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Led by PISC Executive Committee member Zachary F. Meisel, this study aimed to describe the overall risk and factors associated with transitioning to persistent opioid or high-risk use after an initial emergency department (ED) opioid prescription. After performing a retrospective cohort study of Washington Medicaid beneficiaries, it found that among 202,807 ED visits, 23,381 resulted in a new opioid prescription, and that 13.7% of such new prescriptions led to persistent or high-risk opioid prescription fills within 12 months. The results indicate that Medicaid recipients are at moderate risk, and that even visits that lead to guideline-concordant prescriptions can still potentially lead to long-term or high-risk use.