How the commercial virtual care industry gathers, uses and values patient data: a Canadian qualitative study.

OBJECTIVES: To understand and report on the direct-to-consumer virtual care industry in Canada, focusing on how companies collect, use and value patient data. DESIGN: Qualitative study using situational analysis methodology. SETTING: Canadian for-profit virtual care industry. PARTICIPANTS: 18 individuals employed by or affiliated with the Canadian virtual care industry. METHODS: Semistructured interviews were conducted between October 2021 and January 2022 and publicly available documents on websites of commercial virtual care platforms were retrieved. Analysis was informed by situational analysis, a constructivist grounded theory methodology, with a continuous and iterative process of data collection and analysis; theoretical sampling and creation of theoretical concepts to explain findings. RESULTS: Participants described how companies in the virtual care industry highly valued patient data. Companies used data collected as patients accessed virtual care platforms and registered for services to generate revenue, often by marketing other products and services. In some cases, virtual care companies were funded by pharmaceutical companies to analyse data collected when patients interacted with a healthcare provider and adjust care pathways with the goal of increasing uptake of a drug or vaccine. Participants described these business practices as expected and appropriate, but some were concerned about patient privacy, industry influence over care and risks to marginalised communities. They described how patients may have agreed to these uses of their data because of high levels of trust in the Canadian health system, problematic consent processes and a lack of other options for care. CONCLUSIONS: Patients, healthcare providers and policy-makers should be aware that the direct-to-consumer virtual care industry in Canada highly values patient data and appears to view data as a revenue stream. The industry's data handling practices of this sensitive information, in the context of providing a health service, have implications for patient privacy, autonomy and quality of care.

Virtual Visits With Own Family Physician vs Outside Family Physician and Emergency Department Use.

Importance: Virtual visits became more common after the COVID-19 pandemic, but it is unclear in what context they are best used. Objective: To investigate whether there was a difference in subsequent emergency department use between patients who had a virtual visit with their own family physician vs those who had virtual visits with an outside physician. Design, Setting, and Participants: This propensity score-matched cohort study was conducted among all Ontario residents attached to a family physician as of April 1, 2021, who had a virtual family physician visit in the subsequent year (to March 31, 2022). Exposure: The type of virtual family physician visit, with own or outside physician, was determined. In a secondary analysis, own physician visits were compared with visits with a physician working in direct-to-consumer telemedicine. Main Outcome and Measure: The primary outcome was an emergency department visit within 7 days after the virtual visit. Results: Among 5 229 240 Ontario residents with a family physician and virtual visit, 4 173 869 patients (79.8%) had a virtual encounter with their own physician (mean [SD] age, 49.3 [21.5] years; 2 420 712 females [58.0%]) and 1 055 371 patients (20.2%) had an encounter with an outside physician (mean [SD] age, 41.8 [20.9] years; 605 614 females [57.4%]). In the matched cohort of 1 885 966 patients, those who saw an outside physician were 66% more likely to visit an emergency department within 7 days than those who had a virtual visit with their own physician (30 748 of 942 983 patients [3.3%] vs 18 519 of 942 983 patients [2.0%]; risk difference, 1.3% [95% CI, 1.2%-1.3%]; relative risk, 1.66 [95% CI, 1.63-1.69]). The increase in the risk of emergency department visits was greater when comparing 30 216 patients with definite direct-to-consumer telemedicine visits with 30 216 patients with own physician visits (risk difference, 4.1% [95% CI, 3.8%-4.5%]; relative risk, 2.99 [95% CI, 2.74-3.27]). Conclusions and Relevance: In this study, patients whose virtual visit was with an outside physician were more likely to visit an emergency department in the next 7 days than those whose virtual visit was with their own family physician. These findings suggest that primary care virtual visits may be best used within an existing clinical relationship.

Enterprise Healthcare Physician Services in Canada: An Environmental Scan.

Employers in Canada are increasingly offering physician services to their employees through third-party "enterprise" virtual care platforms. In our environmental scan, we identified nine enterprise healthcare companies offering physician services to millions of Canadian employees via enterprise platforms. All platforms offered rapid access to virtual physician services. Some offered in-person visits, access to specialists, health system navigation and sharing of information with an employee's regular care provider. Almost half shared aggregate or de-identified health data with employers. These platforms provide rapid and convenient access to physician services but also disrupt the continuity of care, pose risks to employee privacy and expand two-tiered healthcare.

For health or for profit? Understanding how private financing and for-profit delivery operate within Canadian healthcare (4H|4P): protocol for a multimethod knowledge mobilisation research project.

INTRODUCTION: Privatisation through the expansion of private payment and investor-owned corporate healthcare delivery in Canada raises potential conflicts with equity principles on which Medicare (Canadian public health insurance) is founded. Some cases of privatisation are widely recognised, while others are evolving and more hidden, and their extent differs across provinces and territories likely due in part to variability in policies governing private payment (out-of-pocket payments and private insurance) and delivery. METHODS AND ANALYSIS: This pan-Canadian knowledge mobilisation project will collect, classify, analyse and interpret data about investor-owned privatisation of healthcare financing and delivery systems in Canada. Learnings from the project will be used to develop, test and refine a new conceptual framework that will describe public-private interfaces operating within Canada's healthcare system. In Phase I, we will conduct an environmental scan to: (1) document core policies that underpin public-private interfaces; and (2) describe new or emerging forms of investor-owned privatisation ('cases'). We will analyse data from the scan and use inductive content analysis with a pragmatic approach. In Phase II, we will convene a virtual policy workshop with subject matter experts to refine the findings from the environmental scan and, using an adapted James Lind Alliance Delphi process, prioritise health system sectors and/or services in need of in-depth research on the impacts of private financing and investor-owned delivery. ETHICS AND DISSEMINATION: We have obtained approval from the research ethics boards at Simon Fraser University, University of British Columbia and University of Victoria through Research Ethics British Columbia (H23-00612). Participants will provide written informed consent. In addition to traditional academic publications, study results will be summarised in a policy report and a series of targeted policy briefs distributed to workshop participants and decision/policymaking organisations across Canada. The prioritised list of cases will form the basis for future research projects that will investigate the impacts of investor-owned privatisation.

Commercializing Personal Health Information: A Critical Qualitative Content Analysis of Documents Describing Proprietary Primary Care Databases in Canada.

BACKGROUND: Commercial data brokers have amassed large collections of primary care patient data in proprietary databases. Our study objective was to critically analyze how entities involved in the collection and use of these records construct the value of these proprietary databases. We also discuss the implications of the collection and use of these databases. METHODS: We conducted a critical qualitative content analysis using publicly available documents describing the creation and use of proprietary databases containing Canadian primary care patient data. We identified relevant commercial data brokers, as well as entities involved in collecting data or in using data from these databases. We sampled documents associated with these entities that described any aspect of the collection, processing, and use of the proprietary databases. We extracted data from each document using a structured data tool. We conducted an interpretive thematic content analysis by inductively coding documents and the extracted data. RESULTS: We analyzed 25 documents produced between 2013 and 2021. These documents were largely directed at the pharmaceutical industry, as well as shareholders, academics, and governments. The documents constructed the value of the proprietary databases by describing extensive, intimate, detailed patient-level data holdings. They provided examples of how the databases could be used by pharmaceutical companies for regulatory approval, marketing and understanding physician behaviour. The documents constructed the value of these data more broadly by claiming to improve health for patients, while also addressing risks to privacy. Some documents referred to the trade-offs between patient privacy and data utility, which suggests these considerations may be in tension. CONCLUSION: Documents in our analysis positioned the proprietary databases as socially legitimate and valuable, particularly to pharmaceutical companies. The databases, however, may pose risks to patient privacy and contribute to problematic drug promotion. Solutions include expanding public data repositories with appropriate governance and external regulatory oversight.

Characteristics and Health Care Use of Patients Attending Virtual Walk-in Clinics in Ontario, Canada: Cross-sectional Analysis.

BACKGROUND: Funding changes in response to the COVID-19 pandemic supported the growth of direct-to-consumer virtual walk-in clinics in several countries. Little is known about patients who attend virtual walk-in clinics or how these clinics contribute to care continuity and subsequent health care use. OBJECTIVE: The objective of the present study was to describe the characteristics and measure the health care use of patients who attended virtual walk-in clinics compared to the general population and a subset that received any virtual family physician visit. METHODS: This was a retrospective, cross-sectional study in Ontario, Canada. Patients who had received a family physician visit at 1 of 13 selected virtual walk-in clinics from April 1 to December 31, 2020, were compared to Ontario residents who had any virtual family physician visit. The main outcome was postvisit health care use. RESULTS: Virtual walk-in patients (n=132,168) had fewer comorbidities and lower previous health care use than Ontarians with any virtual family physician visit. Virtual walk-in patients were also less likely to have a subsequent in-person visit with the same physician (309/132,168, 0.2% vs 704,759/6,412,304, 11%; standardized mean difference [SMD] 0.48), more likely to have a subsequent virtual visit (40,030/132,168, 30.3% vs 1,403,778/6,412,304, 21.9%; SMD 0.19), and twice as likely to have an emergency department visit within 30 days (11,003/132,168, 8.3% vs 262,509/6,412,304, 4.1%; SMD 0.18), an effect that persisted after adjustment and across urban/rural resident groups. CONCLUSIONS: Compared to Ontarians attending any family physician virtual visit, virtual walk-in patients were less likely to have a subsequent in-person physician visit and were more likely to visit the emergency department. These findings will inform policy makers aiming to ensure the integration of virtual visits with longitudinal primary care.

Palliative care for people who use drugs during communicable disease epidemics and pandemics: A scoping review on access, policies, and programs and guidelines.

BACKGROUND: People who use drugs with life-limiting illnesses experience substantial barriers to accessing palliative care. Demand for palliative care is expected to increase during communicable disease epidemics and pandemics. Understanding how epidemics and pandemics affect palliative care for people who use drugs is important from a service delivery perspective and for reducing population health inequities. AIM: To explore what is known about communicable disease epidemics and pandemics, palliative care, and people who use drugs. DESIGN: Scoping review. DATA SOURCES: We searched six bibliographic databases from inception to April 2021 as well as the grey literature. We included English and French records about palliative care access, programs, and policies and guidelines for people ⩾18 years old who use drugs during communicable disease epidemics and pandemics. RESULTS: Forty-four articles were included in our analysis. We identified limited knowledge about palliative care for people who use drugs during epidemics and pandemics other than HIV/AIDS. Through our thematic synthesis of the records, we generated the following themes: enablers and barriers to access, organizational barriers, structural inequity, access to opioids and other psychoactive substances, and stigma. CONCLUSIONS: Our findings underscore the need for further research about how best to provide palliative care for people who use drugs during epidemics and pandemics. We suggest four ways that health systems can be better prepared to help alleviate the structural barriers that limit access as well as support the provision of high-quality palliative care during future epidemics and pandemics.

Evaluation of the gap in delivery of opioid agonist therapy among individuals with opioid-related health problems: a population-based retrospective cohort study.

AIMS: Although opioid-related harms have reached new heights across North America, the size of the gap in opioid agonist therapy (OAT) delivery for opioid-related health problems is unknown in most jurisdictions. This study sought to characterize the gap in OAT treatment using a cascade of care framework, and determine factors associated with engagement and retention in treatment. DESIGN: A population-based retrospective cohort study. SETTING: Ontario, Canada. PARTICIPANTS: Individuals who sought medical care for opioid-related health problems or died from an opioid-related cause between 2005 and 2019. MEASUREMENTS: Monthly treatment status for buprenorphine/naloxone or methadone OAT between 2013 and 2019 (i.e. 'off OAT', 'retained on OAT < 6 months', 'retained on OAT ≥ 6 months'). FINDINGS: Of 122 811 individuals in the cohort, 97 516 (79.4%) received OAT at least once during the study period. There was decreasing 6-month treatment retention over time. Model results indicated that males had higher odds of being on OAT each month [odds ratio (OR) = 1.26, 95% confidence interval (CI) = 1.23-1.28] but lower odds of OAT retention (OR = 0.90, 95% CI = 0.88-0.92), while the reverse was observed for older individuals (monthly: OR = 0.76 per 10-year increase, 95% CI = 0.76-0.77; retention: OR = 1.36 per 10-year increase, 95% CI = 1.34-1.38) and individuals with higher neighbourhood income (e.g. highest income quintile, monthly: OR = 0.79, 95% CI = 0.77-0.82; highest income quintile, retention: OR = 1.15, 95% CI = 1.11-1.20). Individuals residing in rural areas and with a history of mental health diagnoses had poorer outcomes overall, including lower odds of being on OAT each month (rural: OR = 0.75, 95% CI = 0.73-0.78; mental health: OR = 0.89, 95% CI = 0.87-0.92) and OAT retention (rural: OR = 0.79, 95% CI = 0.77-0.82; mental health: OR = 0.81, 95% CI = 0.78-0.83), as well as higher risk of starting/stopping OAT [rural, starting OAT: hazard ratio (HR) = 1.07, 95% CI = 1.05-1.10; mental health, starting OAT: HR = 1.20, 95% CI: 1.18-1.23; rural, stopping OAT: HR = 1.24, 95% CI: = 1.22-1.26; mental health, stopping OAT: HR = 1.11, 95% CI = 1.09-1.13]. Individuals with a history of mental health diagnoses also had a higher risk of death, regardless of OAT status (off OAT death: HR = 1.49, 95% CI = 1.33-1.66; on OAT death: HR = 1.20, 95% CI = 1.09-1.31). CONCLUSIONS: Factors influencing engagement and declining retention in treatment with opioid agonist therapy in Ontario's health system include age, sex and neighbourhood income, as well as mental health diagnoses or residing in rural regions.

Examining Access to Primary Care for People With Opioid Use Disorder in Ontario, Canada: A Randomized Clinical Trial.

Importance: People with opioid use disorder are less likely than others to have a primary care physician. Objective: To determine if family physicians are less likely to accept people with opioid use disorder as new patients than people with diabetes. Design, Setting, and Participants: This randomized clinical trial used an audit design to survey new patient intake at randomly selected family physicians in Ontario, Canada. Eligible physicians were independent practitioners allowed to prescribe opioids who were located in an office within 50 km of a population center greater than 20 000 people. A patient actor made unannounced telephone calls to family physicians asking for a new patient appointment. The data were analyzed in September 2021. Intervention: In the first randomly assigned scenario, the patient actor played a role of patient with diabetes in treatment with an endocrinologist. In the second scenario, the patient actor played a role of a patient with opioid use disorder undergoing methadone treatment with an addiction physician. Main Outcomes and Measures: Total offers of a new patient appointment; a secondary analysis compared the proportions of patients offered an appointment stratified by gender, population, model of care, and years in practice. Results: Of a total 383 family physicians included in analysis, a greater proportion offered a new patient appointment to a patient with diabetes (21 of 185 physicians [11.4%]) than with opioid use disorder (8 of 198 physicians [4.0%]) (absolute difference, 7.4%; 95% CI, 2.0 to 12.6; P = .007). Physicians with more than 20 years in practice were almost 13 times less likely to offer an appointment to a patient with opioid use disorder compared with diabetes (1 of 108 physicians [0.9%] vs 10 of 84 physicians [11.9%]; absolute difference, 11.0; 95% CI, 3.8 to 18.1; P = .001). Women were almost 5 times less likely (3 of 111 physicians [2.7%] vs 14 of 114 physicians [12.3%]; absolute difference, 9.6%; 95% CI, 2.4 to 16.3; P = .007) to offer an appointment to a patient with opioid use disorder than with diabetes. Conclusions and Relevance: In this randomized clinical trial, family physicians were less likely to offer a new patient appointment to a patient with opioid use disorder compared with a patient with diabetes. Potential health system solutions to this disparity include strengthening policies for accepting new patients, improved compensation, and clinician anti-oppression training. Trial Registration: ClinicalTrials.gov Identifier: NCT05484609.

How the Suboxone Education Programme presented as a solution to risks in the Canadian opioid crisis: a critical discourse analysis.

OBJECTIVES: Pharmaceutical industry involvement in medical education, research and clinical practice can lead to conflicts of interest. Within this context, this study examined how the 'Suboxone Education Programme', developed and delivered by a pharmaceutical company as part of a federally regulated risk management program, was presented as a solution to various kinds of risks relating to opioid use in public documents from medical institutions across Canada. SETTING: These documents were issued during the Canadian opioid crisis, a time when the involvement of industry in health policy was being widely questioned given industry's role in driving the overprescribing of opioid analgesics and contributing to population-level harms. DESIGN: A critical discourse analysis of 69 documents collected between July 2020 and May 2021 referencing the Suboxone Education Program spanning 13 years (2007-2021) from medical, nursing and pharmacy institutions sourced from every Canadian province and territory. Discursive themes were identified through iterative and duplicate analyses using a semistructured data extraction instrument. RESULTS: Documents characterised the Programme as addressing iatrogenic risks from overprescribing opioid analgesics, environmental risks from a toxic street drug supply and pharmacological risks relating to the dominant therapeutic alternative of methadone. The programme was identified as being able to address these risks by providing mechanisms to surveil healthcare professionals and to facilitate the prescribing of Suboxone. Medical institutions legitimised the Suboxone Education Programme by lending their regulatory, epidemiological and professional authority. CONCLUSIONS: Addressing risk is considered as a central, moral responsibility of contemporary healthcare services. In this case, moral imperatives to address opioid crisis-related risks overrode other ethical concerns regarding conflicts of interest between industry and public welfare. Failing to address these conflicts potentially imperils efforts of mitigating population health harms by propagating an important driving force of the opioid crisis.

Chronic Pain and Opioid Prescribing: Three Ways for Navigating Complexity at the Clinical‒Population Health Interface.

Clinically focused interventions for people living with pain, such as health professional education, clinical decision support systems, prescription drug monitoring programs, and multidisciplinary care to support opioid tapering, have all been promoted as important solutions to the North American opioid crisis. Yet none have so far delivered substantive beneficial opioid-related population health outcomes. In fact, while total opioid prescribing has leveled off or reduced in many jurisdictions, population-level harms from opioids have continued to increase dramatically. We attribute this failure partly to a poor recognition of the epistemic and ethical complexities at the interface of clinical and population health. We draw on a framework of knowledge networks in wicked problems to identify 3 strategies to help navigate these complexities: (1) designing and evaluating clinically focused interventions as complex interventions, (2) reformulating evidence to make population health dynamics apparent, and (3) appealing to the inseparability of facts and values to support decision-making in uncertainty. We advocate that applying these strategies will better equip clinically focused interventions as complements to structural and public health interventions to achieve the desired beneficial population health effects. (Am J Public Health. 2022;112(S1):S56-S65. https://doi.org/10.2105/AJPH.2021.306500).

Palliative care for people who use substances during communicable disease epidemics and pandemics: a scoping review protocol.

INTRODUCTION: Communicable disease epidemics and pandemics magnify the health inequities experienced by marginalised populations. People who use substances suffer from high rates of morbidity and mortality and should be a priority to receive palliative care, yet they encounter many barriers to palliative care access. Given the pre-existing inequities to palliative care access for people with life-limiting illnesses who use substances, it is important to understand the impact of communicable disease epidemics and pandemics such as COVID-19 on this population. METHODS AND ANALYSIS: We will conduct a scoping review and report according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews reporting guidelines. We conducted a comprehensive literature search in seven bibliographical databases from the inception of each database to August 2020. We also performed a grey literature search to identify the publications not indexed in the bibliographical databases. All the searches will be rerun in April 2021 to retrieve recently published information because the COVID-19 pandemic is ongoing at the time of this writing. We will extract the quantitative data using a standardised data extraction form and summarise it using descriptive statistics. Additionally, we will conduct thematic qualitative analyses and present our findings as narrative summaries. ETHICS AND DISSEMINATION: Ethics approval is not required for a scoping review. We will disseminate our findings to healthcare providers and policymakers through professional networks, digital communications through social media platforms, conference presentations and publication in a scientific journal.

Clinical Decision Support Systems for Opioid Prescribing for Chronic Non-Cancer Pain in Primary Care: A Scoping Review.

BACKGROUND AND OBJECTIVES: Clinical decision support systems (CDSSs) may help clinicians prescribe opioids for chronic noncancer pain (CNCP) more appropriately. This scoping review determined the extent and range of the current evidence on CDSSs for opioid prescribing for CNCP in primary care, and whether investigators followed best evidence and current guidance in designing, implementing and evaluating these complex interventions. METHODS: We searched 9 electronic databases and other data sources for studies from January 1, 2008 to October 11, 2019. Two reviewers independently screened the citations. One reviewer extracted data and a second verified for accuracy. INCLUSION CRITERIA: study of a CDSS for opioid prescribing for CNCP in a primary care clinical setting. We reported quantitative results in tables and qualitative results in narrative form. RESULTS: Our search yielded 5068 records, of which 14 studies met our inclusion criteria. All studies were conducted in the United States. Six studies examined local (eg, health center) CDSSs and 8 examined prescription drug monitoring program CDSSs. Three CDSSs incorporated evidence-based components. Study aims were heterogeneous and study designs included both quantitative and qualitative methodologies. No studies assessed patient health outcomes. Few studies appeared to be following guidance for evaluating complex interventions. CONCLUSIONS: Few studies have rigorously assessed the use of CDSSs for opioid prescribing for CNCP in primary care settings. Going forward, investigators should include evidence-based components into the design of CDSSs and follow guidance for the development and evaluation of complex interventions.

Drivers of the opioid crisis: An appraisal of financial conflicts of interest in clinical practice guideline panels at the peak of opioid prescribing.

BACKGROUND: Starting in the late 1990s, the pharmaceutical industry sought to increase prescribing of opioids for chronic non-cancer pain. Influencing the content of clinical practice guidelines may have been one strategy industry employed. In this study we assessed potential risk of bias from financial conflicts of interest with the pharmaceutical industry in guidelines for opioid prescribing for chronic non-cancer pain published between 2007 and 2013, the peak of opioid prescribing. METHODS: We used the Guideline Panel Review (GPR) to appraise the guidelines included in the 2014 systematic review and critical appraisal by Nuckols et al. These were English language opioid prescribing guidelines for adults with chronic non-cancer pain published between July 2007 and July 2013, the peak of opioid prescribing. The GPR assigns red flags to items known to introduce potential bias from financial conflicts of interest. We operationalized the GPR by creating specific definitions for each red flag. Two reviewers independently evaluated each guideline. Disagreements were resolved with discussion. We also compared our score to the critical appraisal scores for overall quality from the study by Nuckols et al. RESULTS: We appraised 13 guidelines, which received 43 red flags in total. Guidelines had 3.3 red flags on average (out of a possible seven) with range from one to six. Four guidelines had missing information, so red flags may be higher than reported. The guidelines with the highest and second highest scores for overall quality in the 2014 critical appraisal by Nuckols et al. had five and three red flags, respectively. CONCLUSION: Our findings reveal that the guidelines for opioid prescribing chronic non-cancer pain from 2007 to 2013 were at risk of bias because of pervasive conflicts of interest with the pharmaceutical industry and a paucity of mechanisms to address bias. Even highly-rated guidelines examined in a 2014 systematic review and critical appraisal had many red flags.

Improving opioid guideline adherence: evaluation of a multifaceted, theory-informed pilot intervention for family physicians.

OBJECTIVES: Opioid-related deaths continue to increase in North America, an epidemic that was initiated by high rates of opioid prescribing. We designed a multifaceted, theory-informed Opioid Self-Assessment (OSA) package, to increase adherence to the Canadian Opioid Guideline among family physicians. This study aimed to assess changes in Canadian family physicians' knowledge and practices after completing the OSA package. DESIGN: We conducted a mixed-method evaluation using a pre-test and post-test design that involved the collection of both qualitative and quantitative data. SETTING: This research was conducted in the primary care setting in Ontario, Canada. PARTICIPANTS: We recruited a purposive sample of nine family physicians in Ontario who use long-term opioid therapy to treat patients with chronic pain. INTERVENTIONS: The OSA package included four components: an online knowledge test, an online learning programme, a safe medication practice self-assessment questionnaire and chart audit with feedback. OUTCOME MEASURES: Our measures included changes in knowledge, opioid safety practices and physicians' perspectives on the OSA package. RESULTS: We found statistically significant improvements between pre-test and post-test knowledge scores at both baseline and 6-month follow-up. Physicians' scores improved significantly on five of the seven core characteristics of the practice self-assessment questionnaire. On the chart audits, we observed an improvement in patient education between baseline and 6 months. Qualitative interviews showed that participants appreciated embedded resources in the OSA package. The completion of the package stimulated identification of gaps or deficits in practice and served as a useful reminder to discuss risk and safety with patients. Participants described the chart review as helpful in prompting discussions with their patients, identifying deficits and strengths and a 'primary motivator' for project participation. CONCLUSIONS: The OSA package has the potential to improve medication safety practices in primary care related to opioid monitoring and adherence to current opioid guidelines.