Buprenorphine/naloxone initiation and referral as a quality improvement intervention for patients who live with opioid use disorder: quantitative evaluation of provincial spread to 107 rural and urban Alberta emergency departments.

OBJECTIVES: Opioid use disorder is a major public health concern that accounts for a high number of potential years of life lost. Buprenorphine/naloxone is a recommended treatment for opioid use disorder that can be started in the emergency department (ED). We developed an ED-based program to initiate buprenorphine/naloxone for eligible patients who live with opioid use disorder, and to provide unscheduled, next-day follow-up referrals to an opioid use disorder treatment clinic (in person or virtual) for continuing patient care throughout Alberta. METHODS: In this quality improvement initiative, we supported local ED teams to offer buprenorphine/naloxone to eligible patients presenting to the ED with suspected opioid use disorder and refer these patients for follow-up care. Process, outcome, and balancing measures were evaluated over the first 2 years of the initiative (May 15, 2018-May 15, 2020). RESULTS: The program was implemented at 107 sites across Alberta during our evaluation period. Buprenorphine/naloxone initiations in the ED increased post-intervention at most sites with baseline data available (11 of 13), and most patients (67%) continued to fill an opioid agonist prescription at 180 days post-ED visit. Of the 572 referrals recorded at clinics, 271 (47%) attended their first follow-up visit. Safety events were reported in ten initiations and were all categorized as no harm to minimal harm. CONCLUSIONS: A standardized provincial approach to initiating buprenorphine/naloxone in the ED for patients living with opioid use disorder was spread to 107 sites with dedicated program support staff and adjustment to local contexts. Similar quality improvement approaches may benefit other jurisdictions.

ABSTRAIT: OBJECTIFS: Le trouble lié à la consommation d'opioïdes est une préoccupation majeure en santé publique qui explique le nombre élevé d'années potentielles de vie perdues. La buprénorphine/naloxone est un traitement recommandé pour le trouble lié à l'utilisation d'opioïdes qui peut être commencé au service des urgences (SU). Nous avons mis au point un programme axé sur les urgences pour commencer la buprénorphine/naloxone pour les patients éligibles qui vivent avec un trouble lié à l'utilisation d'opioïdes, et pour fournir suivis des cas référés le jour suivant vers une clinique de soins des troubles liés à l'utilisation d'opioïdes (sur place ou virtuelle) pour les soins continus aux patients partout en Alberta. MéTHODES: Dans le cadre de cette initiative d'amélioration de la qualité, nous avons aidé les équipes locales de SU à offrir la buprénorphine/naloxone aux patients admissibles qui se présentent à la SU avec un trouble présumé de consommation d'opioïdes et à les diriger vers des soins de suivi. Le processus, les résultats et les mesures d'équilibre ont été évalués au cours des deux premières années de l'initiative (du 15 mai 2018 au 15 mai 2020). RéSULTATS: Le programme a été mis en œuvre dans 107 sites en Alberta pendant notre période d'évaluation. Les initiations à la buprénorphine/naloxone à l'urgence ont augmenté après l'intervention dans la plus grande partie de sites pour lesquels des données de référence étaient disponibles (11 sur 13), et la plupart des patients (67 %) ont continué de remplir une ordonnance d'agonistes opioïdes 180 jours après la visite à l'urgence. Sur les 572 renvois enregistrés aux cliniques, 271 (47 %) ont assisté à leur première visite de suivi. Des événements liés à la sécurité ont été signalés dans 10 initiatives et ont tous été classés comme n'ayant causé aucun conséquences à des conséquences minimes. CONCLUSIONS: Une approche provinciale standardisé de lancement de la buprénorphine/naloxone à l'urgence pour les patients atteints d'un trouble lié à la consommation d'opioïdes a été diffusée à 107 sites à l'aide de soutien aux programmes spécialisé et des ajustements aux contextes locaux. Des approches semblables d'amélioration de la qualité pourraient profiter à d'autres juridictions.

Food for Thought: A Dissonance Between Healthcare Utilization Costs and Research Funding for Eating Disorders in Canada.

In this commentary, we present the premise that, in Canada, mental illness research specific to eating disorders is underfunded, and many Canadians are suffering the consequences of this underinvestment. We highlight three critical aspects of eating disorders: 1) the increasingly common yet potentially life-threatening nature of eating disorders, with an onset usually during adolescence; 2) the challenges and costs to treating eating disorders, with a discussion of current hospital-related costs across Canada; and 3) the glaring discrepancy between the money spent on eating disorder diagnoses/treatment and the funding dollars granted for eating disorder research in Canada (i.e. only $0.70 per affected Canadian in 2018). Research funding per affected individual for other psychiatric and neurodevelopmental conditions are used as comparisons (e.g. $50.17 per affected Canadian with schizophrenia). We suggest that it is time to revolutionize treatment for individuals with eating disorders and use our resources in a more efficient and effective manner, using current neuroimaging and neuromodulation methods as promising examples. We conclude by emphasizing the need for increased research funding in the field of eating disorders in Canada, as the current research-related investments hinder progress in developing neuroscientifically-sound treatments for these populations.

Dans ce commentaire, nous présentons la prémisse selon laquelle, au Canada, la recherche en maladie mentale propre aux troubles alimentaires est sous-financée, et nombre de Canadiens souffrent des conséquences de ce sous-investissement. Nous soulignons trois aspects essentiels des troubles alimentaires: 1) la nature de plus en plus répandue et pourtant potentiellement mortelle des troubles alimentaires, qui débutent habituellement à l'adolescence; 2) les défis et les frais de traiter les troubles alimentaires, et une présentation des coûts actuels en milieu hospitalier au Canada; et 3) l'écart flagrant entre les sommes dépensées pour le traitement/diagnostic des troubles alimentaires et le financement accordé à la recherche sur les troubles alimentaires au Canada (c.-à-d., seulement 0,70 $ par Canadien touché en 2018). Le financement de la recherche par personne touchée par d'autres troubles psychiatriques et neurodéveloppementaux sert de comparaison (p. ex., 50,17$ par Canadien touché par la schizophrénie). Nous suggérons qu'il est temps de révolutionner le traitement pour les personnes souffrant de troubles alimentaires et d'utiliser nos ressources de façon plus efficiente et efficace, en nous servant de la neuroimagerie actuelle et des méthodes de neuromodulation, soit des exemples prometteurs. Nous concluons en mettant l'accent sur le besoin d'un financement accru de la recherche dans le domaine des troubles alimentaires au Canada, car les investissements actuels dans la recherche freinent le progrès du développement de traitements neuroscientifiquement efficaces pour ces populations.

Lower limb peripersonal space and the desire to amputate a leg.

Body integrity identity disorder (BIID) is a rare condition defined by a persistent desire to amputate or paralyze a healthy limb (usually one or both of the legs). This desire arises from experiencing a mismatch between the internal body model and the actual physical/functional boundaries of the body. People with BIID show an abnormal physiological response to stimuli approaching the affected (unwanted) but not the unaffected leg, which might suggest a retracted peripersonal space (PPS: a multisensory integration zone near the body) around the unwanted limb. Thus, using a visuo-tactile interaction task, we examined leg PPS in a group of healthy men and three men with BIID who desired unilateral leg amputation. PPS size (~ 70 cm) around the unwanted BIID legs did not differ from that of healthy controls. Although the leg feels foreign in BIID, it still seems to maintain a PPS, presumably to protect it and facilitate interactions within the surrounding environment.

An Investigation of Lower Limb Representations Underlying Vision, Touch, and Proprioception in Body Integrity Identity Disorder.

Individuals with Body Integrity Identity Disorder (BIID) have a (non-psychotic) longstanding desire to amputate or paralyze one or more fully-functioning limbs, often the legs. This desire presumably arises from experiencing a mismatch between one's perceived mental image of the body and the physical structural and/or functional boundaries of the body itself. While neuroimaging studies suggest a disturbed body representation network in individuals with BIID, few behavioral studies have looked at the manifestation of this disrupted lower limb representations in this population. Specifically, people with BIID feel like they are overcomplete in their current body. Perhaps sensory input, processed normally on and about the limb, cannot communicate with a higher-order model of the leg in the brain (which might be underdeveloped). We asked individuals who desire paralysis or amputation of the lower legs (and a group of age- and sex-matched controls) to make explicit and implicit judgments about the size and shape of their legs while relying on vision, touch, and proprioception. We hypothesized that BIID participants would mis-estimate the size of their affected leg(s) more than the same leg of controls. Using a multiple single-case analysis, we found no global differences in lower limb representations between BIID participants and controls. Thus, while people with BIID feel that part of the body is foreign, they can still make normal sensory-guided implicit and explicit judgments about the limb. Moreover, these results suggest that BIID is not a body image disorder, per se, and that an examination of leg representation does not uncover the disturbed bodily experience that individuals with BIID have.

Mental rotation of feet in individuals with Body Integrity Identity Disorder, lower-limb amputees, and normally-limbed controls.

Body Integrity Identity Disorder (BIID) is a non-psychotic condition wherein individuals desire amputation or paralysis of one or more healthy, fully-functioning limbs (predominantly the legs). Individuals with BIID have been suggested to have a mismatch between the perceived mental representation of the body and its actual physical structure, such that their desired identity matches that of a lower-limb amputee. Accordingly, studies have reported an altered central network involving body representation of the legs in BIID, but its relationship to behavior remains unclear. In the present study, we investigated the integrity of body representation in individuals with BIID, acquired lower-limb amputees, and normally-limbed controls using an online mental rotation task. Participants judged the laterality of left and right foot images presented from different views, orientations, and of different types. We expected BIID participants to be slower for mentally rotating images that corresponded to their affected legs than lower-limb amputees and normally-limbed participants. We found that the groups did not significantly differ in their performance. All participants were slower at judging feet presented in awkward postures than natural postures, replicating previous studies and validating our online paradigm. The results are discussed in terms of the robust nature of visual and sensorimotor lower-limb representations, whether related to the self or as prototype, in the context of disturbed lower-limb integrity.

The disappearing limb trick and the role of sensory suggestibility in illusion experience.

Body ownership (the feeling that my body belongs to me) can be easily perturbed in healthy individuals by inducing bodily illusions. For example, dis-integrating vision, touch, and proprioception can produce the feeling that your limb is 'lost', such as in "the disappearing hand trick" (DHT). Following this illusion, participants report that the hand feels as though it is no longer part of the body, that it does not belong to them anymore, and that they do not know its location. However, it remains unknown whether this illusion can also be applied to the feet. Lower body ownership is disturbed in some populations, such as in Body Integrity Identity Disorder (BIID), where people have a longstanding desire to paralyze or amputate a (disowned) part of their body (i.e. usually the legs), thus exploring the efficacy and utility of lower body illusions might be useful for populations like such. In the current study, we induced the disappearing hand and foot trick in two groups of healthy adults. As the illusion crucially relies on illusory sensory feedback, we also explored if one's level of sensory suggestibility influenced the experience of the illusion. Questionnaire data showed that the DHT can be applied to the feet, as there was no difference in experience between those who experienced the illusion for the hands and those who experienced the illusion for the feet. Moreover, one's level of sensory suggestibility correlated positively with the experience of illusory sensations (like warmth, numbness, or the presence of an extra limb) following the illusion. We discuss the implications of bodily illusions in clinical populations and emphasize the critical role that sensory signals (even illusory) play in creating the bodily experience.

The influence of vision, touch, and proprioception on body representation of the lower limbs.

Numerous studies have shown that the representation of the hand is distorted. When participants are asked to localize unseen points on the hand (e.g. the knuckle), it is perceived to be wider and shorter than its physical dimensions. Similar distortions occur when people are asked to judge the distance between two tactile points on the hand; estimates made in the longitudinal direction are perceived as significantly shorter than those made in the transverse direction. Yet, when asked to visually compare the shape and size of one's own hand to a template hand, individuals are accurate at estimating the size of their own hands. Thus, it seems that body representations are, at least in part, a function of the most prominent underlying sensory modality used to perceive the body part. Yet, it remains unknown if the representations of other body parts are similarly distorted. The lower limbs, for example, are structurally and functionally very different from the hands, yet their representation(s) are seldom studied. What does the body representation for the leg look like? And is leg representation dependent on which sense is probed when making judgments about its shape and size? In the current study, we investigated what the representation of the leg looks like in visually-, tactually-, and proprioceptively-guided tasks. Results revealed that the leg, like the hand, is distorted in a highly systematic manner. Distortions seem to rely, at least partly, on sensory input. This is the first study, to our knowledge, to systematically investigate leg representation in healthy individuals.

The contributions of vision and haptics to reaching and grasping.

This review aims to provide a comprehensive outlook on the sensory (visual and haptic) contributions to reaching and grasping. The focus is on studies in developing children, normal, and neuropsychological populations, and in sensory-deprived individuals. Studies have suggested a right-hand/left-hemisphere specialization for visually guided grasping and a left-hand/right-hemisphere specialization for haptically guided object recognition. This poses the interesting possibility that when vision is not available and grasping relies heavily on the haptic system, there is an advantage to use the left hand. We review the evidence for this possibility and dissect the unique contributions of the visual and haptic systems to grasping. We ultimately discuss how the integration of these two sensory modalities shape hand preference.

Manual preferences for visually- and haptically-guided grasping.

Studies have shown that individuals exhibit a right-hand preference for grasping during visually-guided tasks. Recently, we have found that when vision is occluded right-hand preference decreases dramatically. It remains unknown however, if this decrease is a result of visual occlusion or the effects of relying only on haptic feedback. Therefore, in the present study, we sought to explore the contributions of vision and haptics (separately and in conjunction) to hand preference for grasping. Right- and left-handed individuals were tested on a block building task under four different visual and haptic conditions: 1) vision/normal haptic feedback (V/H), 2) no vision/normal haptic feedback (NV/H), 3) vision/constrained haptic feedback (V/Constrained-H), and 4) no vision/constrained haptic feedback (NV/Constrained-H). Vision was occluded using a blindfold and haptic feedback was constrained by asking participants to wear textured gloves. Right-handed individuals displayed a right-hand preference when vision was available (V/H and V/Constrained-H groups), but this preference was much greater when haptic feedback was constrained (V/Constrained-H group). When vision was occluded and haptic feedback was used to complete the task (NV/H) no hand preference was found. Finally hand preference was similar between the V/H and the NV/Constrained-H groups. For left-handed individuals, no differences in hand use were found between the different sensory groups, but the NV/H group showed a clear left-hand preference for haptically-guided grasping. The results suggest that haptics plays an important role in hand preference for grasping. Furthermore, they support a left-hand/right-hemisphere specialization for haptically-guided grasping (regardless of handedness) and a right-hand/left-hemisphere specialization for visually-guided grasping (at least in right-handed individuals).

Evidence for right-hand feeding biases in a left-handed population.

We have recently shown that actions with similar kinematic requirements, but different end-state goals may be supported by distinct neural networks. Specifically, we demonstrated that when right-handed individuals reach-to-grasp food items with intent to eat, they produce smaller maximum grip apertures (MGAs) than when they grasp the same item with intent to place it in a location near the mouth. This effect was restricted to right-handed movements; left-handed movements showed no difference between tasks. The current study investigates whether (and to which side) the effect may be lateralized in left-handed individuals. Twenty-one self-identified left-handed participants grasped food items of three different sizes while grasp kinematics were captured via an Optotrak Certus motion capture array. A main effect of task was identified wherein the grasp-to-eat action generated significantly smaller MGAs than did the grasp-to-place action. Further analysis revealed that similar to the findings in right-handed individuals, this effect was significant only during right-handed movements. Upon further inspection however, we found individual differences in the magnitude and direction of the observed lateralization. These results underscore the evolutionary significance of the grasp-to-eat movement in producing population-level right-handedness in humans as well as highlighting the heterogeneity of the left-handed population.

Grasping without sight: insights from the congenitally blind.

We reach for and grasp different sized objects numerous times per day. Most of these movements are visually-guided, but some are guided by the sense of touch (i.e. haptically-guided), such as reaching for your keys in a bag, or for an object in a dark room. A marked right-hand preference has been reported during visually-guided grasping, particularly for small objects. However, little is known about hand preference for haptically-guided grasping. Recently, a study has shown a reduction in right-hand use in blindfolded individuals, and an absence of hand preference if grasping was preceded by a short haptic experience. These results suggest that vision plays a major role in hand preference for grasping. If this were the case, then one might expect congenitally blind (CB) individuals, who have never had a visual experience, to exhibit no hand preference. Two novel findings emerge from the current study: first, the results showed that contrary to our expectation, CB individuals used their right hand during haptically-guided grasping to the same extent as visually-unimpaired (VU) individuals did during visually-guided grasping. And second, object size affected hand use in an opposite manner for haptically- versus visually-guided grasping. Big objects were more often picked up with the right hand during haptically-guided, but less often during visually-guided grasping. This result highlights the different demands that object features pose on the two sensory systems. Overall the results demonstrate that hand preference for grasping is independent of visual experience, and they suggest a left-hemisphere specialization for the control of grasping that goes beyond sensory modality.

Grasping with the eyes of your hands: hapsis and vision modulate hand preference.

Right-hand preference has been demonstrated for visually guided reaching and grasping. Grasping, however, requires the integration of both visual and haptic cues. To what extent does vision influence hand preference for grasping? Is there a hand preference for haptically guided grasping? Two experiments were designed to address these questions. In Experiment 1, individuals were tested in a reaching-to-grasp task with vision (sighted condition) and with hapsis (blindfolded condition). Participants were asked to put together 3D models using building blocks scattered on a tabletop. The models were simple, composed of ten blocks of three different shapes. Starting condition (Vision-First or Hapsis-First) was counterbalanced among participants. Right-hand preference was greater in visually guided grasping but only in the Vision-First group. Participants who initially built the models while blindfolded (Hapsis-First group) used their right hand significantly less for the visually guided portion of the task. To investigate whether grasping using hapsis modifies subsequent hand preference, participants received an additional haptic experience in a follow-up experiment. While blindfolded, participants manipulated the blocks in a container for 5 min prior to the task. This additional experience did not affect right-hand use on visually guided grasping but had a robust effect on haptically guided grasping. Together, the results demonstrate first that hand preference for grasping is influenced by both vision and hapsis, and second, they highlight how flexible this preference could be when modulated by hapsis.

Hand preference across the lifespan: effects of end-goal, task nature, and object location.

In the present study we investigate age-related changes in hand preference for grasping and the influence of task demands on such preference. Children (2-11), young-adults (17-28) and older-adults (57-90) were examined in a grasp-to-eat and a grasp-to-construct task. The end-goal of these tasks was different (eat vs. construct) as was the nature of the task (unimanual vs. bimanual). In both tasks, ipsilateral and contralateral grasps were analyzed. Results showed a right-hand preference that did not change with age. Across the three age groups, a more robust right-hand preference was observed for the unimanual, grasp-to-eat task. To disentangle if the nature (unimanual) or the end-goal (grasp-to-eat) was the driver of the robust right-hand preference, a follow up experiment was conducted. Young-adult participants completed a unimanual grasp-to-place task. This was contrasted with the unimanual grasp-to-eat task and the bimanual grasp-to-construct task. Rates of hand preference for the grasp-to-eat task remained the highest when compared to the other two grasping tasks. Together, the results demonstrate that hand preference remains stable from childhood to older adulthood, and they suggest that a left hemisphere specialization exists for grasping, particularly when bringing food to the mouth.

Hand use for grasping in a bimanual task: evidence for different roles?

It has been proposed that the two hands play different roles during bimanual object interaction. The right hand takes on an explorative, highly precise, manipulative role while the left hand supports and stabilizes the object. Does this division of labour influence hand use during visually guided grasping? Three experiments were designed to address this question: right-handed individuals put together 3D models using big or small building blocks scattered across a tabletop. Participants were free to build the models; however, it felt comfortable (Experiment 1) or they were required to build on a large (Experiment 2) or small (Experiment 3) base plate. In Experiment 1, the right hand was preferred for grasping while the left hand stabilized the building model. When participants used the large base plate (Experiment 2), right hand use for grasping decreased and left hand use increased. The plate provided freedom to the left hand from having to stabilize the building model, but it also interfered with right/left hand movements directed towards the opposite side of the grasping hand (contralateral movements). To investigate which of these two factors would explain the change in hand use for grasping, a very small base plate was used in the last experiment. Results showed similar right hand use values to those seen in the first experiment (without the use of a plate), even though the left hand was 'released from its stabilizing duties.' The results predict a left-hemisphere right hand advantage in the control of grasping.