Ligne directrice canadienne pour la prise en charge clinique de la consommation d'alcool à risque élevé et du trouble d'utilisation de l'alcool.

CONTEXTE: Au Canada, on note que les équipes soignantes et les personnes qui bénéficieraient de soins ciblés connaissent peu les interventions fondées sur des données probantes pour la prise en charge clinique du trouble d'utilisation de l'alcool. Pour combler cette lacune, l'Initiative canadienne de recherche sur l'abus de substances a créé un comité national dans le but d'élaborer une ligne directrice pour la prise en charge clinique de la consommation d'alcool à risque élevé et du trouble lié à la consommation d'alcool. MÉTHODES: L'élaboration de cette ligne directrice s'est faite selon le processus ADAPTE, et est inspirée par une ligne directrice britanno-colombienne de 2019 pour le trouble lié à la consommation d'alcool. Un comité national de rédaction de la ligne directrice (composé de 36 membres de divers horizons, notamment des universitaires, des médecins, des personnes ayant ou ayant eu des expériences de consommation d'alcool et des personnes s'identifiant comme Autochtones ou Métis) a choisi les thèmes prioritaires, a passé en revue les données probantes et atteint un consensus relatif aux recommandations. Nous avons utilisé l'outil AGREE II (Appraisal of Guidelines for Research and Evaluation Instrument II) et les principes de divulgation des intérêts et de gestion des conflits lors du processus de rédaction des lignes directrices (Principles for Disclosure of Interests and Management of Conflicts in Guidelines) publiés en anglais par le Réseau international des lignes directrices (Guidelines International Network) pour nous assurer que la ligne directrice répondait aux normes internationales de transparence, de qualité élevée et de rigueur méthodologique. Nous avons évalué les recommandations finales à l'aide de l'approche GRADE (Grading of Recommendations Assessment, Development, and Evaluation). Les recommandations ont fait l'objet d'une revue externe par 13 spécialistes et parties prenantes d'ici et de l'étranger. RECOMMANDATIONS: La ligne directrice comprend 15 recommandations qui concernent le dépistage, le diagnostic, la prise en charge du sevrage et le traitement continu, y compris les interventions psychosociales, les pharmacothérapies et les programmes communautaires. Le comité de rédaction de la ligne directrice a reconnu la nécessité d'insister sur la sous-utilisation des interventions qui pourraient être bénéfiques et sur les modes de prescription et autres pratiques d'usage courant qui ne reposent pas sur des données probantes et pourraient aggraver les effets de la consommation d'alcool. INTERPRÉTATION: La ligne directrice se veut une ressource à l'intention des médecins, des responsables des orientations politiques et des membres des équipes cliniques et autres, de même que des personnes, des familles et des communautés affectées par la consommation d'alcool. Ces recommandations proposent un cadre fondé sur des données probantes pour alléger le lourd fardeau du trouble d'utilisation de l'alcool au Canada et combler les besoins en matière de traitements et de soins.

Examining inequities in access to opioid agonist treatment (OAT) take-home doses (THD): A Canadian OAT guideline synthesis and systematic review.

BACKGROUND: Daily supervised Opioid Agonist Treatment (OAT) medication has been identified as a barrier to treatment retention. Canadian OAT guidelines outline take-home dose (THD) criteria, yet, OAT prescribers use their clinical judgement to decide whether an individual is 'clinically stable' to receive THD. There is limited information regarding whether these decisions may result in inequitable access to THD, including in the context of updated COVID-19 guidance. The current Canadian OAT THD guideline synthesis and systematic review aimed to address this knowledge gap. METHODS: This systematic review included a two-pronged approach. First, we searched available academic literature in Embase, Medline, and PsychINFO up until October 12th, 2022, to identify studies that compared characteristics of individuals on OAT who had and had not been granted access to THD to explore potential inequities in access. Next, we identified all Canadian national and provincial OAT guidelines through a semi-structured grey literature search (conducted between September-October 2022) and extracted all THD 'stability' and allowances/timeline criteria to compare against characteristics identified in the literature search. Data from both review arms were synthesized and narratively presented. RESULTS: A total of n = 56 guidelines and n = 7 academic studies were included. The systematic review identified a number of patient characteristics such as age, sex, race/ethnicity, marital status, housing, employment, neighborhood income, drug use, mental health, health service utilization, as well as treatment duration that were associated with differential access to THD. The Canadian OAT THD guideline synthesis identified many of these same characteristics as 'stability' criteria, underscoring the potential for Canadian OAT guidelines to result in inequitable access to THD. CONCLUSIONS: This two-pronged literature review demonstrated that current guidelines likely contribute to inequitable OAT THD access due primarily to inconsistent 'stability' criteria across guidelines. More research is needed to understand differential OAT THD access with a focus on prescriber decision-making and evaluating associated treatment and safety outcomes. The development of a client-centered, equity-focused, and evidence-informed decision making framework that incorporates more clear definitions of 'stability' criteria and indications for prescriber discretion is warranted.

Antiracist training programs for mental health professionals: A scoping review.

Racism has been shown to be directly deleterious to the mental health care received by minoritized peoples. In response, some mental health institutions have pledged to provide antiracist mental health care, which includes training mental health care professionals in this approach. This scoping review aimed to synthesize the existing published material on antiracist training programs among mental health care professionals. To identify studies, a comprehensive search strategy was developed and executed by a research librarian in October 2022 across seven databases (APA PsycInfo, Education Source, Embase, ERIC, MEDLINE, CINAHL, and Web of Science). Subject headings and keywords relating to antiracist training as well as to mental health professionals were used and combined. There were 7186 studies generated by the initial search and 377 by the update search, 30 were retained and included. Findings revealed four main antiracist competencies to develop in mental health professionals: importance of understanding the cultural, social, and historical context at the root of the mental health problems; developing awareness of individual biases, self-identity and privilege; recognizing oppressive and racism-sustaining behaviors in mental health care settings; and, employing antiracist competencies in therapy. Professionals who have taken trainings having the main components have developed skills on the interconnectedness between racialized groups' mental health and the cultural, religious, social, historical, economic, and political issues surrounding race, necessary for successful clinical practice and for providing anti-racist mental health care. This scoping review presents a summary of the essential antiracist competencies drawn from the literature which must be applied in a mental health care setting, to improve help seeking behaviors, and reduce distrust in mental health care professionals and settings.

A Rapid Access Brief Psychotherapy Intervention to Respond to Healthcare Workers in Ontario Whose Mental Health was Negatively Impacted During the COVID-19 Pandemic.

OBJECTIVE: Although the coronavirus disease 2019 (COVID-19) pandemic has had widespread negative impacts on the mental health of healthcare workers (HCWs), there has been little research on psychological interventions during the pandemic for this population. The current study examines whether a brief coping-focused treatment intervention delivered in a virtual individual format would be associated with positive changes in Canadian HCWs' mental health during the pandemic. METHOD: Three hundred and thirty-three HCWs receiving the intervention at 3 large specialty tertiary care hospitals in Ontario, Canada, completed measures of anxiety, depression, perceived stress, work/social impairment, insomnia and fear of COVID-19. After completing treatment, HCWs rated their satisfaction with the treatment. RESULTS: The intervention was associated with large effect size improvements in anxiety, depression, perceived stress, insomnia and fear of COVID-19, and moderate effect size improvements in work/social impairment. At treatment session 1, prior mental health diagnosis and treatment were both significantly correlated with depression, anxiety, and work/social impairment scores. Secondary analyses of data from one of the sites revealed that treatment-related changes in anxiety, depression, perceived stress and work/social impairment were independent of age, gender, occupational setting, profession and the presence of a previous mental health diagnosis or treatment, with the exception that nurses improved at a slightly greater rate than other professions in terms of work/social impairment. HCWs were highly satisfied with the treatment. CONCLUSIONS: A large number of HCWs experiencing significant distress at baseline self-referred for assistance. Timely and flexible access to a brief virtual coping-focused intervention was associated with improvements in symptoms and impairment, and treatment response was largely unrelated to demographic or professional characteristics. Short-term psychological interventions for HCWs during a pandemic may have a highly positive impact given their association with improvement in various aspects of HCWs' mental health improvement.

Mortality in adolescents and young adults following a first presentation to the emergency department for alcohol.

BACKGROUND AND METHODS: We conducted a population-based, retrospective cohort study of first-time emergency department (ED) visits in adolescents and young adults (AYA) due to alcohol and compared mortality to AYA with nonalcohol ED visits between 2009 and 2015 using standardized all-cause mortality ratios (age, sex, income, and rurality). We described the cause of death for AYA and examined the association between clinical factors and mortality rates in the alcohol cohort using proportional hazard models. RESULTS: A total of 71,776 AYA had a first-time ED visit due to alcohol (56.1% male, mean age 20.7 years) between 2009 and 2015, representing 3.3% of the 2,166,838 AYA with an ED visit in this time period. At 1 year, there were 2396 deaths, 248 (10.3%) following an ED visit related to alcohol. First-time alcohol ED visits were associated with a threefold higher risk in mortality at 1 year (0.35% vs. 0.10%, adjusted hazard ratio [aHR] 3.07, 95% confidence interval [CI] 2.69-3.51). Mortality was associated with age 25-29 years (aHR 3.88, 95% CI 2.56-5.86), being male (aHR 1.98, 95% CI 1.49-2.62), having a history of mental health or substance use (aHR 3.22, 95% CI 1.64-6.32), cause of visit being withdrawal/dependence (aHR 2.81, 95% CI 1.96-4.02), and having recurrent ED visits (aHR 1.97, 95% CI 1.27-3.05). Trauma (42.7%), followed by poisonings from drugs other than opioids (38.3%), and alcohol (28.6%) were the most common contributing causes of death. CONCLUSION: Incident ED visits due to alcohol in AYA are associated with a high risk of 1-year mortality, especially in young adults, those with concurrent mental health or substance use disorders, and those with a more severe initial presentation. These findings may help inform the need and urgency for follow-up care in this population.

Service-level barriers to and facilitators of accessibility to treatment for problematic alcohol use: a scoping review.

Introduction: Services to treat problematic alcohol use (PAU) should be highly accessible to optimize treatment engagement. We conducted a scoping review to map characteristics of services for the treatment of PAU that have been reported in the literature to be barriers to or facilitators of access to treatment from the perspective of individuals with PAU. Methods: A protocol was developed a priori, registered, and published. We searched MEDLINE®, Embase, the Cochrane Library, and additional grey literature sources from 2010 to April 2022 to identify primary qualitative research and surveys of adults with current or past PAU requiring treatment that were designed to identify modifiable characteristics of PAU treatment services (including psychosocial and pharmacologic interventions) that were perceived to be barriers to or facilitators of access to treatment. Studies of concurrent PAU and other substance use disorders were excluded. Study selection was performed by multiple review team members. Emergent barriers were coded and mapped to the accessibility dimensions of the Levesque framework of healthcare access, then descriptively summarized. Results: One-hundred-and-nine included studies reported an extensive array of unique service-level barriers that could act alone or together to prevent treatment accessibility. These included but were not limited to lack of an obvious entry point, complexity of the care pathway, high financial cost, unacceptably long wait times, lack of geographically accessible treatment, inconvenient appointment hours, poor cultural/demographic sensitivity, lack of anonymity/privacy, lack of services to treat concurrent PAU and mental health problems. Discussion: Barriers generally aligned with recent reviews of the substance use disorder literature. Ranking of barriers may be explored in a future discrete choice experiment of PAU service users. The rich qualitative findings of this review may support the design of new or modification of existing services for people with PAU to improve accessibility. Systematic Review Registration: Open Science Framework doi: 10.17605/OSF.IO/S849R.

Rapid Access Addiction Medicine Clinics for People With Problematic Opioid Use.

Importance: New approaches are needed to provide care for individuals with problematic opioid use (POU). Rapid access addiction medicine (RAAM) clinics offer a flexible, low-barrier, rapid access care model for this population. Objective: To assess the associations of RAAM clinics with emergency department (ED) visits, hospitalizations, and mortality for people with POU. Design, Setting, and Participants: A retrospective cohort study involving a matched control group was performed using health administrative data from Ontario, Canada. Anonymized data from 4 Ontario RAAM clinics (cities of Ottawa, Toronto, Oshawa, and Sudbury) were linked with health administrative data. Analyses were performed on a cohort of individuals who received care at participating RAAM clinics and geographically matched controls who did not receive care at a RAAM clinic. All visits occurred between October 2, 2017, and October 30, 2019, and data analyses were completed in spring 2023. A propensity score-matching approach was used to balance confounding factors between groups, with adjustment for covariates that remained imbalanced after matching. Exposures: Individuals who initiated care through the RAAM model (including assessment, pharmacotherapy, brief counseling, harm reduction, triage to appropriate level of care, navigation to community services and primary care, and related care) were compared with individuals who did not receive care through the RAAM model. Main Outcomes and Measures: The primary outcome was a composite measure of ED visits for any reason, hospitalization for any reason, and all-cause mortality (all measured up to 30 days after index date). Outcomes up to 90 days after index date, as well as outcomes looking at opioid-related ED visits and hospitalizations, were also assessed. Results: In analyses of the sample of 876 patients formed using propensity score matching, 440 in the RAAM group (mean [SD] age, 36.5 [12.6] years; 276 [62.7%] male) and 436 in the control group (mean [SD] age, 36.8 [13.8] years; 258 [59.2%] male), the pooled odds ratio (OR) for the primary, 30-day composite outcome of all-cause ED visit, hospitalization, or mortality favored the RAAM model (OR, 0.68; 95% CI, 0.50-0.92). Analysis of the same outcome for opioid-related reasons only also favored the RAAM intervention (OR, 0.47; 95% CI, 0.29-0.76). Findings for the individual events of hospitalization, ED visit, and mortality at both 30-day and 90-day follow-up also favored the RAAM model, with comparisons reaching statistical significance in most cases. Conclusions and Relevance: In this cohort study of individuals with POU, RAAM clinics were associated with reductions in ED visits, hospitalizations, and mortality. These findings provide valuable evidence toward a broadened adoption of the RAAM model in other regions of North America and beyond.

Canadian guideline for the clinical management of high-risk drinking and alcohol use disorder.

BACKGROUND: In Canada, low awareness of evidence-based interventions for the clinical management of alcohol use disorder exists among health care providers and people who could benefit from care. To address this gap, the Canadian Research Initiative in Substance Misuse convened a national committee to develop a guideline for the clinical management of high-risk drinking and alcohol use disorder. METHODS: Development of this guideline followed the ADAPTE process, building upon the 2019 British Columbia provincial guideline for alcohol use disorder. A national guideline committee (consisting of 36 members with diverse expertise, including academics, clinicians, people with lived and living experiences of alcohol use, and people who self-identified as Indigenous or Métis) selected priority topics, reviewed evidence and reached consensus on the recommendations. We used the Appraisal of Guidelines for Research and Evaluation Instrument (AGREE II) and the Guidelines International Network's Principles for Disclosure of Interests and Management of Conflicts to ensure the guideline met international standards for transparency, high quality and methodological rigour. We rated the final recommendations using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) tool; the recommendations underwent external review by 13 national and international experts and stakeholders. RECOMMENDATIONS: The guideline includes 15 recommendations that cover screening, diagnosis, withdrawal management and ongoing treatment, including psychosocial treatment interventions, pharmacotherapies and community-based programs. The guideline committee identified a need to emphasize both underused interventions that may be beneficial and common prescribing and other practice patterns that are not evidence based and that may potentially worsen alcohol use outcomes. INTERPRETATION: The guideline is intended to be a resource for physicians, policymakers and other clinical and nonclinical personnel, as well as individuals, families and communities affected by alcohol use. The recommendations seek to provide a framework for addressing a large burden of unmet treatment and care needs for alcohol use disorder within Canada in an evidence-based manner.

Psychosocial and pharmacologic interventions for problematic methamphetamine use: Findings from a scoping review of the literature.

RATIONALE: Methamphetamine use and related harms have risen at alarming rates. While several psychosocial and pharmacologic interventions have been described in the literature, there is uncertainty regarding the best approach for the management of methamphetamine use disorder (MUD) and problematic methamphetamine use (PMU). We conducted a scoping review of recent systematic reviews (SR), clinical practice guidelines (CPG), and primary controlled studies of psychosocial and pharmacologic treatments for MUD/PMU. METHODS: Guided by an a priori protocol, electronic database search updates (e.g., MEDLINE, Embase) were performed in February 2022. Screening was performed following a two-stage process, leveraging artificial intelligence to increase efficiency of title and abstract screening. Studies involving individuals who use methamphetamine, including key subgroups (e.g. those with mental health comorbidities; adolescents/youths; gay, bisexual, and other men who have sex with men) were sought. We examined evidence related to methamphetamine use, relapse, use of other substances, risk behaviors, mental health, harms, and retention. Figures, tables and descriptive synthesis were used to present findings from the identified literature. RESULTS: We identified 2 SRs, one CPG, and 54 primary studies reported in 69 publications that met our eligibility criteria. Amongst SRs, one concluded that psychostimulants had no effect on methamphetamine abstinence or treatment retention while the other reported no effect of topiramate on cravings. The CPG strongly recommended psychosocial interventions as well as self-help and family support groups for post-acute management of methamphetamine-related disorders. Amongst primary studies, many interventions were assessed by only single studies; contingency management was the therapy most commonly associated with evidence of potential effectiveness, while bupropion and modafinil were analogously the most common pharmacologic interventions. Nearly all interventions showed signs of potential benefit on at least one methamphetamine-related outcome measure. DISCUSSION: This scoping review provides an overview of available interventions for the treatment of MUD/PMU. As most interventions were reported by a single study, the effectiveness of available interventions remains uncertain. Primary studies with longer durations of treatment and follow-up, larger sample sizes, and of special populations are required for conclusive recommendations of best approaches for the treatment of MUD/PMU.

From design to action: participatory approach to capacity building needs for local overdose response plans.

BACKGROUND: In response to the rise in opioid-related deaths, communities across Ontario have developed opioid or overdose response plans to address issues at the local level. Public Health Ontario (PHO) leads the Community Opioid / Overdose Capacity Building (COM-CAP) project, which aims to reduce overdose-related harms at the community level by working with communities to identify, develop, and evaluate capacity building supports for local needs around overdose planning. The 'From Design to Action' co-design workshop used a participatory design approach to engage communities in identifying the requirements for capacity building support. METHODS: A participatory approach (co-design) provided opportunity for collaborative discussion around capacity building needs at the community level. The co-design workshop included three structured collaborative activities to 1) prioritize scenarios that illustrated various challenges associated with community overdose response planning, 2) prioritize the challenges within each scenario and 3) prioritize the supports to address each of these challenges. It was conducted with fifty-two participants involved in opioid/overdose-related response plans in Ontario. Participatory materials were informed by the results of a situational assessment (SA) data gathering process, including survey, interview, and focus group data. A voting system, including dot stickers and discussion notes, was applied to identify priority supports and delivery mechanisms. RESULTS: At the workshop, key challenges and top-priority supports were identified, for development and implementation. The prioritized challenges were organized into five categories of capacity building supports addressing: 1) stigma & equity; 2) trust-based relationships, consensus building & on-going communication; 3) knowledge development & on-going access to information and data; 4) tailored strategies and plan adaptation to changing structures and local context; and 5) structural enablers and responsive governance. CONCLUSION: Using a participatory approach, the workshop provided an opportunity for sharing, generating, and mobilizing knowledge to address research-practice gaps at the community level for opioid response planning. The application of health design methods such as the 'From Design to Action' co-design workshop supports teams to gain a deeper understanding of needs for capacity building as well as illustrating the application of participatory approaches in identifying capacity building needs for complex public health issues such as the overdose crisis.

Impacts of medical and non-medical cannabis on the health of older adults: Findings from a scoping review of the literature.

BACKGROUND: Cannabis legalization has enabled increased consumption in older adults. Age-related mental, physical, and physiological changes may lead to differences in effects of cannabis in older adults compared to younger individuals. OBJECTIVE: To perform a scoping review to map the evidence regarding the health effects of cannabis use for medical and non-medical purposes in older adults. METHODS: Electronic databases (MEDLINE, Embase, PsycINFO, Cochrane Library) were searched for systematic reviews (SRs), randomized controlled trials (RCTs) and non-randomized/observational studies (NRSs) assessing the health effects and associations of cannabis use (medical or non-medical) in adults ≥ 50 years of age. Included studies met age-related inclusion criteria or involved a priori identified health conditions common among older adults. Records were screened using a liberal accelerated approach and data charting was performed independently by two reviewers. Descriptive summaries, structured tables, effect direction plots and bubble plots were used to synthesize study findings. FINDINGS: From 31,393 citations, 133 publications describing 134 unique studies (26 SRs, 36 RCTs, 72 NRSs) were included. Medical cannabis had inconsistent therapeutic effects in specific patient conditions (e.g., end-stage cancer, dementia), with a number of studies suggesting possible benefits while others found no benefit. For medical cannabis, harmful associations outnumbered beneficial, and RCTs reported more negative effects than NRSs. Cannabis use was associated with greater frequencies of depression, anxiety, cognitive impairment, substance use and problematic substance use, accidents/injuries, and acute healthcare use. Studies often were small, did not consistently assess harms, and did not adjust for confounding. DISCUSSION: The effects of medical cannabis are inconsistent within specific patient conditions. For older adults, generally, the available evidence suggests cannabis use may be associated with greater frequencies of mental health issues, substance use, and acute healthcare use, and the benefit-to-risk ratio is unclear. Studies with a balanced assessment of benefits and harms may guide appropriate public health messaging to balance the marketing pressures of cannabis to older adults.

Supporting community overdose response planning in Ontario, Canada: Findings from a situational assessment.

BACKGROUND: Many communities across North America are coming together to develop comprehensive plans to address and respond to the escalating overdose crisis, largely driven by an increasingly toxic unregulated drug supply. As there is a need to build capacity for successful implementation, the objective of our mixed methods study was to identify the current planning and implementation practices, needs, and priority areas of support for community overdose response plans in Ontario, Canada. METHODS: We used a situational assessment methodology to collect data on current planning and implementation practices, needs, and challenges related to community overdose response plans in Ontario, consisting of three components. Between November 2019 to February 2020, we conducted ten semi-structured key informant interviews, three focus groups with 25 participants, and administered an online survey (N = 66). Purposeful sampling was used to identify professionals involved in coordinating, supporting, or partnering on community overdose response plans in jurisdictions with relevant information for Ontario including other Canadian provinces and American states. Key informants included evaluators, representatives involved in centralised supports, as well as coordinators and partners on community overdose response plans. Focus group participants were coordinators or leads of community overdose response plans in Ontario. RESULTS: Sixty-six professionals participated in the study. The current planning and implementation practices of community overdose response plans varied in Ontario. Our analysis generated four overarching areas for needs and support for the planning and implementation of community overdose response plans: 1) data and information; 2) evidence and practice; 3) implementation/operational factors; and 4) partnership, engagement, and collaboration. Addressing stigma and equity within planning and implementation of community overdose response plans was a cross-cutting theme that included meaningful engagement of people with living and lived expertise and meeting the service needs of different populations and communities. CONCLUSIONS: Through exploring the needs and related supports for community overdose response plans in Ontario, we have identified key priority areas for building local capacity building to address overdose-related harms. Ongoing development and refinement, community partnership, and evaluation of our project will highlight the influence of our supports to advance the capacity, motivation, and opportunities of community overdose response plans.

Resting State EEG Activity Related to Impulsivity in People with Prescription Opioid Use Disorder.

Previous studies on EEG activity in prescription opioid use disorder (OUD) have reported neuronal dysfunction related to heroin use, most consistently reflected by increases in ß-brain oscillations. As similar research has yet to examine EEG associated with non-medical use of prescription opioid and as inhibitory deficits are associated with OUD, this pilot study compared quantitative EEGs of 18 patients with prescription OUD and 18 healthy volunteers and assessed relationships between oscillatory activity and impulsivity with the Barratt Impulsiveness Scale (BIS-11). Spectral EEGs showed greater amplitude density in ß1, ß2, and ß3 frequencies across frontal, temporal-central and posterior recording areas in patients. Similar abnormal amplitude density increases were seen in δ but not in θ or α frequency bands. Patients exhibited greater scores (impaired impulse control) on BIS-11 subscales (attention, motor, self-control) and impairment of these impulsive subtypes was associated with increases in ß and δ oscillations. In patients, ß1, ß2, and δ activity was positively associated with disorder severity. Taken together, the results suggest that altered brain oscillations in persons with prescription OUD show some similarities with reported oscillatory changes in heroin use and may indicate a chronic state of imbalance in neuronal networks regulating impulsive and inhibitory control systems.

Evaluating how has care been affected by the Ontario COVID-19 Opioid Agonist Treatment Guidance: Patients' and prescribers' experiences with changes in unsupervised dosing.

BACKGROUND: The COVID-19 pandemic has exacerbated the opioid crisis. Opioid-related deaths have increased and access to treatment services, including opioid agonist treatment (OAT), has been disrupted. The Ontario COVID-19 OAT Treatment Guidance document was developed to facilitate access to OAT and continuity of care during the pandemic, while supporting physical distancing measures. In particular, the Guidance expanded access to unsupervised OAT dosing. It is important to evaluate the changes in unsupervised OAT dosing after the release of the Ontario COVID-19 OAT Guidance based on patients' and prescribers' reports. METHOD: Online questionnaires were developed collaboratively with people with lived and living expertise, prescribers, clinical experts, and researchers. Patients (N = 402) and prescribers (N = 100) reported their experiences with changes in unsupervised dosing during the first six months of the pandemic. RESULTS: Many patients (57%) reported receiving additional unsupervised OAT doses (i.e., take away doses). Patients who received additional unsupervised doses were not significantly more likely to report adverse health outcomes compared to patients who did not receive additional unsupervised doses. Patients with additional unsupervised doses and prescribers agreed that changes in OAT care were positive (e.g., reported an improved patient-prescriber relationship and more openness between patient and prescriber). Prescribers and some patients reported the need for continued flexibility in unsupervised doses after the pandemic restrictions lift. CONCLUSIONS: Results support the need to re-evaluate historical approaches to OAT care delivery, particularly unsupervised doses. It is crucial to implement policies, regulations, and supports to reduce barriers to OAT care during the pandemic and once the pandemic response restrictions are eased. Flexibility in OAT care delivery, particularly unsupervised dosing, will be key to providing patient-centred care for persons with opioid use disorder.

Psychological and Demographic Determinants of Substance Use and Mental Health During the COVID-19 Pandemic.

Background: Alcohol consumption and distress have increased among Canadians since the start of the COVID-19 pandemic. Methods: We examined whether sociodemographic and COVID-19-related worries are associated with various combinations of alcohol consumption and comorbid psychological distress variables among a Canadian sample of adults. Data were derived from a sample of Canadian adults (N = 1,005, 49.6% female) who participated in an online survey in May 2020. Four multivariate ordinal logistic regression models were used to estimate the odds of binge drinking, increased alcohol consumption during the pandemic, and psychological distress. Predictor variables used in the analyses included self-reported sociodemographic characteristics, financial worries, COVID-19 impact on work, and worrying about getting ill. Results: Women were found to have higher odds of increased drinking and anxiety. Also being divorced, separated, or widowed was associated with higher odds of binge drinking and anxiety, and binge drinking and depression. Furthermore, being 60 or older was associated with lower odds of binge drinking and depression and increased drinking and depression, as well as lower odds of increased drinking and depression and increased drinking and anxiety. High income groups were associated with higher odds of binge drinking, increased drinking, and mental distress. Compared to those less worried, being very worried about finances were associated with higher odds of binge drinking and anxiety, increased drinking and anxiety, and increased drinking and depression. Also, being very worried about getting ill with COVID was associated with higher odds of binge drinking and anxiety and increased drinking and anxiety. Conclusion: Our findings identify several demographic and COVID-related worries for increased odds of alcohol intake and co-morbid psychological distress during the COVID-19 pandemic, including identifying as a woman, high income groups, being divorced, separated or widowed, and experiencing financial worries and COVID illness worries. These characteristics should be considered when developing prevention and treatment programs for adults with problematic alcohol use and comorbid anxiety and depression.

Ending the Pandemic: How Behavioural Science Can Help Optimize Global COVID-19 Vaccine Uptake.

Governments, public health officials and pharmaceutical companies have all mobilized resources to address the COVID-19 pandemic. Lockdowns, social distancing, and personal protective behaviours have been helpful but have shut down economies and disrupted normal activities. Vaccinations protect populations from COVID-19 and allow a return to pre-pandemic ways of living. However, vaccine development, distribution and promotion have not been sufficient to ensure maximum vaccine uptake. Vaccination is an individual choice and requires acceptance of the need to be vaccinated in light of any risks. This paper presents a behavioural sciences framework to promote vaccine acceptance by addressing the complex and ever evolving landscape of COVID-19. Effective promotion of vaccine uptake requires understanding the context-specific barriers to acceptance. We present the AACTT framework (Action, Actor, Context, Target, Time) to identify the action needed to be taken, the person needed to act, the context for the action, as well as the target of the action within a timeframe. Once identified a model for identifying and overcoming barriers, called COM-B (Capability, Opportunity and Motivation lead to Behaviour), is presented. This analysis identifies issues associated with capability, opportunity and motivation to act. These frameworks can be used to facilitate action that is fluid and involves policy makers, organisational leaders as well as citizens and families.

Interventions to Influence Opioid Prescribing Practices for Chronic Noncancer Pain: A Systematic Review and Meta-Analysis.

CONTEXT: This study is a systematic review of interventions to improve adherence to guideline recommendations for prescribing opioids for chronic noncancer pain. EVIDENCE ACQUISITION: Investigators searched CINAHL, Embase, MEDLINE, PsycINFO, the Cochrane Library, and Joanna Briggs Institute Evid Based Pract database from inception until June 3, 2019. Interventional studies to improve adherence to recommendations made by opioid guidelines for chronic noncancer pain in North America were eligible if outcomes included adherence to guideline recommendations or change in quantity of opioids prescribed. Data were extracted independently and in duplicate. Quantitative synthesis was performed using random effects meta-analysis. Confidence in evidence was determined using the Grades of Recommendation, Assessment, Development, and Evaluation. EVIDENCE SYNTHESIS: A total of 20 studies (8 controlled and 12 prospective cohort) involving 1,491 providers and 72 clinics met inclusion. Interventions included education, audit and feedback, interprofessional support, shared decision making, and multifaceted strategies. Multifaceted interventions improved the use of urine drug testing (n=2, or =2.31, 95% CI=1.53, 3.49, z=3.98, p<0.01; high-certainty evidence), treatment agreements (n=2, or =1.96, 95% CI=1.47, 2.61, z=4.56, p<0.01; moderate-certainty evidence), and mental health screening (n=2, 2.57-fold, 95% CI=1.56, 4.24, z=2.32, p=0.02; low-certainty evidence) when prescribing opioids for chronic noncancer pain. Very low-certainty evidence suggests that several interventions improved the use of treatment agreements, urine drug testing, and prescription drug monitoring programs. CONCLUSIONS: Mostly very low-certainty evidence supports a number of interventions for improving adherence to risk management strategies when prescribing opioids for chronic noncancer pain; however, the effect on patient important outcomes (e.g., overdose, addiction, death) is uncertain.

A call for consensus in defining efficacy in clinical trials for opioid addiction: combined results from a systematic review and qualitative study in patients receiving pharmacological assisted therapy for opioid use disorder.

BACKGROUND: Given the complex nature of opioid addiction treatment and the rising number of available opioid substitution and antagonist therapies (OSAT), there is no 'gold standard' measure of treatment effectiveness, and each successive trial measures a different set of outcomes which reflect success in arbitrary or opportune terms. We sought to describe the variation in current outcomes employed across clinical trials for opioid addiction, as well as determine whether a discrepancy exists between the treatment targets that patients consider important and how treatment effectiveness is measured in the literature. METHODS: We searched nine commonly used databases (e.g., EMBASE, MEDLINE) from inception to August 1, 2015. Outcomes used across trials were extracted and categorized according to previously established domains. To evaluate patient-reported goals of treatment, semi-structured interviews were conducted with 18 adults undergoing methadone treatment. RESULTS: We identified 60 trials eligible for inclusion. Once outcomes were categorized into eight broad domains (e.g., abstinence/substance abuse), we identified 21 specific outcomes with furthermore 53 subdomains and 118 measurements. Continued opioid use and treatment retention were the most commonly reported measures (46%, n = 28). The majority of patients agreed that abstinence from opioids was a primary goal in their treatment, although they also stressed goals under-reported in clinical trials. CONCLUSIONS: There is inconsistency in the measures used to evaluate the effectiveness of OSATs. Individual and population level decision making is being guided by a standard of effect considered useful to researchers yet in direct conflict with what patients deem important. TRIAL REGISTRATION: PROSPERO, CRD42013006507.

Healthcare provider knowledge, attitudes, beliefs, and practices surrounding the prescription of opioids for chronic non-cancer pain in North America: protocol for a mixed-method systematic review.

BACKGROUND: Evidence from diverse areas of medicine (e.g., cardiovascular disease, diabetes) indicates that healthcare providers (HCPs) often do not adhere to clinical practice guidelines (CPGs) despite a clear indication to implement recommendations-a phenomenon commonly termed clinical inertia. There are a variety of reasons for clinical inertia, but HCP-related factors (e.g., knowledge, motivation, agreement with guidelines) are the most salient and amenable to intervention aimed to improve adherence. CPGs have been developed to support the safe and effective prescription of opioid medication for the management of chronic non-cancer pain. The extent of physician uptake and adherence to such guidelines is not yet well understood. The purpose of this review is to synthesize the published evidence about knowledge, attitudes, beliefs, and practices that HCPs hold regarding the prescription of opioids for chronic non-cancer pain. METHODS: An experienced information specialist will perform searches of CINAHL, Embase, MEDLINE, and PsycINFO bibliographic databases. The Cochrane library, PROSPERO, and the Joanna Briggs Institute will be searched for systematic reviews. Searches will be performed from inception to the present. Quantitative and qualitative study designs that report on HCP knowledge, attitudes, beliefs, or practices in North America will be eligible for inclusion. Studies reporting on interventions to improve HCP adherence to opioid prescribing CPGs will also be eligible for inclusion. Two trained graduate-level research assistants will independently screen articles for inclusion, perform data extraction, and perform risk of bias and quality assessment using recommended tools. Confidence in qualitative evidence will be evaluated using the Grades of Recommendation, Assessment, Development, and Evaluation-Confidence in the Evidence from Qualitative Reviews (GRADE-CERQual) approach. Confidence in quantitative evidence will be assessed using the GRADE approach. DISCUSSION: The ultimate goal of this work is to support interventions aiming to optimize opioid prescribing practices in order to prevent opioid-related morbidity and mortality without restricting a HCP's ability to select the most appropriate treatment for an individual patient. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018091640 .

Hepatitis C patient communication source and modality preferences in the direct-acting antiviral era.

Background: Although hepatitis C virus (HCV) treatment has improved dramatically, decision making related to treatment continues to be complex and challenging. Little data exists regarding patient information needs and preferences in the direct-acting antiviral (DAA) era. Methods: We evaluated patient-perceived information needs and preferences when making HCV treatment decisions. A cross-sectional survey was conducted at two Ottawa-based sites: a hospital-located outpatient viral hepatitis clinic, and a community-based HCV patient support program. Results: One hundred and seventeen patients completed the survey: the mean age was 52.1 years (range 23 to 78), and 64% were male, 81.5% were White, 48.6% were on disability support or leave, and 60.3% had a high school education or less. Although traditional sources of health information (e.g., direct communication with health care providers) remain preferred by most, a range of preferences were reported including utilization of newer technologies (e.g., emails, text messages). The telephone was rated as the preferred method of contact for medication reminders, with daily or weekly communication reported as most helpful. White participants, those more highly educated, and those with a higher income all indicated a greater acceptability for e-mail and/or text message communication for medication and appointment reminders. Conclusions: There is no single preferred source or method of communicating with patients. These findings indicate that a tailored multi-pronged approach, including newer technologies, is more likely to effectively educate and communicate with the heterogeneous population of individuals living with HCV.