National Variation in Opioid Prescribing and Risk of Prolonged Use for Opioid-Naive Patients Treated in the Emergency Department for Ankle Sprains

Between 2011 and 2015, nearly one in four patients with ankle sprains were prescribed opioids in the emergency department. The overall prescribing rate declined during the study period, but varied significantly by state, ranging from 2.8% in North Dakota to 40% in Arkansas. Patients prescribed the largest amounts of opioid were nearly five times more likely to transition to continued use as those prescribed lesser amounts

Evaluating A State Opioid Prescribing Limit and Electronic Medical Record Alert

Because long-term opioid use has been linked to the length and strength of an initial prescription, 33 states, Medicare, and some private insurers have set limits on the duration of new opioid prescriptions. In May 2017, New Jersey implemented a statewide 5-day limit on new opioid prescriptions and Penn Medicine implemented an Electronic Medical Record (EMR) alert to notify prescribers when a prescription exceeded the limit and provide compliant prescription orders. This study compared outcomes in Penn Medicine outpatient practices in New Jersey with its practices in Pennsylvania not subject to the law. Outcomes included total opioid dose and number of tablets per prescription as well as rates of prescription refills, health care visits, and telephone calls within 30 days to account for potential unintended consequences

Association between Electronic Medical Record Implementation of Default Opioid Prescription Quantities and Prescribing Behavior in Two Emergency Departments

Setting a low quantity of opioid tablets as the default option in electronic medical record prescribing orders may “nudge” clinicians to prescribe fewer opioids. When two emergency departments implemented a 10-tablet default instead of a manual entry, the proportion of 10-tablet prescriptions written more than doubled, from 20.6% to 43.3%. Conversely, 20-tablet prescriptions decreased from 22.8% to 16.1%, and prescriptions for 11-19 tablets decreased from 33.5% to 20.1%

Click Worthy: Stories Encourage Emergency Physicians to Learn More About Opioid Prescribing Guidelines

Narrative vignettes outperform standard summaries in promoting engagement with opioid prescription guidelines among a national sample of emergency physicians

Torsade de pointes caused by polypharmacy and substance abuse in a patient with human immunodeficiency virus

Drug-induced QT prolongation is a potentially dangerous adverse effect of some medication combinations. When QT prolongation progresses to torsade de pointes, life-threatening or fatal outcomes may result. A 57-year-old man with a history of human immunodeficiency syndrome on abacavir, nevirapine, tenofovir, voriconazole, and methadone presented to the emergency department with a chief complaint of new-onset seizures. The physical exam was unremarkable. The electrocardiogram demonstrated sinus bradycardia and a prolonged QTc interval of 690 ms. In the emergency department, he had several episodes of torsade de pointes (TdP) and ventricular tachycardia that resolved spontaneously. These episodes were accompanied by an alteration in mentation and generalized twitching. Magnesium and amiodarone were effective in terminating the dysrhythmia. The patient had multiple risk factors for prolonged QT syndrome including human immunodeficiency virus infection, methadone therapy, and polypharmacy leading to potential drug interactions. Physicians must be aware of multidrug interactions potentiating QT prolongation and leading to torsade de pointes