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Opioid use disorder is a major public health crisis, and evidence suggests ways of better serving patients who live with opioid use disorder in the emergency department (ED). A multi-disciplinary team developed a quality improvement project to implement this evidence.
The intervention was developed by an expert working group consisting of specialists and stakeholders. The group set goals of increasing prescribing of buprenorphine/naloxone and providing next day walk-in referrals to opioid use disorder treatment clinics. From May to September 2018, three Alberta ED sites and three opioid use disorder treatment clinics worked together to trial the intervention. We used administrative data to track the number of ED visits where patients were given buprenorphine/naloxone. Monthly ED prescribing rates before and after the intervention were considered and compared with eight nonintervention sites. We considered whether patients continued to fill opioid agonist treatment prescriptions at 30, 60, and 90 days after their index ED visit to measure continuity in treatment.
The intervention sites increased their prescribing of buprenorphine/naloxone during the intervention period and prescribed more buprenorphine/naloxone than the controls. Thirty-five of 47 patients (74.4%) discharged from the ED with buprenorphine/naloxone continued to fill opioid agonist treatment prescriptions 30 days and 60 days after their index ED visit. Thirty-four patients (72.3%) filled prescriptions at 90 days.
Emergency clinicians can effectively initiate patients on buprenorphine/naloxone when supports for this standardized evidence-based care are in place within their practice setting and timely follow-up in community is available.
Background: Since January 1, 2016 2358 people have died from opioid poisoning in Alberta. Buprenorphine/naloxone (bup/nal) is the recommended first line treatment for opioid use disorder (OUD) and this treatment can be initiated in emergency departments and urgent care centres (EDs). Aim Statement: This project aims to spread a quality improvement intervention to all 107 adult EDs in Alberta by March 31, 2020. The intervention supports clinicians to initiate bup/nal for eligible individuals and provide rapid referrals to OUD treatment clinics. Measures & Design: Local ED teams were identified (administrators, clinical nurse educators, physicians and, where available, pharmacists and social workers). Local teams were supported by a provincial project team (project manager, consultant, and five physician leads) through a multi-faceted implementation process using provincial order sets, clinician education products, and patient-facing information. We used administrative ED and pharmacy data to track the number of visits where bup/nal was given in ED, and whether discharged patients continued to fill any opioid agonist treatment (OAT) prescription 30 days after their index ED visit. OUD clinics reported the number of referrals received from EDs and the number attending their first appointment. Patient safety event reports were tracked to identify any unintended negative impacts. Evaluation/Results: We report data from May 15, 2018 (program start) to September 31, 2019. Forty-nine EDs (46% of 107) implemented the program and 22 (45% of 49) reported evaluation data. There were 5385 opioid-related visits to reporting ED sites after program adoption. Bup/nal was given during 832 ED visits (663 unique patients): 7 visits in the 1st quarter the program operated, 55 in the 2nd, 74 in the 3rd, 143 in the 4th, 294 in the 5th, and 255 in the 6th. Among 505 unique discharged patients with 30 day follow up data available 319 (63%) continued to fill any OAT prescription after receiving bup/nal in ED. 16 (70%) of 23 community clinics provided data. EDs referred patients to these clinics 440 times, and 236 referrals (54%) attended their first follow-up appointment. Available data may under-report program impact. 5 patient safety events have been reported, with no harm or minimal harm to the patient. Discussion/Impact: Results demonstrate effective spread and uptake of a standardized provincial ED based early medical intervention program for patients who live with OUD.
Background: Buprenorphine/naloxone (bup/nal) is a partial opioid agonist/antagonist and recommended first line treatment for opioid use disorder (OUD). Emergency departments (EDs) are a key point of contact with the healthcare system for patients living with OUD. Aim Statement: We implemented a multi-disciplinary quality improvement project to screen patients for OUD, initiate bup/nal for eligible individuals, and provide rapid next business day walk-in referrals to addiction clinics in the community. Measures & Design: From May to September 2018, our team worked with three ED sites and three addiction clinics to pilot the program. Implementation involved alignment with regulatory requirements, physician education, coordination with pharmacy to ensure in-ED medication access, and nurse education. The project is supported by a full-time project manager, data analyst, operations leaders, physician champions, provincial pharmacy, and the Emergency Strategic Clinical Network leadership team. For our pilot, our evaluation objective was to determine the degree to which our initiation and referral pathway was being utilized. We used administrative data to track the number of patients given bup/nal in ED, their demographics and whether they continued to fill bup/nal prescriptions 30 days after their ED visit. Addiction clinics reported both the number of patients referred to them and the number of patients attending their referral. Evaluation/Results: Administrative data shows 568 opioid-related visits to ED pilot sites during the pilot phase. Bup/nal was given to 60 unique patients in the ED during 66 unique visits. There were 32 (53%) male patients and 28 (47%) female patients. Median patient age was 34 (range: 21 to 79). ED visits where bup/nal was given had a median length of stay of 6 hours 57 minutes (IQR: 6 hours 20 minutes) and Canadian Triage Acuity Scores as follows: Level 1 – 1 (2%), Level 2 – 21 (32%), Level 3 – 32 (48%), Level 4 – 11 (17%), Level 5 – 1 (2%). 51 (77%) of these visits led to discharge. 24 (47%) discharged patients given bup/nal in ED continued to fill bup/nal prescriptions 30 days after their index ED visit. EDs also referred 37 patients with OUD to the 3 community clinics, and 16 of those individuals (43%) attended their first follow-up appointment. Discussion/Impact: Our pilot project demonstrates that with dedicated resources and broad institutional support, ED patients with OUD can be appropriately initiated on bup/nal and referred to community care.
Introduction: Morbidity and mortality from opioid overdoses continue to be a significant issue worldwide. In Alberta, there was a 40% increase in accidental opioid-related deaths from 2016 to 2017. In response to this crisis, Alberta Health Services has dramatically expanded access to Naloxone with a province-wide program for the distribution of take-home naloxone (THN) kits. Edmonton Zone ED's began dispensing these kits in 2016. The objectives of this study are to assess the trends in THN kit distribution from these sites in 2016 and 2017. Methods: The Edmonton Zone is a health region that comprises eleven tertiary, urban community and rural community ED's. THN kits in Edmonton Zone ED's were distributed through Pyxis, an automated medication dispensing and tracking system. Pyxis data for THN kits in 2016 and 2017 was extracted for each Edmonton Zone ED and the raw numbers and trends were examined. The National Ambulatory Care Reporting System database was also analyzed to determine the number of opioid related visits to Edmonton Zone ED's over that same time period. Results: A total of 686 THN kits in the Edmonton Zone were distributed over 2016 and 2017. The two tertiary centers distributed 502 kits, while the urban and rural community emergency departments collectively distributed 184 kits. Comparing 2016 (n = 245) to 2017 (n = 441), there was an 80% overall increase in the number of kits distributed, with tertiary center ED's dispensing 92% more kits, urban community ED's 51% more and rural ED's 63% more. Over the same time period, the number of opioid related visits increased in tertiary center ED's by 78%, in urban community sites by 26%, and in rural ED's by 67%. Almost all ED's increased their THN kit distribution from year to year, though there was one urban community site that dispensed fewer kits in the second year of the program. Conclusion: Edmonton Zone ED's dispensed 686 THN kits over two calendar years. Almost every ED distributed more kits in 2017 than 2016, which likely reflects successful uptake of this harm reduction intervention by frontline ED staff. However, there is still evidence of some imbalance in THN kit allocation as the percent increase in kits distributed varied widely based on the type of ED. This data can be used to pinpoint areas in the Edmonton Zone where barriers to THN access may still exist and guide continued quality improvement interventions to increase distribution and education.
On 2 April 1917, United States President Woodrow Wilson delivered his War Message to a special session of the 65th Congress. In his address, Wilson carefully laid out the reasons why he believed it was necessary to ask for a declaration of war against Germany. Chief among his reasons was the unrestricted use of the submarine and the inhumanity that came with it, the legalistic issues the US had with submarine warfare, and the desire for a lasting peace. By 7 April, Congress had voted overwhelmingly to join the war, and the President had signed the War Resolution bringing the country into the war as an associated power, not as a formal member of the Entente Allies.
After two and a half years of a war that had raged in Europe and in the world's oceans, President Wilson had finally decided to bring the United States into the war. The threat of further unrestricted submarine warfare on the part of the Germans and the ensuing Zimmermann Telegram asking for Mexican support seem to be the obvious reasons for Wilson's decision to change policy. But there is more to policy changes than implied threats, and in the case of American entry into the First World War it is clear that the warring sides in Europe were looking for a new ally who could break the deadlock.
From early in the war, the Foreign Offices of Britain and Germany had turned to diplomats in their attempts to shape US President Wilson's decisions. At the heart of First World War diplomatic exchanges were conversations and relationships that developed between the foreign ministers, ambassadors, and special envoys. It was these individuals who carried the diplomatic load, not the individual leaders of each nation – though all clearly played a part. Therefore, an analysis of diplomacy and foreign policy is crucial to understanding America's entry into the war.
When Wilson requested that Congress declare war on Germany in April 1917, Great Britain and her Allies (of primary importance are France, Russia, and Italy) had clearly won the battle for American support. But the American decision to join the war against Germany was complex, and the result of years of diplomatic activity by both belligerent camps.
Aside from the Zimmermann Telegram, Mexico is rarely viewed as having a role in First World War diplomacy. However, Mexican-American relations created an atmosphere of distrust and were therefore essential in creating an opening where German leaders believed they could use their diplomacy to influence the war's outcome. As discussed earlier, German diplomacy was based on the Bismarckian tradition of exploiting opponents’ weaknesses to gain the advantage. The diplomatic tensions between the United States and Mexico that developed just before Wilson took office provided the impetus behind the German decision to offer an alliance to Mexico.
The history of Mexican-American relations is long and violent. The secession of Texas in 1836 had left enough bad feelings between the two nations that they went to war in 1846. That Mexican-American conflict led to the United States gaining the present-day territories of New Mexico, Arizona, Nevada, California, and parts of Colorado – nearly one-third of Mexico's territory – as the spoils of war. Disorder along the US-Mexican border in the late 1870s and early 1880s led many American leaders to call for intervention, followed by more than twenty instances of American troops pursuing Mexican bandits into Mexican territory. US concerns over the stability of its southern neighbor eventually led it to assist in the overthrow of French-installed dictator Maximilian and the installation of the dictator Porfirio Díaz.
During the thirty years when Díaz led Mexico, relations between the two countries became comparatively good, thanks in large part to Díaz's policy of encouraging foreign investment to bring Mexico into the world economy. It was during this period that the United States was joined by the British, Germans, and other European nations in investing in Mexico, particularly in railroads and oil. When Francisco Madero overthrew Díaz in 1910, he continued his predecessor's policies of bringing in foreign investors, while attempting to end the disparity in wealth created by these same policies. Even though Madero attempted to undo the systems of injustice in Mexico, he was unable to quell the indignations of the Mexican people and was himself overthrown and eventually murdered in early 1913. The man who led this bloody coup was Madero's trusted General, Victoriano Huerta.
The winter of 1916 to 1917 brought more than just a renewed push for unrestricted submarine warfare by the Germans. In fall 1916, Grey had once again attempted to squeeze neutral shipping and continue to starve Germany. In what was essentially retaliation by the United States, Congress authorized Wilson to threaten the flow of supplies to Britain and its Allies. The initial British response was to fold. Internally, it formed an Interdepartmental Committee to consider the ramifications of nonintercourse (no trading) with the US. This committee consisted of representatives from the War Trade and Advisory Council, the Ministry of Munitions, and eventually the Treasury. It was tasked with determining Britain's need for US supplies, and whether Britain could punish America if it cut off those supplies.
One aspect of this committee's work was to determine how Britain could force the US to continue supplying the Allied war effort. Report after report detailed the British dependence on American production and finance. Each noted that it was possible to make up the difference in production if Britain was cut off from US trade, if it could corner the remaining world markets. More importantly, the reports also stated that it would take time to secure the markets and an increase in merchant shipping tonnage – and even then, the belief was that it would last only a short while before Britain was again dependent on the United States.
Britain's dependence on the US was heavily mixed with the American recession scare of 1914. Despite Wilson's determination to have the US remain neutral, the economic stimulus that the war in Europe gave the American economy was not something he could ignore. As J. P. Morgan & Co. partner Harry Davison noted to US Treasury Secretary William McAdoo (the son-in-law of the President), in order for the US to maintain its prosperity, it would have to finance the war. British expenditure on the war was costing £5 million a day in 1916 and was expected to rise to £7 million a day in 1917.3 By the end of 1916, British loans through J. P. Morgan & Co. alone amounted to $400 million of debt.
By November 1914, merely three months into the war, it was clear that Germany was unable to win by military might alone; the military situation had begun to dictate diplomacy. In addition to setbacks on land, the German military was facing stumbling blocks due to British naval policy. Under these circumstances, the German military broached the possibility of submarine warfare.
It is an unfortunate reality that the debate about German-American relations during the war is generally framed around how the United States reacted to the idea of submarine warfare, the sinking of neutral merchant ships, and the deaths of American citizens due to submarine attacks on all ships. What has not been placed under the microscope is how the German decision to utilize the submarine drove both the diplomatic response of the US toward the belligerents, and Great Britain's policy toward the United States. To that point, Wilson's ‘strict accountability’ policy is generally confused as a threat of war.
In 1934 Charles Seymour argued that ‘strict accountability’ had meant that, if German submarine attacks continued, US entry into the war was unavoidable. This idea that Germany's unrestricted submarine warfare drove the United States to enter the war against Germany does not account for the almost three full years of submarine activity, along with other issues between the United States and Germany, before President Wilson asked Congress for (and received) a declaration of war against Germany.3 There is no argument that the resumption of unrestricted submarine warfare in 1917 was a key factor in Wilson's decision to enter the war, but a greater understanding of the ‘strict accountability’ policy will lead to a better comprehension of the German-American diplomacy of the period. It is also important to understand how central submarine warfare was to German policy toward the United States, including Bethmann's 1916 peace démarche.
The Chancellor's Challenge
Analysis of German activity in the United States must be tempered by the knowledge that, early in the war (from August to October 1914), most of Germany's leaders – both military and political – were very optimistic that victory would come relatively soon. Germany's plan of attack, the Schlieffen Plan, called for the war in the west to be over in about six weeks, in order to focus on fighting Russia in the hope of forcing that country to sue for peace.
As war clouds loomed and eventually unleashed a storm of unprecedented proportions in Europe in 1914, the vast majority of Americans were opposed to becoming militarily involved in what was seen as a European war. Scientific polling would not be in use until 1935, but it is possible to gauge the mood of the country by the sentiments expressed in newspapers and journals of the time. A New York Sun editorial summarized the mood of the American people in early August 1914 when it printed: ‘There is nothing reasonable in such a war … and it would be folly for the country to sacrifice itself to the … clash of ancient hatreds which is urging the Old World to destruction.’
Indeed, the Literary Digest, known for surveying the American press, polled more than 367 newspaper editors in an attempt to gauge Americans’ sympathies; the outcome pointed to the conclusion that Americans were happy to be at a distance from the fighting. Almost two-thirds of the editors surveyed supported none of the belligerents. During the war's early months, it was clear that they wanted their country to take action only against attacks on US interests at sea (by both Britain and Germany). It was also abundantly clear that outside of the American eastern seaboard and the eastern elites, most Americans preferred that the United States remain neutral.
When leaders of the warring nations considered the potential role of the United States during the early months of the war, they leaned toward the belief that the US would not become involved. They assumed that, because of the United States’ historical reluctance to intervene militarily in European conflicts, and because of its small military, the country would be of little consequence – particularly if the war were short, as many (not all) of the leaders believed it would be. Despite this belief, the reality was that British and German diplomats realized the potential impact of the US on the outcome of the war, and immediately began working to influence the United States for their gain.
Too often, America's role during its period of neutrality is viewed in a vacuum as historians focus on events during the war years, rather than tying the issues to actions that preceded Germany's invasion of Belgium.
The person seeking a greater understanding of First World War diplomacy, and of diplomacy in general, must look beyond the four years of war to understand why diplomats and politicians made some of the decisions that they did. The diplomatic policies that Britain and Germany pursued in their attempts to acquire American assistance during its period of neutrality followed the same patterns as those formulated in previous decades, and the significance of this history should not be underestimated. That First World War diplomacy was an extension of long-established British and German strategic policy toward the United States is key to understanding the diplomatic and foreign policy decisions being made. This continuity played a determining role in the American entry into the war.
In the one hundred years since the end of the First World War, scholars have written innumerable articles and books concerning every aspect of America's entry into the war, analyzing German, British, and US diplomacy. Historians have focused on German blunders, the apparent ineptitude of Germany's diplomats, and the perceived success of Britain's Foreign Office. Analyses have also focused on the diplomacy surrounding particular periods: from the assassination of the Archduke and the crucial first months to the international relations between European powers. A few have looked at the official propaganda's impact on both population and government, and others have examined a particular event in the war and attempted to build a case on that one incident. Those who have written about the period of US neutrality tend to focus on US President Woodrow Wilson's view of the war, belligerent propaganda aimed at the United States, or the impact of the dueling blockades. There has been no adequate discussion of the diplomatic efforts used by the British and German Foreign Offices as they attempted to bring America into the war. This book seeks to fill this gap in the debate.
This is not a hagiography about President Wilson, British Foreign Secretary Sir Edward Grey, or German Chancellor Theobald von Bethmann Hollweg. This is a book about the foreign policy and diplomacy used by the British and Germans in their respective attempts to direct US involvement in the First World War.
H. C. Allen points out that since 1776, when Adam Smith published his masterpiece, The Wealth of Nations, the majority of world trade has been maritime trade. For the newly formed American nation, this marine trade was no less essential to its well-being than it was for the Europeanbased empires, and by 1812 the United States was at war with Britain. This second war for independence was ostensibly due to British violations of maritime law during its war against Napoleonic France. In 1914, as Britain set the Royal Navy to its wartime task of strangling German commerce, and with it Germany's ability to wage a successful war, British policy once again came into conflict with American interests. Had it not been for the diplomatic actions of Foreign Secretary Sir Edward Grey, American insistence on freedom of the seas could have seriously harmed Anglo-American relations, and – more germane to the issues of August 1914 – it could have wrecked the British war effort.
Understanding why the United States dropped its objections to the rules by which Britain had chosen to prosecute the war is directly related to the extent of the influence Britain had over America. By the time Grey first took office in 1905, the promotion of friendship between the United States and Britain had become a staple of British foreign policy. Under Grey's direction, the British Foreign Office had gone from just promoting friendship to influencing US foreign policy decisions to support British interests.
By September 1914 British influence had reached, as historian Ray Stannard Baker correctly characterized, ‘the point of domination – over American diplomacy’. Though domination does not guarantee victory, Britain wielded this diplomatic power as yet another tool in its arsenal throughout the Great War. It was Foreign Secretary Grey's understanding of this power of persuasion, his deftness at timing, and his understanding of America's tendencies in diplomatic matters that led him successfully to assure US acquiescence in British naval strategy. As Britain began to turn the screws on Germany's commerce – using the Royal Navy to seize ships carrying both licit and illicit goods to European ports – the US Secretary of State William Jennings Bryan was appealing to all warring nations to abide by the Declaration of London of 1909.
President Wilson declared on 18 August 1914 that the United States would remain neutral in the European war. But before he established American neutrality, he had extended an offer to the belligerent nations to help bring an immediate end to the conflict, or to mediate ‘at any other time that might be thought more suitable’. Though none of the warring nations chose to accept his offer, leaders in Berlin and London quickly came to understand the importance Wilson placed on mediating an end to the war – in large part because Colonel House spent the balance of 1914 attempting to coax them into mediation.
Despite having had his offer refused, Wilson would hold on to the possibility of American-led mediation for the next three years. Having already attempted to prevent a general European war by sending House to Europe in the months preceding the assassination of the heir to the Austrian throne, the President was not entirely naïve to the difficulties of bringing nations to the negotiating table. Throughout the war, there would be ongoing discussions about bringing peace to Europe – all seemingly falling upon deaf ears, as one or the other belligerent government backed away from the mediation efforts of the United States. Despite the repeated attempts of the United States to end the war, and despite the repeated troubles between the belligerents and the United States – including blockade issues with Britain and submarine issues with Germany – Wilson and his cabinet continued to talk about peace with whoever would listen.
Historians in general, and diplomatic historians specifically, have not viewed mediation and peace offers as diplomatic tools. Instead, they discuss the peace proposals as a means of exploring the personalities of those involved, or as part of a larger, separate issue. For instance, Fritz Fischer is one of the earlier historians to examine the German motive for peace in his groundbreaking and controversial book, Germany's Aims in the First World War. But Fischer was describing what Germany wanted to gain when the war had come to a successful conclusion – one where the German armies were victorious – not what they would gain from a mediated peace or peace without victory.
The aim of this analysis was to test if changes in insomnia symptoms and global sleep quality are associated with coinciding changes in depressed mood among older adults. We report on results yielded from secondary analysis of longitudinal data from a clinical trial of older adults (N = 49) aged 55 to 80 years who reported at least moderate levels of sleep problems. All measures were collected at baseline and after the trial ten weeks later. We computed change scores for two separate measures of disturbed sleep, the Athens Insomnia Scale (AIS) and the Pittsburgh Sleep Quality Index (PSQI), and tested their association with change in depressed mood (Beck Depression Inventory-II; BDI-II) in two separate linear regression models adjusted for biological covariates related to sleep (sex, age, body mass index, and NF-κB as a biological marker previously correlated with insomnia and depression). Change in AIS scores was associated with change in BDI-II scores (β = 0.38, p < 0.01). Change in PSQI scores was not significantly associated with change in BDI-II scores (β = 0.17, p = 0.26). Our findings suggest that improvements over ten weeks in insomnia symptoms rather than global sleep quality coincide with improvement in depressed mood among older adults.