Once a patient is deemed stable for discharge from the ED by the trauma service, the rest of the patient’s care is up to the discretion of the emergency physician, which includes any and all medication prescriptions and ultimate disposition decisions. Lastly, as a supplementary analysis to look more specifically into potential associations with THC use we compared opioid prescriptions against three separate groups that included patients with negative toxicology screens for THC, patients with positive screens for THC, and patients without a toxicology screen.The study population was divided into five subgroups that included the following: negative urine and serum toxicology screen ; depressants; stimulants; mixed; and no toxicology screens. The median total MME for the five separate subgroups was as follows: none ; depressant ; stimulants ; mixed ; and no toxicology screens . The median total number of pills for the five separate subgroups was as follows: none ; depressant ; stimulants ; mixed ; and no toxicology screen . When comparing the 103 patients from whom toxicology screens were obtained to the 255 patients without toxicology screens, we found no statistically significant differences in the total prescribed MME or in the number of pills prescribed . Notably, none of the 103 patients who had toxicology screens were prescribed naloxone upon discharge. We also looked into whether the type of injury had any association with opioid prescriptions. Our data, shown in Table 2 below, indicates there was no statistically significant difference in total prescribed MME or amount of pills prescribed when comparing patients with fractures, dislocations,flood tray or amputations. As a supplementary analysis we aimed to determine whether or not the presence of THC on urine toxicology screens was associated with an increase or decrease in the amount and total MME prescribed . The median total prescribed MME for patients with urine toxicology screens positive for THC was 87.5.
The median for patients with urine toxicology screens negative for THC was 75.0, and there was no statistically significant difference between the two groups . The median total number of pills for patients with urine toxicology screens positive for THC was 15.0. The median total number of pills for patients with urine toxicology screens negative for THC was 15.0, and there was no statistically significant difference between the two groups .At our Level I trauma center it is routine to obtain urine and serum toxicology screens for trauma activations. Most often, the results of these toxicology screens are not pertinent and will not significantly affect the patient’s disposition. However, previous reports have suggested that in some circumstances the urine drug screen is of utility in improving patient care by identifying patients who are at risk for diversion and mismanagement of controlled substances. 33 Our results did not substantiate these reports. For context, providers in California must consult the Controlled Substance Utilization Review and Evaluation System , the state’s prescription drug monitoring program, prior to prescribing Schedules II-IV controlled substances for the first time and at least once every four months thereafter if the patient continues to use the controlled substances.34 However, if prescribed in the ED, providers do not have to consult CURES if the quantity of controlled substance does not exceed a nonrefillable seven-day supply. In fact, it is common practice to prescribe less than one week’s supply and to consult CURES only if the prescriber has suspicion of diversion, misuse, or abuse. For these reasons we suspect CURES reports likely had limited to no effect on prescribing habits. A large-scale study based upon Medicaid States Drug Utilization Data found an associated decrease in the number of opioid prescriptions, dosages, and Medicaid spending in states that have legalized medical cannabis. 30 A similar study found that in states that have legalized recreational marijuana, there was a notable decrease in opioid prescriptions of about 6.38%. 35 Since then, several studies have failed to demonstrate similar findings in actual clinical practice, and many have actually found that cannabis use was associated with an increased risk of opioid use disorder and opioid misuse. 36-39 In our study, we found no statistically significant difference in opioid prescriptions in terms of either total MME or number of pills prescribed between groups. Thus, we do not see that emergency physicians reduce or significantly change the quantity of prescribed opioids when urine toxicology screens are noted to be positive for THC. This was consistently true even when our study population was divided into different classes of toxicology results .There was also no difference in opioid prescriptions between these four separate groups. Thus, physician knowledge of prior drug use was not associated with a decrease in the total quantity of opioid prescriptions.
This may be explained in part by the legal status of cannabis in the state of California and may portend an overall reduction in the stigma that was previously endured by patients who used cannabis medicinally or recreationally. Another salient finding within this data was the absence of naloxone prescriptions for any patient in this study. In the state of California, Assembly Bill No. 2760 was passed on September 10, 2018, and took effect January 1 2019. This bill mandates that opioid prescribers must offer a prescription of naloxone hydrochloride when the prescription dosage is 90 MME or more per day, when an opioid is prescribed concurrently with a benzodiazepine, and when the patient is at increased risk for overdose, which includes patients with a history of overdose, patients with substance use disorder, or patients at risk for returning to a high dose of opioid medications.We collected the data for our study prior to the enactment of this law. However, it is prudent to recognize that even within this law, there is no clear mandate on prescribing naloxone based upon toxicology results that imply higher risk of illicit drug use, such as urine drug screens that are positive for both opioids and benzodiazepines. We also found that of the 103 patients who had toxicology screens performed, were prescribed a total MME <90, and 46 were prescribed a total MME >90. Thus, had the law been in effect, 44.7% of these patients should have received a prescription for naloxone regardless of their drug screens, strictly due to the total MME prescribed. While this study was performed at an academic tertiary care center, if it were repeated at other community-based institutions, we could see similar patterns regarding the lack of naloxone prescriptions. Furthermore, we undertook this study in Orange County, California, a densely populated setting in Southern California that was ranked 17th out of 58 counties in the state for rates of prescription opioid deaths and unintentional injuries. Drug overdose was the largest contributor and the number 1 cause of death in patients between the ages of 15-44 years old.One study that surveyed emergency providers at an academic, urban, Level I trauma center found that the factors most commonly influencing providers’ willingness to prescribe naloxone were the prevalence of prescribing these medications in their institution, or if there was a strong mortality benefit.Sixty-two percent of prescribers endorsed that lack of training was a barrier to prescribing, and 52% cited lack of knowledge as a barrier. Thus, it is pertinent that as a medical community, we focus on methods to improve research and education on naloxone so that prescribing can become a more common practice.
Several initiatives have been developed and described in the literature aimed at improving naloxone prescription rates. Some examples include screening questionnaires for patients, pharmacy-led opioid overdose risk assessments, and multi-disciplinary teams with clinical nurse specialists for overdose education and naloxone distribution. In one study a program was implemented within the electronic health record system to search for keywords within nursing assessment notes to identify patients who were at high risk for opioid overdose. This then prompted the physician to consider naloxone prescriptions. Overall, the study found that since implementation of this integrated EHR programming, there was an associated increase in the rate of take-home naloxone prescriptions. Implementation of similar programming in EHRs could be used to flag patients with toxicology results positive for high-risk illicit drug use such as benzodiazepines, other opiates,grow table supplier and alcohol. These flagged patients could then trigger a prompt to consider prescribing naloxone if the clinician attempts to prescribe an opioid. Given that some states have implemented mandates requiring the prescription of naloxone when prescribing opioid regimens greater than 90 MME, an additional prompt from the EHR recommending naloxone in these situations may prove useful to ensure compliance with local laws and practice guidelines.39Despite the health risks and societal costs of cigarette smoking, the prevalence of smoking in the USA remains high at ∼19 % . Roughly 44 % of cigarettes are used by smokers with substance abuse/dependence and/or mental illness , and people with almost all substance abuse and mental illness diagnoses have elevated rates of cigarette smoking .Roughly half of smokers drink coffee and report drinking almost twice as much coffee per day as nonsmokers . Similarly, among smokers, 57.9 % have ever used marijuana, and smokers are about 8 times more likely than non-smokers to have a marijuana use disorder , with cigarette smoking and marijuana use being associated even after controlling for potential confounding variables, such as depression, alcohol use, and stressful life events . Given the high comorbidity of smoking and both caffeine and marijuana use, it is important to better understand biological factors that may be associated with these co-occurrences. One of the most well-established effects of chronic cigarette smoking on the human brain is widespread upregulation of α4β2* nicotinic acetylcholine receptors . Recent studies using single-photon emission computed tomographyand positron emission tomographyhave consistently demonstrated significant upregulation of these receptors in smokers compared to nonsmokers. These in vivo studies were an extension of much prior research, including human postmortem brain tissue studies, demonstrating that chronic smokers have increased nAChR density compared to non-smokers and former smokers . Additionally, many studies of laboratory animals have demonstrated upregulation of markers of nAChR density in response to chronic nicotine administration . In a previous study by our group comparing nAChR availability between smokers and nonsmokers , we explored the effect of many variables, including caffeine and marijuana use. Both heavy caffeine and marijuana use were exclusionary, such that participants drank an average of 1.3 coffee cup equivalents per day and only 12 % of the study sample reported occasional marijuana use. PET results indicated that caffeine and marijuana use had significant relationships with α4β2* nAChR availability in this group with low levels of usage. Based on these preliminary findings, we undertook a study of the effect of heavy caffeine or marijuana usage on α4β2* nAChR density in cigarette smokers.
One hundred and one otherwise healthy male adults completed the study and had usable data. Participants were recruited and screened using the same methodology as in our prior reports , with the exception that this study only included Veterans. For smokers, the central inclusion criteria were current nicotine dependence and smoking 10 to 40 cigarettes per day, while for non-smokers, the central inclusion criterion was no cigarette usage within the past year. Heavy caffeine use was defined as the equivalent of ≥3 cups of coffee per day, and heavy marijuana use was defined as ≥4 uses of at least 1 marijuana cigarette per week. Exclusion criteria for all participants were as follows: use of a medication or history of a medical condition that might affect the central nervous system at the time of scanning, any history of mental illness, or any substance abuse/dependence diagnosis within the past year other than caffeine or marijuana diagnoses. Occasional use of alcohol or illicit drugs was not exclusionary. There was no overlap between this study and prior research by our group. During an initial visit, screening data were obtained to verify participant reports and characterize smoking history. Rating scales obtained were as follows: the Smoker’s Profile Form , Fagerström Test for Nicotine Dependence , Beck Depression Inventory , Hamilton Depression Rating Scale , and Hamilton Anxiety Rating Scale . An exhaled carbon monoxide level was determined using a Micro Smokerlyzer to verify smoking status. A breathalyzer test and urine toxicology screen were obtained at the screening visit to support the participant’s report of no current alcohol abuse or other drug dependencies. This study was approved by the local institutional review board , and participants provided written informed consent.