Opioid use disorder and type 2 diabetes mellitus: Effect of participation in buprenorphine-naloxone substitution programs on glycemic control.

OBJECTIVE: To measure the effect of buprenorphine-naloxone as opioid substitution therapy on glycemic control in patients with type 2 diabetes mellitus and opioid use disorder. DESIGN: Retrospective cohort study and secondary data analysis. SETTING: Northwestern Ontario. PARTICIPANTS: Patients with diabetes receiving opioid substitution therapy, as well as patients with diabetes only, who live in 6 remote First Nations communities. MAIN OUTCOME MEASURES: Glycated hemoglobin A1c values during a 2-year time period in the 2 groups. RESULTS: Over a 2-year period, there was an absolute decrease of 1.20% in mean glycated hemoglobin A1c values in patients with diabetes who also received opioid substitution therapy, compared with patients with diabetes who were not being treated for opioid dependence, whose values rose by 0.02%. CONCLUSION: Patients with diabetes who also suffer from opioid use disorder achieve significant (P = .011) improvement in glycemic control when treated with buprenorphine-naloxone substitution therapy compared with other patients with diabetes. Treating opioid use disorder with buprenorphine-naloxone substitution therapy has an unintended positive effect on diabetes management.

Evaluation of 6 remote First Nations community-based buprenorphine programs in northwestern Ontario: Retrospective study.

OBJECTIVE: To evaluate established opioid addiction treatment programs that use traditional healing in combination with buprenorphine-naloxone maintenance treatment in 6 First Nations communities in the Sioux Lookout region of northwestern Ontario. DESIGN: Retrospective cohort study. SETTING: Six First Nations communities in northwestern Ontario. PARTICIPANTS: A total of 526 First Nations participants in opioid-dependence treatment programs. INTERVENTION: Buprenorphine-naloxone substitution therapy and First Nations healing programming. MAIN OUTCOME MEASURES: Retention rates and urine drug screening (UDS) results. RESULTS: Treatment retention rates at 6, 12, and 18 months were 84%, 78%, and 72%, respectively. We estimate that the rate at 24 months will also be more than 70%. The UDS programming varied and was implemented in only 1 community. Initially urine testing was voluntary and it then became mandatory. Screening with either method found the proportion of urine samples with negative results for illicit opioids ranged between 84% and 95%. CONCLUSION: The program's treatment retention rates and negative UDS results were higher than those reported for most methadone and buprenorphine-naloxone programs, despite a patient population where severe posttraumatic stress disorder is endemic, and despite the programs' lack of resources and addiction expertise. Community-based programs like these overcome the initial challenge of cultural competence. First Nations communities in other provinces should establish their own buprenorphinenaloxone programs, using local primary care physicians as prescribers. Sustainable core funding is needed for programming, long-term aftercare, and trauma recovery for such initiatives.

Observational study of the safety of buprenorphine+naloxone in pregnancy in a rural and remote population.

OBJECTIVES: To describe the effect of in utero exposure to the buprenorphine+naloxone combination product in a rural and remote population. SETTING: A district hospital that services rural and remote, fly-in communities in Northwestern Ontario, Canada. PARTICIPANTS: A retrospective cohort study was conducted of 855 mother infant dyads between 1 July 2013 and 30 June 2015. Cases included all women who had exposure to buprenorphine+naloxone during pregnancy (n=62). 2 control groups were identified; the first included women with no opioid exposure in pregnancy (n=618) and the second included women with opioid exposure other than buprenorphine+naloxone (n=159). Women were excluded if they had multiple pregnancy or if they were part of a methadone programme (n=16). The majority of women came from Indigenous communities. OUTCOMES: The primary outcomes were birth weight, preterm delivery, congenital anomalies and stillbirth. Secondary neonatal outcomes included gestational age at delivery, Apgar scores at 1 and 5 min, NAS Score >7 and treatment for neonatal abstinence syndrome (NAS). Secondary maternal outcomes included the number of caesarean sections, postpartum haemorrhages, out of hospital deliveries and transfer of care to tertiary centres. RESULTS: No difference was found in the primary outcomes or in the Apgar score and caesarean section rate between in utero buprenorphine+naloxone exposure versus no opioid exposure in pregnancy. Compared to women taking other opioids, women taking buprenorphine+naloxone had higher birthweight babies (p=0.001) and less exposure to marijuana (p<0.001) during pregnancy. CONCLUSIONS: Retrospective data suggest that there likely is no harm from taking buprenorphine+naloxone opioid agonist treatment in pregnancy. Larger, prospective studies are needed to further assess safety.

Respect for other selves.

Philosophers have mostly advocated that advance directives should bear the same authority, with regard to refusal of life-extending treatment, as a patient's contemporaneous consent or refusal. Such authors typically support this position through a theory of persistent personal identity. I agree that the loss of mental competence does not render someone a moral stranger to their prior goal but argue that equating advance direction with consent is to ignore the capacity of nonpersons to attribute and withhold moral value. A distinction should be drawn between advance directives that seek to pursue deeply held goals and those that express contempt for the mentally incompetent.

Dosimetry audit for a multi-centre IMRT head and neck trial.

BACKGROUND AND PURPOSE: PARSPORT was a multi-centre randomised trial in the UK which compared Intensity-Modulated Radiotherapy (IMRT) and conventional radiotherapy (CRT) for patients with head and neck cancer. The dosimetry audit goals were to verify the plan delivery in participating centres, ascertain what tolerances were suitable for head and neck IMRT trials and develop an IMRT credentialing program. MATERIALS AND METHODS: Centres enrolling patients underwent rigorous quality assurance before joining the trial. Following this each centre was visited for a dosimetry audit, which consisted of treatment planning system tests, fluence verification films, combined field films and dose point measurements. RESULTS: Mean dose point measurements were made at six centres. For the primary planning target volume (PTV) the differences with the planned values for the IMRT and CRT arms were -0.6% (1.8% to -2.4%) and 0.7% (2.0% to -0.9%), respectively. Ninety-four percent of the IMRT fluence films for individual fields passed gamma criterion of 3%/3mm and 75% of the films for combined fields passed gamma criterion 4%/3mm (no significant difference between dynamic delivery and step and shoot delivery). CONCLUSIONS: This audit suggests that a 3% tolerance could be applied for PTV point doses. For dose distributions tolerances of 3%/3mm on individual fields and 4%/3mm for combined fields are proposed for multi-centre head and neck IMRT trials.

Multipoint laser vibrometer for modal analysis.

Experimental modal analysis of multifrequency vibration requires a measurement system with appropriate temporal and spatial resolution to recover the mode shapes. To fully understand the vibration it is necessary to be able to measure not only the vibration amplitude but also the vibration phase. We describe a multipoint laser vibrometer that is capable of high spatial and temporal resolution with simultaneous measurement of 256 points along a line at up to 80 kHz. The multipoint vibrometer is demonstrated by recovering modal vibration data from a simple test object subject to transient excitation. A practical application is presented in which the vibrometer is used to measure vibration on a squealing rotating disk brake.