Article

Improved Emergency Medicine Physician Attitudes Towards Individuals with Opioid Use Disorder Following Naloxone Kit Training

Correspondence / American Journal of Emergency Medicine 38 (2020) 10231042 1039

block, ankle arthrocentesis, etc.), and feel that when the target of the procedure is shallow, the in-plane technique can be more difficult.

Second, the patient was not on any anticoagulation. We do feel that if the patient was on anticoagulation, a more thorough evaluation of the risks and benefits of joint injection would have to be determined.

Sincerely,

John Gelber Arun Nagdev? Carlos Mikell

Department of Emergency Medicine, Highland General Hospital,

Alameda Health System, United States

?Corresponding author.

E-mail address: [email protected] (A. Nagdev).

4 November 2019

https://doi.org/10.1016/j.ajem.2019.11.011

Improved Emergency Medicine Physician Attitudes Towards Individuals with Opioid use disorder Following Naloxone Kit Training

Every day in the United States, 130 people die of opioid-related causes [1]. In 2017, there were 47,600 overdose deaths related to opi- oids, which accounted for approximately two-thirds of all drug over- dose deaths that year [2]. Patients with Opioid use disorder who present to emergency departments are especially vulnerable, as they are at higher risk for fatal overdose, trauma and suicide, than pa- tients not seen in emergency departments [4,5,32,33]. Despite the need for increased hospital engagement in mortality-reducing efforts, it stands that many physicians are unfamiliar with addiction treatment best practices and also generally hold negative attitudes towards pa- tients with Substance use disorders (SUDs). These subOptimal treatment behaviors have compounded the current opioid crisis and should be addressed.

Since receiving FDA approval in November 2015, naloxone has de- creased overdose Death rates associated with OUD [6-9]. Naloxone, an opioid receptor antagonist that disrupts the action of many commonly abused opioids, can be easily administered by patients or by anyone who might be nearby at the time of overdose. Furthermore, naloxone has no effect on individuals who are not actively taking opioids, thereby holding no abuse potential [10-12]. In April 2018, the Surgeon General of the United States prioritized it as one of the most effective evidence- based, preventative strategies for combating OUD and encouraged more healthcare professionals to take an active role in distribution to at-risk patients [13,14]. For many individuals with OUD, the only way they might become aware of naloxone and its potential benefits, and be dis- tributed it when indicated, is through EM physicians [15,16]. Yet, there remain two significant barriers for distribution in these settings: knowl- edge of proper OUD management and stigma towards patients with OUD.

Stigma towards individuals with SUDs is substantial: according to a recent study, 37% of Americans believe that individuals with SUD suffer from personal weakness (a lack of self-control or moral fibre) rather than a medical illness [15], and these attitudes are reflected in the US healthcare system, where physicians embrace similarly stigmatizing be- liefs [3]. Negative attitudes intensify negative communication tenden- cies and decrease rapport within the patient-physician dyad. When patients do not trust their physicians, they are less inclined to engage in treatment recommendations, express motivation to change their be- haviors, or seek treatment in the first place [17-20]. In turn, physicians feel powerless to establish a therapeutic relationship and thus may

avoid working with these individuals [21-27]. Therefore, it is impera- tive to explore ways to improve physician attitudes towards patients with OUD.

Recent studies on naloxone training have failed to assess the rela- tionship between physicians’ knowledge regarding naloxone kits and their attitudes towards patients with OUD [28,29]. The goal of the pres- ent study was to evaluate EM physicians’ perceptions towards this pa- tient population before and after a one-time training on Naloxone distribution. According to research, one way to reduce stigma towards patients with psychiatric illnesses is through evidence-based training, such that physicians might feel more equipped to manage patient encounters.

The Weill Cornell Medicine Institutional Review Board approved the study. The training consisted of a 1-page guide and a 15-minute module. Both provided information on OUD risk factors, categorical criteria by which a diagnosis of OUD would be met, how to engage in a conversa- tion with patients about naloxone benefits, and indicators for adminis- tration. An online questionnaire was sent to participants prior to training and again six months later. It was comprised of two sections:

(a) demographic questions and (b) the 11-item Medical Condition Re- gard Scale (MCRS) for individuals with OUD. The MCRS is a valid and re- liable 11-item instrument scored on a 6-point Likert scale, designed to assess the degree to which clinicians find individuals with a given medical condition to be enjoyable, treatable, and worthy of medical re- sources [31]. Higher scores indicate greater enjoyment, perceived treat- ability, and belief in the utility of dedicating medical resources for treatment.

A total of 31 EM physicians completed the initial survey and 28 EM physicians completed the post-training survey (Table 1). As hypothe- sized, attitudes toward individuals with OUD, as reflected by an increase in MCRS scores, were improved six months after the training module (Fig. 1). The mean MCRS scores increased from 3.21 (SD = 0.85) to

4.02 (SD = 0.99) (t(53.6) = -3.37, p = 0.001). The analyses also showed improvements in Comfort level in distributing naloxone rescue kits for at-risk patients; specifically, an increase in mean scores from 3.26 (SD = 2.18) to 4.64 (SD = 1.29) (t(49.9) = -2.95, p-value = 0.005).

Such results are consistent with research demonstrating that once a psychiatric illness is formally considered as being amenable to treat- ment–and clear treatment options are outlined–stigma towards the ill- ness declines [3,30]. In conclusion, our results suggest that adding evidence-based management for OUD to physicians’ treatment toolbox can improve their attitudes towards patients with OUD.

Funding sources

Kaylee Ho was partially supported by the following grant: Clinical and Translational Science Center at Weill Cornell Medical College (1- UL1-TR002384-01).

Table 1

Descriptive statistics of survey respondents.

Pre-training

Post-training

(n = 31)

(n = 28)

Age

25-34

0 (0.0)

3 (10.7)

35-44

15 (48.4)

13 (46.4)

45-54

14 (45.2)

8 (28.6)

55-64

2 (6.45)

1 (3.57)

No response

0 (0.0)

3 (10.7)

Gender

Male

17 (54.8)

15 (53.6)

Female

14 (45.2)

10 (35.7)

No response

0 (0.0)

3 (10.7)

In the previous work week, % of patients with a

20.3 (15.8)

17.9 (13.6)

diagnosed substance use disorder.

1040 Correspondence / American Journal of Emergency Medicine 38 (2020) 1023-1042

Fig. 1. Change in emergency medicine physicians’ attitudes toward patients with opioid use disorder before and after naloxone training.

Joseph J. Avery was supported by the Department of Defense (DoD) through the National Defense Science & Engineering Graduate Fellow- ship (NDSEG) Program.

Giselle Appel, MS Department of Psychiatry, Weill Cornell Medical College, New York- Presbyterian Hospital, 525 East 68th Street Box 104, New York, NY 10065,

United States

Department of Emergency Medicine, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 East 68th Street M130, New York, NY

10065, United States Corresponding author at: Department of Psychiatry,Weill Cornell Medical College, New York-Presbyterian Hospital, 525 East 68th Street –

Box 104, New York, NY 10065, United States.

E-mail address: [email protected].

Joseph J. Avery, JD

Department of Psychology, Princeton University, 522 Peretsman Scully Hall,

Princeton, NJ 08540, United States E-mail address: [email protected].

Kaylee Ho, MS Division of Biostatistics and Epidemiology, Department of Healthcare Policy & Research, Weill Cornell Medical College, New York-Presbyterian Hospital, 402 E. 67th Street, New York, NY 10065, United States

E-mail address: [email protected].

Zhanna Livshits, MD Rama B. Rao, MD

Department of Emergency Medicine, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 East 68th Street M130, New York, NY

10065, United States

E-mail addresses: [email protected] (Z. Livshits MD),

[email protected] (R.B. Rao MD).

Jonathan Avery, MD Department of Psychiatry, Weill Cornell Medical College, New York- Presbyterian Hospital, 525 East 68th Street Box 104, New York, NY 10065,

United States

E-mail address: [email protected].

27 October 2019

https://doi.org/10.1016/j.ajem.2019.11.019

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Topical agents causing methemoglobinemia

We read with great interest the recent article by Lerner et al. re- garding EMLA induced methemoglobinemia published in your esteemed journal [1]. Based on our previous experience, and recent available literature, we would like to mention a few additional comments in order to enhance the understanding of AJEM readers [2-8].

EMLA cream seems to be most likely cause of methemoglobine- mia in Lerner et al’s case [1]. However, it is essential to simulta- neously look for the other concurrent causes like topical dapsone cream, use of e-cigarettes, naphthalene ball exposure, paint thin- ners, acetaminophen, and nitrates/nitrites contaminated frozen food items and so on [2-8]. These medications or agents mentioned above are often available in grocery stores or as over-the-counter medications which in most cases are not thought of as a cause of methemoglobinemia and hence overlooked in most cases.

Shamriz et al. did an extensive medline review of all cases of “EMLA and Topical anesthetic agents” and found 13 cases of methe- moglobin anemia reported from 1 January 1985 to 17 October 2013. Most cases where either female (10 cases) or infants (5 cases). EMLA cream was applied either for laser therapy or circum- cision. Interestingly, 5 patients also had known skin lesions which could have probably increased the systemic absorption of topical anesthetics. 4 out of 13 also had seizures at presentation. In total, only 6 patients were treated with intravenous Methylene blue. All cases recovered and discharged successfully after treatment [9]. From 2014 till today, we also reviewed the 7 other reported cases of EMLA induced methemoglobinemia (Table 1).

Multiple factors are responsible in an individual to develop EMLA induced methemoglobinemia such as total Cumulative dose of local anesthetics, surface area of application, duration of expo- sure, body weight, skin breach, skin thickness and so on. With regards to infants, the US National Library of Medicine advises against using topical local anesthetics in infants less than

12 months if they are also receiving other methemoglobin- inducing agents [10].

Definitive method for confirming EMLA as the culprit agent would be to check for the plasma levels of local anesthetics. Care at al mentioned about use of liquid chromatography coupled with tandem mass spectrometry (LC-MS/MS) method in detecting the plasma levels of lidocaine and prilocaine in their case series [11].

While, o-toluidine and 4-hydroxy-2-methyl-aniline are the 2 metabolites of prilocaine which are known to cause methemoglo- binemia, it is yet unclear about the mechanism with which lido- caine induces methemoglobinemia [12,13]. Lidocaine metabolizes to monoethylglycinexylidide (MEGX) and glycinexylidide (GX) which per se are not known to cause methemoglobinemia. Lido- caine undergoes a partial cutaneous CYP450 and hepatic CYP1A2 metabolism, which might be affected by multiple factors like drugs, exposure to other local creams and over-the-counter agents [14]. Not to forget about the CNS toxicity secondary to lidocaine which can present in the form of seizures due to blocking effect over inhibitory cortical synapses [15]. Hence, it is important to ad- dress the other contributing factors and possibly educate the pa- tient to avoid them for the definitive prevention and to avoid the recurrence of methemoglobinemia.

In conclusion, it is important to evaluate the patient for other concurrent causes of methemoglobinemia while treating them for EMLA induced methemoglobinemia. Also, to remember that the same dose of EMLA cream may have a variable effect in 2 different individuals due to the skin comorbidities, texture, thickness, sur- face area of exposure, total body weight etc. Dermatologists, anes- thesiologists and cosmetic surgeons should be aware about this disease entity which will certainly be helpful in the initiating treat- ment promptly.

1. Verification

All authors have seen the manuscript and agree to the content and data. All the authors played a significant role in the paper.

Ethical statement

The article doesn’t contain the participation of any human being and animal.

Declaration of Competing Interest

Authors have no conflicts of interest to declare.

Kamal Kant Sahu? Regina Brown

Ajay Kumar Mishra

Amos Lal Susan V. George

Department of Internal Medicine, Saint Vincent Hospital,

Worcester 01608, MA, United States

?Corresponding [email protected] (K.K. Sahu).

9 October 2019

https://doi.org/10.1016/j.ajem.2019.11.023

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