Challenges with buprenorphine inductions in the context of the fentanyl overdose crisis: A case series.

INTRODUCTION AND AIMS: North America is currently experiencing an epidemic of opioid overdose deaths, driven by the proliferation of fentanyl in the street drug market. Although buprenorphine/naloxone (BUP/NX) is an evidence-based, first-line opioid agonist for the management of opioid use disorder, a key challenge in its prescribing lies in the fact that it can precipitate opioid withdrawal during its initial induction process. At this time, there is minimal literature on the BUP/NX induction process in individuals who use illicit fentanyl regularly. DESIGN, METHODS AND RESULTS: A case series from a Vancouver, Canada addiction medicine clinic of three fentanyl-exposed patients who experienced unexpected, precipitated withdrawal when initiating BUP/NX. DISCUSSION AND CONCLUSION: These cases describe incidents of precipitated opioid withdrawal occurring after unusually long periods of fentanyl abstention. Although fentanyl is experienced as a short-acting opioid, the drug persists much longer in the body's peripheral tissues. Here, we highlight the new challenges fentanyl may pose to current BUP/NX induction strategies, and explore the possibility of a long-acting pharmacokinetic effect of fentanyl in the setting of repeated illicit use.

The Power of Small Conversations: Bridging the Gap Between Diabetes and Pregnancy Planning.

Despite the established importance of preconception counselling among women with pre-existing diabetes, many Canadian women of this demographic continue to report inadequate medical planning of pregnancy. Primarily due to the teratogenic effects of hyperglycemia in the early weeks of pregnancy, minimizing the risk of adverse pregnancy outcomes requires a proactive approach toward medical optimization before conception. Primary care providers are well placed to provide preconception counselling to reproductive age women with pre-existing diabetes to alert them to the importance of pregnancy planning. This counselling may not necessarily require dedicated visits but may take the form of simple check-ins and key messages interspaced between other interactions. Herein we discuss the importance and challenges of preconception counselling among women with pre-existing diabetes and provide a pragmatic approach to the delivery of preconception counselling among primary care providers.

Auditory stream segregation of iterated rippled noises by normal-hearing and hearing-impaired listeners.

Individuals with hearing loss are thought to be less sensitive to the often subtle variations of acoustic information that support auditory stream segregation. Perceptual segregation can be influenced by differences in both the spectral and temporal characteristics of interleaved stimuli. The purpose of this study was to determine what stimulus characteristics support sequential stream segregation by normal-hearing and hearing-impaired listeners. Iterated rippled noises (IRNs) were used to assess the effects of tonality, spectral resolvability, and hearing loss on the perception of auditory streams in two pitch regions, corresponding to 250 and 1000 Hz. Overall, listeners with hearing loss were significantly less likely to segregate alternating IRNs into two auditory streams than were normally hearing listeners. Low pitched IRNs were generally less likely to segregate into two streams than were higher pitched IRNs. High-pass filtering was a strong contributor to reduced segregation for both groups. The tonality, or pitch strength, of the IRNs had a significant effect on streaming, but the effect was similar for both groups of subjects. These data demonstrate that stream segregation is influenced by many factors including pitch differences, pitch region, spectral resolution, and degree of stimulus tonality, in addition to the loss of auditory sensitivity.

Blood glucose self-monitoring and internet diabetes management on A1C outcomes in patients with type 2 diabetes.

OBJECTIVES: The purpose of this study was to determine any correlation between frequency of self-monitoring of blood glucose (SMBG), frequency of patient-provider communication of SMBG (reporting), and hemoglobin A1C for patients with non-insulin-dependent diabetes solely on oral medications. RESEARCH DESIGN AND METHODS: 191 charts of patients with type 2 diabetes treated solely with oral hypoglycemic agents were reviewed retrospectively. A1C, SMBG frequency, and frequency of online communication with an endocrinologist within the most recent 6-month period were used in the analyses. Regression analysis was used to determine correlations to A1C. For subsequent subgroup analysis, patients were separated into infrequent and frequent SMBG groups, defined as those who test on average once or less per day or twice or more per day. RESULTS: Although testing frequency did not correlate with A1C, higher reporting frequency correlated with lower A1C. Subgroup analysis of the frequent SMBG group showed a significantly lower A1C in frequent reporters when compared to infrequent reporters (N=118, p<0.05). This trend was not observed in the infrequent SMBG group (N=73, p=0.161). CONCLUSIONS: The inverse correlation between reporting frequency and A1C, as well as the significant difference in A1C only for the frequent testers, suggests that frequent SMBG has an effect on reducing A1C only when combined with regular, frequent communication of SMBG with a healthcare provider.

Determining starting basal rates of insulin infusion for insulin pump users: a comparison between methods.

OBJECTIVE: We aimed to assess the accuracy and safety of presently available methods of estimating starting basal insulin rates for patients with type 1 and 2 diabetes, and to compare them against an empirically derived standard basal rate and a newly developed regression formula. RESEARCH DESIGN AND METHODS: Data on 61 patients with type 1 diabetes on continuous subcutaneous insulin infusion (CSII) therapy and 34 patients with type 2 diabetes on CSII were reviewed. Patient data were first analyzed for correlations between initial patient parameters and final basal rates. Starting basal rates were then retrospectively calculated for these patients according to the weight-based method (WB-M), the total daily dose (TDD) of insulin method (TDD-M), a flat empiric value, and a new formula developed by regression analysis of clinical data. These 4 methods were subsequently compared in their accuracy and potential risk of hypoglycemia. RESULTS: For type 1 diabetes, patient weight and TDD of long-acting insulin correlated with final basal rates. Both the regression formula and the TDD-M appeared safer than the WB-M and empirical estimates. For type 2 diabetes, only patient TDD of long-acting insulin correlated with final basal rates. The regression formula was significantly more accurate for patients with type 2 diabetes overall, but the TDD-M estimate was marginally safer. CONCLUSIONS: The pre-existing TDD-M was found to be the safest presently recommended estimate of initial basal rates for pump initiation in both type 1 and 2 diabetes. The best-fit regression was found to have potential use for type 2 CSII initiation.