Objective Opioid abuse and overdose constitute an ongoing health emergency. Many presume opioids have little potential for iatrogenic addiction when used as directed, particularly in short courses as is typical of the ED setting. We preliminarily explored the possibility that initial exposure to opioids by EDs could be related to subsequent opioid misuse. Methods This cross-sectional study surveyed a convenience sample of patients reporting heroin or non-medical opioid use at an urban, academic ED. We estimated the proportion whose initial exposure to opioids was a legitimate medical prescription and the proportion of those prescriptions that came from an ED. Secondary measurements included 1) the proportion using non-opioid substances before initial opioid exposure, 2) the source of opioids between initial exposure and onset of regular non-medical use, and 3) time from initial prescription to opioid use disorder. Results Of 59 subjects, 35 (59%; 95%CI: 47-71) reported they were first exposed to opioids by a legitimate medical prescription, and for 10/35 (29%; 95%CI: 16-45), the prescription came from an ED. Most medically exposed subjects (28/35, 80%; 95%CI: 65-91) reported non-opioid substance use or treatment for non-opioid substance use disorders preceding the initial opioid exposure. Emergency providers were a source of opioids between exposure and onset of regular non-medical use in 11/35 (31%, 95%CI: 18-48) cases. Thirty-one of the 35 medically exposed subjects reported the time of onset of non-medical use; median time from exposure to onset of non-medical use was: 6 months for use to get high (N=25; IQR 2-36), 12 months for regular use to get high (N=24, IQR: 2-36), 18 months for use to avoid withdrawal (N=26, IQR: 2-38), and 24 months for regular use to avoid withdrawal (N=27, IQR: 2-48). Eleven (36%, 95%CI: 21-53) began non-medical use within 2 months, and 9/11 (82%, 95%CI: 53-96) reported non-opioid substance use or treatment for alcohol abuse prior to initial opioid exposure. Conclusion Although short-term opioid administration by emergency providers is unlikely to cause addiction by itself, ED opioid prescriptions may contribute to the development of addiction in some patients. There is an urgent need for further research to estimate long-term risks of short-course opioid therapy, so that the risk of iatrogenic addiction can be appropriately balanced with the benefit of analgesia.

This meta-analysis found no significant benefit of antidepressant over placebo in the treatment of MDD following TBI. Pooled estimates showed a high degree of bias and heterogeneity. Prospective studies on the impact of antidepressants in well-defined cohorts of TBI patients are warranted.

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IMPORTANCE The National HIV Strategic Plan for the US recommends HIV screening in emergency departments (EDs). The most effective approach to ED-based HIV screening remains unknown. OBJECTIVE To compare strategies for HIV screening when integrated into usual ED practice. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial included patients visiting EDs at 4 US urban hospitals between April 2014 and January 2016. Patients included were ages 16 years or older, not critically ill or mentally altered, not known to have an HIV positive status, and with an anticipated length of stay 30 minutes or longer. Data were analyzed through March 2021.INTERVENTIONS Consecutive patients underwent concealed randomization to either nontargeted screening, enhanced targeted screening using a quantitative HIV risk prediction tool, or traditional targeted screening as adapted from the Centers for Disease Control and Prevention. Screening was integrated into clinical practice using opt-out consent and fourth-generation antigen-antibody assays. MAIN OUTCOMES AND MEASURESNew HIV diagnoses using intention-to-treat analysis, absolute differences, and risk ratios (RRs). RESULTSA total of 76 561 patient visits were randomized; median (interquartile range) age was 40 (28-54) years, 34 807 patients (51.2%) were women, and 26 776 (39.4%) were Black, 22 131 (32.6%) non-Hispanic White, and 14 542 (21.4%) Hispanic. A total of 25 469 were randomized to nontargeted screening; 25 453, enhanced targeted screening; and 25 639, traditional targeted screening. Of the nontargeted group, 6744 participants (26.5%) completed testing and 10 (0.15%) were newly diagnosed; of the enhanced targeted group, 13 883 participants (54.5%) met risk criteria, 4488 (32.3%) completed testing, and 7 (0.16%) were newly diagnosed; and of the traditional targeted group, 7099 participants (27.7%) met risk criteria, 3173 (44.7%) completed testing, and 7 (0.22%) were newly diagnosed. When compared with nontargeted screening, targeted strategies were not associated with a higher rate of new diagnoses