Rethinking Substance Use as Social History: Charting a Way Forward.

Physicians have traditionally asked about substance use within the Social History section of the consultation note. Drawing on social science theory and using the authors' own experiences as generalists and addiction scholars, we consider the possible unintended harms associated with this approach. The inclusion of the substance use history within the Social History reproduces the discourse of substance use disorders as "life-style choices" rather than medical conditions, and reinforces stigma among healthcare workers through the attribution of personal responsibility for complications associated with problematic substance use. The ongoing placement of the substance use history within the Social History may lead to a failure to diagnose and make appropriate management plans for clients with substance use disorders. These missed opportunities may include inadequate withdrawal management leading to discharge before medically advised, insufficient use of evidence-based pharmacotherapy and psychotherapy, polypharmacy, medical complications, and repeated admissions to hospital. We argue instead that the Substance Use History should be a stand-alone section within the consultation note. This new section would reduce the invisibility of substance use disorders within our medical systems and model that these chronic medical conditions are amenable to prevention, treatment and harm reduction through the application of evidence-based practices.

Patterns of use and adverse events reported among persons who regularly inject buprenorphine: a systematic review.

BACKGROUND AND AIMS: Given the ongoing opioid crisis, novel interventions to treat severe opioid use disorder (OUD) are urgently needed. Injectable opioid agonist therapy (iOAT) with diacetylmorphine or hydromorphone is effective for the treatment of severe, treatment-refractory OUD, however barriers to implementation persist. Intravenous buprenorphine for the treatment of OUD (BUP iOAT) has several possible advantages over traditional iOAT, including a safety profile that might enable take-home dosing. We aimed to characterize injecting practices among real-world populations of persons who regularly inject buprenorphine, as well as associated adverse events reported in order to inform a possible future BUP iOAT intervention. METHODS: We conducted a systematic review. We searched MEDLINE, EMBASE, and PsycINFO from inception through July 2020 and used backwards citation screening to search for publications reporting on dose, frequency among persons who regularly inject the drug, or adverse events associated with intravenous use of buprenorphine. The review was limited to English language publications and there was no limitation on study type. Study quality and risk of bias was assessed using the Mixed Methods Appraisal Tool. Narrative synthesis was used in reporting the results. RESULTS: Eighty-eight studies were included in our review. Regular injection of buprenorphine was identified across diverse settings world-wide. Daily dose of oral buprenorphine injected was < 1-12 mg. Frequency of injection was 0-10 times daily. Adverse events could be characterized as known side effects of opioids/buprenorphine or injection-related complications. Most studies were deemed to be of low quality. CONCLUSIONS: Extramedical, intravenous use of buprenorphine, continues to be documented. BUP iOAT may be feasible and results may inform the development of a study to test the efficacy and safety of such an intervention. Future work should also examine acceptability among people with severe OUD in North America. Our review was limited by the quality of included studies.

Association Between Increased Dispensing of Opioid Agonist Therapy Take-Home Doses and Opioid Overdose and Treatment Interruption and Discontinuation.

Importance: During the COVID-19 pandemic, modified guidance for opioid agonist therapy (OAT) allowed prescribers to increase the number of take-home doses to promote treatment retention. Whether this was associated with an increased risk of overdose is unclear. Objective: To evaluate whether increased take-home doses of OAT early in the COVID-19 pandemic was associated with treatment retention and opioid-related harm. Design, Setting, and Participants: A retrospective propensity-weighted cohort study of 21 297 people actively receiving OAT on March 21, 2020, in Ontario, Canada. Changes in OAT take-home dose frequency were assessed between March 22, 2020, and April 21, 2020, and individuals were observed for up to 180 days to assess outcomes (last date of follow-up, October 18, 2020). Exposures: Exposure was defined as extended take-home doses in the first month of the pandemic within each of 4 cohorts based on OAT type and baseline take-home dose frequency (daily dispensed methadone, 5-6 take-home doses of methadone, daily dispensed buprenorphine/naloxone, and 5-6 take-home doses of buprenorphine/naloxone). Main Outcomes and Measures: Primary outcomes were opioid overdose, interruption in OAT, and OAT discontinuation. Results: Among 16 862 methadone and 4435 buprenorphine/naloxone recipients, the median age ranged between 38 and 42 years, and 29.1% to 38.2% were women. Among individuals receiving daily dispensed methadone (n = 5852), initiation of take-home doses was significantly associated with lower risks of opioid overdose (6.9% vs 9.5%/person-year; weighted hazard ratio [HR], 0.73 [95% CI, 0.56-0.96]), treatment discontinuation (51.0% vs 63.6%/person-year; weighted HR, 0.80 [95% CI, 0.72-0.90]), and treatment interruption (19.0% vs 23.9%/person-year; weighted HR, 0.80 [95% CI, 0.67-0.95]) compared with no change in take-home doses. Among individuals receiving daily dispensed buprenorphine/naloxone (n = 662), there was no significant difference in any outcomes between exposure groups. Among individuals receiving weekly dispensed OAT (n = 11 010 for methadone; n = 3773 for buprenorphine/naloxone), extended take-home methadone doses were significantly associated with lower risks of OAT discontinuation (14.1% vs 19.6%/person-year; weighted HR, 0.72 [95% CI, 0.62-0.84]) and interruption in therapy (5.1% vs 7.4%/person-year; weighted HR, 0.69 [95% CI, 0.53-0.90]), and extended take-home doses of buprenorphine/naloxone were significantly associated with lower risk of interruption in therapy (9.5% vs 12.9%/person-year; weighted HR, 0.74 [95% CI, 0.56-0.99]) compared with no change in take-home doses. Other primary outcomes were not significantly different between groups. Conclusions and Relevance: In Ontario, Canada, during the COVID-19 pandemic, dispensing of increased take-home doses of opioid agonist therapy was significantly associated with lower rates of treatment interruption and discontinuation among some subsets of patients receiving opioid agonist therapy, and there were no statistically significant increases in opioid-related overdoses over 6 months of follow-up. These findings may be susceptible to residual confounding and should be interpreted cautiously.

Street-involved youth engaged in sex work at increased risk of syringe sharing.

Syringe sharing places street-involved young people at risk of acquiring HIV and hepatitis C. While markers of economic marginalization, such as homelessness, have been linked with syringe sharing and have led to targeted interventions, the relationship between syringe sharing and other markers of economic vulnerability, such as sex work, are not well documented among young people. This study examines whether those engaged in sex work are at increased risk of syringe borrowing and syringe lending among street-involved youth who use injection drugs in Vancouver, Canada. Between September 2005 and May 2014, data was collected from the At-Risk Youth Study (ARYS), a prospective cohort of street involved youth aged 14-26. Generalized estimating equations with a confounding model building approach was used to examine the relationship between sex work and syringe borrowing and lending. 498 youth reported injecting drugs at some point during the study period and were therefore included in the analysis. In multivariable analysis, youth who engaged in sex work were at an elevated risk of both syringe borrowing (Adjusted Odds Ratio (AOR) = 2.17, 95% Confidence Interval [CI] = 1.40-3.36) and syringe lending (AOR = 1.66, 95% CI = 1.07-2.59). Our study found that youth engaged in street-based sex work were at a significantly higher risk of both syringe borrowing and lending among youth who use injection drugs in Vancouver. Ready access to clean syringes, safer working conditions for sex workers to enable risk reduction measures, and increased access to addiction treatment are identified as promising opportunities for reducing syringe sharing in this setting.

"They Will Come to Understand": Supervisor Reflections on International Medical Electives.

Phenomenon: Increasing numbers of medical students from high-income countries are undertaking international medical electives (IMEs) during their training. Much has been written about the benefits of these experiences for the student, and concerns have been raised regarding the burden of IMEs on host communities. The voices of physicians from low- and middle-income countries who supervise IMEs have not been explored in depth. The current study sought to investigate host-physician perspectives on IMEs. Approach: Host supervisors were recruited by convenience sampling through students travelling abroad for IMEs during the summer of 2012. From 2012 through 2014, 11 semistructured interviews were conducted by telephone with host supervisors from Nepal, Uganda, Ghana, Guyana, and Kenya. Participants were invited to describe their motivations for hosting IMEs and their experiences of the benefits and harms of IMEs. Interviews were transcribed verbatim and checked for accuracy. An initial coding framework was developed and underwent multiple revisions, after which analytic categories were derived using conventional qualitative content analysis. Findings: For host supervisors, visits from international medical students provided a window into the resource-rich medical practice of high-income countries, and supervisors positioned themselves, their education, and clinical expertise against perceived standards of the international students' context. Hosting IMEs also contributed to supervisors' identities as educators connected to a global community. Supervisors described the challenge of helping students navigate their distress when confronting global health inequity. Finally, the desire for increasingly reciprocal relationships was expressed as a hope for the future. Insights: IMEs can be formative for host supervisors' identities and are used to benchmark host institutions compared with international medical standards. Reciprocity was articulated as essential for IMEs moving forward.

Syringe Sharing Among a Prospective Cohort of Street-Involved Youth: Implications for Needle Distribution Programs.

The sharing of previously used syringes is associated with the transmission of Hepatitis C and HIV. This longitudinal study examines syringe borrowing and syringe lending within a prospective cohort of street-involved youth in Vancouver, Canada. From September 2005 to May 2014, data were collected from the At-Risk Youth Study, a cohort of street-involved youth age 14-26 at enrollment, and analyzed using generalized estimating equations. Among 505 participants, 142 (28.1%) reported syringe borrowing and 132 (26.1%) reported syringe lending during the study period. In separate multivariable analyses, having difficulty finding clean needles and homelessness were significantly associated with syringe borrowing (Adjusted Odds Ratio (AOR) = 2.28, 95% CI 1.66-3.12 and AOR = 1.52, CI 1.05-2.21, respectively) and syringe lending (AOR = 1.89, 95% CI 1.32-2.71 and AOR = 1.65, 95% CI 1.11-2.44, respectively) (all p values < 0.05). Findings highlight gaps in syringe access for vulnerable young injectors and suggest that service delivery for youth may be suboptimal. Further examination of how needle distribution efforts might be improved to better meet the needs of young people is warranted.

Toward reciprocity: host supervisor perspectives on international medical electives.

CONTEXT: An increasing number of medical students are engaging in international medical electives, the majority of which involve travel from northern, higher-income countries to southern, lower-income countries. Existing research has identified benefits to students participating in these experiences. However, reports on the impacts on host communities are largely absent from the literature. OBJECTIVES: The current study aims to identify host country perspectives on international medical electives. METHODS: Questionnaires were delivered to a convenience sample of supervisors hosting international elective students (n = 39) from a Canadian medical school. Responses represented 22 countries. Conventional content analysis of the qualitative data was used to identify themes in host supervisor perspectives on the impact of international medical electives. RESULTS: Host country supervisors identified that in addition to the benefits realised by the elective students, supervisors and their institutions also benefited from hosting Canadian students. Although some host supervisors denied the occurrence of any harm, others expressed concern that international elective students may negatively impact the local community in terms of resource use and patient care. Host country supervisors also identified potential harms to travelling students including health risks and emotional distress. Ideas for improving international electives were identified and were largely centred around increasing the bidirectional flow of students by establishing formal partnerships between institutions. CONCLUSIONS: This research provides important insights into the impacts of international medical student electives from the perspective of host country supervisors. This research may be a starting point for further research and the establishment of meaningful partnerships that incorporate the self-identified needs of receiving institutions, especially those in lower-income settings.

"Not doing it justice": Perspectives of Recent Family Medicine Graduates on Mental Health and Addictions Training in Residency.

OBJECTIVES: Family physicians report feeling inadequately prepared to meet the evolving mental health care needs of the population. Little scholarship exists evaluating the effectiveness of curricula designed to teach mental health and addiction (MH&A) care to family medicine (FM) residents. As such, the purpose of this study was to explore the experiences of recent FM residency graduates in providing mental health care, and their perceptions of mental health training gaps during their residencies. METHODS: A qualitative descriptive study design was conducted by 8 recent graduates of the University of Toronto's FM residency program, who participated in semi-structured video interviews. A thematic analysis approach was used to collect and analyze the data. RESULTS: Through thematic analysis, 3 overarching themes were developed: (1) barriers in providing mental health and addiction care, (2) curriculum renewal, and (3) the role of FPs and professional identity. Consistent with the literature, the majority of recent FM graduates expressed discomfort when managing patients with mental health and addiction concerns. Additionally, participants perceived residency program time constraints, rotational site differences, and limited exposure to marginalized populations all impacted learning and mastery of skills. CONCLUSION: The findings of this study underscore current gaps within the FM residency curriculum and highlight the need to address current curricular deficits.

Examining inequities in access to opioid agonist treatment (OAT) take-home doses (THD): A Canadian OAT guideline synthesis and systematic review.

BACKGROUND: Daily supervised Opioid Agonist Treatment (OAT) medication has been identified as a barrier to treatment retention. Canadian OAT guidelines outline take-home dose (THD) criteria, yet, OAT prescribers use their clinical judgement to decide whether an individual is 'clinically stable' to receive THD. There is limited information regarding whether these decisions may result in inequitable access to THD, including in the context of updated COVID-19 guidance. The current Canadian OAT THD guideline synthesis and systematic review aimed to address this knowledge gap. METHODS: This systematic review included a two-pronged approach. First, we searched available academic literature in Embase, Medline, and PsychINFO up until October 12th, 2022, to identify studies that compared characteristics of individuals on OAT who had and had not been granted access to THD to explore potential inequities in access. Next, we identified all Canadian national and provincial OAT guidelines through a semi-structured grey literature search (conducted between September-October 2022) and extracted all THD 'stability' and allowances/timeline criteria to compare against characteristics identified in the literature search. Data from both review arms were synthesized and narratively presented. RESULTS: A total of n = 56 guidelines and n = 7 academic studies were included. The systematic review identified a number of patient characteristics such as age, sex, race/ethnicity, marital status, housing, employment, neighborhood income, drug use, mental health, health service utilization, as well as treatment duration that were associated with differential access to THD. The Canadian OAT THD guideline synthesis identified many of these same characteristics as 'stability' criteria, underscoring the potential for Canadian OAT guidelines to result in inequitable access to THD. CONCLUSIONS: This two-pronged literature review demonstrated that current guidelines likely contribute to inequitable OAT THD access due primarily to inconsistent 'stability' criteria across guidelines. More research is needed to understand differential OAT THD access with a focus on prescriber decision-making and evaluating associated treatment and safety outcomes. The development of a client-centered, equity-focused, and evidence-informed decision making framework that incorporates more clear definitions of 'stability' criteria and indications for prescriber discretion is warranted.

An environmental scan of residential treatment service provision in Ontario.

BACKGROUND: Ontario has one of the highest rates of substance-related harms in Canada. Residential treatment programs in the province provide a variety of in-house treatment services to support the needs of individuals with substance use disorders (SUD). However, these programs are not standardized, often varying in the type, quality, and availability of services offered, including evidence-based interventions such as Opioid Agonist Treatment (OAT). Local treatment systems are also rather fragmented and complex to navigate, creating barriers for potential services users to identify and make informed choices on available treatment options. METHODS: Between May to August 2023, we conducted an environmental scan to capture available information on all publicly-funded residential treatment programs in Ontario using the ConnexOntario service portal, a government-funded, health services information platform. Data were captured on organization name, geographical location, program description, program type (residential addictions treatment or supportive recovery programs), eligibility criteria, target population, the program's OAT policies, number of available beds, minimum and maximum length of stay, projected wait times, funding source, and associated fees for program admission. Data were extracted and organized by geographic region, and findings were presented descriptively. RESULTS: A total of 102 residential addiction treatment programs and 36 residential supportive recovery programs in Ontario were identified. The scan noted substantial regional variations in program availability and wait times, along with a lack of programs tailored to unique populations such as women, youth, and Indigenous peoples. There is also a paucity of publicly-available information on program offerings, including detailed specifics on OAT policies within residential treatment programs that are crucial to ensuring that the services being offered are safe and grounded in evidence-based practice. CONCLUSIONS: Findings from the scan highlight notable gaps in program types, offerings, and availability among residential treatment programs in the province, including a lack of standardization on OAT policies across programs. Efforts should be made to ensure access to treatment-specific program information relevant to potential service users and to enhance coordinated access to residential treatment services in the province.

Patient Satisfaction With Standard Methadone and Flexible Buprenorphine/Naloxone Models of Care: Results From a Pragmatic Randomized Controlled Clinical Trial.

INTRODUCTION: Patient satisfaction is a critical measure of quality of care across health disciplines because it may affect clinical outcomes. OBJECTIVES: This study aimed to examine longitudinal patient satisfaction in individuals with opioid use disorder (OUD) randomized to receive either standard methadone or flexible buprenorphine/naloxone models of care, its predictors, and association with dropout/illicit drug use. METHODS: This study assessed patient satisfaction, using the 8-item version of the Client Satisfaction Questionnaire (CSQ), as a secondary outcome of a large phase IV pragmatic randomized controlled trial (OPTIMA). The effectiveness of standard methadone model of care was compared with flexible take-home buprenorphine/naloxone dispensation model of care in patients with prescription-type OUD. Of 272 participants recruited and followed up for 24 weeks, 183 were eligible for this study. RESULTS: Throughout the study, patients were "satisfied" with their treatment. The average CSQ score was not significantly different between weeks 4, 12, and 24 in the total sample (χ 2 = 0.35; P = 0.84). There was no significant difference in CSQ based on treatment assignment (methadone vs flexible buprenorphine/naloxone) either overall ( z = 0.87; P = 0.38) or over time (χ 2 = 0.65; P = 0.72). High levels of depression at baseline and decreased depressive symptoms over the follow-up period predicted positive changes in patient satisfaction ( P = 0.03 and P = <0.01, respectively). Satisfaction was significantly associated with treatment retention but not illicit drug use. CONCLUSIONS: This study demonstrates that patients with OUD on either standard methadone or flexible buprenorphine were generally satisfied with their treatment, with no difference in patient satisfaction based on treatment allocation. Given the ongoing opioid crisis, strategies to improve patient satisfaction should be further explored.

Opioid agonist therapy switching among individuals with prescription-type opioid use disorder: Secondary analysis of a pragmatic randomized trial.

BACKGROUND: Engagement and retention in opioid agonist therapy (OAT) remains a challenge. This study evaluated the impact of initial randomized OAT allocation on subsequent switching among people with prescription-type opioid use disorder (POUD). METHODS: Secondary analysis of a 24-week Canadian multicenter, pragmatic, randomized trial conducted between 2017 and 2020 comparing flexible take-home buprenorphine/naloxone versus supervised methadone models of care for POUD. We used Cox Proportional Hazards modeling to assess for impact of treatment assignment on time to OAT switching, adjusting for important confounders. For clinical correlates, we analyzed data from baseline questionnaires on demographic, substance use, and health factors as well as urine drug screen. RESULTS: Of 272 randomized participants, 210 initiated OAT within 14 days per trial protocol, of whom 103 participants were randomized to buprenorphine/naloxone and 107 to methadone. Within 24-week follow-up, 41 (20.5%) of all participants switched OAT with 25 (24.3%, median 27 days, 88.4 per 100 person-years) and 16 participants (15.0%, median 53.5 days, 46.1 per 100 person-years) switching from buprenorphine/naloxone and methadone arms, respectively. In adjusted analysis, allocation to buprenorphine/naloxone was associated with significantly higher risk of switching (aHR = 2.31, 95% CI 1.22 - 4.38). CONCLUSIONS: OAT switching was common in this sample of individuals with POUD, with individuals randomly allocated to buprenorphine/naloxone being more than twice as likely to switch versus methadone. This may reflect a stepped care approach in OUD management. More research is needed to evaluate overall retention and outcomes with the different observed risks of switching between methadone and buprenorphine/naloxone.

GABAergic signaling in alcohol use disorder and withdrawal: pathological involvement and therapeutic potential.

Alcohol is one of the most widely used substances. Alcohol use accounts for 5.1% of the global disease burden, contributes substantially to societal and economic costs, and leads to approximately 3 million global deaths yearly. Alcohol use disorder (AUD) includes various drinking behavior patterns that lead to short-term or long-lasting effects on health. Ethanol, the main psychoactive molecule acting in alcoholic beverages, directly impacts the GABAergic system, contributing to GABAergic dysregulations that vary depending on the intensity and duration of alcohol consumption. A small number of interventions have been developed that target the GABAergic system, but there are promising future therapeutic avenues to explore. This review provides an overview of the impact of alcohol on the GABAergic system, the current interventions available for AUD that target the GABAergic system, and the novel interventions being explored that in the future could be included among first-line therapies for the treatment of AUD.

Incidence of acute hepatitis C virus infection among men who have sex with men with and without HIV infection: a systematic review.

BACKGROUND: A recent increase in reports of acute hepatitis C virus infection (HCV) in HIV-infected and HIV-uninfected men who have sex with men (MSM), with the sole risk factor being sexual exposure, has led to routine screening and targeted prevention requests for this population; current evidence for this necessity is unclear. OBJECTIVE: A systematic review was conducted to assess the incidence of HCV infection among studies conducted in HIV-positive and/or HIV-negative MSM to explore the implications for routine HCV screening. DATA SOURCES: The MEDLINE, EMBASE and BIOSYS databases were searched for the period January 2000 to May 2012, yielding 21 studies. Six conferences were hand-searched for the same period yielding four abstracts. STUDY SELECTION: Only studies in English presenting incidence rates of HCV and specifying HIV status were included. DATA ABSTRACTION: Data were abstracted by two authors using predefined data fields. The STROBE checklist was used to assess study quality. DATA SYNTHESIS: Data were divided into HIV-negative MSM and HIV-positive MSM subgroups, and HCV incidence density measurements were pooled. Using a DerSimonian-Laird random effects model, pooled incidence was 1.48/1000 person-years (95% CI 0.75 to 2.21) for the HIV-negative MSM subgroup. The HIV-positive MSM subgroup was at 4.1 times higher risk of acquiring HCV at 6.08/1000 person-years (95% CI 5.18 to 6.99). Studies directly comparing subgroups estimated a pooled risk difference of 3.45/1000 person-years (95% CI 1.63 to 5.27). CONCLUSION: HIV-positive MSM were at higher risk for acute HCV infection than HIV-negative MSM, substantiating the need for routine screening initiatives. Insufficient evidence exists to warrant routine screening of HIV-negative MSM, except on a case-by-case basis, such as high-risk sexual behaviour.

Prescribing Characteristics Associated With Opioid Overdose Following Buprenorphine Taper.

Importance: Retention in buprenorphine therapy is associated with a lower risk of opioid overdose. Nevertheless, many patients discontinue treatment, and there is limited evidence to guide buprenorphine tapering. Objective: To understand what prescribing characteristics are associated with opioid overdose following buprenorphine taper. Design, Setting, and Participants: This is a population-based, retrospective, cohort study of adults who were maintained on buprenorphine for at least 60 days and underwent a buprenorphine taper. The study was conducted in the Canadian province of Ontario, using linked administrative health data. New buprenorphine treatment episodes were accrued between January 1, 2013, and January 1, 2019, and the maximum follow-up was April 30, 2020. Data analysis was performed from December 2020 to August 2022. Exposures: The primary exposure of interest was time to taper initiation (≤1 year vs >1 year). Secondary exposures included mean rate of taper, percentage days during which the dose was decreasing, and taper duration. Main Outcomes and Measures: The primary outcome measure was time to fatal or nonfatal opioid overdose within 18 months following treatment discontinuation. Results: Among 5774 individuals, the median (IQR) age at index date was 34 (28-44) years, and 3462 individuals (60.0%) were male. Time to taper initiation longer than 1 year vs 1 year or less (6.73 vs 10.35 overdoses per 100 person-years; adjusted hazard ratio [aHR], 0.69; 95% CI, 0.48-0.997), a lower mean rate of taper (≤2 mg per month, 6.95 overdoses per 100 person-years; >2 to ≤4 mg per month, 11.48 overdoses per 100 person-years; >4 mg per month, 17.27 overdoses per 100 person-years; ≤2 mg per month vs >4 mg per month, aHR, 0.65; 95% CI, 0.46-0.91; >2 to ≤4 mg per month vs >4 mg per month, aHR, 0.69; 95% CI, 0.51-0.93), and dose decreases in 1.75% or less of days vs more than 3.50% of days during the taper period (5.87 vs 13.87 overdoses per 100 person-years; aHR, 0.64; 95% CI, 0.43-0.93) were associated with reduced risk of opioid overdose; however, taper duration was not. Conclusions and Relevance: In this retrospective cohort study, buprenorphine tapers undertaken after at least 1 year of therapy, a slower rate of taper, and a lower percentage of days during which the dose was decreasing were associated with a significantly lower risk of opioid overdose, regardless of taper duration. These findings underscore the importance of a carefully planned taper and could contribute to reduction in opioid-related overdose death.

Impact of the COVID-19 pandemic on the provision of take-home doses of opioid agonist therapy in Ontario, Canada: A population-based time-series analysis.

BACKGROUND: In March 2020, the Ontario government declared a state of emergency due to the growing risk of COVID-19. In response, new guidance for the management of opioid agonist therapy (OAT) was released, which included the expansion of eligibility for take-home doses. We investigated the impact of these changes on trends in the distribution of take-home doses of OAT. METHODS: We conducted a population-based time series analysis among residents of Ontario, Canada who were dispensed OAT between June 25, 2019 and November 30, 2020. For each week of the study period, we calculated the percentage of people dispensed (a) methadone and (b) buprenorphine/naloxone by the number of take-home doses received. We used interventional autoregressive integrated moving average models to estimate changes in the percentage of people dispensed each category of take-home doses in the weeks following the declaration of the state of emergency and release of the OAT dispensing guidance. RESULTS: Following the state of emergency and release of the OAT dispensing guidance, there was a significant increase in the percentage of Ontarians dispensed 7 to 13 (3.6% increase; p = 0.033) and 14 or more (0.8% increase; p<0.001) take-home doses of methadone, and in the percentage of people dispensed 7 to 13 (4.3% increase; p = 0.001), 14 to 27 (2.8% increase; p<0.001), and 28 or more (0.3% increase; p = 0.008) take-home doses of buprenorphine/naloxone. There were significant decreases in the percentage of Ontarians receiving daily dispensed buprenorphine/naloxone (-3.1%; p = 0.001), as well as the percentage dispensed 1 to 6 take-home doses of methadone (-4.5%; p = 0.001) and buprenorphine/naloxone (-4.9%; p = 0.001). CONCLUSION: The new guidance for dispensing OAT in Ontario resulted in increases in the duration of take-home doses of methadone and buprenorphine/naloxone supplied. However, given that changes were small, strategies to improve retention in OAT and ensure equitable access to take-home dosing should continue.