Long-term treatment outcomes in a First Nations high school population with opioid use disorder.

OBJECTIVE: To assess for long-term positive effects of buprenorphine treatment (BT) on opioid use disorder (OUD) at a Nishnawbe Aski Nation high school clinic. DESIGN: Postgraduation telephone survey of high school students between March 2017 and January 2018. SETTING: Dennis Franklin Cromarty High School in Thunder Bay, Ont. PARTICIPANTS: All 44 students who had received BT in the high school clinic during its operation from 2011 to 2013 were eligible to participate. MAIN OUTCOME MEASURES: Current substance use, BT status, and social and employment status. RESULTS: Thirty-eight of the 44 students who had received BT in the high school clinic were located and approached; 32 consented to participate in the survey. A descriptive analysis of the surveyed indicators was undertaken. Almost two-thirds (n = 20, 62.5%) of the cohort had graduated from high school, more than one-third (n = 12, 37.5%) were employed full time, and most (n = 29, 90.6%) rated their health as "good" or "OK." A greater percentage of participants who continued taking BT after high school (n = 19, 61.3%) were employed full time (n = 8, 42.1% vs n = 4, 33.3%) and were abstinent from alcohol (n = 12, 63.2% vs n = 4, 33.3%). Participants still taking BT were significantly more likely to have obtained addiction counseling in the past year than those participants not in treatment (n = 9, 47.4% vs n = 1, 8.3%; P = .0464). CONCLUSION: The study results suggest that offering OUD treatment to youth in the form of BT in a high school clinic might be an effective strategy for promoting positive long-term health and social outcomes. Clinical treatment guidelines currently recommend long-term opioid agonist treatment as the treatment of choice for OUD in the general population; they should consider adding youth to the population that might also benefit.

Individuals' experiences of the integration of substance use/addiction and HIV/AIDS services in community settings: a qualitative systematic review protocol.

OBJECTIVE: The objectives of this systematic review are: i) to identify, appraise, and synthesize the best available evidence on individuals' experiences of the integration of substance use/addiction and HIV/AIDS services in community settings, and ii) to identify barriers to and facilitators of the integration of the services. INTRODUCTION: The integration of drug use treatment and HIV services has shown to improve HIV prevention, decrease HIV infection and progression, while improving access to social and support services among substance users. Combined pharmacological and behavioral drug use treatments have been proven to diminish behaviors that increase HIV risk, decrease incidence of the disease, and improve adherence to antiretroviral therapy among individuals who use drugs and are HIV-positive. INCLUSION CRITERIA: The populations of interest in this review include patients who have experienced integrated substance use/addiction and HIV services, as well as health care professionals and policy makers who have been involved in developing or implementing integrated substance use/addiction and HIV/AIDS services. Eligible studies will focus on the views, attitudes, understandings, and perceptions of patients, health care professionals, and policy makers resulting from experience in developing or implementing strategies that have or could inform the integration of substance use/addiction and HIV/AIDS services in community settings. METHODS: Searches will be conducted in MEDLINE, Embase, PsycINFO, and CINHAL. The search for unpublished studies will include OpenGrey, Grey Matters, New York Academy of Medicine's Grey Literature Report, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform. Selected studies will be critically appraised by two independent reviewers for methodological quality. Data will be extracted and then synthesized following the JBI meta-aggregative approach. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD42020185858.

Predictors of Opioid-Related Death During Methadone Therapy.

We aimed to examine pharmacologic, demographic and medical comorbidity risk factors for opioid-related mortality among patients currently receiving methadone for an opioid use disorder. We conducted a population-based, nested case-control study linking healthcare and coroner's records in Ontario, Canada, from January 31, 1994 to December 31, 2010. We included social assistance recipients receiving methadone for an opioid use disorder. Within this group, cases were those who died of opioid-related causes. For each case, we identified up to 5 controls matched on calendar quarter. The primary analysis examined the association between use of psychotropic drugs (benzodiazepines, antidepressants or antipsychotics) and opioid-related mortality. Secondary analyses examined the associations between baseline characteristics, health service utilization, comorbidities and opioid-related mortality. Among 43,545 patients receiving methadone for an opioid use disorder, we identified 175 (0.4%) opioid-related deaths, along with 873 matched controls. Psychotropic drug use was associated with a two fold increased risk of opioid-related death (adjusted odds ratio (OR) 2.0; 95% confidence interval (CI) 1.2 to 3.5). Specifically, benzodiazepines (adjusted OR 1.6; 95% CI 1.1 to 2.5) and antipsychotics (adjusted OR 2.3; 95% CI 1.5 to 3.5) were independently associated with opioid-related death. Other associated factors included chronic lung disease (adjusted OR 1.7; 95% CI 1.2 to 2.6), an alcohol use disorder (adjusted OR 1.9; 95% CI 1.2 to 3.2), mood disorders (adjusted OR 1.8; 95% CI 1.0 to 3.2), and a history of heart disease (adjusted OR 5.3; 95% CI 2.0 to 14.0). Psychotropic drug use is associated with opioid-related death in patients receiving methadone. Mindfulness of these factors may reduce the risk of death among methadone recipients.

Prescribing smoked cannabis for chronic noncancer pain: preliminary recommendations.

OBJECTIVE: To offer preliminary guidance on prescribing smoked cannabis for chronic pain before the release of formal guidelines. QUALITY OF EVIDENCE: We reviewed the literature on the analgesic effectiveness of smoked cannabis and the harms of medical and recreational cannabis use. We developed recommendations on indications, contraindications, precautions, and dosing of smoked cannabis, and categorized the recommendations based on levels of evidence. Evidence is mostly level II (well conducted observational studies) and III (expert opinion). MAIN MESSAGE: Smoked cannabis might be indicated for patients with severe neuropathic pain conditions who have not responded to adequate trials of pharmaceutical cannabinoids and standard analgesics (level II evidence). Smoked cannabis is contraindicated in patients who are 25 years of age or younger (level II evidence); who have a current, past, or strong family history of psychosis (level II evidence); who have a current or past cannabis use disorder (level III evidence); who have a current substance use disorder (level III evidence); who have cardiovascular or respiratory disease (level III evidence); or who are pregnant or planning to become pregnant (level II evidence). It should be used with caution in patients who smoke tobacco (level II evidence), who are at increased risk of cardiovascular disease (level III evidence), who have anxiety or mood disorders (level II evidence), or who are taking higher doses of opioids or benzodiazepines (level III evidence). Cannabis users should be advised not to drive for at least 3 to 4 hours after smoking, for at least 6 hours after oral ingestion, and for at least 8 hours if they experience a subjective "high" (level II evidence). The maximum recommended dose is 1 inhalation 4 times per day (approximately 400 mg per day) of dried cannabis containing 9% delta-9-tetrahydrocannabinol (level III evidence). Physicians should avoid referring patients to "cannabinoid" clinics (level III evidence). CONCLUSION: Future guidelines should be based on systematic review of the literature on the safety and effectiveness of smoked cannabis. Further research is needed on the effectiveness and long-term safety of smoked cannabis compared with pharmaceutical cannabinoids, opioids, and other standard analgesics.

Integrated care for pregnant women on methadone maintenance treatment: Canadian primary care cohort study.

OBJECTIVE: To describe the characteristics of a national cohort of pregnant women on methadone maintenance treatment (MMT) and to provide treatment outcome data for integrated care programs. DESIGN: Retrospective chart review. SETTING: Three different integrated care programs in geographically distinct cities: the Toronto Centre for Substance Use in Pregnancy in Toronto, Ont; the Herzl Family Practice Centre in Montreal, Que; and the Sheway clinic in Vancouver, BC. PARTICIPANTS: Pregnant women meeting criteria for opioid dependence and attending an integrated care program between 1997 and 2009. Women were excluded if they were on MMT only for chronic pain. MAIN OUTCOME MEASURES: Patient demographic characteristics, concurrent medical and psychiatric disorders, and substance use outcome data. RESULTS: A total of 102 opioid-dependent pregnancies were included. The mean age was 29.7 years and 64% of women were white. Women in Montreal were more likely to have partners and had fewer children. Differences in living and housing situations among the sites tended to resolve by the time of delivery. Almost half of this cohort tested positive for hepatitis C. Women had a high prevalence of depression and anxiety across all sites. Half of this cohort was on MMT before conception and for the other half, MMT was initiated at a mean gestational age of 20.7 weeks, resulting in a mean dose of 82.4 mg at delivery. At the first visit, polysubstance use was common. Prescription opioid use was more frequent in Toronto and heroin use was more prevalent in Vancouver and Montreal. For the entire population, significant reductions were found by the time of delivery for illicit (P < .001) and prescription opioids (P = .001), cocaine (P < .001), marijuana (P = .009), and alcohol use (P < .001). CONCLUSION: Despite geographic differences, all 3 integrated care programs have been associated with significant decreases in substance use in pregnant opioid-dependent women.

Comprehensive treatment program for pregnant substance users in a family medicine clinic.

PROBLEM BEING ADDRESSED: Substance use during pregnancy is a substantial public health problem and a risk factor for poor neonatal outcomes. Prenatal care is often provided in high-risk pregnancy units, separate from addiction treatment. OBJECTIVE OF PROGRAM: To provide comprehensive prenatal care and addiction treatment in a family medicine setting. DESCRIPTION OF PROGRAM: The Toronto Centre for Substance Use in Pregnancy (T-CUP) is a family medicine-based program in a large urban city in Ontario. The T-CUP program comprises an interdisciplinary team using a one-stop access model to provide comprehensive services for pregnant women with a history of alcohol or drug abuse, including prenatal and postnatal medical care, addiction counseling, and assistance with complex psychosocial needs. EVALUATION: A retrospective chart review was performed, including charts for 121 women who received care at T-CUP from August 2000 to January 2006. Women demonstrated a high compliance rate with prenatal care attendance. Most women reported reduction in a variety of drug use categories. Significant differences were found especially among women who presented earlier in their pregnancies (P < .05). As a result, neonatal outcomes were satisfactory and approximately 75% of newborns were discharged home in the care of their mothers. CONCLUSION: Pregnant substance-using women have positive maternal and infant health outcomes when they receive comprehensive care in a family medicine setting.