Interventions for physician prescribers of opioids for chronic non-cancer pain: protocol for an overview of systematic reviews.

INTRODUCTION: Interventions targeting behaviours of physician prescribers of opioids for chronic non-cancer pain have been introduced to combat the opioid crisis. Systematic reviews have evaluated effects of specific interventions (eg, prescriber education, prescription drug monitoring programmes) on patient and population health outcomes and prescriber behaviour. Integration of findings across intervention types is needed to better understand the effects of prescriber-targeted interventions. METHODS AND ANALYSIS: We will conduct an overview of systematic reviews. Eligible systematic reviews will include primary studies that evaluated any intervention targeting the behaviours of physician prescribers of opioids for chronic non-cancer pain in an outpatient or mixed setting, compared with no intervention, usual practice or another active or control intervention. Eligible outcomes will pertain to the intervention effect on patient and population health or opioid prescribing behaviour. We will search MEDLINE, Embase and PsycInfo via Ovid; the Cochrane Database of Systematic Reviews and Epistemonikos from inception. We will also hand search reference lists for additional publications. Screening and data extraction will be conducted independently by two reviewers, with disagreements resolved by consensus or consultation with a third reviewer. The risk of bias of included systematic reviews will be assessed in duplicate by two reviewers using the Risk of Bias in Systematic Reviews tool. Results will be synthesised narratively by intervention type and grouped by outcome. To assist with result interpretation, outcomes will be labelled as intended or unintended according to intervention objectives, and as positive, negative, evidence of no effect or inconclusive evidence according to effect on the population (for patient and population health outcomes) or intervention objectives (for prescriber outcomes). ETHICS AND DISSEMINATION: As the proposed study will use published data, ethics approval is not required. Dissemination of results will be achieved through publication of a manuscript in a peer-reviewed journal and conference presentations. PROSPERO REGISTRATION NUMBER: CRD42020156815.

Improving substance misuse outcomes in contingency management treatment with adjunctive formal psychotherapy: a systematic review and meta-analysis.

OBJECTIVES: Contingency management (CM) is a treatment for substance misuse that involves the provision of incentives. This review examines the hypothesis that adding another formal psychotherapy, such as cognitive-behavioural therapy (CBT) or motivational enhancement therapy (MET), to CM improves substance use outcomes at both treatment end and at post-treatment follow-up compared with CM only. DATA SOURCES: Searches were performed in December 2017 and July 2019 of seven electronic bibliographic databases (MEDLINE, PsycINFO, EMBASE, Scopus, Web of Science, CINAHL, PsycEXTRA), as well as online trial registries and EThoS, and were followed by reference list screening. ELIGIBILITY CRITERIA: Included studies were randomised controlled trials of adults (18-65) who were using illicit substances, alcohol or tobacco. Studies featured an experimental arm delivering CM combined with a structured evidence-based psychotherapeutic intervention and a CM-only arm. Studies published up to July 2019 were included. DATA EXTRACTION AND SYNTHESIS: The primary outcome was biometrically verified point prevalent abstinence (PPA) at treatment end. Secondary outcomes included biometrically verified PPA at post-treatment follow-up and self-reported days of use at treatment end and post-treatment follow-up. Pooled risk ratios for PPA outcomes and standardised mean differences for days of use were calculated using random effects models. Risk of bias was assessed using the Grading of Recommendations Assessment, Development and Evaluation. RESULTS: 12 studies (n=1654) were included. The primary analysis found no evidence of a synergistic effect in PPA at treatment end (relative risk (RR) 0.97, 95% CI 0.85 to 1.09; p=0.57). Sensitivity analysis of studies featuring CBT/MET also found no evidence of an effect (RR 0.92; 95% CI 0.79 to 1.08; p=0.32). None of the secondary outcomes showed any evidence of benefit. CONCLUSION: The results of the meta-analyses found no evidence that combining CM with another intervention improves the short-term or long-term effects of CM treatment.

Social network confidants, duration of untreated psychosis and cannabis use in people with first episode psychosis: An exploratory study.

AIM: Reduced social network (SN) might be associated with a longer duration of untreated psychosis (DUP) in people with first episode psychosis (FEP). We aimed at exploring the specific role of SN confidants on DUP, taking into account cannabis misuse, which is known to influence DUP and might be associated with social functioning. METHODS: People with FEP recently referred to an inner London Early Intervention Service were assessed with standardized instruments exploring SN characteristics, DUP and cannabis misuse. RESULTS: Taking into account cannabis misuse, we found an association between confidants and DUP (P = 0.020), with the higher the number of confidants, the shorter the DUP. CONCLUSIONS: Confidants may provide access to, and perceptions of, social support and this may increase early engagement for people with FEP, reducing DUP and possibly improving outcomes. Future research should identify correlates of small networks of confidants, which could inform early detection community initiatives.

Results and lessons learned from radiological/nuclear emergency response exercise held in Québec, Canada.

The Ministry of Sustainable Development, Environment and Parks of Québec (Ministère du Développement durable, de l'Environnement et des Parcs du Québec-MDDEP) held a 3-d provincial nuclear emergency response exercise in September 2008 that saw participation from Canadian provincial and federal departments. Nuclear emergency exercises are regularly held in Québec, given the presence of the Gentilly-2 nuclear power plant situated in Bécancour on the St. Lawrence River. The significance of this exercise is that it marks the first exercise held in Canada where environmental samples spiked with relevant radioisotopes were analyzed during the exercise, both on-site and remotely, and where the results of those analyses had a direct impact on the decisions made during the exercise. Following the exercise, samples were sent to two other laboratories that are part of the Canadian National Nuclear Laboratory Network for analysis, providing the first intercomparison exercise for the Network. The results of the analysis of the air and drinking water samples, as well as the lessons learned during the exercise, are presented and discussed in this article.

Indicators predicting use of mental health services in Piedmont, Italy.

BACKGROUND: Since the 1978 Italian reform, an integrated network of community mental health services has been introduced. With few exceptions, research on determinants of mental health service use at the district level has focused on inpatient activities and social deprivation indicators. The European Psychiatric Care Assessment Team (EPCAT) standardized methodology allows for an evidence-based comparison of mental health systems between geographical areas. AIMS: To compare service provision and utilization between local catchment areas; to explore quantitative relationships between residential and community service use and socio-demographic indicators at the ecological level. METHODS: The European Socio-demographic Schedule (ESDS) was used to describe area characteristics, and the European Service Mapping Schedule (ESMS) to measure service provision and utilization in 18 catchment areas in Piedmont. RESULTS: Substantial variation in service use emerged. Acute hospital bed occupancy rates were lower in areas with more intensive community continuing care service users and with a smaller percentage of the population living alone. The non-acute hospital bed occupancy rate was directly related to the percentage of the population living alone or in overcrowded conditions, and to the level of mobile continuing care service users. Community continuing care service use was highest in areas with a larger percentage of the population living alone. DISCUSSION: Multiple regression models explained between 48 and 55% of the variation in inpatient and community service use between areas. Relationships based on ecological characteristics do not necessarily apply to the individual. This level of assessment, however, is necessary in evaluating mental health policy and service systems, and in allocating resources. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: The distribution of mental health care resources should be weighted in terms of indicators of social deprivation shown to be important predictors of both inpatient and community service use, as these are likely to be related. IMPLICATIONS FOR HEALTH POLICIES: To ensure horizontal equity in access to mental health care, particularly for people with severe mental illness, evaluation of mental health policy should be based on a concurrent evidence-based assessment of the organization and use of both residential and community services, in relation to area level indicators of social deprivation. IMPLICATIONS FOR FURTHER RESEARCH: Cross-national research using an internationally standardized methodology should consider the influence of the social network independently of other socio-economic indicators, to verify the relative importance of this in predicting service use in southern and in northern European countries.

Whole-body lymphoscintigraphy using transmission scans.

OBJECTIVE: Our objective was to show the advantages of performing whole-body lymphoscintigraphy using transmission sources. This technique should decrease scanning time, help locate the sentinel lymph node, and decrease radiation exposure to the technologist. METHODS: Twenty patients with proven melanoma received 18.5 MBq (0.5 mCi) filtered (0.22 microm) (99m)Tc-sulfur colloid in a 0.2-mL volume, administered as multiple intradermal or subcutaneous injections around the known melanoma lesion or scar. All 20 patients underwent serial static imaging immediately after the injection, along with whole-body scanning after the static imaging. The static emission images were acquired for 5 min and the transmission images for 1 min using a 256 x 256 matrix. The whole-body transmission scans were acquired after the whole-body emission scans. The transmission scans were obtained with the same parameters as the emission scans, with the addition of placement of a (57)Co sheet source on one of the detectors of the large-field-of-view dual-head camera. The planar static axial images (transmission, emission) were compared with the whole-body images (transmission, emission) to determine whether the same number of lymph nodes was visualized with each technique. Posterior outlines were obtained through computer manipulation of anterior transmission images. RESULTS: In all 20 patients, the number of lymph nodes seen on the static images was the same as that seen on the whole-body emission and transmission images. The whole-body emission and transmission scanning time was an average of 30 min less than the time required to acquire the serial static images. CONCLUSION: The anatomic location of the sentinel lymph node is seen more easily on whole-body images, both anterior transmission and posterior transmission, than on planar static images. Whole-body emission and transmission imaging decreased scanning time and thus improved patient comfort and throughput. Technologists received less radiation exposure when handling the (57)Co source only twice during whole-body imaging, as opposed to several times during static imaging.