Assessing support for mental health policies among policy influencers and the general public in Alberta and Manitoba, Canada.

BACKGROUND: There is a need to improve mental health policy in Canada to address the growing population burden of mental illness. Understanding support for policy options is critical for advocacy efforts to improve mental health policy. Our purpose was to describe support for population-level healthy public policies to improve mental health among policy influencers and the general public in Alberta and Manitoba; and, identify associations between levels of support and sociodemographic variables and relative to the Nuffield Bioethics Intervention Ladder framework. METHODS: We used data from the 2019 Chronic Disease Prevention Survey, which recruited a representative sample of the general public in Alberta (n = 1792) and Manitoba (n = 1909) and policy influencers in each province (Alberta n = 291, Manitoba n = 129). Level of support was described for 16 policy options using a Likert-style scale for mental health policy options by province, sample type, and sociodemographic variables using ordinal regression modelling. Policy options were coded using the Nuffield Council on Bioethics Intervention Ladder to classify support for policy options by level of intrusiveness. RESULTS: Policy options were categorized as 'Provide Information' and 'Enable Choice' according to the Nuffield Intervention Ladder. There was high support for all policy options, and few differences between samples or provinces. Strong support was more common among women and among those who were more politically left (versus center). Immigrants were more likely to strongly support most of the policies. Those who were politically right leaning (versus center) were less likely to support any of the mental health policies. Mental health status, education, and Indigenous identity were also associated with support for some policy options. CONCLUSIONS: There is strong support for mental health policy in Western Canada. Results demonstrate a gap between support and implementation of mental health policy and provide evidence for advocates and policy makers looking to improve the policy landscape in Canada.

The development and evaluation of a provider-focused educational intervention about alcohol use disorder in patients with cirrhosis.

Background: Alcohol use disorder (AUD) is a leading cause of cirrhosis. Insufficient clinician knowledge and comfort managing AUD impacts access to treatment. Using Kern's Framework for Curriculum Development, we aimed to (i) develop and evaluate the effect of an "AUD in cirrhosis" educational intervention on clinicians' knowledge, attitudes, comfort, preparedness, and intention (practice habits) to integrate AUD management into their practice, and (ii) assess clinicians' motivation using Self Determination Theory. Methods: Kern's approach was used for curriculum development. Pilot session feedback informed a three-part flipped-classroom series conducted by interdisciplinary clinicians in hepatology, psychiatry, primary care, and addiction psychology. Participants watched a video followed by a live session focused on (a) withdrawal, (b) screening and brief intervention, and (c) prescribing pharmacotherapy. Questionnaires assessing knowledge and practice habits were adapted from the literature. Attitudes were evaluated using the Short Alcohol and Alcohol Problems Perception Questionnaire (SAAPPQ). Self Determination Theory informed motivation questions. Results: Paired sample t-tests on pre-post questionnaires (n = 229 clinicians; 95 completed questionnaires) revealed significant improvements in preparedness and comfort screening, providing a brief intervention, prescribing pharmacotherapy, and SAAPPQ domains. No significant changes were observed in the intention to prescribe pharmacotherapy. Effect size analysis showed medium to large effects across most topic areas. Conclusions: The developed sessions improved knowledge, attitudes, and practice habits of clinicians caring for this patient population. Given the rise in AUD and significant consequences in cirrhosis, this data offers promise that interactive education may improve practice habits of clinicians interfacing with this patient population.

Canadian newspaper coverage on harm reduction featuring bereaved mothers: A mixed methods analysis.

A growing body of evidence suggests that news media which includes a sympathetic portrayal of a mother bereaved by substance use can increase public support for harm reduction initiatives. However, the extent to which such news media coverage occurs in Canada is unknown, and research has not documented how the news media in Canada covers such stories. We undertook a mixed-method secondary analyses of 5681 Canadian newspaper articles on harm reduction (2000-2016). Quantitative analyses described the volume and content of harm reduction reporting featuring a mother whose child's death was related to substance use while qualitative thematic analysis provided in-depth descriptions of the discourses underlying such news reporting. Newspaper articles featuring a mother whose child's death was related to substance use were rarely published (n = 63; 1.1% of total harm reduction media coverage during the study period). Deductive content analysis of these 63 texts revealed that coverage of naloxone distribution (42.9%) and supervised drug consumption services (28.6%) were prioritized over other harm reduction services. Although harm reduction (services or policies) were advocated by the mother in most (77.8%) of these 63 texts, inductive thematic analysis of a subset (n = 52) of those articles revealed that mothers' advocacy was diminished by newspaper reporting that emphasized their experiences of grief, prioritized individual biographies over structural factors contributing to substance use harms, and created rhetorical divisions between different groups of people who use drugs (PWUD). Bereaved mothers' advocacy in support of harm reduction programs and services may be minimized in the process of reporting their stories for newspaper readers. Finding ways to report bereaved mothers' stories in ways that are inclusive of all PWUD while highlighting the role of broad, structural determinants of substance use has the potential to shift public opinion and government support in favour of these life-saving services.

Policy actor views on structural vulnerability in harm reduction and policymaking for illegal drugs: A qualitative study.

BACKGROUND: Health risks associated with drug use are concentrated amongst structurally vulnerable people who use illegal drugs (PWUD). We described how Canadian policy actors view structural vulnerability in relation to harm reduction and policymaking for illegal drugs, and what solutions they suggest to reduce structural vulnerability for PWUD. METHODS: The Canadian Harm Reduction Policy Project is a mixed-method, multiple case study. The qualitative component included 73 semi-structured interviews conducted with harm reduction policy actors across Canada's 13 provinces and territories between November 2016 and December 2017. Interviews explored perspectives on harm reduction and illegal drug policies and the conditions that facilitate or constrain policy change. Our sub-analysis utilized a two-step inductive analytic process. First, we identified transcript segments that discussed structural vulnerability or analogous terms. Second, we conducted latent content analysis on the identified excerpts to generate main findings. RESULTS: The central role of structural vulnerability (including poverty, unstable/lack of housing, racialization) in driving harm for PWUD was acknowledged by participants in all provinces and territories. Criminalization, in particular, was seen as a major contributor to structural vulnerability by justifying formal and informal sanctions against drug use and, by extension, PWUD. Many participants expressed that their personal understanding of harm reduction included addressing the structural conditions facing PWUD, yet identified that formal government harm reduction policies focused solely on drug use rather than structural factors. Participants identified several potential policy solutions to intervene on structural vulnerability including decriminalization, safer supply, and enacting policies encompassing all health and social sectors. CONCLUSIONS: Structural vulnerability is salient within Canadian policy actors' discourses; however, formal government policies are seen as falling short of addressing the structural conditions of PWUD. Decriminalization and safer supply have the potential to mitigate immediate structural vulnerability of PWUD while policies evolve to advance social, economic, and cultural equity.

Impact of fentanyl use on initiation and discontinuation of methadone and buprenorphine/naloxone among people with prescription-type opioid use disorder: secondary analysis of a Canadian treatment trial.

BACKGROUND AND AIMS: Fentanyl is primarily responsible for the current phase of the overdose epidemic in North America. Despite the benefits of treatment with medications for opioid use disorder (MOUD), there are limited data on the association between fentanyl, MOUD type and treatment engagement. The objectives of this analysis were to measure the impact of baseline fentanyl exposure on initiation and discontinuation of MOUD among individuals with prescription-type opioid use disorder (POUD). DESIGN, SETTING AND PARTICIPANTS: Secondary analysis of a Canadian multi-site randomized pragmatic trial conducted between 2017 and 2020. Of the 269 randomized participants, 65.4% were male, 67.3% self-identified as white and 55.4% had a positive fentanyl urine drug test (UDT) at baseline. Fentanyl-exposed participants were more likely to be younger, to self-identify as non-white, to be unemployed or homeless and to be currently using stimulants than non-fentanyl-exposed participants. INTERVENTIONS: Flexible take-home dosing buprenorphine/naloxone or supervised methadone models of care for 24 weeks. MEASUREMENTS: Outcomes were (1) MOUD initiation and (2) time to (a) assigned and (b) overall MOUD discontinuation. Independent variables were baseline fentanyl UDT (predictor) and assigned MOUD (effect modifier). FINDINGS: Overall, 209 participants (77.7%) initiated MOUD. In unadjusted analyses, fentanyl exposure was associated with reduced likelihood of treatment initiation [odds ratio (OR) = 0.18, 95% confidence interval (CI) = 0.08-0.36] and shorter median times in assigned [20 versus 168 days, hazard ratio (HR) = 3.61, 95% CI = 2.52-5.17] and any MOUD (27 versus 168 days, HR = 3.32, 95% CI = 2.30-4.80). The negative effects were no longer statistically significant in adjusted models, and no interaction between fentanyl and MOUD was observed for any of the outcomes (all P > 0.05). CONCLUSIONS: Both buprenorphine/naloxone and methadone may be appropriate treatment options for people with prescription-type opioid use disorder regardless of fentanyl exposure. Other characteristics of fentanyl-exposed individuals appear to be driving the association with poorer treatment outcomes.

Flexible Buprenorphine/Naloxone Model of Care for Reducing Opioid Use in Individuals With Prescription-Type Opioid Use Disorder: An Open-Label, Pragmatic, Noninferiority Randomized Controlled Trial.

OBJECTIVE: Extensive exposure to prescription-type opioids has resulted in major harm worldwide, calling for better-adapted approaches to opioid agonist therapy. The authors aimed to determine whether flexible take-home buprenorphine/naloxone is as effective as supervised methadone in reducing opioid use in prescription-type opioid consumers with opioid use disorder. METHODS: This seven-site, pan-Canadian, 24-week, pragmatic, open-label, noninferiority, two-arm parallel randomized controlled trial involved treatment-seeking adults with prescription-type opioid use disorder. Participants were randomized in a 1:1 ratio to treatment with sublingual buprenorphine/naloxone (target dosage, 8 mg/2 mg to 24 mg/6 mg per day; flexible take-home dosing) or oral methadone (≈60-120 mg/day; closely supervised). The primary outcome was the proportion of opioid-free urine drug screens over 24 weeks (noninferiority margin, 15%). All randomized participants were analyzed, excluding one who died shortly after randomization, for the primary analysis (modified intention-to-treat analysis). RESULTS: Of 272 participants recruited (mean age, 39 years [SD=11]; 34.2% female), 138 were randomized to buprenorphine/naloxone and 134 to methadone. The mean proportion of opioid-free urine drug screens was 24.0% (SD=34.4) in the buprenorphine/naloxone group and 18.5% (SD=30.5) in the methadone group, with a 5.6% adjusted mean difference (95% CI=-0.3, +∞). Participants in the buprenorphine/naloxone group had 0.47 times the odds (95% CI=0.24, 0.90) of being retained in the assigned treatment compared with those in the methadone group. Overall, 24 drug-related adverse events were reported (12 in the buprenorphine/naloxone group [N=8/138; 5.7%] and 12 in the methadone group [N=12/134; 9.0%]) and mostly included withdrawal, hypogonadism, and overdose. CONCLUSIONS: The buprenorphine/naloxone flexible model of care was safe and noninferior to methadone in reducing opioid use among people with prescription-type opioid use disorder. This flexibility could help expand access to opioid agonist therapy and reduce harms in the context of the opioid overdose crisis.

Impact of an addiction medicine consult team intervention in a Canadian inner city hospital on acute care utilization: a pragmatic quasi-experimental study.

BACKGROUND: Inner city patients have a higher illness burden and need for care, but experience more unmet care needs. Hospital Addiction Medicine Consult Teams (AMCTs) are a promising emerging intervention. The objective of this study was to assess the impact of a Canadian AMCT-like intervention for inner city patients on reduction in high emergency department (ED) use, hospital admission, and inpatient length of stay. METHODS: Using a community-engaged, two-arm, pre-post, longitudinal quasi-experimental study design, 572 patients reporting active substance use, unstable housing, unstable income, or a combination thereof (302 at intervention site, 270 at control sites) were enrolled. Survey and administrative health service data were collected at baseline, six months post-enrolment, and 12 months post-enrolment. Multivariable regression models tested the intervention effect, adjusting for clinically important covariables (inpatient status at enrolment, medical complexity, age, gender, Indigenous identity, shelter use, opioid use). RESULTS: Initial bivariable analyses demonstrated an intervention effect on reduction in admissions and length of stay, however, this effect was no longer significant after adjusting for covariables. There was no evidence of reduction in high ED use on either bivariable or subsequent multivariable analysis. CONCLUSIONS: After adjusting for covariables, no AMCT intervention effect was detected for reduction in high ED use, inpatient admission, or hospital length of stay. Further research is recommended to assess other patient-oriented intervention outcomes.

Clinicians' perspectives and perceived barriers to caring for patients with alcohol use disorder and cirrhosis.

BACKGROUND: Alcohol use disorder (AUD) is one of the leading etiologies for liver cirrhosis and liver transplantation. Few individuals with AUD receive guideline-based care in the form of screening, brief intervention, referral to treatment, or prescription of pharmacotherapy for relapse prevention. We interviewed clinicians across Alberta to assess the current experience and perceived barriers to managing AUD in people who have cirrhosis. The aim of this paper is to summarize these findings to inform the development of an educational intervention. METHODS: We used a qualitative descriptive approach to explore the experiences of clinicians who care for patients with cirrhosis and AUD in Alberta. We conducted semi-structured interviews directed by an interview guide. Interviews were recorded and transcribed verbatim. We used an inductive thematic analysis approach whereby transcripts were coded, with codes grouped into larger categories, then themes. RESULTS: Sixteen clinicians participated in this study. Many participants acknowledged that they do not use a standardized approach to screening, brief intervention, and referral to treatment. Through thematic analysis we identified four themes surrounding barriers to managing AUD in patients with cirrhosis: (i) Practicing within knowledge constraints, (ii) Navigating limited resources and system challenges, (iii) Balancing the complexity of cirrhosis and AUD, and (iv) Acknowledging the influence of provider perceptions on care. CONCLUSION: This article presents the perspectives of clinicians who care for people who have AUD and cirrhosis. Significant barriers exist, including limited knowledge and resources, systemic challenges, and patient complexity. The information gathered will be used to develop an educational intervention that will delve deeper into these issues in order to have the greatest impact on clinicians who routinely interface with this patient population.

Unmet service needs and barriers to care of individuals experiencing absolute homelessness in Edmonton, Canada: a cross-sectional survey.

PURPOSE: Individuals experiencing absolute homelessness have complex needs but limited access to services, contributing to high rates of morbidity and mortality. The aim of this article is to describe the perceived unmet service needs of individuals experiencing absolute homelessness, identify their barriers to care, and examine factors associated with specific unmet service needs. METHODS: Using a cross-sectional survey, 150 individuals experiencing absolute homelessness were recruited from Edmonton's inner city and adjoining areas. The majority of participants were male (71.3%) and self-identified as Indigenous (74.0%). An adapted version of the Perceived Need for Care Questionnaire was used to measure past-year unmet needs for 4 types of services: hospital care, counselling, skills training, and harm reduction. Descriptive statistics and bivariate analyses were used; odds ratio and confidence intervals were calculated for statistically significant outcomes. RESULTS: Overall, 89.3% of participants perceived a need for care for one or more general health and social services during the past year regarding their substance use and/or mental health problems; participants reported the highest levels of unmet need for counselling (42.9%) and skills training (39.2%). Though 73.3% of participants reported receiving any service, only 8.0% of participants reported having their perceived needs fully met. CONCLUSION: In this study, individuals reported a high percentage of unmet needs. By interacting and engaging with these hard-to-reach individuals, healthcare systems will be more equipped to service them and address their barriers to care. Better patient-centred care, housing and supports for this neglected and underserved population is needed.

Perceived unmet substance use and mental health care needs of acute care patients who use drugs: A cross-sectional analysis using the Behavioral Model for Vulnerable Populations.

INTRODUCTION: The perceived unmet service needs of acute care-seeking people who use illegal drugs (PWUD) have been poorly documented, despite evidence of frequent hospital utilisation. This study applies the Behavioral Model for Vulnerable Populations to investigate correlates of unmet service needs in this subpopulation. METHODS: Survey data from 285 PWUD at three urban Canadian acute care centres were examined. The survey included the Perceived Need for Care Questionnaire, which measured service seeking and care satisfaction for mental health and substance use concerns across seven types of services, as well as barriers to having care needs met. The Behavioral Model for Vulnerable Populations was applied in hierarchical setwise logistic regression to examine associations between high unmet service need and socio-structural predictors (i.e. predisposing, enabling and need factors). RESULTS: Almost half (46%) of participants reported a high level of unmet service need, despite seeking services during the past year. Participants reporting recent criminal activity, adverse childhood experiences, transitory sleeping, having no community support worker, and meeting screening criteria for depression were more likely to report a high level of unmet service needs. Structural barriers to care (57%) were more commonly reported than motivational barriers (43%). DISCUSSION AND CONCLUSIONS: Acute care-seeking PWUD experience high rates of unmet service needs for their mental health and substance use problems. Strategies that can help overcome structural barriers to care are necessary to help address the service needs of this population.

Health Systems Responsiveness in Addressing Indigenous Residents' Health and Mental Health Needs Following the 2016 Horse River Wildfire in Northern Alberta, Canada: Perspectives From Health Service Providers.

Following the 2016 Horse River Wildfire in northern Alberta, the provincial health authority, the ministry of health, non-profit and charitable organizations, and regional community-based service agencies mobilized to address the growing health and mental health concerns among Indigenous residents and communities through the provision of services and supports. Among the communities and residents that experienced significant devastation and loss were First Nation and Métis residents in the region. Provincial and local funding was allocated to new recovery positions and to support pre-existing health and social programs. The objective of this research was to qualitatively describe the health systems response to the health impacts following the wildfire from the perspective of service providers who were directly responsible for delivering or organizing health and mental wellness services and supports to Indigenous residents. Semi-structured qualitative interviews were conducted with 15 Indigenous and 10 non-Indigenous service providers from the Regional Municipality of Wood Buffalo (RMWB). Interviews were transcribed verbatim and a constant comparative analysis method was used to identify themes. Following service provider interviews, a supplemental document review was completed to provide background and context for the qualitative findings from interviews. The document review allowed for a better understanding of the health systems response at a systems level following the wildfire. Triangulation of semi-structured interviews and organization report documents confirmed our findings. The conceptual framework by Mirzoev and Kane for understanding health systems responsiveness guided our data interpretation. Our findings were divided into three themes (1) service provision in response to Indigenous mental health concerns (2) gaps in Indigenous health-related services post-wildfire and (3) adopting a health equity lens in post-disaster recovery. The knowledge gained from this research can help inform future emergency management and assist policy and decision makers with culturally safe and responsive recovery planning. Future recovery and response efforts should consider identifying and addressing underlying health, mental health, and emotional concerns in order to be more effective in assisting with healing for Indigenous communities following a public health emergency such as a wildfire disaster.

Correlates of driving after cannabis use in high school students.

Driving under the influence of cannabis is a growing public health concern among young people. This study assessed the prevalence of cannabis-impaired driving and its related sociodemographic, psychological, and knowledge-based correlates among Canadian adolescents. The sample for this study were drawn from the 2017 Ontario Student Health and Drug Use Survey (OSDUHS), consisting of high school students with valid driver's licenses (mean age = 16.8, SD = 0.71) who were asked about their driving behaviors, drug use, and attitudes regarding cannabis use (N = 1161). A multivariable logistic regression model was performed to determine the strongest correlates of driving after cannabis use. The prevalence of past-year driving within an hour of cannabis use was 10.3% (95% CI: 7.8,13.5). In the final multivariable model, probable cannabis dependence (OR = 12.7, 95%CI: 3.4,47.7), low perceived risk of cannabis use (OR = 5.3, 95%CI: 2.5,11.1), pro-legalization attitudes, (OR = 4.3, 95%CI: 2.0,9.1) and male gender (OR = 2.6, 95%CI: 1.5,4.5) were significantly associated with driving under the influence of cannabis. Other correlates of driving after cannabis user were risky driving behaviors, including past-year texting and driving and driving after alcohol use. There are various correlates of driving under the influence of cannabis, including attitudes related to cannabis which may be amenable to intervention. Future efforts should continue to monitor the prevalence of cannabis-impaired driving in this population and determine whether changes in students' attitudes surrounding cannabis are linked to behavioural changes.

Public support for harm reduction: A population survey of Canadian adults.

We described public views toward harm reduction among Canadian adults and tested a social exposure model predicting support for these contentious services, drawing on theories in the morality policy, intergroup relations, addiction, and media communication literatures. A quota sample of 4645 adults (18+ years), randomly drawn from an online research panel and stratified to match age and sex distributions of adults within and across Canadian provinces, was recruited in June 2018. Participants completed survey items assessing support for harm reduction for people who use drugs (PWUD) and for seven harm reduction interventions. Additional items assessed exposure to media coverage on harm reduction, and scales assessing stigma toward PWUD (α = .72), personal familiarity with PWUD (α = .84), and disease model beliefs about addiction (α = .79). Most (64%) Canadians supported harm reduction (provincial estimates = 60% - 73%). Five of seven interventions received majority support, including: outreach (79%), naloxone (72%), drug checking (70%), needle distribution (60%) and supervised drug consumption (55%). Low-threshold opioid agonist treatment and safe inhalation interventions received less support (49% and 44%). Our social exposure model, adjusted for respondent sex, household income, political views, and education, exhibited good fit and accounted for 17% of variance in public support for harm reduction. Personal familiarity with PWUD and disease model beliefs about addiction were directly associated with support (ßs = .07 and -0.10, respectively), and indirectly influenced public support via stigmatized attitudes toward PWUD (ßs = 0.01 and -0.01, respectively). Strategies to increase support for harm reduction could problematize certain disease model beliefs (e.g., "There are only two possibilities for an alcoholic or drug addict-permanent abstinence or death") and creating opportunities to reduce social distance between PWUD, the public, and policy makers.

Treating latent tuberculosis infection (LTBI) with isoniazid and rifapentine (3HP) in an inner-city population with psychosocial barriers to treatment adherence: A qualitative descriptive study.

In Canada, preventive therapy for latent tuberculosis infection (LTBI) has required multiple doses of medication over an extended period of time. Such regimens are associated with poor adherence and completion rates. A shortened treatment regimen of once weekly isoniazid plus rifapentine for 3 months (3HP), is now available, and holds promise in populations facing challenges to treatment adherence. Although many factors impact treatment adherence, a knowledge gap exists in describing these factors in the context of this regimen. We present findings from a qualitative descriptive study, involving semi-structured interviews with unstably housed or homeless individuals in Edmonton and Fort McMurray, Alberta, Canada who were offered directly-observed preventive therapy (DOPT) with 3HP, and their health care providers. Latent content analysis revealed incomplete understandings of LTBI and about the need for preventive therapy. Clients' motivation to be healthy, alongside education, health care outreach, relationships developed in the context of DOPT, ease of treatment regimen, incentives, and collaboration were all described as supporting treatment completion. Competing priorities, difficulty in reaching clients, undesirable aspects of the regimen and difficulties obtaining and initiating 3HP were identified as barriers. Perceptions of stigma related to LTBI and TB were described by clients in addition to feelings of shame related to their diagnosis. Our study provides insight into LTBI and indicates that multiple interacting psychosocial factors influence preventive therapy access, uptake, and adherence. Findings from this study of both client and provider perspectives can be used to inform and address inequities among individuals experiencing homelessness, and ultimately contribute to a diminished reservoir of LTBI.

Cannabis norm perceptions among Canadian university students.

BACKGROUND AND HYPOTHESES: Extant research has not studied whether norm perceptions differ between young adult cannabis users who do and do not meet screening criteria for problematic cannabis use. Drawing on sociocultural norms research on alcohol, we hypothesized that users meeting screening criteria for cannabis problems would be more likely than those not meeting those criteria to (1) mistakenly believe that social reference groups use about the same amount of cannabis as they do, (2) adjust private approval of peer cannabis use to match mistaken public approval norms, and (3) believe that behavioral and social consequences are less definitive of problematic cannabis use. METHODS: Secondary analyses of data from 753 cannabis users recruited from a Canadian university population survey (57% female; M age = 22.58). Parametric and non-parametric ANOVAs examined respondents' perceptions and beliefs regarding the cannabis use of same-sex friends, students, and adults living in the same Canadian province. RESULTS: Contrary to prediction, problematic cannabis users were more likely than non-problematic users to (accurately) believe that social reference groups use cannabis less frequently than themselves. As hypothesized, problematic users were more likely than non-problematic users to adjust private approval of fellow students' cannabis use to match perceived public approval, and to believe that sociobehavioral criteria are less definitive of cannabis problems. CONCLUSION: Results support the need to develop brief interventions to correct misperceptions of (a) injunctive cannabis norms and (b) sociobehavioral criteria that define safe versus problematic use, rather than perceived frequency of use in social reference groups.

Forty-eight years of research on psychosocial interventions in the treatment of opioid use disorder: A scoping review.

BACKGROUND: Mapped the sources and types of evidence available on psychosocial interventions in the treatment of opioid use disorder (OUD), with and without pharmacotherapies. METHODS: Six electronic databases were searched for research published until July 1, 2019. Included studies were coded on publication characteristics, evidence sources, treatment settings and modalities, study populations and patient characteristics, intervention(s) offered to patients, research questions addressed in experimental studies, and outcomes investigated. RESULTS: We identified 305 empirical studies of 54,607 patients. Most studies (64 %; n = 194) compared psychosocial interventions to alternative treatment(s) (183 RCTs and 11 quasi-experiments) while 28 % (n = 86) used observational designs, and 8% (n = 25) used qualitative methods. Trials infrequently investigated effects of stand-alone psychosocial interventions without pharmacotherapies (20% of all RCTs). Regardless of research question or study design, program retention and illicit drug use were the most common outcomes investigated (> 81% of all studies and RCTs), typically among longstanding male heroin users attending specialty outpatient addiction services. Studies rarely examined (a) OUD treatment in general health care or prescription OUD (each < 6 % of all studies and RCTs), (b) effects of social assistance (employment, education, social support) and harm reduction (each < 6 % of studies; < 7 % of RCTs), and (c) health-related quality of life and satisfaction with care (each < 10 % and < 15 % of all studies and RCTs, respectively). CONCLUSIONS: Scant evidence is available on the putative rehabilitative effects of psychosocial interventions, either as stand-alone treatments or in an adjunct role to pharmacotherapies.

Predictive utility of the brief Screener for Substance and Behavioral Addictions for identifying self-attributed problems.

BACKGROUND AND AIMS: The Brief Screener for Substance and Behavioral Addictions (SSBAs) was developed to assess a common addiction construct across four substances (alcohol, tobacco, cannabis, and cocaine), and six behaviors (gambling, shopping, videogaming, eating, sexual activity, and working) using a lay epidemiology perspective. This paper extends our previous work by examining the predictive utility of the SSBA to identify self-attributed addiction problems. METHOD: Participants (N = 6,000) were recruited in Canada using quota sampling methods. Receiver Operating Characteristics (ROCs) analyses were conducted, and thresholds established for each target behavior's subscale to predict self-attributed problems with these substances and behaviors. For each substance and behavior, regression models compared overall classification accuracy and model fit when lay epidemiologic indicators assessed using the SSBA were compared with validated screening measures to predict selfattributed problems. RESULTS: ROC analyses indicted moderate to high diagnostic accuracy (Area under the curves (AUCs) 0.73-0.94) across SSBA subscales. Thresholds for identifying self-attributed problems were 3 for six of the subscales (alcohol, tobacco, cannabis, cocaine, shopping, and gaming), and 2 for the remaining four behaviors (gambling, eating, sexual activity, and working). Compared to other instruments assessing addiction problems, models using the SSBA provided equivalent or better model fit, and overall had higher classification accuracy in the prediction of self-attributed problems. DISCUSSION AND CONCLUSIONS: The SSBA is a viable screening tool for problematic engagement across ten potentially addictive behaviors. Where longer screening tools are not appropriate, the SSBA may be used to identify individuals who would benefit from further assessment.

Transdiagnostic or Disorder Specific? Indicators of Substance and Behavioral Addictions Nominated by People with Lived Experience.

Using a transdiagnostic perspective, the present research examined the prominent indicators of substance (alcohol, cocaine, marijuana, tobacco) and behavioral (gambling, video games, sex, shopping, work, eating) addictions nominated by people with lived experiences. Specifically, we aimed to explore whether the perceived most important indicators nominated were consistent across the 10 addictions or differed based on the specific addiction. Additionally, we explored gender differences in the perceived most important indicators across addictive behaviors. A large online sample of adults recruited from a Canadian province (n = 3503) were asked to describe the most important signs or symptoms of problems with these substances and behaviors. Open-ended responses were analyzed among a subsample of 2603 respondents (n = 1562 in the past year) who disclosed that they had personally experienced a problem with at least one addiction listed above. Content analyses revealed that dependence (e.g., craving, impairments in control) and patterns of use (e.g., frequency) were the most commonly perceived indicators for both substance and behavioral addictions, accounting for over half of all the qualitative responses. Differences were also found between substance and behavioral addictions regarding the proportion of the most important signs nominated. Consistent with the syndrome model of addiction, unique indicators were also found for specific addictive behaviors, with the greatest proportion of unique indicators found for eating. Supplemental analyses found that perceived indicators across addictions were generally gender invariant. Results provide some support for a transdiagnostic conceptualization of substance and behavioral addictions. Implications for the study, prevention, and treatment of addictions are discussed.

Willingness to participate in hepatitis C vaccine trials among socially marginalized people who use drugs.

A major complicating factor for hepatitis C virus (HCV) vaccine clinical trial design and implementation is engagement and retention of people who use drugs (PWUD). Informed willingness to participate (WTP) in vaccine trials has emerged as a critical issue to describe, understand, and promote among populations at increased risk of communicable disease incidence. The present study addressed this topic by examining correlates of WTP among 320 socially marginalized PWUD as part of the Edmonton Drug Use and Health Survey (EDUHS). WTP was analyzed in relation to: gender, age, housing stability, ethnicity; self-reported hospital care in the past six months, self-reported injection drug use in the past 6 months, lifetime addiction treatment for alcohol or drugs, severity of drug use problems, and unmet healthcare needs. EDUHS participants reported high rates of current injection drug use (91%), and about two-thirds (67.3%) reported a lifetime HCV positive status. HCV positive respondents were older, had more severe substance use problems, and reported injecting drugs more frequently, compared to HCV negative respondents. Among the subsample of HCV negative respondents, 81% affirmed that they would be willing to enroll in a HCV vaccine prevention trial. Those reporting WTP were more likely to have had a recent hospital admission, to report more total unmet healthcare needs, and greater unmet needs for information, hospital care, and counseling, compared to HCV negative respondents not willing to enroll in a vaccine trial. No association was observed between WTP and other assessed variables. Results suggest that connecting PWUD not infected with HCV to local healthcare resources may be important in motivating vaccine trial participation.

Principles, practice, and policy vacuums: Policy actor views on provincial/territorial harm reduction policy in Canada.

INTRODUCTION: Canada is experiencing a new era of harm reduction policymaking and investment. While many provinces and territories are expanding access to these services, harm reduction policy and policymaking varies across the country. The present study, part of the Canadian Harm Reduction Policy Project (CHARPP), described policy actors' views on formal harm reduction policies in Canada's 13 provinces and territories. METHODS: As part of CHARPP's mixed-method, multiple case study, we conducted qualitative interviews with 75 policy actors, including government officials, health system leaders, senior staff at community organizations, and advocates with self-identified lived experience of using drugs. Interviews were conducted in English or French, and recorded and transcribed verbatim. We used latent content analysis to inductively code the data and generate main findings. NVivo 11 was used to organize the transcripts. RESULTS: Participants expressed divergent views on formal provincial/territorial policies and their impact on availability of harm reduction programs and services. While some identified a need to develop new policies or improve existing ones, others resisted bureaucratization of harm reduction or felt the absence of formal policy was instead, advantageous. Instances where harm reduction was advanced outside of formal policymaking were also described. DISCUSSION: Previous CHARPP research documented wide variability in quantity and quality of formal harm reduction policies across Canada, and characterized official policy documents as serving largely rhetorical rather than instrumental functions. The present findings highlight diverse ways that actors used their discretion to navigate these weak policy contexts. Participants' views and experiences sometimes referred to strengthening policy support, but institutionalization of harm reduction was also resisted or rejected. Results suggest that actors adopt a range of pragmatic strategies to advance harm reduction services in response to policy vacuums characteristic of morality policy domains, and challenge assumptions about the utility of formal policies for advancing harm reduction.