Co-occurring Illicit Fentanyl Use and Psychiatric Disorders in Emergency Department Patients

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ED patients with a fentanyl-positive urine drug screen were identified, and patient characteristics, medical histories, and test results were extracted. Among the fentanyl positive drug screens of ED patients, the majority were between the ages of 25 and 44, male, white, and uninsured. Additionally, more than one third of these patients had concurrent psychiatric disorders with mood disorders being the most prevalent, followed by psychotic disorders. Patients with co-occurring psychiatric disorders were found to have higher rates of marijuana use, repeat ED visits and/or hospital admissions at six months, and more admissions to psychiatry inpatient settings compared to those patients without co-occurring psychiatric disorders. Concurrent other substance use and rates of buprenorphine prescribing at discharge were not different between the groups; however, rates of naloxone provision at discharge were lower in patients with co-occurring psychiatric disorders. This cohort demonstrates higher healthcare recidivism and utilization. Biological sciences/Psychology Health sciences/Diseases/Psychiatric disorders illicit fentanyl psychiatric disorders emergency department concurrent healthcare utilization 1.0 Introduction The United States is experiencing an ongoing nationwide opioid epidemic which has been exacerbated by the COVID-19 pandemic. Several abrupt social changes, dictated by the pandemic, along with the increased introduction of synthetic opioids (e.g., fentanyl) into the domestic illicit drug supply, have resulted in a dramatic increase in opioid overdoses and overdose deaths since 2020 [ 1 ]. Per the CDC, the rate of drug overdose deaths has increased by 279% over a 5-year span for drug overdoses involving fentanyl; specifically, the rate increased from 5.7 per 100,000 standard population in 2016 to 21.6 per 100,000 in 2021[ 2 ]. Further, the impact of synthetic opioids, which may be 50 times more potent than heroin [ 3 ], are not limited to persons who misuse opioids. Fentanyl, inexpensive to produce, has permeated and contaminated the illicit domestic drug supply, resulting in accidental use, overdose, and death, by persons with no intent to use fentanyl or opioids [ 4 ]. Although illicit fentanyl use is not equivalent to opioid use disorder (OUD), many patients with OUD are using illicit fentanyl, which significantly increases their overdose risk and even death [ 5 , 6 ]. Studies have also shown that numerous people with OUD have concurrent psychiatric disorders [ 7 ]. Studies showed that patients with a psychiatric disorder are more likely to be prescribed opioids, resulting in greater likelihood of developing OUD [ 7 ]. Other studies reported that patients with psychiatric disorders usually use opioids to self-medicate for their disease which can lead to or result in OUD [ 8 , 9 ]. One study indicated that mood disorders were the most common psychiatric disorder in patients with OUD [ 10 ], and those with mood disorders showed a high rate of self-medication using nonmedical opioids [ 11 ]. Furthermore, the number of psychiatric disorders a patient is diagnosed with largely increases the presence of concurrent OUD [ 12 ]. For example, patients diagnosed with 3 or 4 psychiatric disorders exhibit a 9-fold increase in developing OUD [ 12 ]. Although the relationship of OUD and psychiatric disorders has been investigated, studies on illicit fentanyl use and psychiatric disorders are limited, especially in Emergency Department (ED) patients. Illicit fentanyl use has been a major reason for historically high records of opioid-related overdose; thus, it is important to understand their relationship [ 13 ]. The Emergency Department represents a unique medical setting which has been particularly impacted by the opioid epidemic. The number of opioid-related ED visits have increased, despite the pandemic, even when general ED patient volumes decreased [ 14 , 15 ]. Further, the proportion of ED visits for mental health complaints has also been on the rise [ 16 ]. As ED clinicians are increasingly tasked with the acute management of psychiatric illness as well as patients with opioid exposure or misuse, understanding how these patient presentations and pathology might overlap is increasingly important. To our knowledge, there are no prior studies which specifically consider illicit fentanyl use and its association with psychiatric disorders and other patient characteristics in the ED. This study seeks to better understand the attributes of ED patients with co-occurring illicit fentanyl use and psychiatric disorders, as well as the associated impact on healthcare recidivism and utilization in the Southeastern region. 2.0 Methods This was a retrospective, cross-sectional review that received full approval by the Institutional Review Board at the University of Alabama at Birmingham (UAB) (IRB-300002304) on 4/30/2022. All methods were performed in accordance with relevant guidelines and regulations. Informed consent was waived due to the use of electronic medical records (EMR). Patients presenting to the ED at UAB Hospital with a urine drug screen positive for illicit fentanyl from June 1, 2021 until November 31, 2021 were identified from the EMR and included in the analysis. The use of other illicit substances, identified in the urine drug screen results, was obtained as well. The Fentanyl Enzyme Immunoassay in urine drug screening is a qualitative assay that screens for the presence of norfentanyl, the major metabolite of fentanyl, in human urine. Samples that contain greater than 5 ng/mL of norfentanyl are reported as positive for fentanyl at UAB ED. Samples that are below the 5 ng/mL cutoff are reported as negative. Trauma patients were excluded because they may have been exposed to fentanyl in the pre-hospital setting per Emergency Medical Service pain control protocols. Patients with prescribed fentanyl (either while in the ED or as an outpatient) were also excluded during the study period. Demographic characteristics, including sex, age, race/ethnicity, and registration-verified insurance status were also obtained from the EMR. Additional characteristics included initial visit disposition, discharge (from ED or hospital) with buprenorphine and/or naloxone, and repeat ED or hospital admission within 30 days and six months after the initial visit. We queried provider documentation in the patient’s problem list and past medical history. The problem list allowed documentation of all pre-existing medical and psychiatric diagnoses, such as non-substance-induced psychiatric disorders, which are electronically linked to International Classification of Diseases-10 codes, including F01.xx-F99.xx. Nasal spray naloxone prescription or kit provision in the ED and buprenorphine prescriptions among ED patients during the study period were also considered. Descriptive statistical and Chi-square analyses were performed using SPSS version 27 (IBM). 3.0 Results 3.1 Patient Characteristics During the study period, a total of 2,158 patients tested positive for illicit fentanyl by urine drug screen when they presented to the ED. Among them, 408 unique patients were identified with 67.2% white, 30.1% Black, 63.5% men (Table 1 ). A majority of patients (67.4%) were between 25–44 years of age: 25–34 years (32.1%) and 35–44 years (35.3%) (Table 1 ). Approximately half of patients were insured. Commercial insurance was the most prevalent (16.7%) followed by public insurance (33.5%). 49.8% of patients were uninsured (Table 1 ). Table 1 Patients’ Characteristics (N = 408) N (%) Age groups 0–24 25–34 35–44 45–54 55–64 65+ 22 (5.4) 131 (32.1) 144 (35.3) 69 (16.9) 35 (8.6) 7 (1.7) Gender Female Male 149 (36.5) 259 (63.5) Race White Black Other 274 (67.2) 123 (30.1) 11 (2.7) Ethnicity Non-Hispanic Hispanic Other 376 (92.2) 9 (2.2) 23 (5.6) Insurance Private Public Self-pay 68 (16.7) 137 (33.5) 203 (49.8) 3.2 Co-occurring Psychiatric Disorders and Concurrent Substance Use Disorders Approximately 36.0% of patients had co-occurring psychiatric disorders with mood disorders as the most prevalent (47.6%) followed by psychotic disorders (19.1%) and anxiety disorders (8.8%) (Table 2 ). Approximately 21.8% of patients had more than one psychiatric disorder (Table 2 ). Table 2 Co-occurring Psychiatric Disorders (N = 408) N (%) Concurrent Psychiatric Disorders Yes No 147 (36.0) 261 (64.0) Diagnosis of Psychiatric Disorder Mood Disorder Psychotic Disorder Anxiety Disorder 70 (47.6) 28 (19.1) 13 (8.8) > 1 Diagnosed Psychiatric Disorder Yes No 32 (21.8) 115 (78.2) Compared to patients without co-occurring psychiatric disorders, patients with concurrent psychiatric disorders had significantly higher rates of marijuana use (53.8% vs. 38.0%, p < 0.05) (Table 3 ). The concurrent use of other substances, including heroin and self-reported nonmedical opioid use, cocaine, and methamphetamine, did not differ between the two groups (Table 3 ). Additionally, more patients with psychiatric disorders were using polysubstance (≥ 3) than patients without psychiatric disorders, but not significantly so (51.0% vs. 41.1%, p = 0.06) (Table 3 ). Table 3 Comparisons between Patients with and without Psychiatric Disorders Substances use With Psychiatric Disorders (N = 147) Without Psychiatric Disorders (N = 261) P value Benzodiazepine 28 46 0.69 Cannabis 78 (53.8%) 100 (38.0%) 0.002 Cocaine 58 86 0.16 Methamphetamine 74 133 1.0 Heroin 29 53 1.0 Other opioids 77 159 0.17 Polysubstance use, ≥3 74 (51.0%) 108 (41.1%) 0.06 Psychiatry admission at initial ED visit 128 (87.1%) 58 (22.2%) 0.002 Repeat ED/hospital utilization within 30 days 49 65 0.065 Repeat ED/hospital utilization within 6 months 83 (57.2%) 113 (43.0%) 0.007 Discharge with naloxone 12 (8.3%) 43 (16.3%) 0.029 Discharge with buprenorphine 49 68 0.115 3.3 Healthcare Utilization When comparing healthcare utilization between patients with and without psychiatric disorders, patients with psychiatric disorders had a higher rate of repeat ED visit and/or hospital admission at six months (57.2% vs. 43.0%, p < 0.05), but not within 30 days after ED discharge (Table 3 ). Additionally, a higher rate of patients with concurrent psychiatric disorders were admitted to psychiatry inpatient settings during the study period ( p = 0.002). Rates of naloxone provision (8.3% vs. 16.3%, p < 0.05), but not buprenorphine prescribing, at discharge were different between the two groups (Table 3 ). 4.0 Discussion In this study, a substantial proportion of ED patients using illicit fentanyl were found to have co-occurring psychiatric disorders. They had higher rates of lack of naloxone provision at ED discharge, concurrent other substance use, and inpatient admission. They also had higher rates of repeat ED use and hospital admission at six months after initial ED visit, indicative of a lower proportion seeking and retaining definitive treatment after discharge. Our findings indicate that patients with co-occurring illicit fentanyl use and psychiatric disorders represent a highly disadvantaged group as the majority are uninsured, at increased risk for adverse outcomes, and facing challenging barriers to treatment. Studies reported that patients with opioid use disorder and co-occurring psychiatric disorders or receiving antidepressants had higher odds of retention in addiction care, including buprenorphine treatment [ 17 , 18 , 19 , 20 ]. Another study identified several risk factors for discontinuing buprenorphine, including low initial buprenorphine dosage (i.e., ≤4mg), male sex, comorbid substance use disorders, opioid overdose history, and inpatient care [ 21 ]. Findings from our study and referenced studies indicate that more strategic and supportive treatment options should be available to engage this disadvantaged and vulnerable patient population. The critical importance of screening for and treating psychiatric disorders concomitantly with illicit fentanyl use or potentially opioid use disorder should be noted. Currently, emergency departments, such as the UAB ED, have established Screening, Brief Intervention, and Referral to Treatment (SBRIT) protocols to screen for substance use disorders and refer patients. However, there are no standardized and broadly implemented ED-based screening, intervention, and referral protocols for patients with illicit fentanyl use and co-occurring psychiatric disorders. Although point-of-care toxicology tests for fentanyl in human urine are available, they are not routinely used in many EDs, and detailed guidance on how to use and interpret such test results in the ED setting is not available. Most likely, routine fentanyl testing would introduce additional workload on patient evaluation in the ED and add economic costs, but they could be warranted if needed for aiding clinical decisions. Furthermore, routine collection of self-reported opioid misuse data and urine toxicology tests, including illicit fentanyl detection, could help guide ED treatment and referral for ongoing care. For example, FDA approved medications for treatment of opioid use disorders and harm reduction approaches (i.e., naloxone and fentanyl test strips) are available if illicit fentanyl use is identified and diagnosis of opioid use disorder is accurately made [ 22 ]. Identification, evaluation, treatment, and referral of individuals with illicit fentanyl use should be considered as part of strategic plans to prevent nonfatal and fatal opioid overdose. Further rigorous research and intervention development is needed to address these challenges. Our findings are consistent with the existing literature in many areas. Specifically, our results show that a great number of patients who engage in illicit fentanyl use and may concomitantly be impacted by opioid use disorder also suffer from at least one psychiatric illness. Additionally, we found that mood disorders are the most common among ED patients with illicit fentanyl use (Table 2 ). Regarding treatment and healthcare utilization, we found that patients with co-occurring illicit fentanyl use and psychiatric disorders presented to the ED more often in a six-month period than those without (Table 3 ), which is also consistent with previous studies [ 23 , 24 ]. There are multiple reasons why patients may return to the ED. One reason is that patients have not received the help and treatment they need in the interim. This cohort is likely further impacted by under-insured status or lack of insurance, as evidenced by this study (Table 1 ). They may have limited options for definitive outpatient addiction and/or psychiatric follow-up, particularly in a non-Medicaid expansion state such as Alabama. The ED may be a patients’ only recourse for social support and medical care. Studies have shown that individuals who use illicit opioids also use other substances [ 25 , 26 ]. Consistently, our study observed the concurrent use of illicit fentanyl and other substances in patients (Table 3 ), indicating the need to evaluate other substance use among individuals presenting with illicit fentanyl use and/or psychiatric disorders. Despite significant barriers to providing effective interventions for illicit fentanyl use and other substance use, medications and behavioral or psychosocial interventions that could be potentially effective for treatment have been identified [ 27 ]. Effective ED treatment approaches in the subset of individuals with illicit fentanyl use and concurrent other substance use will need to be augmented by additional medical or behavioral interventions and enhanced social support efforts. For example, peer support specialists and addiction counselors could be helpful to engage and link patients with community programs for definitive addiction care. Additionally, diagnosing patients with illicit fentanyl use for opioid use disorder and then providing medications for opioid use disorder with referral for ongoing treatment may be essential for patients with concurrent opioid use disorder and other substance use. 4.1 Limitations The data in this study comes from a large, urban, tertiary hospital ED over a limited time during the COVID-19 pandemic. Therefore, results may not be generalizable to other settings or regions. Furthermore, because our designation of co-occurring psychiatric disorders resulted from patients’ problem lists in the EMR and not from a diagnostic interview, it is likely that the prevalence of co-occurring psychiatric disorders is underestimated in this study. Additionally, our ED has over 75,000 visits annually, and urine drug screening tests are conducted in selected patients, not universally, resulting in potential selection bias. We did not confirm illicit fentanyl results in urine drug screening because the confirmatory tests are not available in the ED setting at UAB Hospital. Lastly, this current study did not include alcohol use disorder because we realize that alcohol use is significantly under reported or not reported. 5.0 Conclusion The opioid overdose epidemic, which has been markedly exacerbated by illicit fentanyl, highlights the urgency for ED providers to be well versed on the proper screening for it and management of potential opioid use disorder. Co-occurring psychiatric disorders among patients presenting to the ED with illicit fentanyl use is associated with distinct sociodemographic characteristics and increased healthcare utilization. Improved identification, treatment, and referral for individuals with illicit fentanyl use (potentially opioid use disorder) and psychiatric disorders are needed to engage them in effective interventions, decrease ED use, and improve patient treatment outcomes. Declarations Competing Interests: The authors declare no competing interests. Author Contribution A.D. : Formal Analysis, Writing-Original DraftL.W. : Methodology, Investigation, Writing-Review & EditingR.S. : Writing-Review & Editing L.L. : Conceptualization, Methodology, Writing-Review & Editing Acknowledgement We would like to thank UAB Informatics Team for their contribution in obtaining EMR data for this project. 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Accessed 4 Dec 2023, from https://www.justice.gov/opioidawareness/opioid-facts#:~:text=The%20 increase%20in%20drug%20overdose,cocaine%2C%20and%20other%20street%20drugs. Walter, L. A., & Li, L. (2020). Opioid use disorder in the Emergency Department amid COVID-19. Journal of Addiction Medicine, 14 (6), e281–e283. https://doi.org/10.1097/ADM.0000000000000717 . Soares, W. E., 3rd, et al. (2022). Emergency Department visits for nonfatal opioid overdose during the COVID-19 pandemic across six US health care systems. Annals of Emergency Medicine, 79 (2), 158–167. https://doi.org/10.1016/j.annemergmed.2021.03.013 . Theriault, K. M., Rosenheck, R. A., & Rhee, T. G. (2020). Increasing Emergency Department visits for mental health conditions in the United States. The Journal of Clinical Psychiatry, 81 (5), 20m13241. https://doi.org/10.4088/JCP.20m13241 . Bailey, S. R., et al. (2021). 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Journal of Clinical Psychiatry, 83 (3), 21m14001. https://doi.org/10.4088/JCP.21m14001 . Samples, H., Williams, A. R., Olfson, M., & Crystal, S. (2018). Risk factors for discontinuation of buprenorphine treatment for opioid use disorders in a multi-state sample of Medicaid enrollees. Journal of Substance Abuse Treatment, 95 , 9–17. https://doi.org/10.1016/j.jsat.2018.09.001 . National Institutes on Drug Abuse. (2021a). Fentanyl DrugFacts. Accessed 4 Dec 2023, from https://nida.nih.gov/publications/drugfacts/fentanyl . Curran, G. M., et al. (2003). Emergency department use of persons with comorbid psychiatric and substance abuse disorders. Annals of Emergency Medicine, 41 (5), 659–667. https://doi.org/10.1067/mem.2003.154 . Curran, G. M., et al. (2008). The association of psychiatric comorbidity and use of the emergency department among persons with substance use disorders: an observational cohort study. BMC Emergency Medicine, 8 , 17. https://doi.org/10.1186/1471-227X-8-17 . Ciccarone, D. (2021). The rise of illicit fentanyls, stimulants and the fourth wave of the opioid overdose crisis. Curr Opin Psychiatry, 34(4), 344–350. https://doi.org/10.1097/YCO.0000000000000717 . Warfield, S. C., et al. (2022). Trends in comorbid opioid and stimulant use disorders among Veterans receiving care from the Veterans Health Administration, 2005–2019. Drug and Alcohol Dependence, 232 , 109310. https://doi.org/10.1016/j.drugalcdep.2022.109310 . National Institutes on Drug Abuse. (2022, March 23). Strengthening Federal Mental Health and Substance Use Disorder Programs: Opportunities, Challenges, and Emerging Issues. Accessed 4 Oct 2023, from https://nida.nih.gov/about-nida/legislative-activities/testimony-to-congress/2022/strengthening-federal-mental-health-and-substance-use-disorder-programs-opportunities-challenges-and-emerging-issues . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 01 Apr, 2025 Read the published version in Scientific Reports → Version 1 posted Editorial decision: Revision requested 18 Nov, 2024 Reviews received at journal 16 Nov, 2024 Reviewers agreed at journal 14 Nov, 2024 Reviews received at journal 20 Oct, 2024 Reviewers agreed at journal 01 Oct, 2024 Reviewers invited by journal 29 Aug, 2024 Editor assigned by journal 29 Aug, 2024 Editor invited by journal 22 Aug, 2024 Submission checks completed at journal 17 Aug, 2024 First submitted to journal 13 Aug, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4909624","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":349112173,"identity":"dddd3864-a254-46a2-89ad-852acb6b317d","order_by":0,"name":"Allie Downs","email":"","orcid":"","institution":"University of Alabama at Birmingham","correspondingAuthor":false,"prefix":"","firstName":"Allie","middleName":"","lastName":"Downs","suffix":""},{"id":349112174,"identity":"ca22619d-906d-4033-bea5-a167797cc1c0","order_by":1,"name":"Lauren Walter","email":"","orcid":"","institution":"University of Alabama at Birmingham","correspondingAuthor":false,"prefix":"","firstName":"Lauren","middleName":"","lastName":"Walter","suffix":""},{"id":349112175,"identity":"8ba7e701-c9a1-471d-b709-f8fddf01521a","order_by":2,"name":"Richard Shelton","email":"","orcid":"","institution":"University of Alabama at Birmingham","correspondingAuthor":false,"prefix":"","firstName":"Richard","middleName":"","lastName":"Shelton","suffix":""},{"id":349112176,"identity":"6f582229-2f95-49d4-8335-97d410cec338","order_by":3,"name":"Li Li","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAq0lEQVRIiWNgGAWjYBACPmYGxgMJFQwMBmAuGxFa2JgZGA4knCFJCxAfYGwjSQs7j8GBh/MOy5uLHX7A8KHsMDEOA2pJ3HbYcOfsNAPGGedI0MK44XYOAzNvG9Fa5hy2B2v5S7yWhsOJYC2MxGlhKziQcCw9GeSXgz3n0glr4ec/vPHhjxpr2+3SyQ8f/CizJqyFgYHDAM48QIx6IGB/QKTCUTAKRsEoGLEAAF+6OnCfEg/yAAAAAElFTkSuQmCC","orcid":"","institution":"University of Alabama at Birmingham","correspondingAuthor":true,"prefix":"","firstName":"Li","middleName":"","lastName":"Li","suffix":""}],"badges":[],"createdAt":"2024-08-13 23:02:25","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4909624/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4909624/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41598-025-92311-2","type":"published","date":"2025-04-01T15:57:06+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":80082401,"identity":"11d128c7-ac1f-43d2-b948-c06692bd4880","added_by":"auto","created_at":"2025-04-07 16:08:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":685171,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4909624/v1/af740be2-dd30-4823-b240-52b838577e37.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Co-occurring Illicit Fentanyl Use and Psychiatric Disorders in Emergency Department Patients","fulltext":[{"header":"1.0 Introduction","content":"\u003cp\u003eThe United States is experiencing an ongoing nationwide opioid epidemic which has been exacerbated by the COVID-19 pandemic. Several abrupt social changes, dictated by the pandemic, along with the increased introduction of synthetic opioids (e.g., fentanyl) into the domestic illicit drug supply, have resulted in a dramatic increase in opioid overdoses and overdose deaths since 2020 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Per the CDC, the rate of drug overdose deaths has increased by 279% over a 5-year span for drug overdoses involving fentanyl; specifically, the rate increased from 5.7 per 100,000 standard population in 2016 to 21.6 per 100,000 in 2021[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Further, the impact of synthetic opioids, which may be 50 times more potent than heroin [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], are not limited to persons who misuse opioids. Fentanyl, inexpensive to produce, has permeated and contaminated the illicit domestic drug supply, resulting in accidental use, overdose, and death, by persons with no intent to use fentanyl or opioids [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Although illicit fentanyl use is not equivalent to opioid use disorder (OUD), many patients with OUD are using illicit fentanyl, which significantly increases their overdose risk and even death [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eStudies have also shown that numerous people with OUD have concurrent psychiatric disorders [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Studies showed that patients with a psychiatric disorder are more likely to be prescribed opioids, resulting in greater likelihood of developing OUD [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Other studies reported that patients with psychiatric disorders usually use opioids to self-medicate for their disease which can lead to or result in OUD [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. One study indicated that mood disorders were the most common psychiatric disorder in patients with OUD [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], and those with mood disorders showed a high rate of self-medication using nonmedical opioids [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Furthermore, the number of psychiatric disorders a patient is diagnosed with largely increases the presence of concurrent OUD [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. For example, patients diagnosed with 3 or 4 psychiatric disorders exhibit a 9-fold increase in developing OUD [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Although the relationship of OUD and psychiatric disorders has been investigated, studies on illicit fentanyl use and psychiatric disorders are limited, especially in Emergency Department (ED) patients. Illicit fentanyl use has been a major reason for historically high records of opioid-related overdose; thus, it is important to understand their relationship [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe Emergency Department represents a unique medical setting which has been particularly impacted by the opioid epidemic. The number of opioid-related ED visits have increased, despite the pandemic, even when general ED patient volumes decreased [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Further, the proportion of ED visits for mental health complaints has also been on the rise [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. As ED clinicians are increasingly tasked with the acute management of psychiatric illness as well as patients with opioid exposure or misuse, understanding how these patient presentations and pathology might overlap is increasingly important. To our knowledge, there are no prior studies which specifically consider illicit fentanyl use and its association with psychiatric disorders and other patient characteristics in the ED. This study seeks to better understand the attributes of ED patients with co-occurring illicit fentanyl use and psychiatric disorders, as well as the associated impact on healthcare recidivism and utilization in the Southeastern region.\u003c/p\u003e"},{"header":"2.0 Methods","content":"\u003cp\u003e This was a retrospective, cross-sectional review that received full approval by the Institutional Review Board at the University of Alabama at Birmingham (UAB) (IRB-300002304) on 4/30/2022. All methods were performed in accordance with relevant guidelines and regulations. Informed consent was waived due to the use of electronic medical records (EMR). Patients presenting to the ED at UAB Hospital with a urine drug screen positive for illicit fentanyl from June 1, 2021 until November 31, 2021 were identified from the EMR and included in the analysis. The use of other illicit substances, identified in the urine drug screen results, was obtained as well. The Fentanyl Enzyme Immunoassay in urine drug screening is a qualitative assay that screens for the presence of norfentanyl, the major metabolite of fentanyl, in human urine. Samples that contain greater than 5 ng/mL of norfentanyl are reported as positive for fentanyl at UAB ED. Samples that are below the 5 ng/mL cutoff are reported as negative. Trauma patients were excluded because they may have been exposed to fentanyl in the pre-hospital setting per Emergency Medical Service pain control protocols. Patients with prescribed fentanyl (either while in the ED or as an outpatient) were also excluded during the study period.\u003c/p\u003e \u003cp\u003e Demographic characteristics, including sex, age, race/ethnicity, and registration-verified insurance status were also obtained from the EMR. Additional characteristics included initial visit disposition, discharge (from ED or hospital) with buprenorphine and/or naloxone, and repeat ED or hospital admission within 30 days and six months after the initial visit. We queried provider documentation in the patient\u0026rsquo;s problem list and past medical history. The problem list allowed documentation of all pre-existing medical and psychiatric diagnoses, such as non-substance-induced psychiatric disorders, which are electronically linked to International Classification of Diseases-10 codes, including F01.xx-F99.xx. Nasal spray naloxone prescription or kit provision in the ED and buprenorphine prescriptions among ED patients during the study period were also considered. Descriptive statistical and Chi-square analyses were performed using SPSS version 27 (IBM).\u003c/p\u003e"},{"header":"3.0 Results","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e\u003cem\u003e3.1 Patient Characteristics\u003c/em\u003e\u003c/h2\u003e \u003cp\u003eDuring the study period, a total of 2,158 patients tested positive for illicit fentanyl by urine drug screen when they presented to the ED. Among them, 408 unique patients were identified with 67.2% white, 30.1% Black, 63.5% men (Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). A majority of patients (67.4%) were between 25\u0026ndash;44 years of age: 25\u0026ndash;34 years (32.1%) and 35\u0026ndash;44 years (35.3%) (Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Approximately half of patients were insured. Commercial insurance was the most prevalent (16.7%) followed by public insurance (33.5%). 49.8% of patients were uninsured (Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatients\u0026rsquo; Characteristics (N\u0026thinsp;=\u0026thinsp;408)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge groups\u003c/b\u003e\u003c/p\u003e \u003cp\u003e0\u0026ndash;24\u003c/p\u003e \u003cp\u003e25\u0026ndash;34\u003c/p\u003e \u003cp\u003e35\u0026ndash;44\u003c/p\u003e \u003cp\u003e45\u0026ndash;54\u003c/p\u003e \u003cp\u003e55\u0026ndash;64\u003c/p\u003e \u003cp\u003e65+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (5.4)\u003c/p\u003e \u003cp\u003e131 (32.1)\u003c/p\u003e \u003cp\u003e144 (35.3)\u003c/p\u003e \u003cp\u003e69 (16.9)\u003c/p\u003e \u003cp\u003e35 (8.6)\u003c/p\u003e \u003cp\u003e7 (1.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003cp\u003eFemale\u003c/p\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e149 (36.5)\u003c/p\u003e \u003cp\u003e259 (63.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRace\u003c/b\u003e\u003c/p\u003e \u003cp\u003eWhite\u003c/p\u003e \u003cp\u003eBlack\u003c/p\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e274 (67.2)\u003c/p\u003e \u003cp\u003e123 (30.1)\u003c/p\u003e \u003cp\u003e11 (2.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEthnicity\u003c/b\u003e\u003c/p\u003e \u003cp\u003eNon-Hispanic\u003c/p\u003e \u003cp\u003eHispanic\u003c/p\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e376 (92.2)\u003c/p\u003e \u003cp\u003e9 (2.2)\u003c/p\u003e \u003cp\u003e23 (5.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInsurance\u003c/b\u003e\u003c/p\u003e \u003cp\u003ePrivate\u003c/p\u003e \u003cp\u003ePublic\u003c/p\u003e \u003cp\u003eSelf-pay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e68 (16.7)\u003c/p\u003e \u003cp\u003e137 (33.5)\u003c/p\u003e \u003cp\u003e203 (49.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Co-occurring Psychiatric Disorders and Concurrent Substance Use Disorders\u003c/h2\u003e \u003cp\u003eApproximately 36.0% of patients had co-occurring psychiatric disorders with mood disorders as the most prevalent (47.6%) followed by psychotic disorders (19.1%) and anxiety disorders (8.8%) (Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Approximately 21.8% of patients had more than one psychiatric disorder (Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCo-occurring Psychiatric Disorders (N\u0026thinsp;=\u0026thinsp;408)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eConcurrent Psychiatric Disorders\u003c/b\u003e\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e147 (36.0)\u003c/p\u003e \u003cp\u003e261 (64.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDiagnosis of Psychiatric Disorder\u003c/b\u003e\u003c/p\u003e \u003cp\u003eMood Disorder\u003c/p\u003e \u003cp\u003ePsychotic Disorder\u003c/p\u003e \u003cp\u003eAnxiety Disorder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70 (47.6)\u003c/p\u003e \u003cp\u003e28 (19.1)\u003c/p\u003e \u003cp\u003e13 (8.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e\u0026gt;\u0026thinsp;1 Diagnosed Psychiatric Disorder\u003c/b\u003e\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (21.8)\u003c/p\u003e \u003cp\u003e115 (78.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eCompared to patients without co-occurring psychiatric disorders, patients with concurrent psychiatric disorders had significantly higher rates of marijuana use (53.8% vs. 38.0%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The concurrent use of other substances, including heroin and self-reported nonmedical opioid use, cocaine, and methamphetamine, did not differ between the two groups (Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Additionally, more patients with psychiatric disorders were using polysubstance (\u0026ge;\u0026thinsp;3) than patients without psychiatric disorders, but not significantly so (51.0% vs. 41.1%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.06) (Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparisons between Patients with and without Psychiatric Disorders\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubstances use\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWith Psychiatric Disorders\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;147)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWithout Psychiatric Disorders\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;261)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBenzodiazepine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.69\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCannabis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e78 (53.8%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e100 (38.0%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCocaine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMethamphetamine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e133\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeroin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther opioids\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e159\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePolysubstance use, \u0026ge;3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e74 (51.0%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e108 (41.1%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.06\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePsychiatry admission at initial ED visit\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e128 (87.1%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e58 (22.2%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRepeat ED/hospital utilization within 30 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.065\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRepeat ED/hospital utilization within 6 months\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e83 (57.2%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e113 (43.0%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.007\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDischarge with naloxone\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e12 (8.3%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e43 (16.3%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.029\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDischarge with buprenorphine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.115\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Healthcare Utilization\u003c/h2\u003e \u003cp\u003eWhen comparing healthcare utilization between patients with and without psychiatric disorders, patients with psychiatric disorders had a higher rate of repeat ED visit and/or hospital admission at six months (57.2% vs. 43.0%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), but not within 30 days after ED discharge (Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Additionally, a higher rate of patients with concurrent psychiatric disorders were admitted to psychiatry inpatient settings during the study period (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002). Rates of naloxone provision (8.3% vs. 16.3%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), but not buprenorphine prescribing, at discharge were different between the two groups (Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"4.0 Discussion","content":"\u003cp\u003eIn this study, a substantial proportion of ED patients using illicit fentanyl were found to have co-occurring psychiatric disorders. They had higher rates of lack of naloxone provision at ED discharge, concurrent other substance use, and inpatient admission. They also had higher rates of repeat ED use and hospital admission at six months after initial ED visit, indicative of a lower proportion seeking and retaining definitive treatment after discharge. Our findings indicate that patients with co-occurring illicit fentanyl use and psychiatric disorders represent a highly disadvantaged group as the majority are uninsured, at increased risk for adverse outcomes, and facing challenging barriers to treatment.\u003c/p\u003e \u003cp\u003eStudies reported that patients with opioid use disorder and co-occurring psychiatric disorders or receiving antidepressants had higher odds of retention in addiction care, including buprenorphine treatment [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Another study identified several risk factors for discontinuing buprenorphine, including low initial buprenorphine dosage (i.e., \u0026le;4mg), male sex, comorbid substance use disorders, opioid overdose history, and inpatient care [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Findings from our study and referenced studies indicate that more strategic and supportive treatment options should be available to engage this disadvantaged and vulnerable patient population. The critical importance of screening for and treating psychiatric disorders concomitantly with illicit fentanyl use or potentially opioid use disorder should be noted.\u003c/p\u003e \u003cp\u003eCurrently, emergency departments, such as the UAB ED, have established Screening, Brief Intervention, and Referral to Treatment (SBRIT) protocols to screen for substance use disorders and refer patients. However, there are no standardized and broadly implemented ED-based screening, intervention, and referral protocols for patients with illicit fentanyl use and co-occurring psychiatric disorders. Although point-of-care toxicology tests for fentanyl in human urine are available, they are not routinely used in many EDs, and detailed guidance on how to use and interpret such test results in the ED setting is not available. Most likely, routine fentanyl testing would introduce additional workload on patient evaluation in the ED and add economic costs, but they could be warranted if needed for aiding clinical decisions. Furthermore, routine collection of self-reported opioid misuse data and urine toxicology tests, including illicit fentanyl detection, could help guide ED treatment and referral for ongoing care. For example, FDA approved medications for treatment of opioid use disorders and harm reduction approaches (i.e., naloxone and fentanyl test strips) are available if illicit fentanyl use is identified and diagnosis of opioid use disorder is accurately made [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Identification, evaluation, treatment, and referral of individuals with illicit fentanyl use should be considered as part of strategic plans to prevent nonfatal and fatal opioid overdose. Further rigorous research and intervention development is needed to address these challenges.\u003c/p\u003e \u003cp\u003eOur findings are consistent with the existing literature in many areas. Specifically, our results show that a great number of patients who engage in illicit fentanyl use and may concomitantly be impacted by opioid use disorder also suffer from at least one psychiatric illness. Additionally, we found that mood disorders are the most common among ED patients with illicit fentanyl use (Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Regarding treatment and healthcare utilization, we found that patients with co-occurring illicit fentanyl use and psychiatric disorders presented to the ED more often in a six-month period than those without (Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e), which is also consistent with previous studies [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. There are multiple reasons why patients may return to the ED. One reason is that patients have not received the help and treatment they need in the interim. This cohort is likely further impacted by under-insured status or lack of insurance, as evidenced by this study (Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). They may have limited options for definitive outpatient addiction and/or psychiatric follow-up, particularly in a non-Medicaid expansion state such as Alabama. The ED may be a patients\u0026rsquo; only recourse for social support and medical care.\u003c/p\u003e \u003cp\u003eStudies have shown that individuals who use illicit opioids also use other substances [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Consistently, our study observed the concurrent use of illicit fentanyl and other substances in patients (Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e), indicating the need to evaluate other substance use among individuals presenting with illicit fentanyl use and/or psychiatric disorders. Despite significant barriers to providing effective interventions for illicit fentanyl use and other substance use, medications and behavioral or psychosocial interventions that could be potentially effective for treatment have been identified [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Effective ED treatment approaches in the subset of individuals with illicit fentanyl use and concurrent other substance use will need to be augmented by additional medical or behavioral interventions and enhanced social support efforts. For example, peer support specialists and addiction counselors could be helpful to engage and link patients with community programs for definitive addiction care. Additionally, diagnosing patients with illicit fentanyl use for opioid use disorder and then providing medications for opioid use disorder with referral for ongoing treatment may be essential for patients with concurrent opioid use disorder and other substance use.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Limitations\u003c/h2\u003e \u003cp\u003eThe data in this study comes from a large, urban, tertiary hospital ED over a limited time during the COVID-19 pandemic. Therefore, results may not be generalizable to other settings or regions. Furthermore, because our designation of co-occurring psychiatric disorders resulted from patients\u0026rsquo; problem lists in the EMR and not from a diagnostic interview, it is likely that the prevalence of co-occurring psychiatric disorders is underestimated in this study. Additionally, our ED has over 75,000 visits annually, and urine drug screening tests are conducted in selected patients, not universally, resulting in potential selection bias. We did not confirm illicit fentanyl results in urine drug screening because the confirmatory tests are not available in the ED setting at UAB Hospital. Lastly, this current study did not include alcohol use disorder because we realize that alcohol use is significantly under reported or not reported.\u003c/p\u003e \u003c/div\u003e"},{"header":"5.0 Conclusion","content":"\u003cp\u003eThe opioid overdose epidemic, which has been markedly exacerbated by illicit fentanyl, highlights the urgency for ED providers to be well versed on the proper screening for it and management of potential opioid use disorder. Co-occurring psychiatric disorders among patients presenting to the ED with illicit fentanyl use is associated with distinct sociodemographic characteristics and increased healthcare utilization. Improved identification, treatment, and referral for individuals with illicit fentanyl use (potentially opioid use disorder) and psychiatric disorders are needed to engage them in effective interventions, decrease ED use, and improve patient treatment outcomes.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eCompeting Interests:\u003c/h2\u003e \u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eA.D. : Formal Analysis, Writing-Original DraftL.W. : Methodology, Investigation, Writing-Review \u0026amp; EditingR.S. : Writing-Review \u0026amp; Editing L.L. : Conceptualization, Methodology, Writing-Review \u0026amp; Editing\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe would like to thank UAB Informatics Team for their contribution in obtaining EMR data for this project.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGhose, R., Forati, A. 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Accessed 4 Oct 2023, from \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://nida.nih.gov/about-nida/legislative-activities/testimony-to-congress/2022/strengthening-federal-mental-health-and-substance-use-disorder-programs-opportunities-challenges-and-emerging-issues\u003c/span\u003e\u003cspan address=\"https://nida.nih.gov/about-nida/legislative-activities/testimony-to-congress/2022/strengthening-federal-mental-health-and-substance-use-disorder-programs-opportunities-challenges-and-emerging-issues\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"illicit fentanyl, psychiatric disorders, emergency department, concurrent, healthcare utilization","lastPublishedDoi":"10.21203/rs.3.rs-4909624/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4909624/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThis paper sought to describe the characteristics of emergency department (ED) patients with illicit fentanyl use and concurrent psychiatric disorders, as studies within this population of patients is limited. ED patients with a fentanyl-positive urine drug screen were identified, and patient characteristics, medical histories, and test results were extracted. Among the fentanyl positive drug screens of ED patients, the majority were between the ages of 25 and 44, male, white, and uninsured. Additionally, more than one third of these patients had concurrent psychiatric disorders with mood disorders being the most prevalent, followed by psychotic disorders. Patients with co-occurring psychiatric disorders were found to have higher rates of marijuana use, repeat ED visits and/or hospital admissions at six months, and more admissions to psychiatry inpatient settings compared to those patients without co-occurring psychiatric disorders. Concurrent other substance use and rates of buprenorphine prescribing at discharge were not different between the groups; however, rates of naloxone provision at discharge were lower in patients with co-occurring psychiatric disorders. This cohort demonstrates higher healthcare recidivism and utilization.\u003c/p\u003e","manuscriptTitle":"Co-occurring Illicit Fentanyl Use and Psychiatric Disorders in Emergency Department Patients","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-13 21:01:34","doi":"10.21203/rs.3.rs-4909624/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-11-18T14:03:41+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-16T19:40:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"73985000914873598134978182924869742489","date":"2024-11-14T22:40:51+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-21T03:49:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"333355114538303814557618630760617528647","date":"2024-10-01T15:13:14+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-08-29T18:25:31+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-29T18:11:46+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-08-22T04:33:25+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-08-17T06:28:39+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2024-08-13T23:01:01+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f3444811-a954-4024-9f5e-013d8e04e89b","owner":[],"postedDate":"September 13th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":37051455,"name":"Biological sciences/Psychology"},{"id":37051456,"name":"Health sciences/Diseases/Psychiatric disorders"}],"tags":[],"updatedAt":"2025-04-07T16:07:11+00:00","versionOfRecord":{"articleIdentity":"rs-4909624","link":"https://doi.org/10.1038/s41598-025-92311-2","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2025-04-01 15:57:06","publishedOnDateReadable":"April 1st, 2025"},"versionCreatedAt":"2024-09-13 21:01:34","video":"","vorDoi":"10.1038/s41598-025-92311-2","vorDoiUrl":"https://doi.org/10.1038/s41598-025-92311-2","workflowStages":[]},"version":"v1","identity":"rs-4909624","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4909624","identity":"rs-4909624","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}