Objectives
To characterize the effects of Michigan’s controlled substance legislation on acute care prescriber behavior by specialty, in a single hospital system.
Design
A retrospective study of opioid and benzodiazepine prescription records from a hospital electronic medical record system between August 1, 2016 and March 31, 2019 in Detroit, MI.
Setting
Discharges from inpatient and emergency department visits.
Intervention
Evaluating the impact of implementation of state controlled substance legislation, comparing prescriptions by physicians before, upon, and after June 1, 2018 using regression discontinuity analysis.
Methods
Total daily prescriptions of opioids and total daily prescriptions of benzodiazepine by physicians in the hospital system. Prescriptions were converted to morphine and lorazepam equivalents for comparability.
Results
We find 38.5% (CI: 74.1% – 2.9%) decrease of prescription in milligrams of opioid equivalents attributable to implementation of legislation. The main catalyst of the decrease was emergency medicine which experienced 63.9% (CI: 109.7% - 18.0%) decrease in milligrams of opioid equivalent prescriptions, while surgery increased prescriptions. Though we do not find any statistically significant changes in prescriptions of milligram equivalent of benzodiazepines, we estimate 43.1% (CI: 82.6 – 3.7%) decrease in count of these prescriptions, implying a significant increase in average dosage of prescriptions.
Conclusions
The introduction of new regulatory requirements for the prescription of controlled substances led to a general decrease in morphine equivalent milligrams prescribed in most specialties, though it may have increased the dosage of benzodiazepine prescriptions. The change in prescription behavior could be motivated by regulatory hassle or by change in attitude towards opioid prescriptions and increased recognition of opioid use disorder.
Dosing of enoxaparin for deep vein thrombosis (DVT) prophylaxis in acutely burned patients has been shown to result in anti‐Xa levels below target range. We describe the first case report, to our knowledge, of a severely burned patient who, despite prophylactic dosing of enoxaparin 30 mg subcutaneously twice daily, developed an acute DVT that required high‐dose enoxaparin (100 mg [1.5 mg/kg] subcutaneously every 8 hours) to maintain anti‐Xa levels within the therapeutic range (0.6–1 IU/ml). Pharmacokinetic evaluations were performed using anti‐Xa levels measured throughout the patient's hospital stay to validate the appropriateness of this high‐dose regimen based on established therapeutic anti‐Xa level ranges. These results suggest that routine anti‐Xa level monitoring, regardless of enoxaparin dosing, is necessary for burn patients who are receiving enoxaparin given their hypermetabolic state following injury.
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