Workplace Violence and Hospital Security Programs: Regulatory Compliance, Program Benchmarks, Innovative Strategies

The authors describe the issue of workplace violence in hospitals, a New Jersey state law and regulations regarding workplace violence in healthcare, and some innovative strategies that are being utilized to help reduce the occurrence and risk of violence. The authors also discuss compliance with the New Jersey regulations

Intracranial Pressure Monitoring in Infants and Young Children With Traumatic Brain Injury

OBJECTIVE: To examine the use of intracranial pressure monitors and treatment for elevated intracranial pressure in children 24 months old or younger with traumatic brain injury in North Carolina between April 2009 and March 2012 and compare this with a similar cohort recruited 2000-2001. DESIGN: Prospective, observational cohort study. SETTING: Twelve PICUs in North Carolina. PATIENTS: All children 24 months old or younger with traumatic brain injury, admitted to an included PICU. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: The use of intracranial pressure monitors and treatments for elevated intracranial pressure were evaluated in 238 children with traumatic brain injury. Intracranial pressure monitoring (risk ratio, 3.7; 95% CI, 1.5-9.3) and intracranial pressure therapies were more common in children with Glasgow Coma Scale less than or equal to 8 compared with Glasgow Coma Scale greater than 8. However, only 17% of children with Glasgow Coma Scale less than or equal to 8 received a monitoring device. Treatments for elevated intracranial pressure were more common in children with monitors; yet, some children without monitors received therapies traditionally used to lower intracranial pressure. Unadjusted predictors of monitoring were Glasgow Coma Scale less than or equal to 8, receipt of cardiopulmonary resuscitation, nonwhite race. Logistic regression showed no strong predictors of intracranial pressure monitor use. Compared with the 2000 cohort, children in the 2010 cohort with Glasgow Coma Scale less than or equal to 8 were less likely to receive monitoring (risk ratio, 0.5; 95% CI, 0.3-1.0), although the estimate was not precise, or intracranial pressure management therapies. CONCLUSION: Children in the 2010 cohort with a Glasgow Coma Scale less than or equal to 8 were less likely to receive an intracranial pressure monitor or hyperosmolar therapy than children in the 2000 cohort; however, about 10% of children without monitors received therapies to decrease intracranial pressure. This suggests treatment heterogeneity in children 24 months old or younger with traumatic brain injury and a need for better evidence to support treatment recommendations for this group of children

Abuse-Deterrent Opioids: A Survey of Physician Beliefs, Behaviors, and Psychology

Objective: Evaluate beliefs and behaviors pertaining to abuse-deterrent opioids (ADFs). Design: Survey in 2019 by invitation to all licensed physicians. Setting: Commonwealth of Kentucky. Participants: 374 physicians. Methods: Descriptive statistics, and hypothesis test that early adopter prescribers would have greater endorsement of opioid risk management. Results: Of all prescribers, 55% believed all opioid analgesics should have ADF requirements (15% were unsure); 74% supported mandating insurance coverage. Only one-third considered whether an opioid was ADF when prescribing, motivated by patient family diversion (94%) and societal supply reduction (88%). About half believed ADFs were equally effective in preventing abuse by intact swallowing, injection, chewing, snorting, smoking routes. Only 4% of OxyContin prescribers chose it primarily because of ADF properties. Instead, the most common reason (33%) was being started by another prescriber. A quarter of physicians chose not to prescribe ADFs because of heroin switching potential. Early adopters strongly believed ADFs were effective in reducing abuse (PR 3.2; 95% CI 1.5, 6.6) compared to mainstream physicians. Early-adopter risk-management practices more often included tools increasing agency and measurement: urine drug screens (PR 2.0; 1.3, 3.1), risk screening (PR 1.3; 0.94, 1.9). While nearly all respondents (96%) felt that opioid abuse was a problem in the community, only 57% believed it was a problem among patients in their practice. Attribution theory revealed an externalization of opioid abuse problems that deflected blame from patients on to family members. Conclusions: The primary motivator for prescribing ADFs was preventing diversion by family members, not patient-level abuse concerns

Prescriber Survey - Methodological Advances in Evaluating Abuse-deterrent Opioid Analgesics

Survey collecting information and opinions related to the prescribing and dispensing of abuse-deterrent formulation opioid analgesics. This study is being conducted on behalf of the U.S. Food and Drug Administration by researchers at the University of Kentucky Colleges of Pharmacy and Public Health, and the University of North Carolina at Chapel Hill. Project Website: OpioidData.or

Do early prescribers of new drugs have different risk management practices?

A statewide prescriber survey to evaluate if self described early prescribers have differences in risk management practices compared to later prescribers

Crystal Clear: Prevalence of fentanyl in methamphetamine and cocaine samples collected by community-based drug checking services

MANUSCRIPT DRAFT – NOT PEER REVIEWED Background: Overdose deaths involving stimulants and opioids simultaneously have raised the specter of widespread contamination of the stimulant supply with fentanyl. Methods: We quantified prevalence of fentanyl in street methamphetamine and cocaine, stratified by crystalline texture, analyzing samples sent voluntarily to a public mail-in drug checking service (May 2021-June 2023). Samples from 77 harm reduction programs and clinics originated in 25 US states. Sample donors reported expected drug and physical descriptions. Substances were identified by gas chromatography-mass spectrometry. Negative binomial models were used to calculate fentanyl prevalence, adjusting for potential confounders related to sample selection. We also examined if xylazine modified donors’ expectations of fentanyl positivity. Results: We analyzed 718 lab-confirmed samples of methamphetamine (64%) and cocaine (36%). The adjusted prevalence of fentanyl was 12.5% (95% CI: 2.2%, 22.9%) in powder methamphetamine and 14.8% (2.3%, 27.2%) in powder cocaine. Crystalline forms of both methamphetamine (2=57, p<0.001) and cocaine (2=18, p<0.001) were less likely to contain fentanyl: less than 1% of crystal methamphetamine (2/276) and no crack cocaine (0/53). Heroin was present in 6.6% of powder cocaine samples. Xylazine reduced donors’ ability to detect fentanyl, with correct classification dropping from 92% to 42%. Conclusions: Fentanyl was detected primarily in powder forms of methamphetamine and cocaine. Recommended interventions include expanding community-based drug checking, naloxone and fentanyl test strip distribution for stimulant users, and supervised drug consumption sites. New strategies to dampen variability in street drug composition are needed to reduce inadvertent fentanyl exposure.Pre-registration DOI: 10.17605/OSF.IO/QKF57 Data & code DOI: 10.17605/OSF.IO/EV7N

Challenges with misclassification of American Indian/Alaska Native race and Hispanic ethnicity on death records in North Carolina occupational fatalities surveillance

As frequently segregated and exploitative environments, workplaces are important sites in driving health and mortality disparities by race and ethnicity. Because many worksites are federally regulated, US workplaces also offer opportunities for effectively intervening to mitigate these disparities. Development of policies for worker safety and equity should be informed by evidence, including results from research studies that use death records and other sources of administrative data. North Carolina has a long history of Black/white disparities in work-related mortality and evidence of such disparities is emerging in Hispanic and American Indian/Alaska Native (AI/AN) worker populations. The size of Hispanic and AI/AN worker populations have increased in North Carolina over the last decade, and North Carolina has the largest AI/AN population in the eastern US. Previous research indicates that misidentification of Hispanic and AI/AN identities on death records can lead to underestimation of race/ethnicity-specific mortality rates. In this commentary, we describe problems and complexities involved in determining AI/AN and Hispanic identities from North Carolina death records. We provide specific examples of misidentification that are likely introducing bias to occupational mortality disparity documentation, and offer recommendations for improved data collection, analysis, and interpretation. Our primary recommendation is to build and maintain relationships with local community leadership, so that improvements in the ascertainment of race and ethnicity are grounded in the lived experience of workers from communities of color

Effectiveness of a Statewide Abusive Head Trauma Prevention Program in North Carolina

Abusive head trauma (AHT) is a serious condition, with an incidence of approximately 30 cases per 100 000 person-years in the first year of life

Instructions and data collection card for mail-in drug checking

Printable PDF (4x6") of instructions on how to prepare samples for mail-in drug checking. Obverse is the brief data collection form

Variation among Pharmacists in Calculating Days’ Supply

Background: Pharmacoepidemiologic studies utilize the days’ supply field in prescription (Rx) claims to classify exposures and outcomes; however, data on the accuracy of days’ supply are lacking. In the United States, days’ supply is calculated at the time of Rx filling. Pharmacists’ interpretation may influence days’ supply calculations leading to variability. Objectives: The objectives of this study are to assess consistency of pharmacists’ calculation of days’ supply for opioid Rxs and identify factors pharmacists consider when calculating days’ supply for a given Rx. Methods: A cross-sectional survey was designed to collect information from Kentucky-licensed pharmacists about opioid analgesic dispensing practices and days’ supply calculations. The survey was distributed electronically via email through the Kentucky Board of Pharmacy. Responses were collected anonymously over a 4-week period in December 2019. Inclusion criterion was experience dispensing opioid analgesics; other questions were voluntary. For days’ supply calculations, pharmacists saw 2 hypothetical opioid Rxs and calculated days’ supply. Additional questions examined factors influencing days’ supply and pharmacists’ perception of the importance of accuracy. Results: Of 753 responses, 643 were eligible. For hydrocodone tablets, 19.4% (n=347) of pharmacists assigned inaccurate days’ supply, ranging from 7 days to 90 days. Common mistakes were 40 and 45 days instead of the correct 30. For morphine solution, days’ supply was inaccurate in 10.0% (n=351), ranging from 2 to 90 days. Common mistakes were 10 and 15 days instead of the correct 7. Most reported considerations when assigning days’ supply were instructions from the prescriber on intended duration (75.5%), third-party payer restrictions (48.4%) and familiarity with practitioners prescribing habits (45.3%). Most pharmacists perceived that accurate days’ supply are important to determine when medication is due to be filled/refilled (89.8%) and to support safe medication use for patients (80.8%), although fewer perceive accuracy as important for calculating morphine milligram equivalents (61.8%) and assessment of doctor shopping in the state prescription drug monitoring program (63.7%). Conclusions: Between 10-20% of pharmacists inaccurately assigned days’ supply values to opioid analgesic Rx. While most believe accuracy in days’ supply is important to dispensing decisions, fewer consider it important for other activities such as surveillance monitoring. The estimated error rate from the survey will be used to inform the design of a validation study using stratification-sampled pharmacy records