Oxycodone is an opioid analgesic metabolized to oxymorphone and noroxycodone by cytochrome P450 (CYP) 2D6 and 3A4/5, respectively. This was a retrospective study to evaluate sex, age, urinary pH and concurrent medication use on oxycodone, oxymorphone and noroxycodone distributions. Urine specimens obtained from patients on chronic opioid therapy were analyzed by LC-MS-MS. There were 108,923 specimens from a subject's first or single visit, who were at least 18 years of age, and had documented physician-reported oxycodone use. The majority of specimens had detectable oxycodone urine concentrations (n = 106,852) resulting in oxycodone mole fractions (arithmetic mean ± SD) of 0.44 ± 0.27. Ninety-eight percent (n = 106,229) and 49% (n = 53,394) had detectable oxymorphone and noroxycodone, respectively. Oxycodone and oxymorphone mole fractions were lower in women compared with men (P < 0.0001). Mean ± SD age was 49.1 ± 12.9 years. Noroxycodone mole fractions were highest in the 65 years and older age group. Concurrent use of a CYP2D6 inhibitor, but not a CYP3A4/5 inhibitor, altered oxycodone and oxymorphone mole fractions. Dual inhibition of CYP2D6 and CYP3A4/5 did not result in a statistical difference upon comparison with CYP2D6 inhibitor or CYP3A4/5 inhibitor use. Patient factors affect oxycodone and metabolite mole fractions and suggest increased awareness of each contribution when attempting to monitor therapy with urine drug testing.
Improving emergency department (ED) care for older adults is a critical issue in emergency medicine. Institutions throughout the United States and Canada have recognized the growing need for a workforce of emergency physician (EP) leaders focused on clinical innovation, education, and research and have developed specialized fellowship training in geriatric emergency medicine (GEM). We describe here the overview, structure, and curricula of these fellowships as well as successes and challenges they have encountered. Seven GEM fellowships are active in the United States and Canada, with five offering postresidency training only, one offering fellowship training during residency only, and one offering both. The backbone of the curriculum for all fellowships is the achievement of core competencies in various aspects of GEM, and each includes clinical rotations, teaching, and From the content. SWL contributed to ideas, content, and structure of this concept paper; provided information about fellowship experience; and participated in synthesis of information, manuscript initial drafting, and critical revision of the manuscript for important intellectual content. LCC contributed to ideas, content, and structure of this concept paper; provided information about fellowship experience; and participated in synthesis of information, manuscript initial drafting, and critical revision of the manuscript for important intellectual content. SC contributed to ideas, content, and structure of this concept paper and participated in synthesis of information and critical revision of the manuscript for important intellectual content. KB contributed to ideas, content, and structure of this concept paper; provided information about fellowship experience; and participated in synthesis of information and critical revision of the manuscript for important intellectual content. PM contributed to ideas, content, and structure of this concept paper; provided information about fellowship experience; and participated in synthesis of information and critical revision of the manuscript for important intellectual content. KRT contributed to ideas, content, and structure of this concept paper; provided information about fellowship experience; and participated in synthesis of information and critical revision of the manuscript for important intellectual content. DM contributed to ideas, content, and structure of this concept paper; provided information about fellowship experience; and participated in synthesis of information and critical revision of the manuscript for important intellectual content. PT contributed to ideas, content, and structure of this concept paper and participated in synthesis of information and critical revision of the manuscript for important intellectual content. TW contributed to ideas, content, and structure of this concept paper and participated in synthesis of information and critical revision of the manuscript for important intellectual content. NME contributed to ideas, content, and structure of this concept paper and par...
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