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1.
Basic Clin Pharmacol Toxicol ; 126(2): 99-109, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31429204

RESUMO

The nitrate-nitrite-nitric oxide (NO) pathway represents an alternative source of NO generation, which is independent of NO synthase and potentiated by hypoxia. Augmentation of this pathway by dietary nitrate has proven favourable effects in several cardiovascular disease models. However, less is known regarding its potential value in pulmonary arterial hypertension (PAH). The aim of this study was to assess the effects of oral inorganic nitrate administration in monocrotaline (MCT)-induced PAH. Male 12-week-old Wistar rats were injected subcutaneously with monocrotaline (MCT, 60 mg/kg). Nitrate treatment (0.3 or 1 mmol/kg/d; drinking water) commenced on day 12 following the MCT injection and continued for 16 days. Nitrate administration did not attenuate right ventricular (RV) hypertrophy, increased lung weight and up-regulated mRNA expression of brain natriuretic peptide. Plasma nitrate and nitrite levels were significantly increased as well as lung nitrate level, whereas nitrite lung level was decreased following nitrate treatment (1 mmol/kg/d). MCT-induced PAH resulted in an increased MnSOD protein level, which was not observed following nitrate treatment. MCT-associated up-regulation of nNOS in the lung appeared to be dose-dependently prevented by nitrate treatment. Western blot analysis did not reveal any differences in eNOS, iNOS, XO or gp91phox expression in the lungs among the groups. In conclusion, nitrate treatment did not significantly attenuate pathological RV and lung remodelling in the rat MCT model of PAH. The suppression of MnSOD and nNOS expression by nitrate could be interpreted as reduced demand of endogenous antioxidant defence in this model.

3.
JAMA ; : 1-3, 2019 Oct 10.
Artigo em Inglês | MEDLINE | ID: mdl-31600370
4.
BMC Health Serv Res ; 19(1): 663, 2019 Sep 14.
Artigo em Inglês | MEDLINE | ID: mdl-31521159

RESUMO

BACKGROUND: Although opioid agonist therapy is effective in treating opioid use disorders (OUD), retention in opioid agonist therapy is suboptimal, in part, due to quality of care issues. Therefore, we sought to describe the planning and implementation of a quality improvement initiative aimed at closing gaps in care for people living with OUD through changes to workflow and care processes in Vancouver, Canada. METHODS: The Best-practice in Oral Opioid agoniSt Therapy (BOOST) Collaborative followed the Institute for Healthcare Improvement's Breakthrough Series Collaborative methodology over 18-months. Teams participated in a series of activities and events to support implementing, measuring, and sharing best practices in OAT and OUD care. Teams were assigned monthly implementation scores to monitor their progress on meeting Collaborative aims and implementing changes. RESULTS: Seventeen health care teams from a range of health care practices caring for a total of 4301 patients with a documented diagnosis of OUD, or suspected OUD based on electronic medical record chart data participated in the Collaborative. Teams followed the Breakthrough Series Collaborative methodology closely and reported monthly on a series of standardized process and outcome indicators. The majority of (59%) teams showed some improvement throughout the Collaborative as indicated by implementation scores. CONCLUSIONS: Descriptive data from the evaluation of this initiative illustrates its success. It provides further evidence to support the implementation of quality improvement interventions to close gaps in OUD care processes and treatment outcomes for people living with OUD. This system-level approach has been spread across British Columbia and could be used by other jurisdictions facing similar overdose crises.


Assuntos
Centros Comunitários de Saúde/organização & administração , Implementação de Plano de Saúde/organização & administração , Tratamento de Substituição de Opiáceos , Transtornos Relacionados ao Uso de Opioides/reabilitação , Melhoria de Qualidade/organização & administração , Canadá , Pesquisa sobre Serviços de Saúde , Humanos , Equipe de Assistência ao Paciente
5.
J Pharm Pharmacol ; 71(9): 1440-1450, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31270818

RESUMO

OBJECTIVE: Daunorubicin (DAU) downregulates cytokines promoting stem cell migration and homing into the heart, reducing cardiac regeneration after anticancer chemotherapy. Pegfilgrastim (PFIL) protects from DAU-induced neutropenia but its cardioprotective potential remains unclear. We tested whether pegfilgrastim and a dipeptidyl peptidase-4 inhibitor linagliptin, potential enhancers of stem cells migration and homing, would improve DAU-cardiomyopathy. METHODS: DAU (7.5 mg/kg, i.v.) was administered to male Wistar rats to induce cardiotoxicity. Pegfilgrastim (100 µg/kg, s.c.) was administered 24h after DAU, and linagliptin was administered orally for 8 weeks (5 mg/kg/day, LINA). Cardiac damage markers (Nppa, Myh6, Myh7, Gp91phox), cytokines (Sdf-1alpha, Mcp-1, Vegf, Hgf, Igf-1), stem cell markers (Cxcr4, Ccr2, Cd34, Cd133, Cd44, Cd105) were determined by qRT-PCR. KEY FINDINGS: Decreased Myh6, elevated Myh7 Nppa, and Gp91phox were not ameliorated by PFIL + LINA. Downregulated expressions of cytokines (Vegf, Sdf-1alpha) and stem cells markers (Cxcr4, Cd34, Cd133, and Cd105) remained decreased after PFIL + LINA. DAU-induced upregulation of Mcp-1, Ccr2 and Cd44 was further potentiated by PFIL + LINA. PFIL + LINA normalised expression of Hgf and Igf-1. CONCLUSIONS: Although PFIL + LINA failed in universal potentiation of stem cells migration and homing, the expression of stem cell markers Ccr2 and Cd44 in the heart potentially increased through the preservation of Hgf, Igf-1 and upregulation of Mcp-1.


Assuntos
Citocinas/metabolismo , Filgrastim/farmacologia , Receptores de Hialuronatos/metabolismo , Linagliptina/farmacologia , Polietilenoglicóis/farmacologia , Receptores CCR2/metabolismo , Células-Tronco/metabolismo , Animais , Biomarcadores/metabolismo , Cardiomiopatias/metabolismo , Movimento Celular/efeitos dos fármacos , Quimiocina CCL2 , Daunorrubicina/efeitos adversos , Coração , Fator de Crescimento de Hepatócito , Fator de Crescimento Insulin-Like I , Estimativa de Kaplan-Meier , Masculino , Miocárdio/metabolismo , Estresse Oxidativo/efeitos dos fármacos , Ratos , Ratos Wistar , Células-Tronco/efeitos dos fármacos
6.
Int J Med Sci ; 16(6): 854-863, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31337959

RESUMO

Background: HGF/MET pathway may have a role in pulmonary hypertension (PH). However, the link between the pathway and development of target organ damage in PH remains elusive. We aimed to demonstrate the relation between plasma HGF and HGF/MET tissue expressions in affected organs during PH progression. Methods: 12 weeks old male Wistar rats were injected with monocrotaline (MCT, 60 mg/kg, s.c.) to induce PH and sacrificed after 1, 2 and 4 weeks. Controls received saline. mRNA levels of HGF regulatory complex (Hgf, Met, Hgfa, Hai-1, Hai-2) were determined in right and left ventricles (RV, LV), lungs, pulmonary artery and liver by RT-qPCR. HGF protein levels in plasma were analysed by ELISA. Results: PH development was associated with a progressive elevation of HGF plasma levels that correlated with relative RV mass. Furthermore, Hgf mRNA expressions at week 4 were upregulated solely in the cardiac ventricles while being downregulated in a. pulmonalis, lungs and liver. Met and Hai-1/Hai-2 followed a similar pattern and were upregulated in cardiac ventricles, where Hgfa remained unchanged, but downregulated in lungs. Conclusion: We suggest that cardiac overexpression of Hgf might contribute to increased plasma HGF in MCT-induced PH. HGF could be exploited as a cardiospecific biomarker and HGF/MET pathway as a target in drug discovery for PH.


Assuntos
Insuficiência Cardíaca/diagnóstico , Ventrículos do Coração/patologia , Fator de Crescimento de Hepatócito/metabolismo , Hipertensão Pulmonar/complicações , Remodelação Ventricular , Animais , Biomarcadores/sangue , Biomarcadores/metabolismo , Modelos Animais de Doenças , Progressão da Doença , Regulação para Baixo , Insuficiência Cardíaca/sangue , Insuficiência Cardíaca/etiologia , Fator de Crescimento de Hepatócito/sangue , Humanos , Hipertensão Pulmonar/sangue , Hipertensão Pulmonar/induzido quimicamente , Masculino , Monocrotalina/toxicidade , Proteínas Proto-Oncogênicas c-met/metabolismo , Ratos , Ratos Wistar , Regulação para Cima
7.
Cochrane Database Syst Rev ; 7: CD012764, 2019 07 19.
Artigo em Inglês | MEDLINE | ID: mdl-31323120

RESUMO

BACKGROUND: Mobilization of community first responders (CFRs) to the scene of an out-of-hospital cardiac arrest (OHCA) event has been proposed as a means of shortening the interval from occurrence of cardiac arrest to performance of cardiopulmonary resuscitation (CPR) and defibrillation, thereby increasing patient survival. OBJECTIVES: To assess the effect of mobilizing community first responders (CFRs) to out-of-hospital cardiac arrest events in adults and children older than four weeks of age, in terms of survival and neurological function. SEARCH METHODS: We searched the following databases for relevant trials in January 2019: CENTRAL, MEDLINE (Ovid SP), Embase (Ovid SP), and Web of Science. We also searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov, and we scanned the abstracts of conference proceedings of the American Heart Association and the European Resuscitation Council. SELECTION CRITERIA: We included randomized and quasi-randomized trials (RCTs and q-RCTs) that compared routine emergency medical services (EMS) care versus EMS care plus mobilization of CFRs in instances of OHCA.Trials with randomization by cluster were eligible for inclusion, including cluster-design studies with intervention cross-over.In some communities, the statutory ambulance service/EMS is routinely provided by the local fire service. For the purposes of this review, this group represents the statutory ambulance service/EMS, as distinct from CFRs, and was not included as an eligible intervention.We did not include studies primarily focused on opportunistic bystanders. Individuals who were present at the scene of an OHCA event and who performed CPR according to telephone instruction provided by EMS call takers were not considered to be CFRs.Studies primarily assessing the impact of specific additional interventions such as administration of naloxone in narcotic overdose or adrenaline in anaphylaxis were also excluded.We included adults and children older than four weeks of age who had experienced an OHCA. DATA COLLECTION AND ANALYSIS: Two review authors independently reviewed all titles and abstracts received to assess potential eligibility, using set inclusion criteria. We obtained and examined in detail full-text copies of all papers considered potentially eligible, and we approached authors of trials for additional information when necessary. We summarized the process of study selection in a PRISMA flowchart.Three review authors independently extracted relevant data using a standard data extraction form and assessed the validity of each included trial using the Cochrane 'Risk of bias' tool. We resolved disagreements by discussion and consensus.We synthesized findings in narrative fashion due to the heterogeneity of the included studies. We used the principles of the GRADE system to assess the certainty of the body of evidence associated with specific outcomes and to construct a 'Summary of findings' table. MAIN RESULTS: We found two completed studies involving a total of 1136 participants that ultimately met our inclusion criteria. We also found one ongoing study and one planned study. We noted significant heterogeneity in the characteristics of interventions and outcomes measured or reported across these studies, thus we could not pool study results.One completed study considered the dispatch of police and fire service CFRs equipped with automatic external defibrillators (AEDs) in an EMS system in Amsterdam and surrounding areas. This study was an RCT with allocation made by cluster according to non-overlapping geographical regions. It was conducted between 5 January 2000 and 5 January 2002. All participants were 18 years of age or older and had experienced witnessed OHCA. The study found no difference in survival at hospital discharge (odds ratio (OR) 1.3, 95% confidence interval (CI) 0.8 to 2.2; 1 RCT; 469 participants; low-certainty evidence), despite the observation that all 72 incidences of defibrillation performed before EMS arrival occurred in the intervention group (OR and 95% CI - not applicable; 1 RCT; 469 participants; moderate-certainty evidence). This study reported increased survival to hospital admission in the intervention group (OR 1.5, 95% CI 1.1 to 2.0; 1 RCT; 469 participants; moderate-certainty evidence).The second completed study considered the dispatch of nearby lay volunteers in Stockholm, Sweden, who were trained to perform cardiopulmonary resuscitation (CPR). This represented a supplementary CFR intervention in an EMS system where police and fire services were already routinely dispatched to OHCA in addition to EMS ambulances. This study, an RCT, included both witnessed and unwitnessed OHCA and was conducted between 1 April 2012 and 1 December 2013. Participants included adults and children eight years of age and older. Researchers found no difference in 30-day survival (OR 1.34, 95% CI 0.79 to 2.29; 1 RCT; 612 participants; low-certainty evidence), despite a significant increase in CPR performed before EMS arrival (OR 1.49, 95% CI 1.09 to 2.03; 1 RCT; 665 participants; moderate-certainty evidence).Neither of the included completed studies considered neurological function at hospital discharge or at 30 days, measured by cerebral performance category or by any other means. Neither of the included completed studies considered health-related quality of life. The overall certainty of evidence for the outcomes of included studies was low to moderate. AUTHORS' CONCLUSIONS: Moderate-certainty evidence shows that context-specific CFR interventions result in increased rates of CPR or defibrillation performed before EMS arrival. It remains uncertain whether this can translate to significantly increased rates of overall patient survival. When possible, further high-quality RCTs that are adequately powered to measure changes in survival should be conducted.The included studies did not consider survival with good neurological function. This outcome is likely to be important to patients and should be included routinely wherever survival is measured.We identified one ongoing study and one planned trial whose results once available may change the results of this review. As this review was limited to randomized and quasi-randomized trials, we may have missed some important data from other study types.


Assuntos
Reanimação Cardiopulmonar/métodos , Serviços Médicos de Emergência , Socorristas , Parada Cardíaca Extra-Hospitalar/terapia , Adulto , Criança , Cardioversão Elétrica , Humanos , Parada Cardíaca Extra-Hospitalar/mortalidade , Qualidade da Assistência à Saúde , Ensaios Clínicos Controlados Aleatórios como Assunto , Análise de Sobrevida
8.
JMIR Med Educ ; 5(1): e12474, 2019 May 24.
Artigo em Inglês | MEDLINE | ID: mdl-31127722

RESUMO

BACKGROUND: Despite the enormous bur-den of disease attributable to drug and alcohol addiction, there remain major challenges in implementing evi-dence-based addiction care and treatment modalities. This is partly because of a persistent lack of accessible, specialized training in addiction medicine. In response, a new online certificate in addiction medicine has been established in Vancouver, Canada, free of charge to participants globally. OBJECTIVE: The objective of this study was to evaluate and examine changes in knowledge acquisition among health care professionals before and after the completion of an online certificate in addiction medicine. METHODS: Learners enrolled in a 17-module certificate program and completed pre- and postknowledge tests using online multiple-choice questionnaires. Knowledge acquisition was then evaluated using a repeated measures t test of mean test scores before and after the online course. Following the certificate completion, a subset of learners completed the online course evaluation form. RESULTS: Of the total 6985 participants who registered for the online course between May 15, 2017 and February 22, 2018, 3466 (49.62%) completed the online pretest questionnaire. A total of 1010 participants completed the full course, achieving the required 70% scores. TThe participants self-reported working in a broad range of health-related fields, including nursing (n=371), medicine (n=92), counseling or social work (n=69), community health (n=44), and pharmacy (n=34). The median graduation year was 2010 (n=363, interquartile range 2002-2015). Knowledge of the addiction medicine increased significantly postcertificate (mean difference 28.21; 95% CI 27.32 to 29.10; P<.001). Physicians scored significantly higher on the pretest than any other health discipline, whereas the greatest improvement in scores was seen in the counseling professions and community outreach. CONCLUSIONS: This free, online, open-access certificate in addiction medicine appeared to improve knowledge of learners from a variety of disciplines and backgrounds. Scaling up low threshold learning opportunities may further advance addiction medicine training, thereby helping to narrow the evidence-to-practice gap.

9.
JAMA Netw Open ; 2(5): e193365, 2019 05 03.
Artigo em Inglês | MEDLINE | ID: mdl-31050783

RESUMO

Importance: Although prescription opioid use disorder is associated with substantial harms, strategies to identify patients with pain among whom prescription opioids can be safely prescribed have not been systematically reviewed. Objective: To review the evidence examining factors associated with opioid addiction and screening tools for identifying adult patients at high vs low risk of developing symptoms of prescription opioid addiction when initiating prescription opioids for pain. Data Sources: MEDLINE and Embase (January 1946 to November 2018) were searched for articles investigating risks of prescription opioid addiction. Study Selection: Original studies that were included compared symptoms, signs, risk factors, and screening tools among patients who developed prescription opioid addiction and those who did not. Data Extraction and Synthesis: Two investigators independently assessed quality to exclude biased or unreliable study designs and extracted data from higher quality studies. The Preferred Reporting Items for Systematic Reviews and Meta-analyses of Diagnostic Accuracy Studies (PRISMA-DTA) reporting guideline was followed. Main Outcomes and Measures: Likelihood ratios (LRs) for risk factors and screening tools were calculated. Results: Of 1287 identified studies, 6 high-quality studies were included in the qualitative synthesis and 4 were included in the quantitative synthesis. The 4 high-quality studies included in the quantitative synthesis were all retrospective studies including a total of 2 888 346 patients with 4470 cases that met the authors' definitions of prescription opioid addiction. A history of opioid use disorder (LR range, 17-22) or other substance use disorder (LR range, 4.2-17), certain mental health diagnoses (eg, personality disorder: LR, 27; 95% CI, 18-41), and concomitant prescription of certain psychiatric medications (eg, atypical antipsychotics: LR, 17; 95% CI, 15-18) appeared useful for identifying patients at high risk of opioid addiction. Among individual findings, only the absence of a mood disorder (negative LR, 0.50; 95% CI, 0.45-0.52) was associated with a lower risk of opioid addiction. Despite their widespread use, most screening tools involving combinations of questions were based on low-quality studies or, when diagnostic performance was assessed among high-quality studies, demonstrated poor performance in helping to identify patients at high vs low risk. Conclusions and Relevance: While a history of substance use disorder, certain mental health diagnoses, and concomitant prescription of certain psychiatric medications appeared useful for identifying patients at higher risk, few quality studies were available and no symptoms, signs, or screening tools were particularly useful for identifying those at lower risk.


Assuntos
Analgésicos Opioides/uso terapêutico , Dor Crônica/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/diagnóstico , Feminino , Humanos , Masculino , Transtornos do Humor/epidemiologia , Padrões de Prática Médica , Estudos Retrospectivos , Medição de Risco , Fatores de Risco
10.
BMJ Open ; 9(4): e025799, 2019 04 02.
Artigo em Inglês | MEDLINE | ID: mdl-30944135

RESUMO

OBJECTIVE: To assess the efficacy of slow release oral morphine (SROM) as a treatment for opioid use disorder (OUD). DESIGN: Systematic review and meta-analysis of randomised controlled trials (RCTs). DATA SOURCES: Three electronic databases were searched through 1 May 2018: the Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE. We also searched the following electronic registers for ongoing trials: ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, Current Controlled Trials and the EU Clinical Trials Register. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: We included RCTs of all durations, assessing the effect of SROM on measures of treatment retention, heroin use and craving in adults who met the diagnostic criteria for OUD. DATA EXTRACTION AND SYNTHESIS: Two independent reviewers extracted data and assessed risk of bias. Data were pooled using the random-effects model and expressed as risk ratios (RRs) or mean differences with 95% CIs. Heterogeneity was assessed (χ2 statistic) and quantified (I2 statistic) and a sensitivity analysis was undertaken to assess the impact of particular high-risk trials. RESULTS: Among 1315 records screened and four studies reviewed, four unique randomised trials met the inclusion criteria (n=471), and compared SROM with methadone. In the meta-analysis, we observed no significant differences between SROM and methadone in improving treatment retention (RR=0.98; 95%CI: 0.94 to 1.02, p=0.34) and heroin use (RR=0.96; 95% CI: 0.61 to 1.52, p=0.86). Craving data was not amenable to meta-analysis. Available data implied no differences in adverse events, heroin, cocaine or benzodiazepine use. CONCLUSIONS: Meta-analysis of existing randomised trials suggests SROM may be generally equal to methadone in retaining patients in treatment and reducing heroin use while potentially resulting in less craving. The methodological quality of the included RCTs was low-to-moderate.

11.
Exp Lung Res ; 45(1-2): 30-41, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31012341

RESUMO

Aim of the Study: Endothelin-1 (ET-1) overexpression was suggested to play a role in pulmonary hypertension (PH). However, the roles of ET-1 in early stages of PH remain unexplored. We examined the expression of ET-1 and relevant disease progression markers in the pulmonary artery and the lungs during the development of PH induced by monocrotaline (MCT). Material and Methods: Male 12-weeks-old Wistar rats were administered with MCT (60 mg/kg, s.c.) or saline (CON). We measured right ventricular pressure (RVP) by catheterization under tribromoethanol anesthesia; hemoglobin oxygen saturation, breathing rate were measured by pulse oximetry in conscious animals. Rats were sacrificed 1, 2 or 4 weeks after MCT. mRNA levels of ET-1, its receptors, inflammatory markers IL-1beta, TNFalpha, IL-6 and genes related to VSMC proliferation or lung damage (Bmpr2, nestin, Pim1, PAI-1, TGFbeta-1) were analyzed by RT-qPCR. Results: RVP and breathing rate increased and hemoglobin oxygen saturation decreased after MCT only at week 4. Lung weight was increased at all time points. ET-1 was upregulated in the pulmonary artery at weeks 1 and 4, while being clearly suppressed in the lungs at all times. Bone morphogenetic protein receptor 2 followed a similar pattern to ET-1. PAI-1 markedly increased in the MCT lungs (but not pulmonary artery) from week 1 to 4. Nestin peaked at week 2 in both tissues. TGFbeta-1 increased in both tissues at week 4. ET-1 expression did not correlate with other genes, however, Bmpr2 tightly negatively correlated with PAI-1 in the lungs, but not pulmonary artery of MCT groups. Conclusions: ET-1 overexpression in the pulmonary artery preceded development of PH, but it was clearly and unexpectedly downregulated in the lungs of monocrotaline-treated rats and showed no correlation to disease progression markers. We speculate that endothelin-1 may play opposing roles in the lungs vs pulmonary artery in monocrotaline-induced PH.

12.
J Subst Abuse Treat ; 99: 61-66, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30797395

RESUMO

BACKGROUND: Addiction is a context specific but common and devastating condition. Though several evidence-based treatments are available, many of them remain under-utilized, among others due to the lack of adequate training in addiction medicine (AM). AM Training needs may differ across countries because of difference in discipline and level of prior AM training or contextual factors like epidemiology and availability of treatment. For appropriate testing of training needs, reliability and validity are key issues. The aim of this study was to evaluate the psychometric properties of the AM-TNA Scale: an instrument specifically designed to develop the competence-based curriculum of the Indonesian AM course. METHODS: In a cross-sectional study in Indonesia, Ireland, Lithuania and the Netherlands the AM-TNA was distributed among a convenience sample of health professionals working in addiction care in The Netherlands, Lithuania, Indonesia and General Practitioners in-training in Ireland. 428 respondents completed the AM-TNA scale. To assess the factor structure, we used explorative factor analysis. Reliability was tested using Cronbach's Alpha, ANOVA determined the discriminative validity. RESULTS: Validity: factor analysis revealed a two-factor structure: One on providing direct patient treatment and care (Factor 1: clinical) and one factor on facilitating/supporting direct patient treatment and care (Factor 2: non-clinical) AM competencies and a cumulative 76% explained variance. Reliability: Factor 1 α = 0.983 and Factor 2: α = 0.956, while overall reliability was (α = 0.986). The AM-TNA was able to differentiate training needs across groups of AM professionals on all 30 addiction medicine competencies (P = .001). CONCLUSIONS: In our study the AM-TNA scale had a strong two-factor structure and proofed to be a reliable and valid instrument. The next step should be the testing external validity, strengthening discriminant validity and assessing the re-test effect and measuring changes over time.

13.
Int J Drug Policy ; 74: 257-265, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-30765118

RESUMO

Canada and the United States (U.S.) face an opioid use disorder (OUD) and opioid overdose epidemic. The most effective OUD treatment is opioid agonist therapy (OAT)-buprenorphine (with and without naloxone) and methadone. Although federal approval for OAT occurred decades ago, in both countries, access to and use of OAT is low. Restrictive policies and complex regulations contribute to limited OAT access. Through a non-systematic literature scan and a review of publicly available policy documents, we examined and compared OAT policies and practice at the federal (Canada vs. U.S.) and local levels (British Columbia [B.C.] vs. Oregon). Differences and similarities were noted between federal and local OAT policies, and subsequently OAT access. In Canada, OAT policy control has shifted from federal to provincial authorities. Conversely, in the U.S., federal authorities maintain primary control of OAT regulations. Local OAT health insurance coverage policies were substantively different between B.C. and Oregon. In B.C., five OAT options were available, while in Oregon, only two OAT options were available with administrative limitations. The differences in local OAT access and coverage policies between B.C. and Oregon, may be explained, in part, to the differences in Canadian and U.S. federal OAT policies, specifically, the relaxation of special federal OAT regulatory controls in Canada. The analysis also highlights the complicating contributions, and likely policy solutions, that exist within other drug policy sub-domains (e.g., the prescription regime, and drug control regime) and broader policy domains (e.g., constitutional rights). U.S. policymakers and health officials could consider adopting Canada's regulatory policy approach to expand OAT access to mitigate the harms of the ongoing opioid overdose epidemic.

14.
Subst Abus ; 40(2): 207-213, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30689528

RESUMO

Background: Hospital-based clinical addiction medicine training can improve knowledge of clinical care for substance-using populations. However, application of structured, self-assessment tools to evaluate differences in knowledge gained by learners who participate in such training has not yet been addressed. Methods: Participants (n = 142) of an elective with the hospital-based Addiction Medicine Consult Team (AMCT) in Vancouver, Canada, responded to an online self-evaluation survey before and immediately after the structured elective. Areas covered included substance use screening, history taking, signs and symptoms examination, withdrawal treatment, relapse prevention, nicotine use disorders, opioid use disorders, safe prescribing, and the biology of substance use disorders. A purposefully selected sample of 18 trainees were invited to participate in qualitative interviews that elicited feedback on the rotation. Results: Of 168 invited trainees, 142 (84.5%) completed both pre- and post-rotation self-assessments between May 2015 and May 2017. Follow-up participants included medical students, residents, addiction medicine fellows, and family physicians in practice. Self-assessed knowledge of addiction medicine increased significantly post-rotation (mean difference in scores = 11.87 out of the maximum possible 63 points, standard deviation = 17.00; P < .0001). Medical students were found to have the most significant improvement in addiction knowledge (estimated mean difference = 4.43, 95% confidence interval = 0.76, 8.09; P = .018). Illustrative quotes describe the dynamics involved in the learning process among trainees. Conclusions: Completion of a hospital-based clinical elective was associated with improved knowledge of addiction medicine. Medical students appear to benefit more from the addiction elective with a hospital-based AMCT than other types of learners.

15.
Int J Drug Policy ; 64: 30-33, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30551003

RESUMO

BACKGROUND: Opioid agonist therapy (OAT) is a first-line treatment for opioid use disorder (OUD); however, the efficacy and role of urine drug screening (UDS) in OAT has received little research attention. Prior evidence suggests that UDS frequency reflects philosophy and practice context rather than differences in patient characteristics or clinical need. Therefore, we reviewed the literature on the effect of and recommendations for the frequency of UDS on health outcomes for persons with OUD who receive OAT. METHODS: We searched Medline and EMBASE for articles published from 1995-2017. Search results underwent double, independent review with discrepancies resolved through discussion with a third reviewer, when necessary. Additional articles were identified through snowball searching, hand searching (Google Scholar), and expert consultation. The Cochrane tool was used to assess risk of bias. RESULTS: Of the 60 potentially eligible articles reviewed, only one three-arm randomized open-label trial, comparing weekly and monthly UDS testing with take-home OAT doses, met our inclusion criteria. CONCLUSIONS: Our review identified an urgent gap in research evidence underpinning an area of clinical importance and that is routinely reported by patients as an area of concern.


Assuntos
Monitoramento de Medicamentos/normas , Transtornos Relacionados ao Uso de Opioides/terapia , Humanos , Programas de Rastreamento , Transtornos Relacionados ao Uso de Substâncias , Resultado do Tratamento , Urinálise
16.
Cochrane Database Syst Rev ; 12: CD009269, 2018 12 05.
Artigo em Inglês | MEDLINE | ID: mdl-30521696

RESUMO

BACKGROUND: Problem alcohol use is common among people who use illicit drugs (PWID) and is associated with adverse health outcomes. It is also an important factor contributing to a poor prognosis among drug users with hepatitis C virus (HCV) as it impacts on progression to hepatic cirrhosis or opioid overdose in PWID. OBJECTIVES: To assess the effectiveness of psychosocial interventions to reduce alcohol consumption in PWID (users of opioids and stimulants). SEARCH METHODS: We searched the Cochrane Drugs and Alcohol Group trials register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, and PsycINFO, from inception up to August 2017, and the reference lists of eligible articles. We also searched: 1) conference proceedings (online archives only) of the Society for the Study of Addiction, International Harm Reduction Association, International Conference on Alcohol Harm Reduction and American Association for the Treatment of Opioid Dependence; and 2) online registers of clinical trials: Current Controlled Trials, ClinicalTrials.gov, Center Watch and the World Health Organization International Clinical Trials Registry Platform. SELECTION CRITERIA: We included randomised controlled trials comparing psychosocial interventions with other psychosocial treatment, or treatment as usual, in adult PWIDs (aged at least 18 years) with concurrent problem alcohol use. DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures expected by Cochrane. MAIN RESULTS: We included seven trials (825 participants). We judged the majority of the trials to have a high or unclear risk of bias.The psychosocial interventions considered in the studies were: cognitive-behavioural coping skills training (one study), twelve-step programme (one study), brief intervention (three studies), motivational interviewing (two studies), and brief motivational interviewing (one study). Two studies were considered in two comparisons. There were no data for the secondary outcome, alcohol-related harm. The results were as follows.Comparison 1: cognitive-behavioural coping skills training versus twelve-step programme (one study, 41 participants)There was no significant difference between groups for either of the primary outcomes (alcohol abstinence assessed with Substance Abuse Calendar and breathalyser at one year: risk ratio (RR) 2.38 (95% confidence interval [CI] 0.10 to 55.06); and retention in treatment, measured at end of treatment: RR 0.89 (95% CI 0.62 to 1.29), or for any of the secondary outcomes reported. The quality of evidence for the primary outcomes was very low.Comparison 2: brief intervention versus treatment as usual (three studies, 197 participants)There was no significant difference between groups for either of the primary outcomes (alcohol use, measured as scores on the Alcohol Use Disorders Identification Test (AUDIT) or Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) at three months: standardised mean difference (SMD) 0.07 (95% CI -0.24 to 0.37); and retention in treatment, measured at three months: RR 0.94 (95% CI 0.78 to 1.13), or for any of the secondary outcomes reported. The quality of evidence for the primary outcomes was low.Comparison 3: motivational interviewing versus treatment as usual or educational intervention only (three studies, 462 participants)There was no significant difference between groups for either of the primary outcomes (alcohol use, measured as scores on the AUDIT or ASSIST at three months: SMD 0.04 (95% CI -0.29 to 0.37); and retention in treatment, measured at three months: RR 0.93 (95% CI 0.60 to 1.43), or for any of the secondary outcomes reported. The quality of evidence for the primary outcomes was low.Comparison 4: brief motivational intervention (BMI) versus assessment only (one study, 187 participants)More people reduced alcohol use (by seven or more days in the past month, measured at six months) in the BMI group than in the control group (RR 1.67; 95% CI 1.08 to 2.60). There was no difference between groups for the other primary outcome, retention in treatment, measured at end of treatment: RR 0.98 (95% CI 0.94 to 1.02), or for any of the secondary outcomes reported. The quality of evidence for the primary outcomes was moderate.Comparison 5: motivational interviewing (intensive) versus motivational interviewing (one study, 163 participants)There was no significant difference between groups for either of the primary outcomes (alcohol use, measured using the Addiction Severity Index-alcohol score (ASI) at two months: MD 0.03 (95% CI 0.02 to 0.08); and retention in treatment, measured at end of treatment: RR 17.63 (95% CI 1.03 to 300.48), or for any of the secondary outcomes reported. The quality of evidence for the primary outcomes was low. AUTHORS' CONCLUSIONS: We found low to very low-quality evidence to suggest that there is no difference in effectiveness between different types of psychosocial interventions to reduce alcohol consumption among people who use illicit drugs, and that brief interventions are not superior to assessment-only or to treatment as usual. No firm conclusions can be made because of the paucity of the data and the low quality of the retrieved studies.


Assuntos
Consumo de Bebidas Alcoólicas/prevenção & controle , Usuários de Drogas/psicologia , Entrevista Motivacional/métodos , Psicoterapia/métodos , Transtornos Relacionados ao Uso de Substâncias/complicações , Adaptação Psicológica , Adulto , Consumo de Bebidas Alcoólicas/psicologia , Alcoólicos Anônimos , Transtornos Relacionados ao Uso de Cocaína/complicações , Transtornos Relacionados ao Uso de Cocaína/terapia , Hepatite C/prevenção & controle , Humanos , Psicoterapia Breve , Ensaios Clínicos Controlados Aleatórios como Assunto , Grupos de Autoajuda , Transtornos Relacionados ao Uso de Substâncias/terapia , Temperança/estatística & dados numéricos , Fatores de Tempo
17.
Can J Addict ; 9(2): 6-9, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30410962

RESUMO

Urine drug screening (UDS) is commonly used to detect or validate self-reported substance use, particularly when beginning and maintaining opioid agonist therapy (OAT). However, there is currently no summary of the published clinical practice guidelines for UDS in Canada, and no measure of the consistency with which different provinces suggest administering UDS. Therefore, we conducted a policy scan of UDS guidelines, examining the published clinical practice guidelines for each Canadian province and extracting all relevant data in March 2017. Our Canadian guideline and policy scan found that UDS frequency recommendations vary greatly among Provinces for persons receiving OAT for opioid use disorder.

18.
JAMA ; 320(8): 825-833, 2018 08 28.
Artigo em Inglês | MEDLINE | ID: mdl-30167704

RESUMO

Importance: Although severe alcohol withdrawal syndrome (SAWS) is associated with substantial morbidity and mortality, most at-risk patients will not develop this syndrome. Predicting its occurrence is important because the mortality rate is high when untreated. Objective: To assess the accuracy and predictive value of symptoms and signs for identifying hospitalized patients at risk of SAWS, defined as delirium tremens, withdrawal seizure, or clinically diagnosed severe withdrawal. Data Sources: MEDLINE and EMBASE (1946-January 2018) were searched for articles investigating symptoms and signs predictive of SAWS in adults. Reference lists of retrieved articles were also searched. Study Selection: Original studies that were included compared symptoms, signs, and risk assessment tools among patients who developed SAWS and patients who did not. Data Extraction and Synthesis: Data were extracted and used to calculate likelihood ratios (LRs), sensitivity, and specificity. A meta-analysis was performed to calculate summary LR. Results: Of 530 identified studies, 14 high-quality studies that included 71 295 patients and 1355 relevant cases of SAWS (1051 cases), seizure (53 cases), or delirium tremens (251 cases) were analyzed. A history of delirium tremens (LR, 2.9 [95% CI 1.7-5.2]) and baseline systolic blood pressure 140 mm Hg or higher (LR, 1.7 [95% CI, 1.3-2.3) were associated with an increased likelihood of SAWS. No single symptom or sign was associated with exclusion of SAWS. Six high-quality studies evaluated combinations of clinical findings and were useful for identifying patients in acute care facilities at high risk of developing SAWS. Of these combinations, the Prediction of Alcohol Withdrawal Severity Scale (PAWSS) was most useful, with an LR of 174 (95% CI, 43-696; specificity, 0.93) when patients had 4 or more individual findings and an LR of 0.07 (95% CI, 0.02-0.26; sensitivity, 0.99) when there were 3 or fewer findings. Conclusions and Relevance: Assessment tools that use a combination of symptoms and signs are useful for identifying patients at risk of developing severe alcohol withdrawal syndrome. Most studies of these tools were not fully validated, limiting their generalizability.


Assuntos
Alcoolismo/complicações , Etanol/efeitos adversos , Medição de Risco/métodos , Síndrome de Abstinência a Substâncias/etiologia , Feminino , Humanos , Incidência , Funções Verossimilhança , Masculino , Fatores de Risco , Sensibilidade e Especificidade , Índice de Gravidade de Doença , Síndrome de Abstinência a Substâncias/epidemiologia
20.
Drug Alcohol Depend ; 186: 182-186, 2018 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-29604525

RESUMO

BACKGROUND: We sought to examine the factors associated with discontinuation of MMT among persons on methadone who use alcohol. METHODS: We evaluated the impact of drug-related and other factors on discontinuation of MMT among persons enrolled in MMT and who reported any use of alcohol versus those who were enrolled in two community-recruited prospective cohorts of people who use illicit drugs (PWUD). Extended Cox models with time-dependent variables identified factors independently associated with time to first MMT discontinuation. RESULTS: Between December 2005 and 2015, 823 individuals on MMT who also reported using alcohol at least once were included in these analyses. During the study period, 391 (47.5%) discontinued methadone. Daily heroin injection (Adjusted Hazard Ratio [AHR] = 2.67, 95% Confidence Interval [CI]: 2.10-3.40) and homelessness (AHR = 1.42, 95% CI: 1.10-1.83) were positively associated with MMT discontinuation, whereas receiving other concurrent addiction treatment in addition to MMT (AHR = 0.07, 95% CI: 0.05-0.08), as well as >60 mg methadone dose (AHR = 0.48, 95% CI: 0.39-0.60), Hepatitis C virus seropositivity (AHR = 0.65, 95% CI: 0.47-0.90), and HIV seropositivity (AHR = 0.72, 95% CI: 0.57-0.91) were negatively associated with MMT discontinuation. Any/heavy alcohol use was not independently associated with MMT discontinuation. CONCLUSIONS: This study reinforces the known risks of continued heroin injection and homelessness for MMT discontinuation among individuals who also consume alcohol and highlights the protective effect of both MMT dose and receipt of concurrent addiction treatment.


Assuntos
Consumo de Bebidas Alcoólicas/epidemiologia , Dependência de Heroína/tratamento farmacológico , Dependência de Heroína/epidemiologia , Metadona/administração & dosagem , Tratamento de Substituição de Opiáceos/tendências , Suspensão de Tratamento/tendências , Adulto , Consumo de Bebidas Alcoólicas/efeitos adversos , Colúmbia Britânica/epidemiologia , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Tratamento de Substituição de Opiáceos/métodos , Estudos Prospectivos , Transtornos Relacionados ao Uso de Substâncias/tratamento farmacológico , Transtornos Relacionados ao Uso de Substâncias/epidemiologia
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