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Most people addicted to opioids began taking them because they were legally prescribed. Little attention has been paid to changing physicians' prescribing behavior. Using a randomized controlled trial format, Doctor et al. monitored the effect of notifying physicians who had a patient die of opioid overdose within 12 months of a prescription. The physicians received an injunction to prescribe safely from their county's medical examiner. This intervention led to reductions in high-intensity prescribing, reductions in the likelihood that an opioid-naïve patient received a prescription, and a reduction in overall cumulative opioid intake. Science , this issue p. 588 Feedback about a patient’s overdose may instill safe opioid prescribing habits in physicians. Most opioid prescription deaths occur among people with common conditions for which prescribing risks outweigh benefits. General psychological insights offer an explanation: People may judge risk to be low without available personal experiences, may be less careful than expected when not observed, and may falter without an injunction from authority. To test these hypotheses, we conducted a randomized trial of 861 clinicians prescribing to 170 persons who subsequently suffered fatal overdoses. Clinicians in the intervention group received notification of their patients’ deaths and a safe prescribing injunction from their county’s medical examiner, whereas physicians in the control group did not. Milligram morphine equivalents in prescriptions filled by patients of letter recipients versus controls decreased by 9.7% (95% confidence interval: 6.2 to 13.2%; P < 0.001) over 3 months after intervention. We also observed both fewer opioid initiates and fewer high-dose opioid prescriptions by letter recipients.

A 32-year-old man with well-controlled HIV infection presented with a chief symptom of severe rectal pain that worsened over the previous week. He had receptive anal intercourse 13 days before presentation. He described a burning or tearing sensation inside his rectum and an associated clear discharge.

Cannabinoid hyperemesis syndrome (CHS) is an entity associated with cannabinoid overuse. CHS typically presents with cyclical vomiting, diffuse abdominal pain, and relief with hot showers. Patients often present to the emergency department (ED) repeatedly and undergo extensive evaluations including laboratory examination, advanced imaging, and in some cases unnecessary procedures. They are exposed to an array of pharmacologic interventions including opioids that not only lack evidence, but may also be harmful. This paper presents a novel treatment guideline that highlights the identification and diagnosis of CHS and summarizes treatment strategies aimed at resolution of symptoms, avoidance of unnecessary opioids, and ensuring patient safety. The San Diego Emergency Medicine Oversight Commission in collaboration with the County of San Diego Health and Human Services Agency and San Diego Kaiser Permanente Division of Medical Toxicology created an expert consensus panel to establish a guideline to unite the ED community in the treatment of CHS. Per the consensus guideline, treatment should focus on symptom relief and education on the need for cannabis cessation. Capsaicin is a readily available topical preparation that is reasonable to use as first-line treatment. Antipsychotics including haloperidol and olanzapine have been reported to provide complete symptom relief in limited case studies. Conventional antiemetics including antihistamines, serotonin antagonists, dopamine antagonists and benzodiazepines may have limited effectiveness. Emergency physicians should avoid opioids if the diagnosis of CHS is certain and educate patients that cannabis cessation is the only intervention that will provide complete symptom relief. An expert consensus treatment guideline is provided to assist with diagnosis and appropriate treatment of CHS. Clinicians and public health officials should identity and treat CHS patients with strategies that decrease exposure to opioids, minimize use of healthcare resources, and maximize patient safety.

Prescription drug–related fatalities remain a significant issue in the United States, yet there is a relative lack of knowledge on the specialty-specific prescription patterns for drug-related deaths. We designed a study that investigated medical examiner reports of prescription drug–related deaths that occurred in San Diego County during 2013. A Prescription Drug Monitoring Program search was performed on each of these cases to ascertain which physician specialties had prescribed controlled substances to these patients. The data were analyzed for each specialty, including pills per prescription, type of prescription, doctor shoppers (4 physicians + 4 pharmacies over 1 year), and chronic users (≥3 consecutive months of medications). In 2013, 4.5% of all providers in San Diego County wrote a prescription for a patient who died a prescription-related death. There were a total of 713 providers who prescribed 4366 medications totaling 328928 pills. Overall, emergency physicians gave the lowest number of prescriptions per provider (1.6), whereas pain management provided the highest amount per provider (12.9). Most prescriptions went to doctor shoppers (>50%) and chronic users (95.8%). Hydrocodone was the most frequently prescribed medication to those patients whose deaths were related to prescription drugs. Emergency physicians appear to provide fewer prescriptions to those patients who die due to prescription drugs. Emergency physicians do, however, account for a significant proportion of total providers in this study. These results highlight the need to use Prescription Drug Monitoring Program data to closely monitor prescription patterns and to intervene when necessary.

This randomized clinical trial evaluates the effect of prescriber notifications of a patient’s fatal overdose on opioid prescribing, including decreases in morphine milligram equivalents, new patients taking opioids, and patients taking a high dose, at 4 to 12 months after notification.

•The majority of methadone deaths came outside the PDMP system.•A risk-benefit analysis should be made to consider changing existing laws.•OTP should make it standard of care to check PDMP data on their patients. Methadone is increasingly implicated in unintentional overdose deaths. Despite major interventions, rates continue to remain high. One primary intervention, Prescription Drug Monitoring Programs (PDMP) are limited in their ability to impact this epidemic due to federal law restricting Opioid Treatment Programs (OTPs) from sharing data to PDMPs, despite being a major source of Methadone dispensing. This retrospective, observational study analyzed all prescription-related deaths occurring in San Diego County during the year 2013 with a specific focus on methadone-related deaths. All patients designated by medical examiner to have died by unintentional prescription were then referenced in the California PDMP, the Controlled Substance Utilization Review and Evaluation System (CURES). As a whole, patients who died had a high number of average prescriptions, 21, and averaged 4.5 different providers, and three different pharmacies. Methadone-related deaths (MRD) accounted for 46 out of the 254 total patient deaths (18.1%). Methadone prescriptions were found in 14 patients with PDMP reports, 10 of who had methadone on toxicology report. Notably, 100% of methadone prescribed by primary care specialists. MRD patients were less likely to have toxicology reports matching PDMP data compared to other related drug deaths (20.6 vs. 61.2%, p<0.0001). Of the 46 methadone deaths, only 10 (29.4%) had prescriptions for methadone recorded in the database. Out of the 51 patients with only one drug recorded at death, methadone was most common (n=12; 23.5%). While all deaths had a notably high rate of chronic prescriptions at death (68.8% compared to 2% for all patients in CURES), there was no significant difference between MRD and other drug-related deaths (73.5 vs. 67.8%, p=0.68, respectively). MRD patients were less likely than other drug patients to have matching PDMP data without any illicit substance or alcohol (14.7 vs. 41.4%, p=0.003, respectively). Methadone is a long-acting opioid that carries a higher risk profile than other opioids. In San Diego, the great majority of MRD had no data on methadone in the statewide PDMP database, bringing to question the restriction of OTP clinics from uploading information into the database. A risk-benefit analysis should be made to consider changing laws that would allow for OTP to input data into PDMP. OTP should make it standard of care to check PDMP data on their patients. Methadone prescribed for pain management should be limited to the most compliant patients.

The Centers of Disease Control and Prevention have declared prescription drug abuse an epidemic in the United States. However, demographic data correlating prescription-related deaths with actual prescriptions written is not well described. The purpose of this study is to compare toxicology reports on autopsy for prescription-related deaths with Prescription Drug Monitor Program (PDMP) data. This is a retrospective analysis comparing 2013 San Diego Medical Examiner data on 254 unintentional prescription-related deaths obtained for 12 months before death with data from the California PDMP. Data were analyzed on age, sex, whether there was information on the PDMP, types and quantities of prescribed medications, number of pharmacies and providers involved, and whether there was a match between the Medical Examiner toxicology report and data from the PDMP. In 2013, there were 254 unintentional prescription-related deaths; 186 patients (73%) had PDMP data 12 months before death. Ingesting prescription medications with illicit drugs, alcohol, and/or over-the-counter medications accounted for 40% of the unintentional deaths. Opioids were responsible for the majority of single medication deaths (36; 70.6%). The average number of prescriptions was 23.5 per patient, and the average patient used 3 pharmacies and had 4.5 providers. Chronic prescription use was found in 68.8% of patients with PDMP data. The PDMP data highlight important patterns that can provide valuable insight to clinicians making decisions regarding types and amounts of medications they prescribe. Although there is no guaranteed solution to prevent prescription-related deaths, PDMP data can be useful to prevent coprescribing and medication interaction and by following best clinical practices.