Healthy eating among people on opioid agonist therapy: a qualitative study of patients' experiences and perspectives.

People with substance use disorders often have unhealthy diets, high in sweets and processed foods but low in nutritious items like fruits and vegetables, increasing noncommunicable disease risks. This study investigates healthy eating perceptions and barriers among individuals with opioid use disorder undergoing opioid agonist therapy. Interviews with 14 participants at opioid agonist therapy clinics in Western Norway, using a semi-structured guide and systematic text condensation for analysis, reveal that most participants view their diet as inadequate and express a desire to improve for better health. Barriers to healthy eating included oral health problems, smoking habits, and limited social relations, while economic factors were less of a concern for the participants. Participants did find healthy eating easier when they were in social settings. This study underscores the importance of understanding and addressing these barriers and facilitators to foster healthier eating patterns in this population, potentially enhancing overall health and well-being.

Electrophysiological biomarkers in dual pathology.

INTRODUCTION: The co-occurrence of substance use disorder with at least one other mental disorder is called dual pathology, which in turn is characterised by heterogeneous symptoms that are difficult to diagnose and have a poor response to treatment. For this reason, the identification and validation of biomarkers is necessary. Within this group, possible electroencephalographic biomarkers have been reported to be useful in diagnosis, treatment and follow-up, both in neuropsychiatric conditions and in substance use disorders. This article aims to review the existing literature on electroencephalographic biomarkers in dual pathology. METHODS: A narrative review of the literature. A bibliographic search was performed on the PubMed, Science Direct, OVID, BIREME and Scielo databases, with the keywords: electrophysiological biomarker and substance use disorder, electrophysiological biomarker and mental disorders, biomarker and dual pathology, biomarker and substance use disorder, electroencephalography, and substance use disorder or comorbid mental disorder. RESULTS: Given the greater amount of literature found in relation to electroencephalography as a biomarker of mental illness and substance use disorders, and the few articles found on dual pathology, the evidence is organised as a biomarker in psychiatry for the diagnosis and prediction of risk and as a biomarker for dual pathology. CONCLUSIONS: Although the evidence is not conclusive, it suggests the existence of a subset of sites and mechanisms where the effects of psychoactive substances and the neurobiology of some mental disorders could overlap or interact.

Screening for harmful substance use in emergency departments: a systematic review.

BACKGROUND: Substance use-related emergency department (ED) visits have increased substantially in North America. Screening for substance use in EDs is recommended; best approaches are unclear. This systematic review synthesizes evidence on diagnostic accuracy of ED screening tools to detect harmful substance use. METHODS: We included derivation or validation studies, with or without comparator, that included adult (≥ 18 years) ED patients and evaluated screening tools to identify general or specific substance use disorders or harmful use. Our search strategy combined concepts Emergency Department AND Screening AND Substance Use. Trained reviewers assessed title/abstracts and full-text articles for inclusion, extracted data, and assessed risk of bias (QUADAS-2) independently and in duplicate. Reviewers resolved disagreements by discussion. Primary investigators adjudicated if necessary. Heterogeneity precluded meta-analysis. We descriptively summarized results. RESULTS: Our search strategy yielded 2696 studies; we included 33. Twenty-one (64%) evaluated a North American population. Fourteen (42%) applied screening among general ED patients. Screening tools were administered by research staff (n = 21), self-administered by patients (n = 10), or non-research healthcare providers (n = 1). Most studies evaluated alcohol use screens (n = 26), most commonly the Alcohol Use Disorders Identification Test (AUDIT; n = 14), Cut down/Annoyed/Guilty/Eye-opener (CAGE; n = 13), and Rapid Alcohol Problems Screen (RAPS/RAPS4/RAPS4-QF; n = 12). Four studies assessing six tools and screening thresholds for alcohol abuse/dependence in North American patients (AUDIT ≥ 8; CAGE ≥ 2; Diagnostic and Statistical Manual of Mental Disorders, 4th Edition [DSM-IV-2] ≥ 1; RAPS ≥ 1; National Institute on Alcohol Abuse and Alcoholism [NIAAA]; Tolerance/Worry/Eye-opener/Amnesia/K-Cut down [TWEAK] ≥ 3) reported both sensitivities and specificities ≥ 83%. Two studies evaluating a single alcohol screening question (SASQ) (When was the last time you had more than X drinks in 1 day?, X = 4 for women; X = 5 for men) reported sensitivities 82-85% and specificities 70-77%. Five evaluated screening tools for general substance abuse/dependence (Relax/Alone/Friends/Family/Trouble [RAFFT] ≥ 3, Drug Abuse Screening Test [DAST] ≥ 4, single drug screening question, Alcohol, Smoking and Substance Involvement Screening Test [ASSIST] ≥ 42/18), reporting sensitivities 64%-90% and specificities 61%-100%. Studies' risk of bias were mostly high or uncertain. CONCLUSIONS: Six screening tools demonstrated both sensitivities and specificities ≥ 83% for detecting alcohol abuse/dependence in EDs. Tools with the highest sensitivities (AUDIT ≥ 8; RAPS ≥ 1) and that prioritize simplicity and efficiency (SASQ) should be prioritized.

Enhancing the SUSTAINable uptake of evidence to minimise harms from alcohol and other drugs in New South Wales, Australia.

Although alcohol and other drug use is increasingly the focus of policy and research efforts, there are challenges identifying and applying evidence-based strategies to minimise harms for alcohol and other drugs in health care and community settings. These challenges include limited available research, variability across settings, and lack of 'fit' between research evidence and their intended settings. In this commentary, we describe a novel approach to develop and evaluate tailored, sustainable strategies to enhance the uptake of evidence-based activities into health services and community settings. Our approach involves four key principles: (i) identifying evidence-based alcohol and other drug harm minimisation strategies; (ii) partnering with local experts to identify and tailor strategies; (iii) implementing strategies into existing practice/infrastructure to build in sustainability; and (iv) using sustainable co-designed outcome measures including value-based health-care principles to measure uptake, feasibility and acceptability, health outcomes and economic implications. We propose that this approach offers a way forward to enhance the relevance and suitability of research in health services and community settings and has potential to be applied in other sectors.

Stigma and mental health among people living with HIV across the COVID-19 pandemic: a cross-sectional study.

BACKGROUND: Mental health (MH) is extremely relevant when referring to people living with a chronic disease, such as people living with HIV (PLWH). In fact - although life expectancy and quality have increased since the advent of antiretroviral therapy (ART) - PLWH carry a high incidence of mental disorders, and this burden has been exacerbated during the COVID-19 pandemic. In this scenario, UNAIDS has set new objectives for 2025, such as the linkage of at least 90% of PLWH to people-centered, context-specific MH services. Aim of this study was to determine the prevalence of MD in PLWH followed at the Clinic of Infectious Diseases of the University of Bari, Italy. METHODS: From January 10th to September 10th, 2022, all PLWH patients accessing our outpatient clinic were offered the following standardized tools: HAM-A for anxiety, BDI-II for depression, PC-PTSD-5 for post-traumatic stress disorder, CAGE-AID for alcohol-drug abuse. Factors associated with testing positive to the four MD were explored with a multivariable logistic regression model. RESULTS: 578 out of 1110 HIV-patients agreed to receive MH screening, with 141 (24.4%) people resulting positive to at least one MH disorder. HAM-A was positive in 15.8% (n = 91), BDI-II in 18% (n = 104), PC-PTSD-5 in 5% (n = 29) and CAGE in 6.1% (n = 35). The multivariable logistic regression showed a higher probability of being diagnosed with anxiety, depression and post-traumatic stress disorder for PLWH who reported severe stigma, social isolation, psychological deterioration during the COVID-19 pandemic and for those receiving a dolutegravir (DTG)-based regimen. Moreover, history of drug use (OR 1.13; [95% CE 1.06-4.35]), family stigma (2.42 [1.65-3.94]) and social isolation (2.72 [1.55;4.84]) were found to be associated to higher risk for substance use disorder. CONCLUSIONS: In this study, stigma was a strong predictor for being diagnosed of a MH disorder among PLWH. Also, the possible role of dolutegravir as a risk factor for the onset of MH disorders should be considered in clinical practice, and MH of patients receiving DTG-containing regimens should be constantly monitored.

Refractory Hypoglycemia Due to Sulfonylurea Contamination of Illicit Opioid Medications.

Illicit drug supply adulteration can heighten the risk for adverse health outcomes. Sulfonylurea medications are widely used in the treatment of diabetes mellitus (DM). Unintentional or intentional overdose of sulfonylureas can cause refractory hypoglycemia. This case report describes a 62-year-old male patient who presented to the emergency department (ED) after being found on the ground with signs of mild trauma. He was noted to be persistently hypoglycemic despite boluses of intravenous dextrose, a dextrose infusion, and oral nutrition. The patient did report purchase and oral ingestion of pills sold as oxycodone and that the pill shape and color were different from his usual supply. The patient was empirically treated with octreotide resulting in normalization of his serum glucose. Testing demonstrated a serum glipizide concentration six times the reporting range. This case represents unintentional sulfonylurea exposure in the setting of non-prescribed oxycodone use, resulting in hypoglycemia refractory to intravenous dextrose and oral nutrition. Octreotide is an additional potential treatment for this condition. As in this case, ingestion of street drugs may present a potential source of sulfonylurea exposure. Opioid contamination with sulfonylureas has not been widely reported in the literature and knowledge about this potential exposure is important for the prompt recognition and treatment of these patients by emergency physicians.

Experiencing violence and other predictors of within-person same-day use of multiple substances in youth: a longitudinal study in emergency settings.

Background: Although experiencing violence is a risk factor for substance use among youth, its association with same-day use of multiple substances (a form of polysubstance use) and mitigating factors is less well understood.Objectives: To identify whether prosocial factors modified the effect of experiencing violence on the frequency of same-day use, and examine gender-specific risk/protective factors for same-day use.Methods: We analyzed longitudinal data from a cohort of youth who use drugs aged 14-24 (n = 599; 58% male) presenting to an urban emergency department between 2009-2011 and assessed biannually for two years. Using Poisson-generalized linear models with person-level fixed effects, we estimated within-person associations between self-reported experiencing violence and same-day use and analyzed gender and peer/parent support as effect modifiers. We adjusted for negative peer influence, parental drug and alcohol use, family conflict, anxiety and depression, and age.Results: Overall, positive parental support corresponded to lower rates of same-day use (rate ratio [RR]:0.93, 95% CI:0.87-0.99) and experiencing violence was associated with higher rates of same-day use (RR:1.25, 95% CI:1.10-1.41). Violence exposure was a risk factor among males (RR:1.42, 95% CI:1.21-1.66), while negative peer influences and parental substance use were risk factors among females (RR:1.63, 95% CI:1.36-1.97 and RR:1.58, 95% CI:1.35-1.83, respectively). Positive peer support reduced the association between violence exposure and same-day use among males (RR:0.69, 95% CI:0.57-0.84, p < .05).Conclusions: Tailored interventions may address gender differences in coping with experiencing violence - including interventions that promote parental support among males and reduce influence from parental substance use among females.

Pharmacist-implemented intervention to surmount COVID-19 vaccination hesitancy in adults with substance use disorders.

DISCLAIMER: In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE: Substance use disorders (SUDs) increase the risk and severity of infectious diseases, including coronavirus disease 2019 (COVID-19). Adults with a co-occurring SUD and psychiatric disorder were studied to elucidate the association between SUD severity and (1) COVID-19 vaccination status, (2) receptivity to a one-session intervention with a pharmacist advocating the benefits of vaccination, and (3) acceptance of referral for vaccination following the intervention. METHODS: COVID-19 vaccination status was recorded in 460 adults with SUD (324 males and 136 females) upon entry into inpatient treatment. A 2-parameter item response theory (IRT) model quantified SUD severity. Pharmacist-delivered intervention, modeled after the screening, brief intervention, and referral to treatment (SBIRT) protocol, was offered to unvaccinated participants. RESULTS: Higher SUD severity was associated with a lower vaccination rate. Nicotine, opioid, and sedative use disorders were most frequently associated with unvaccinated status. SUD severity was not associated with receptivity to intervention advocating vaccination or subsequent acceptance of a referral for vaccination. The portion of the sample that received the intervention was over 7 times more likely to accept a referral for vaccination when compared to participants who rejected the intervention (20.8% vs 2.8%). CONCLUSION: Pharmacist-administered intervention produced motivation for vaccination in a number of recipients; however, receptivity to the intervention was not related to SUD severity.

Co-occurring psychological distress and alcohol or other drug use among Indigenous Australians: Data from the National Aboriginal and Torres Strait Islander Health Survey.

OBJECTIVES: To determine the prevalence and demographic, social and health characteristics associated with co-occurring psychological distress symptoms, risky alcohol and/or substance use among a national sample of Aboriginal and Torres Strait Islander people aged 15 years or older. METHODS: This study uses secondary cross-sectional data from the 2018-19 National Aboriginal and Torres Strait Islander Health Survey (NATSIHS). Data were collected via face-to-face interviews with those living in private dwellings across Australia. Participants were Aboriginal and Torres Strait Islander people (n = 10,579) aged 15 years or older. Data pertaining to psychological distress, alcohol and substance use were obtained and weighted to represent the total population of Aboriginal and Torres Strait Islander people in Australia. RESULTS: A total of 20.3% participants were found to have co-occurring psychological distress, risky alcohol use and/or substance use, and 4.0% reported co-occurrence of all three conditions. Female participants in a registered marriage and fully engaged in study or employment had lower rates of co-occurring conditions. Poorer self-rated health, one or more chronic conditions and increased experiences of unfair treatment and physical harm in the past 12 months were associated with increased rates of co-occurring conditions. CONCLUSION: A range of potential risk and protective factors were identified for co-occurring psychological distress, risky alcohol and/or substance use among Aboriginal and Torres Strait Islander people. This information is critical for planning effective holistic strategies to decrease the burden of suffering imposed upon the individual, family and community members impacted by co-occurring conditions.

Transitioning Virtual-Only Group Therapy for Substance Use Disorder Patients to a Hybrid Model.

Purpose: Telehealth is associated with a myriad of benefits; however, little is known regarding substance use disorder (SUD) treatment outcomes when participants join group therapy sessions in a combination in-person and virtual setting (hybrid model). We sought to determine if treatment completion rates differed. Patients and Methods: Policy changes caused by the COVID-19 pandemic created a naturalistic, observational cohort study at seven intensive outpatient (IOP) programs in rural Minnesota. Virtual-only delivery occurred 6/1/2020-6/30/2021, while hybrid groups occurred 7/1/2021-7/31/2022. Data was evaluated retrospectively for participants who initiated and discharged treatment during the study period. Participants were IOP group members 18 years and older who had a SUD diagnosis that both entered and discharged treatment during the 26-month period. A consecutive sample of 1502 participants (181-255 per site) was available, with 644 removed: 576 discharged after the study conclusion, 49 were missing either enrollment or discharge data, 14 transferred sites during treatment, and 5 initiated treatment before the study initiation. Helmert contrasts evaluated the impact of hybrid group exposure. Results: A total of 858 individuals were included. Data was not from the medical chart and was deidentified preventing specific demographics; however, the overall IOP sample for 2020-2022, from which the sample was derived, was 29.8% female, and 64.1% were 18-40 years of age. For completed treatment, hybrid group exposure relative to virtual-only had a univariate odds ratio of 1.88 (95% CI: 1.50-2.41, p < 0.001). No significant difference was seen across IOP sites. Conclusion: These results describe a novel hybrid group approach to virtual care for SUDs with outcome data not previously documented in the literature. While virtual treatment delivery can increase access, these results suggest a benefit is derived from including an in-person option. Further research is needed to identify how an in-person component may change dynamics and if it can be replicated in virtual-only models.

The Effect of Veteran Status and Chronic Pain on Past 30-Day Sedative Use Among Community-Dwelling Adult Males.

INTRODUCTION: Given the high sedative prescription rate, the sedative-associated morbidity, and mortality nationally (especially among veterans), we aimed to test the hypothesis that veteran status in the presence of chronic pain would be associated with greater sedative use when compared with nonveteran status. METHODS: The study participants were recruited by Community Health Workers (CHWs) through the ongoing community engagement program (HealthStreet) at the University of Florida. CHWs collected information on sociodemographic factors, health status, and past 30-day drug use patterns. RESULTS: The study sample comprised 4,732 male participants, of which 21% were veterans, 58% were Blacks and 8.4% had used prescription sedatives in the past 30 days. Veterans (vs nonveterans) were twice as likely to have used prescription sedatives in the past 30 days in the presence of chronic pain. CONCLUSIONS: Veterans with chronic pain are a high-risk population for current prescription sedative use.

Drug Deactivation Pouches for Primary Prevention of Opioid Overdose: Perceptions and Attitudes of Community Members.

IMPORTANCE: A substantial number of opioid analgesics dispensed into communities will go unused and be susceptible to diversion for misuse. Convenient, efficient, and environmentally safe mechanisms for disposal are needed to prevent the diversion of unused opioid analgesics. OBJECTIVE: This initiative piloted the feasibility of distributing drug deactivation pouches in a community setting and examined community members' acceptance, intention to use drug deactivation pouches, and their current disposal practices of unused opioid analgesics. Although many studies have examined the benefits of deactivation pouches in preventing drug overdose, few have explored community members' perspectives, the feasibility, and the acceptability of these pouches in disposing of unused medications. METHODS: In the fall of 2017, we piloted the distribution of drug deactivation pouches to assess the overall interest in the pouches at a 3-day community event and continued the second wave of this pilot in the community from the summer of 2018 to the spring of 2019.Our main outcomes and measures included the acceptance of the drug deactivation pouches and the intention to use the pouches. "Acceptance" was defined as study participants physically taking the kit and "Intention" was how participants intended to use the pouch. RESULTS: A total of 170 community members were approached at a community event about the drug deactivation pouches and 116 accepted at least 1 pouch (68.2% acceptance rate). In the second wave, 124 community members were approached by Community Health Workers; 100% accepted the pouch. Overall, the acceptance rate was 81.6%. People mentioned significant interest in using the pouches. Furthermore, surveys that assessed community members' intention to use the deactivation pouches showed that 48% intended to use the pouch. CONCLUSIONS AND RELEVANCE: The distribution of drug deactivation pouches is feasible in a community setting and although community members expressed interest in using drug deactivation pouches to dispose of unused opioid analgesics and other drugs, the majority still disposed of their unused medications through other avenues. This, underscore the need to raise community members' awareness about the importance, benefits, and viability of these pouches as a tool for the primary prevention of opioid overdose because of their ease of use, safety, environmental considerations, and cost-effectiveness.

Bacillus pumilus cellulitis with bacteremia in a person who injects drugs, living with HIV-HCV co-infection: a case report.

Bacillus pumilus (B. pumilus) is a ubiquitous spore-forming bacteria that has rarely been implicated in extraintestinal infections, mostly in immunocompromised hosts. The authors report a case of B. pumilus cellulitis with bacteremia in a person who injects drugs living with human immunodeficiency virus-hepatitis C virus (HIV-HCV) co-infection. Although similar cases have been reported for some species of the genus, namely Bacillus anthracis (B. anthracis) and Bacillus cereus (B. cereus), this case reinforces the importance of considering other Bacillus spp. as potential pathogens in skin and soft tissue infections and bloodstream infections related to intravenous drug use.

Nociceptive Flexion Reflex Threshold is No Suitable Marker for Diagnosing Opioid-Induced Hyperalgesia.

Background: Opioid induced hyperalgesia (OIH) describes a state of altered pain sensation due to opioid exposure. It often occurs among persons with opioid use disorder receiving substitution therapy. Methods: The purpose of this study was to find out, whether OIH diagnosis could be facilitated by an objective pain indicating marker: the Nociceptive Flexion Reflex (NFR). Forty persons with opioid use disorder, 20 of them maintained on methadone and 20 treated with buprenorphine, as well as a control group of 20 opioid-free subjects, were examined. It was aimed to find out whether and in which way these opioid agonists alter reflex threshold (NFR-T). A cold-pressor test was performed to investigate the prevalence of OIH. Furthermore, electrical stimulation and electromyography analyzation were used for NFR-T measurement. Subjective pain ratings were evaluated with a numeric rating scale. Results: Significantly increased sensitivity to cold pressor pain was found in both maintenance groups when compared to their opioid-free counterparts (p < 0.001). Neither methadone nor buprenorphine showed any effect on NFR-T. This might be explained by the reflex approaching at the wrong location in the central nervous system. Consequently, NFR-T is not a suitable marker for diagnosing OIH. Conclusion: Although methadone and buprenorphine have been proven to cause OIH, no effect on NFR-T was observed. A statistically significant effect could have been observed with a larger number of participants. Further research, with special focus on patients' adjuvant medication, should be conducted in the future, to facilitate diagnosis of OIH and provide appropriate pain management for maintenance patients.

Cessation of Smoking Trial in the Emergency Department (COSTED): a multicentre randomised controlled trial.

BACKGROUND: Supporting people to quit smoking is one of the most powerful interventions to improve health. The Emergency Department (ED) represents a potentially valuable opportunity to deliver a smoking cessation intervention if it is sufficiently resourced. The objective of this trial was to determine whether an opportunistic ED-based smoking cessation intervention can help people to quit smoking. METHODS: In this multicentre, parallel-group, randomised controlled superiority trial conducted between January and August 2022, adults who smoked daily and attended one of six UK EDs were randomised to intervention (brief advice, e-cigarette starter kit and referral to stop smoking services) or control (written information on stop smoking services). The primary outcome was biochemically validated abstinence at 6 months. RESULTS: An intention-to-treat analysis included 972 of 1443 people screened for inclusion (484 in the intervention group, 488 in the control group). Of 975 participants randomised, 3 were subsequently excluded, 17 withdrew and 287 were lost to follow-up. The 6-month biochemically-verified abstinence rate was 7.2% in the intervention group and 4.1% in the control group (relative risk 1.76; 95% CI 1.03 to 3.01; p=0.038). Self-reported 7-day abstinence at 6 months was 23.3% in the intervention group and 12.9% in the control group (relative risk 1.80; 95% CI 1.36 to 2.38; p<0.001). No serious adverse events related to taking part in the trial were reported. CONCLUSIONS: An opportunistic smoking cessation intervention comprising brief advice, an e-cigarette starter kit and referral to stop smoking services is effective for sustained smoking abstinence with few reported adverse events. TRIAL REGISTRATION NUMBER: NCT04854616.

O uso de drogas e seus efeitos na cavidade oral

Objetivos: Descrever as principais manifestações bucais associadas ao uso das drogas lícitas e ilícitas mais utilizadas atualmente, bem como os cuidados que devem ser tomados durante o atendimento odontológico desses pacientes. Revisão de literatura: Na revisão foi abordada a classificação das substâncias químicas, as principais manifestações orais e os cuidados que o cirurgião-dentista deve ter durante o atendimento odontológico. As substâncias descritas foram álcool, tabaco, benzodiazepínicos, maconha, anfetaminas e cocaína/crack. As complicações de saúde bucal associadas ao abuso de drogas podem resultar da exposição direta dos tecidos orais às drogas durante o fumo ou ingestão, da interação biológica das drogas com a fisiologia normal da cavidade oral e dos efeitos das drogas na função cerebral que resultam em um espectro de comportamentos de dependência, como comportamento de risco, falta de higiene e descuido. Considerações finais: O consumo de substâncias psicoativas, seja a curto ou longo prazo, pode desencadear consequências, tanto na saúde geral como na saúde bucal do usuário. Sob essa perspectiva, o cirurgião-dentista deve estar ciente das manifestações orais e sistêmicas causadas pelas substâncias psicoativas e estar capacitado para diagnosticar, tratar ou também encaminhar o usuário, se necessário, visando um cuidado integral e multiprofissional.

Objective: to describe the main oral manifestations associated with the use of the most commonly used licit and illicit drugs today, as well as the care that should be taken during the dental care of these patients. Literature review: The review covered the classification of chemical substances, the main oral manifestations and the care that dentist should take during dental care. The substances described were alcohol, tobacco, benzodiazepines, marijuana, amphetamines and cocaine/crack. Oral health complications associated with drug abuse can result from direct exposure of oral tissues to drugs during smoking or ingestion, from the biological interaction of drugs with the normal physiology of the oral cavity, and from the effects of drugs on brain function that result in a spectrum of addictive behaviors, such as risk behavior, poor hygiene and carelessness. Final considerations: The consumption of psychoactive substances, whether in the short or long term, can have consequences for both the general health and the oral health of the user. From this perspective, the dentist must be aware of the oral and systemic manifestations caused by psychoactive substances and be able to diagnose, treat or also refer the user, if necessary, aiming for comprehensive, multi-professional care.