the six previous years. Both inhaled and intravenous forms of these substances of abuse can result in a variety of acute and chronic injuries to practically every part of the respiratory tract, leading potentially to permanent morbidities as well as fatal consequences--including but not limited to nasal septum perforation, pulmonary hypertension, pneumothorax, pneumomediastinum, interstitial lung disease, alveolar hemorrhage, reactive airway disease, pulmonary edema, pulmonary granulomatosis, infections, foreign body aspiration, infections, bronchoconstriction, and thermal injuries. Stimulants are all rapidly absorbed substances that can also significantly alter the patient's systemic acid-base balance and central nervous system, thereby leading to further respiratory compromise. Mounting evidence in the past decade has demonstrated that adulterants coinhaled with these substances (e.g., levamisole) and the metabolites of these substances (e.g., cocaethylene) are associated with specific forms of systemic and respiratory complications as well. Recent studies have also demonstrated the effects of stimulants on autoimmune-mediated injuries of the respiratory tract, such as cocaine-induced midline destructive lesions. A persistent challenge to studies involving stimulant-associated respiratory toxidromes is the high prevalence of concomitant usage of various substances by drug abusers, including tobacco smoking. Now more than ever, health care providers must be familiar with the multitude of respiratory toxidromes as well as the diverse pathophysiology related to commonly abused stimulants to provide timely diagnosis and effective treatment.

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.

Application of system-level root cause analysis for drug quality and safety problems: A case study

BackgroundAutomated surveillance indicators are used to identify problems with drug therapy. A previous study automated 39 indicators of possible drug-related emergency department visits and hospitalizations. These indicators were used to investigate the quality and safety of drug use in a large health care coalition in Florida. This study describes a method of capturing this input with an aim of applying it to a root cause analysis (RCA), which may be useful for improving system-level flaws and weaknesses in medication use. ObjectiveTo apply results of a computerized surveillance system containing selected indicators of potential drug-related emergency department and hospital admissions to an RCA for evaluation. Such evaluation might prove effective in determining criteria useful in improving the quality and safety of systemic responses to individual types of drug therapy problems. MethodsThis was a case study that brought together a study group of 6 coalition stakeholders to evaluate findings from 4 indicators. The indicators represented problems in the prescribing, adherence, and monitoring steps in the ambulatory care medication use system. The RCA included the following procedures: brainstorming of possible system failures, organizing proposed system failures into groups and corresponding system levels, voting to prioritize proposed system failures, tree diagramming to illustrate how the system failures are interconnected among system levels, and determining whether system conditions or failure sequences are common among indicator types. ResultsThe group judged 3 themes to be important contributors to drug-related problems identified by the 4 indicators, including lack of patient knowledge, patient nonadherence to medical recommendations, and lack of medication management systems. The group believed that these barriers were interconnected and the result of subsystem influences. ConclusionDrug therapy problems represented by the indicators have certain system failures, flaws, or defects in common, allowing them to occur and persist. RCA may be a useful method for evaluating population-level indicator findings to identify potential failures with the medication use system and develop interventions.

Effects of Welfare Reform on Illicit Drug Use Of Adult Women.

Exploiting changes in welfare policy across states and over time and comparing relevant population subgroups within an econometric difference-in-differences framework, we estimate the effects of welfare reform on adult women's illicit drug use from 1992 to 2002, the period during which welfare reform unfolded in the U.S. The analyses are based on all available and appropriate national datasets, each offering unique strengths and measuring a different drug-related outcome. We investigate self-reported illicit drug use (from the National Household Surveys on Drug Abuse and National Surveys on Drug Use and Health), drug-related prison admissions (from the National Corrections Reporting Program), drug-related arrests (from Federal Bureau of Investigation Uniform Crime Reports), and drug-related emergency department episodes (from the Drug Abuse Warning Network). We find robust evidence that welfare reform led to a 10-21% decline in illicit drug use among women at risk of relying on welfare, as well as associated declines in drug-related arrests (6-7%), drug-related hospital emergency department episodes (7-11%), and possibly drug-related prison admissions (11-19%). The findings indicate that an appropriately designed system with sufficient job opportunities for those are able to work can result in both increases in employment and decreases in drug use.

Impact of Policy Changes on Emergency Department Use by Medicaid Enrollees in Oregon

In 2003, Oregon's Medicaid expansion program, the Oregon Health Plan (OHP), implemented premiums and copayments and eliminated outpatient behavioral health services. We ascertained whether these changes, including $50 copayments for emergency department (ED) visits, affected ED use. This study used statewide administrative data on 414,009 adult OHP enrollees to compare ED utilization rates (adjusted for patient characteristics) in 3 time periods: (1) before the cutbacks, (2) after the cutbacks, and (3) after partial restoration of benefits. We examined overall ED visits and several subsets of ED visits: visits requiring hospital admission, injury-related, drug-related, alcohol-related, and other psychiatric visits. Because the policy changes affected only the expansion program (OHP Standard), we ascertained the impact of these changes compared with a control group of categorically eligible Medicaid enrollees (OHP Plus). Compared with the control group, case-mix-adjusted ED utilization rates fell 18% among OHP Standard enrollees after the cutbacks. The rate of ED visits leading to hospitalization fell 24%. Injury-related visits and psychiatric visits excluding chemical dependency exhibited a similar pattern to overall ED visits. Drug-related ED visits increased 32% in the control group, perhaps reflecting the closure of drug treatment programs after the cutbacks reduced their revenue. The policy changes were followed by a substantial reduction in ED use. That ED visits requiring hospital admission fell to about the same extent as overall ED use suggests that OHP enrollees may have been discouraged from using EDs for emergencies as well as less-serious problems.