1790 Correspondence / American Journal of Emergency Medicine 37 (2019) 1784–1805

Austin Kilaru, MD National Clinician Scholars Program, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States of America The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States of America

Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania,

Philadelphia, PA, United States of America Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America

Jeanmarie Perrone, MD Zachary F. Meisel, MD, MPH, MSHP

The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States of America Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania,

Philadelphia, PA, United States of America Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America

Jessica Hemmons, MS Dina Abdel-Rahman, MS

Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America

M. Kit Delgado, MD, MS The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States of America Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania,

Philadelphia, PA, United States of America Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United

States of America

7 February 2019

https://doi.org/10.1016/j.ajem.2019.02.025

References

1. Understanding the epidemic. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of unintentional injury Prevention. Accessed December 15, 2018, at https://www.cdc.gov/drugoverdose/index.html;

   2018.

   D’Onofrio G, O’Connor PG, Pantalon MV, et al. Emergency department-initiated buprenorphine/naloxone treatment for Opioid dependence: a randomized clinical trial. JAMA 2015;313:1636-44. https://doi.org/10.1001/jama.2015.3474.

2. Martin A, Mitchell A, Wakeman S, White B, Raja A. Emergency department treat- ment of opioid addiction: an opportunity to Lead. Acad Emerg Med Off J Soc Acad Emerg Med 2017. https://doi.org/10.1111/acem.13367.
3. Cunningham CO, Sohler NL, McCoy K, Kunins HV. Attending physicians’ and resi- dents’ attitudes and beliefs about prescribing buprenorphine at an urban teaching hospital. Fam Med 2006;38:336-40.
4. Hutchinson E, Catlin M, Andrilla CH, Baldwin LM, Rosenblatt RA. Barriers to primary care physicians prescribing buprenorphine. Ann Fam Med 2014;12:128-33. https:// doi.org/10.1370/afm.1595.
5. DeFlavio JR, Rolin SA, Nordstrom BR, Kazal Jr LA. Analysis of barriers to adoption of buprenorphine maintenance therapy by family physicians. Rural Remote Health 2015;15:3019.
6. Huhn AS, Dunn KE. Why aren’t physicians prescribing more buprenorphine? J Subst Abuse Treat 2017;78:1-7. https://doi.org/10.1016/j.jsat.2017.04.005.
7. Andraka-Christou B. Capone MJ. A qualitative study comparing physician-reported

   barriers to treating addiction using buprenorphine and extended-release naltrexone in U.S. office-based practices. Int J Drug Policy 2018;54:9-17. https://doi.org/10. 1016/j.drugpo.2017.11.021.

   Haffajee RL, Bohnert ASB, Lagisetty PA. Policy pathways to address provider work- force barriers to buprenorphine treatment. Am J Prev Med 2018;54:S230-s42. https://doi.org/10.1016/j.amepre.2017.12.022.

8. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)–a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009;42: 377-81. https://doi.org/10.1016/j.jbi.2008.08.010.
9. Englander H, Collins D, Perry SP, Rabinowitz M, Phoutrides E, Nicolaidis C. “We’ve learned It’s a medical illness, not a moral choice”: qualitative study of the effects of a multicomponent addiction intervention on hospital Providers’ attitudes and experiences. J Hosp Med 2018;13:752-8. https://doi.org/10. 12788/jhm.2993.
10. Fiscella K, Wakeman SE, Beletsky L. Buprenorphine deregulation and mainstreaming treatment for Opioid use disorder: X the X waiver. JAMA Psychiat 2018. https://doi. org/10.1001/jamapsychiatry.2018.3685.

    Lack of associations of substance use and mental health with self-reported pain scores among emergency department patients

    The most common complaint among Emergency Department (ED) patients is pain [1]. Pain scores have been shown to be influ- enced by factors such as race, age, and gender [2-4]. Addiction disorders are frequently encountered in the ED environment [5- 7].

    The Addiction Severity Index (ASI) is a validated measurement tool as objectively assess addiction [8,9]. This study was under- taken to measure the prevalence and severity of addiction and its relationship to self-reported pain and Mental illness among ED patients.

    This prospective survey study was conducted at Miami Valley Hospi- tal, an urban hospital emergency department. The study was approved by the Wright State University Institutional Review Board. Participants were enrolled by research assistants during June through August of 2018. Eligible participants were at least 18 years of age with a triage pain score of 1 or higher (on a 0-10 scale). Primary outcome measures included substance abuse, mental health, and self- reported pain scores. Portions of the ASI used in this study included information regarding al- cohol use, drug use, and mental health.

    Among 473 eligible participants, 360 consented to participate (76% participation rate). The mean age was 40 (range 18 to 85). Participants reported an average triage pain score of 7 (range 1 to 10). The current episode of pain had a mean duration of 2 days. In addition, 49.5% of par- ticipants suffered from chronic pain, including back pain (25%), mi- graine headache (6%), neck pain (6%), and other types of chronic pain (63%).

    The most common substance reported was alcohol. Forty-one percent (N = 146) of participants reported some alcohol use in the past 30 days, with 8% reporting drinking to intoxication (Fig. 1). Cannabis use was also commonly reported. Twenty-seven percent (N = 96) of participants reported cannabis use in the past 30 days, with the majority reported use at least 3 times (78%) and a minority reporting daily use (33%) (Fig. 2). Other sub- stances reported by participants included cocaine (3%; N = 11), amphetamines (2%; N = 6), heroin (1%; N = 2), other opiates

    (18%; N = 64), and other substances (11%; N = 40).

    The prevalence of mental illness was high. Within the past 30 days, 34% (N = 122) of patients reported experiencing serious anxiety or ten- sion and 27% (N = 96) reported difficulty understanding, concentrating, or remembering, and 22% (N = 79) reported serious depression. Four percent (N = 11) reported serious thoughts of suicide. A significant number of participants had been treated for mental health as an outpa- tient (28%; N = 100) or as an inpatient (21%; N = 77).

    There was no association between self-reported pain scores and sub- stance use. Anxiety was associated with higher self-reported pain scores (p = 0.03) (Table 1). There was no association between chronic pain and triage pain scores. Participants with chronic pain were more likely to experience higher rates of depression, anxiety, and suicidal thoughts (p b 0.001; Table 2).

    Correspondence / American Journal of Emergency Medicine 37 (2019) 1784–1805 1791

    Alcohol Use

    250

    200

    150

    100

    50

    0

    0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

    Days Used in Past 30

    No. Patients

    Fig. 1. Alcohol use in the past 30 days among ED patients.

    No. Patients

    Fig. 2. Cannabis use among ED patients in the past 30 days.

    Cannabis Use

    300

    250

    200

    150

    100

    50

    0

    0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

    Days Used in Past 30

    Table 1

    Associations between Substance Use and Self-Reported Triage Pain Score.

    These data demonstrate high use of alcohol, cannabis, and other sub- stances among ED patients. The emergency department is potentially an

    No. patients

    Triage Pain Score median [IQR]

    Wilcoxon or Kruskal Wallis p-value

    ideal place to identify and intervene for Substance use disorders, which are currently considered to be underdiagnosed [10,11]. Two common

    Chronic pain 178 8 [5 to 9] 0.56

    No chronic pain 182 7 [6 to 9]

    Alcohol (any use at all) 0.81

    0 214 8 [6 to 9]

    1-2 64 7 [6 to 9]

    3 or more 82 7 [5 to 9]

    Heroin 0.19

    0 358 7 [6 to 9]

    1-2 0 –

    3 or more 2 9 [9 to 9]

    Cocaine 0.19

    0 349 7 [6 to 9]

    1-2 7 9 [5 to 10]

    3 or more 4 9.5 [7.5 to 10]

    Amphetamines 0.25

    0 354 7 [6 to 9]

    1-2	2	9.5 [9 to 10]	No.	% with	% with	% with suicidal
    3 or more	4	7 [4.5 to 9]	patients	depression	anxiety	thoughts

    substances abused by the general population presenting to the emer- gency room are cannabis and alcohol, both of which are known to be used for self-medication [12].

    In conclusion, alcohol use and cannabis use were commonly re- ported in this ED patient population. The prevalence of mental illness was high. There was no association between self-reported pain scores and substance use. Anxiety was associated with higher self-reported pain scores. Participants with chronic pain were more likely to experi- ence higher rates of depression, anxiety, and suicidal thoughts.

    Table 2

    Associations between chronic pain and mental health.

    Cannabis 0.41

    0	264	7 [6 to 9]		Chronic pain	178	60 (33.7%)	79 (44.4%)	13 (7.3%)
    1-2	23	7 [6 to 9]		Chi-square p-value		b0.001	b0.001	b0.001

    No chronic pain 182 19 (10.4%) 43 (23.6%) 1 (1.0%)

    1792 Correspondence / American Journal of Emergency Medicine 37 (2019) 1784–1805

    Catherine A. Marco, MD * Dennis Mann, MD, PhD

    Department of Emergency Medicine, Wright State University Boonshoft School of Medicine, Dayton, OH, United States of America

    *Corresponding author at: Department of Emergency Medicine, Wright State University Boonshoft School of Medicine, 3525 Southern Boulevard, Kettering, OH 45429, United States of America.

    E-mail address: [email protected].

    Christian Daahir, BS

    Wright State University Boonshoft School of Medicine, Dayton, OH, United

    States of America

    Harry Savarese, BS

    Miami University, Oxford, OH, United States of America

    John Paul Detherage III , BS Cameron McGlone, BS

    Wright State University Boonshoft School of Medicine, Dayton, OH, United

    States of America

    16 February 2019

    https://doi.org/10.1016/j.ajem.2019.02.026

    References

    Niska R, Bhuiya F, Xu J. National hospital ambulatory medical care survey: 2007 emergency department summary. National Health Statistics Reports; No 26. Hyattsville, MD: National Center for Health Statistics; 2010.

11. Marco CA, Kanitz W, Jolly M. Pain scores among emergency department (ED) pa- tients: comparison by ED diagnosis. J Emerg Med 2013;44:46-52.
12. Marco CA, Marco AP, Buderer NF, Jones JM. Pain perception among ED patients with headache: responses to standardized painful stimuli. J Emerg Med 2007;32 (1):1-6.
13. Marco CA, Nagel J, Klink E, Baehren D. Factors associated with self-reported pain scores among emergency department (ED) patients. Am J Emerg Med 2012;30:331-7.
14. Hansagi H, Engdahl B, Romelsjo A. Predictors of repeated emergency depart-

    ment visits among persons treated for addiction. Eur Addict Res 2012;18(2): 47-53.

    Liu SW, Nagurney JT, Chang Y, Parry BA, Smulowitz P, Atlas SJ. Frequent ED users: are most visits for mental health, alcohol, and drug-related complaints? Am J Emerg Med 2013 Oct;31(10):1512-5.

15. Gorchynski J, Kelly K. Analgesia and addiction in emergency department patients with acute pain exacerbations. Cal J Emerg Med 2005 Jan;6(1):3-8.
16. Denis C, Fatseas M, Beltran V, Serre F, Alexandre JM, Debrabant R, et al. Usefulness and validity of the modified Addiction Severity Index: a focus on alcohol, drugs, to- bacco, and gambling. Subst Abus 2016;37(1):168-75.
17. Denis C, Fatseas M, Beltran V, et al. Validity of the self-reported drug use section of the Addiction Severity Index and associated factors used under naturalistic condi- tions. Subst Use Misuse 2012;47:356-63.
18. Curran GM, Sullivan G, Williams K, Han X, Allee E, Kotrla KJ. The association of psy- chiatric comorbidity and use of the emergency department among persons with substance use disorders: an observational cohort study. BMC Emerg Med 2008;8(1).
19. Vu F, Daeppen J-B, Hugli O, et al. Screening of mental health and substance users in fre- quent users of a general Swiss emergency department. BMC Emerg Med 2015;15(1).
20. Turner S, Mota N, Bolton J, Sareen J. Self-medication with alcohol or drugs for mood and anxiety disorders: a narrative review of the epidemiological literature. Depress Anxiety 2018;35(9):851-60.

    Risk stratification and timing for invasive approach in patients with non-STEMI

    We decipher with interest the study by Langabeer II et al. with large cohort [1], which provide visionary points about gender disparities in patients presenting with non-STEMI acute coronary syndrome. Al- though its well-designed conception, we want to address some points that need more attention.

    The paper [1] clearly demonstrated that males presenting with non- STEMI in younger ages, as expected. But in females, the course of the dis- ease is more catastrophic because of the fact that women have more di- abetes. Beside these findings consistent with the literature, the guidelines recommend that quantitative assessment of ischemic risk because of its superiority to the clinical assessment alone [2]. The most accurate stratification of risk is the GRACE risk score [3] recom- mended by European guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment eleva- tion, as long as TIMI [4,5]. Patients with non-STEMI must be evaluated immediately by risk scores to identify individuals with Life-threatening arrhythmias and those with ongoing myocardial ischemia requiring close surveillance as well as emergent coronary angiography [6]. Al- though the risk is highest at presentation and decreases rapidly over time, also it may remain high for several days due to comorbidities, cor- onary anatomy and revascularization [7]. Furthermore, concomitant diseases, drugs used and major bleeding are associated with increased mortality. Furthermore, it is advisable to use bleeding risk score, namely CRUSADE [8], for achieving balanced treatment strategy. In addition to the findings related to gender disparities in this study population, it would be more appropriate to evaluate the risk stratification and also the above-mentioned risk factors to conclude the results.

    Therefore, coronary angiography and treatment of culprit lesions by

    percutaneous coronary intervention should be performed in patients with non-STEMI. However, approximately one fourth of non-STEMI pa- tients have angiographically normal or non-obstructive coronary arter- ies. The indication for an invasive approach, the timing for myocardial revascularization (immediate invasive strategy (b2 h), Early invasive strategy (b24 h), invasive strategy (b72 h), selective invasive strategy) and the selection of the revascularization modality depend basically on clinical features and risk stratification as outlined before [6]. Langabeer II et al. found in their cohort that patients with non-STEMI who presented later, have longer emergency length of stay, are less likely to receive an early invasive management approach [1], as ex- pected. All in all, longer emergency department length of stay and lon- ger delay in seeking treatment after their symptom onset should be necessary for assessment of clinical, ECG, and cardiac biomarkers which is mandatory for Risk scoring. We want to emphasize that find- ings will be more reliable and valuable, with a better study design where these clinical scoring systems and clinical freatures are used as well as gender.

    Kadir Ugur Mert, MD

    Eskisehir Osmangazi University, Faculty of Medicine, Department of

    Cardiology, Turkey Corresponding author at: Eskisehir Osmangazi University, Faculty of Medicine, Department of Cardiology Eskisehir, Turkey.

    E-mail address: [email protected]

    Gurbet Ozge Mert, MD

    Yunus Emre State Hospital, Department of Cardiology, Turkey

    7 February 2019

    https://doi.org/10.1016/j.ajem.2019.02.033

    References

    Langabeer 2nd JR, Champagne-Langabeer T, Fowler R, Henry T. Gender-based out- come differences for emergency department presentation of non-STEMI acute coro- nary syndrome. Am J Emerg Med 2019;37(2):179-82.

21. Hamm CW, Bassand JP, Agewall S, Bax J, Boersma E, Bueno H, et al. ESC guidelines for the management of acute coronary syndromes in patients presenting without persis- tent ST-segment elevation: the task force for the management of acute coronary syn- dromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2011;32(23):2999-3054.
22. Fox KA, Dabbous OH, Goldberg RJ, Pieper KS, Eagle KA, Van de Werf F, et al. Prediction of risk of death and myocardial infarction in the six months after presentation with