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Wouldes TA, Lester BM. Opioid, methamphetamine, and polysubstance use: perinatal outcomes for the mother and infant. Front Pediatr 2023; 11:1305508. [PMID: 38250592 PMCID: PMC10798256 DOI: 10.3389/fped.2023.1305508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 11/20/2023] [Indexed: 01/23/2024] Open
Abstract
The escalation in opioid pain relief (OPR) medications, heroin and fentanyl, has led to an increased use during pregnancy and a public health crisis. Methamphetamine use in women of childbearing age has now eclipsed the use of cocaine and other stimulants globally. Recent reports have shown increases in methamphetamine are selective to opioid use, particularly in rural regions in the US. This report compares the extent of our knowledge of the perinatal outcomes of OPRs, heroin, fentanyl, two long-acting substances used in the treatment of opioid use disorders (buprenorphine and methadone), and methamphetamine. The methodological limitations of the current research are examined, and two important initiatives that will address these limitations are reviewed. Current knowledge of the perinatal effects of short-acting opioids, OPRs, heroin, and fentanyl, is scarce. Most of what we know about the perinatal effects of opioids comes from research on the long-acting opioid agonist drugs used in the treatment of OUDs, methadone and buprenorphine. Both have better perinatal outcomes for the mother and newborn than heroin, but the uptake of these opioid substitution programs is poor (<50%). Current research on perinatal outcomes of methamphetamine is limited to retrospective epidemiological studies, chart reviews, one study from a treatment center in Hawaii, and the US and NZ cross-cultural infant Development, Environment And Lifestyle IDEAL studies. Characteristics of pregnant individuals in both opioid and MA studies were associated with poor maternal health, higher rates of mental illness, trauma, and poverty. Infant outcomes that differed between opioid and MA exposure included variations in neurobehavior at birth which could complicate the diagnosis and treatment of neonatal opioid withdrawal (NOWs). Given the complexity of OUDs in pregnant individuals and the increasing co-use of these opioids with MA, large studies are needed. These studies need to address the many confounders to perinatal outcomes and employ neurodevelopmental markers at birth that can help predict long-term neurodevelopmental outcomes. Two US initiatives that can provide critical research and treatment answers to this public health crisis are the US Environmental influences on Child Health Outcomes (ECHO) program and the Medication for Opioid Use Disorder During Pregnancy Network (MAT-LINK).
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Affiliation(s)
- Trecia A. Wouldes
- Department of Psychological Medicine, The University of Auckland, Auckland, New Zealand
| | - Barry M. Lester
- Center for the Study of Children at Risk, Warren Alpert Medical School, Brown University, Providence, RI, United States
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Smith BL, Hassler A, Lloyd KR, Reyes TM. Perinatal morphine but not buprenorphine affects gestational and offspring neurobehavioral outcomes in mice. Neurotoxicology 2023; 99:292-304. [PMID: 37981055 PMCID: PMC10842910 DOI: 10.1016/j.neuro.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 10/06/2023] [Accepted: 11/14/2023] [Indexed: 11/21/2023]
Abstract
Within the national opioid epidemic, there has been an increase in the number of infants exposed to opioids in utero. Additionally, opioid agonist medications are the standard of care for women with opioid use disorder during pregnancy. Buprenorphine (BUP), a partial µ -opioid receptor agonist, has been successful in improving gestational and neonatal outcomes. However, in utero exposure has been linked to childhood cognitive and behavioral problems. Therefore, we sought to compare offspring cognitive and behavioral outcomes after prenatal exposure to a clinically relevant low dose of BUP compared to morphine (MO), a full µ -opioid receptor agonist and immediate metabolite of heroin. We used a mouse model to assess gestational and offspring outcomes. Mouse dams were injected once daily s.c. with saline (SAL, n = 12), MO (10 mg/kg, n = 15), or BUP (0.1 mg/kg, n = 16) throughout pre-gestation, gestation, and lactation until offspring were weaned on postnatal day (P)21. Offspring social interaction and exploratory behavior were assessed, along with executive function via the touchscreen 5 choice serial reaction time task (5CSRTT). We then quantified P1 brain gene expression in the frontal cortex and amygdala (AMG). Perinatal MO but not BUP exposure decreased gestational weight gain and was associated with dystocia. In adolescent offspring, perinatal MO but not BUP exposure increased social exploration in males and grooming behavior in females. In the 5CSRTT, male MO exposed offspring exhibited increased impulsive action errors compared to male BUP offspring. In the AMG of P1 MO exposed offspring, we observed an increase in gene expression of targets related to activity of microglia. Importantly, both MO and BUP caused acute hyperlocomotion in the dams to a similar degree, indicating that the selected doses are comparable, in accordance with previous dose comparisons on analgesic and reward efficacy. These data suggest that compared to MO, low dose BUP improves gestational outcomes and has less of an effect on the neonatal offspring brain and later adolescent and adult behavior.
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Affiliation(s)
- Brittany L Smith
- Department of Pharmacology & Systems Physiology, University of Cincinnati, Cincinnati, OH, USA; Department of Psychological Science, Northern Kentucky University, Highland Heights, KY, USA.
| | - Ally Hassler
- Department of Pharmacology & Systems Physiology, University of Cincinnati, Cincinnati, OH, USA
| | - Kelsey R Lloyd
- Department of Pharmacology & Systems Physiology, University of Cincinnati, Cincinnati, OH, USA
| | - Teresa M Reyes
- Department of Pharmacology & Systems Physiology, University of Cincinnati, Cincinnati, OH, USA
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Turner S, Allen VM, Carson G, Graves L, Tanguay R, Green CR, Cook JL. Guideline No. 443b: Opioid Use Throughout Women's Lifespan: Opioid Use in Pregnancy and Breastfeeding. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2023; 45:102144. [PMID: 37977721 DOI: 10.1016/j.jogc.2023.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
OBJECTIVE To provide health care providers the best evidence on opioid use and women's health. Areas of focus include pregnancy and postpartum care. TARGET POPULATION The target population includes all women currently using or contemplating using opioids. OUTCOMES Open, evidence-informed dialogue about opioid use will improve patient care. BENEFITS, HARMS, AND COSTS Exploring opioid use through a trauma-informed approach provides the health care provider and patient with an opportunity to build a strong, collaborative, and therapeutic alliance. This alliance empowers women to make informed choices about their own care. It also allows for the diagnosis and possible treatment of opioid use disorders. Opioid use should not be stigmatized, as stigma leads to poor "partnered care" (i.e., the partnership between the patient and care provider). Health care providers need to understand the effect opioids can have on pregnant women and support them to make knowledgeable decisions about their health. EVIDENCE A literature search was designed and carried out in PubMed and the Cochrane Library databases from August 2018 until March 2023 using following MeSH terms and keywords (and variants): opioids, opioid agonist therapy, illicit drugs, fertility, pregnancy, fetal development, neonatal abstinence syndrome, and breastfeeding. VALIDATION METHODS The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations). INTENDED AUDIENCE All health care providers who care for pregnant and/or post-partum women and their newborns. TWEETABLE ABSTRACT Opioid use during pregnancy often co-occurs with mental health issues and is associated with adverse maternal, fetal, and neonatal outcomes; treatment of opioid use disorder with agonist therapy for pregnant women can be safe during pregnancy where the risks outnumber the benefits. SUMMARY STATEMENTS RECOMMENDATIONS.
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Turner S, Allen VM, Carson G, Graves L, Tanguay R, Green CR, Cook JL. Directive clinique n o 443b : Opioïdes aux différentes étapes de la vie des femmes : Grossesse et allaitement. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2023; 45:102146. [PMID: 37977719 DOI: 10.1016/j.jogc.2023.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
OBJECTIF Présenter aux professionnels de la santé les données probantes concernant l'utilisation des opioïdes et la santé des femmes. Les domaines d'intérêt sont la grossesse et les soins post-partum. POPULATION CIBLE Toutes les femmes qui utilisent des opioïdes. RéSULTATS: Un dialogue ouvert et éclairé sur l'utilisation des opioïdes améliorera les soins aux patientes. BéNéFICES, RISQUES ET COûTS: L'exploration de l'utilisation d'opioïdes par une approche tenant compte des traumatismes antérieurs donne au professionnel de la santé et à la patiente l'occasion de bâtir une alliance solide, collaborative et thérapeutique. Cette alliance permet aux femmes de faire des choix éclairés. Elle favorise le diagnostic et le traitement possible du trouble lié à l'utilisation d'opioïdes. L'utilisation ne doit pas être stigmatisée, puisque la stigmatisation affaiblit le partenariat (le partenariat entre patiente et professionnel de la santé). Les professionnels de la santé ceus-ci doivent comprendre l'effet potentiel des opioïdes sur la santé les femmes enceintes et les aider à prendre des décisions éclairées sur leur santé. DONNéES PROBANTES: Une recherche a été conçue puis effectuée dans les bases de données PubMed et Cochrane Library pour la période d'août 2018 à mars 2023 des termes MeSH et mots clés suivants (et variantes) : opioids, opioid agonist therapy, illicit drugs, fertility, pregnancy, fetal development, neonatal abstinence syndrome et breastfeeding. MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique GRADE (Grading of Recommendations, Assessment, Development, and Evaluation). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et conditionnelles [faibles]). PROFESSIONNELS CONCERNéS: Tous les professionnels de la santé qui prodiguent des soins aux femmes et aux nouveaux-nés. RéSUMé POUR TWITTER: La consommation d'opioïdes pendant la grossesse coïncide souvent avec des problèmes de santé mentale et est associée à des conséquences néfastes pour la mère, le fœtus et le nouveau-né ; le traitement des troubles liés à la consommation d'opioïdes par agonistes peut être sûr pendant la grossesse lorsque les risques sont plus nombreux que les avantages. DÉCLARATIONS SOMMAIRES: RECOMMANDATIONS.
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Szlyk HS, Constantino-Pettit A, Li X, Kasson E, Maranets E, Worku Y, Montayne M, Banks DE, Kelly JC, Cavazos-Rehg PA. Self-Identified Stage in Recovery and Substance-Use Behaviors among Pregnant and Postpartum Women and People with Opioid Use Disorder. Healthcare (Basel) 2023; 11:2392. [PMID: 37685426 PMCID: PMC10486579 DOI: 10.3390/healthcare11172392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 08/09/2023] [Accepted: 08/23/2023] [Indexed: 09/10/2023] Open
Abstract
Opioid use among pregnant and postpartum women and people (PPWP) has significant health repercussions. This study explores how substance-use behaviors may vary by stage in recovery among PPWP with opioid use disorder (OUD). We recruited 29 PPWP with OUD. "High-risk" participants self-identified as "not being engaged in treatment" or "new or early in their recovery" (n = 11); "low-risk" participants self-identified as being "well-established" or "in long-term recovery" (n = 18). Participants were queried regarding sociodemographic, mental health, and drug-misuse factors; urine drug screens were collected at baseline. Univariate group comparisons between high-risk and low-risk PPWP were conducted. High-risk PPWP were more likely to self-identify as non-Hispanic African American and more likely to report current opioid use, other illicit drugs, and tobacco. High-risk PPWP had higher opioid cravings versus low-risk PPWP. High-risk PPWP were more likely to screen positive on urine tests for non-opioid drugs and on concurrent use of both non-opioid drugs and opioids versus low-risk participants. PPWP earlier in recovery are at higher-risk for opioid and other illicit drug misuse but are willing to disclose aspects of their recent use. PPWP early in recovery are an ideal population for interventions that can help facilitate recovery during the perinatal period and beyond.
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Affiliation(s)
- Hannah S. Szlyk
- Department of Psychiatry, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO 63110, USA; (A.C.-P.); (X.L.); (E.K.); (E.M.); (Y.W.); (M.M.); (P.A.C.-R.)
| | - Anna Constantino-Pettit
- Department of Psychiatry, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO 63110, USA; (A.C.-P.); (X.L.); (E.K.); (E.M.); (Y.W.); (M.M.); (P.A.C.-R.)
- Brown School, Washington University in St. Louis, 1 Brookings Dr., St. Louis, MO 63130, USA
| | - Xiao Li
- Department of Psychiatry, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO 63110, USA; (A.C.-P.); (X.L.); (E.K.); (E.M.); (Y.W.); (M.M.); (P.A.C.-R.)
| | - Erin Kasson
- Department of Psychiatry, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO 63110, USA; (A.C.-P.); (X.L.); (E.K.); (E.M.); (Y.W.); (M.M.); (P.A.C.-R.)
| | - Emily Maranets
- Department of Psychiatry, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO 63110, USA; (A.C.-P.); (X.L.); (E.K.); (E.M.); (Y.W.); (M.M.); (P.A.C.-R.)
| | - Yoseph Worku
- Department of Psychiatry, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO 63110, USA; (A.C.-P.); (X.L.); (E.K.); (E.M.); (Y.W.); (M.M.); (P.A.C.-R.)
| | - Mandy Montayne
- Department of Psychiatry, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO 63110, USA; (A.C.-P.); (X.L.); (E.K.); (E.M.); (Y.W.); (M.M.); (P.A.C.-R.)
| | - Devin E. Banks
- Department of Psychological Sciences, University of Missouri–St. Louis, One University Blvd., 325 Stadler Hall, St. Louis, MO 63121, USA;
| | - Jeannie C. Kelly
- Department of Obstetrics & Gynecology, Washington University School of Medicine, 660 S. Euclid Ave., St. Louis, MO 63110, USA;
| | - Patricia A. Cavazos-Rehg
- Department of Psychiatry, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO 63110, USA; (A.C.-P.); (X.L.); (E.K.); (E.M.); (Y.W.); (M.M.); (P.A.C.-R.)
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Swain JE, Ho SS. Brain circuits for maternal sensitivity and pain involving anterior cingulate cortex among mothers receiving buprenorphine treatment for opioid use disorder. J Neuroendocrinol 2023; 35:e13316. [PMID: 37491982 DOI: 10.1111/jne.13316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 06/09/2023] [Accepted: 06/10/2023] [Indexed: 07/27/2023]
Abstract
Opioid-induced deficits in maternal behaviors are well-characterized in rodent models. Amid the current epidemic of opioid use disorder (OUD), prevalence among pregnant women has risen sharply. Yet, the roles of buprenorphine replacement treatment for OUD (BT/OUD) in the brain functions of postpartum mothers are unclear. Using functional magnetic resonance imaging (fMRI), we have developed an evolutionarily conserved maternal behavior neurocircuit (MBN) model to study human maternal care versus defensive/aggressive behaviors critical to mother-child bonding. The anterior cingulate gyrus (ACC) is not only involved in the MBN for mother-child bonding and attachment, but also part of an opioid sensitive "pain-matrix". The literature suggests that prescription opioids produce physical and emotional "analgesic" effects by disrupting specific resting-state functional connectivity (rs-FC) of ACC to regions related to MBN. Thus, in this longitudinal study, we report findings of overlapping MBN and pain matrix circuits, for mothers with chronic exposure of BT/OUD. A total of 32 mothers were studied with 6 min rs-FC at 1 month (T1) and 4 months postpartum (T2), including seven on BT/OUD and 25 non-BT/OUD mothers as a comparison group. We analyzed rs-FC between the insula, putamen, and the dorsal anterior cingulate cortex (DACC) and rostral ACC (RACC), as the regions of interest that mediate opioid analgesia. BT/OUD mothers, as compared to non-BT/OUD mothers, showed less left insula-RACC rs-FC but greater right putamen-DACC rs-FC at T1, with these between-group differences diminished at T2. Some of these rs-FC results were correlated with the scores of postpartum parental bonding questionnaire. We found time-by-treatment interaction effects on DACC and RACC-dependent rs-FC, potentially identifying brain mechanisms for beneficial effects of BT, normalizing dysfunction of maternal brain and behavior over the first four months postpartum. This study complements recent studies to ascertain how BT/OUD affects maternal behaviors, mother-child bonding, and intersubjectivity and reveals potential MBN/pain-matrix targets for novel interventions.
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Affiliation(s)
- James E Swain
- Department of Psychiatry and Behavioral Health, Renaissance School Of Medicine at Stony Brook University, Stony Brook, New York, USA
- Department of Psychology, Program in Public Health, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York, USA
- Department of Obstetrics, Gynecology and Reproductive Medicine, Program in Public Health, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York, USA
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - S Shaun Ho
- Department of Psychiatry and Behavioral Health, Renaissance School Of Medicine at Stony Brook University, Stony Brook, New York, USA
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Kushnir A, Bhavsar R, Hanna E, Hegyi T. Neonatal Abstinence Syndrome in Infants with Prenatal Exposure to Methadone versus Buprenorphine. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1030. [PMID: 37371262 DOI: 10.3390/children10061030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 05/31/2023] [Accepted: 06/04/2023] [Indexed: 06/29/2023]
Abstract
Neonatal abstinence syndrome (NAS) has been of increasing concern. Studies suggest that prenatal exposure to buprenorphine may be preferred to methadone in regard to neonatal withdrawal. Our aim was to determine whether the incidence and severity of NAS are different between babies prenatally exposed to methadone or buprenorphine in pregnancy. This retrospective analysis of infants ≥ 35-weeks-old exposed to methadone/buprenorphine alone or in conjunction with other substances in utero. They were divided into four groups: 1-methadone alone (Met), 2-buprenorphine alone (Bup), 3 and 4-those exposed to methadone and buprenorphine, respectively, in conjunction with other drugs (Met+ and Bup+). The frequency of NAS treatment, duration of treatment (LOT) and length of stay (LOS) were compared between groups. Of the 290 mothers, 59% were in the Met group, 18% in the Bup group, 14% in the Met or Bup and another opiate group, and 9% took methadone or buprenorphine plus various other substances. Infants born to Met/Met+ mothers had a four-times higher likelihood of developing NAS (p < 0.001). There was no difference in the LOS (p = 0.08) or LOT (p = 0.11) between groups. The buprenorphine treatment in pregnancy decreased the risk of babies developing NAS. However, once the NAS required pharmacological treatment, the type of maternal prenatal exposure did not affect the LOS or LOT.
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Affiliation(s)
- Alla Kushnir
- Division of Neonatology, Department of Pediatric, Cooper University Hospital, Camden, NJ 08103, USA
| | - Ravi Bhavsar
- Division of Neonatology, Department of Pediatric, Cooper University Hospital, Camden, NJ 08103, USA
| | - Emad Hanna
- Division of Neonatology, Department of Pediatrics, Robert Wood Johnson Medical School, New Brunswick, NJ 08901, USA
| | - Thomas Hegyi
- Division of Neonatology, Department of Pediatrics, Robert Wood Johnson Medical School, New Brunswick, NJ 08901, USA
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Kropp FB, Smid MC, Lofwall MR, Wachman EM, Martin PR, Murphy SM, Wilder CM, Winhusen TJ. Collaborative care programs for pregnant and postpartum individuals with opioid use disorder: Organizational characteristics of sites participating in the NIDA CTN0080 MOMs study. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2023; 149:209030. [PMID: 37023858 DOI: 10.1016/j.josat.2023.209030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 11/17/2022] [Accepted: 03/20/2023] [Indexed: 04/07/2023]
Abstract
INTRODUCTION Pregnant individuals with substance use disorders face complex issues that may serve as barriers to treatment entry and retention. Several professional organizations have established recommendations on comprehensive, collaborative approaches to treatment to meet the needs of this population, but information on real-world application is lacking. Sites participating in the NIDA CTN0080 "Medication treatment for Opioid use disorder in expectant Mothers (MOMs)"-a randomized clinical trial of extended release compared to sublingual buprenorphine among pregnant and postpartum individuals (PPI)-were selected, in part, because they have a collaborative approach to treating PPI with opioid use disorder (OUD). However, organizational differences among sites and how they implement expert recommendations for collaborative care could impact study outcomes. METHODS Prior to study launch at each of the 13 MOMs sites, investigators used the Pregnancy and Addiction Services Assessment (PAASA) to collect information about organizational factors. Input from a team of addiction, perinatal, and economic evaluation experts guided the development of the PAASA. Investigators programmed the PAASA into a web-based data system and summarized the resultant site data using descriptive statistics. RESULTS Study sites represented four US census regions. Most sites were specialty obstetrics & gynecology (OB/GYN) programs providing OUD services (n = 9, 69.2 %), were affiliated with an academic institution (n = 11, 84.6 %), and prescribed buprenorphine in an ambulatory/outpatient setting (n = 11, 84.6 %); all sites offered access to naloxone. Sites reported that their population was primarily White, utilized public insurance, and faced numerous psychosocial barriers to treatment. Although all sites offered many services recommended by expert consensus groups, they varied in how they coordinated these services. CONCLUSIONS By providing the organizational characteristics of sites participating in the MOMs study, this report assists in filling the current gap in knowledge regarding similar programs providing services to PPI with OUD. Collaborative care programs such as those participating in MOMs are uniquely positioned to participate in research to determine the most effective models of care and to determine how research can be integrated into those clinical care settings.
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Affiliation(s)
- Frankie B Kropp
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH 45229, USA.
| | - Marcela C Smid
- University of Utah, 50 N. Medical Drive, Salt Lake City, UT 84132, USA.
| | - Michelle R Lofwall
- Departments of Behavioral Science and Psychiatry, University of Kentucky College of Medicine, 845 Angliana Avenue, Lexington, KY 40508, USA.
| | - Elisha M Wachman
- Boston Medical Center, 801 Albany Street, Boston, MA 02119, USA.
| | - Peter R Martin
- Vanderbilt Psychiatric Hospital, Vanderbilt University Medical Center, 1601 23rd Avenue South, Suite 3035, Nashville, TN 372124, USA.
| | - Sean M Murphy
- Department of Population Health Sciences, Weill Cornell Medical College, 1300 York Avenue, New York, NY 10065, USA.
| | - Christine M Wilder
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH 45229, USA; Center for Addiction Research, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH 45267, USA.
| | - T John Winhusen
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH 45229, USA; Center for Addiction Research, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH 45267, USA.
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Vella A, Savona-Ventura C, Mahmood T. Harmful effects of opioid use in pregnancy: A scientific review commissioned by the European Board and College of obstetrics and gynaecology (EBCOG). Eur J Obstet Gynecol Reprod Biol 2023; 286:70-75. [PMID: 37216740 DOI: 10.1016/j.ejogrb.2023.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Caring for pregnant women who have a recreational opioid use disorder is a common clinical challenge in modern obstetric care. These are an elusive population who often have multiple social issues that complicate their pregnancy management. Comprehensive and supportive maternal care can motivate these mothers to change her lifestyle. Multidisciplinary non-judgemental approach with appropriate medication and management, can result in good pregnancy outcomes for mother and her baby.
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Affiliation(s)
| | - Charles Savona-Ventura
- Department of Obstetrics and Gynaecology, University of Malta, Member EBCOG Standing Committee on Standards of Care and Position Statements, Malta; Member of the EBCOG Standing Committee on Standards of Care and Position Statements, Malta
| | - Tahir Mahmood
- Victoria Hospital, Kirkcaldy and Spire Murrayfield Hospital, Edinburgh, United Kingdom; Member of the EBCOG Standing Committee on Standards of Care and Position Statements, Malta
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James L, Venable T, Caro A, Moran JH, Nesmith C, Gannon MA, Cornett LE. Development of a clinical and translational research curriculum for undergraduate students. J Clin Transl Sci 2023; 7:e118. [PMID: 37313383 PMCID: PMC10260337 DOI: 10.1017/cts.2023.532] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 03/03/2023] [Accepted: 04/11/2023] [Indexed: 06/15/2023] Open
Abstract
Introduction Research participation during undergraduate years has a powerful influence on career selection and attitudes toward scientific research. Most undergraduate research programs in academic health centers are oriented toward basic research or address a particular disease focus or research discipline. Undergraduate research programs that expose students to clinical and translational research may alter student perceptions about research and influence career selection. Methods We developed an undergraduate summer research curriculum, anchored upon a clinical and translational research study developed to address a common unmet needs in neonatal nurseries (e.g., assessment of neonatal opioid withdrawal syndrome). Program topics reflected the cross-disciplinary expertise that contributed to the development of this "bedside to bench" study, including opioid addiction, vulnerable populations, research ethics, statistics, data collection and management, assay development, analytical laboratory analysis, and pharmacokinetics. The curriculum was delivered through three offerings over 12 months, using Zoom video-conferencing due to restrictions imposed by the COVID-19 pandemic. Results Nine students participated in the program. Two-thirds reported the course enhanced their understanding of clinical and translational research. Over three-quarters reported the curriculum topics were very good or excellent. In open-ended questions, students reported that the cross-disciplinary nature of the curriculum was the strongest aspect of the program. Conclusion The curriculum could be readily adapted by other Clinical and Translational Science Award programs seeking to provide clinical and translational research-oriented programs to undergraduate students. Application of cross-disciplinary research approaches to a specific clinical and translational research question provides students with relevant examples of translational research and translational science.
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Affiliation(s)
- Laura James
- The Departments of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Tara Venable
- The Departments of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Andres Caro
- Department of Chemistry, Hendrix College, Conway, AR, USA
| | - Jeffrey H. Moran
- Department of Pharmacology and Toxicology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Claire Nesmith
- The Departments of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Matthew A. Gannon
- Community Health and Research, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Lawrence E. Cornett
- Department of Physiology and Cell Biology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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The Influence of Mediators on the Relationship Between Antenatal Opioid Agonist Exposure and the Severity of Neonatal Opioid Withdrawal Syndrome. Matern Child Health J 2023; 27:1030-1042. [PMID: 36905529 DOI: 10.1007/s10995-022-03521-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2022] [Indexed: 03/12/2023]
Abstract
OBJECTIVES (1) To evaluate the direct (un-mediated) and indirect (mediated) relationship between antenatal exposure to opioid agonist medication as treatment for opioid use disorder (MOUD) and the severity of neonatal opioid withdrawal syndrome (NOWS), and (2) to understand the degree to which mediating factors influence the direct relationship between MOUD exposure and NOWS severity. METHODS This cross-sectional study includes data abstracted from the medical records of 1294 opioid-exposed infants (859 MOUD exposed and 435 non-MOUD exposed) born at or admitted to one of 30 US hospitals from July 1, 2016, to June 30, 2017. Regression models and mediation analyses were used to evaluate the relationship between MOUD exposure and NOWS severity (i.e., infant pharmacologic treatment and length of newborn hospital stay (LOS)) to identify potential mediators of this relationship in analyses adjusted for confounding factors. RESULTS A direct (un-mediated) association was found between antenatal exposure to MOUD and both pharmacologic treatment for NOWS (aOR 2.34; 95%CI 1.74, 3.14) and an increase in LOS (1.73 days; 95%CI 0.49, 2.98). Delivery of adequate prenatal care and a reduction in polysubstance exposure were mediators of the relationship between MOUD and NOWS severity and as thus, were indirectly associated with a decrease in both pharmacologic treatment for NOWS and LOS. CONCLUSIONS FOR PRACTICE MOUD exposure is directly associated with NOWS severity. Prenatal care and polysubstance exposure are potential mediators in this relationship. These mediating factors may be targeted to reduce the severity of NOWS while maintaining the important benefits of MOUD during pregnancy.
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White SA, McCourt A, Bandara S, Goodman DJ, Patel E, McGinty EE. Implementation of State Laws Giving Pregnant People Priority Access to Drug Treatment Programs in the Context of Coexisting Punitive Laws. Womens Health Issues 2023; 33:117-125. [PMID: 36272928 DOI: 10.1016/j.whi.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 08/23/2022] [Accepted: 09/15/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND In response to increased prenatal drug use since the 2000s, states have adopted treatment-oriented laws giving pregnant and postpartum people priority access to public drug treatment programs as well as multiple punitive policy responses. No prior studies have systematically characterized these state statutes or examined implementation of state priority access laws in the context of co-existing punitive laws. METHODS We conducted legal mapping to examine state priority access laws and their overlap with state laws deeming prenatal drug use to be child maltreatment, mandating reporting of prenatal drug use to child protective services, or criminalizing prenatal drug use. We also conducted interviews with 51 state leaders with expertise on their states' prenatal drug use laws to understand how priority access laws were implemented. RESULTS Thirty-three states and the District of Columbia have a priority access law, and more than 80% of these jurisdictions also have one of the punitive prenatal drug use laws described. Leaders reported major barriers to implementing state priority access laws, including the lack of drug treatment programs, stigma, and conflicts with punitive prenatal drug use laws. CONCLUSIONS Our results suggest that state laws granting pregnant and postpartum people priority access to drug treatment programs are likely insufficient to significantly increase access to evidence-based drug treatment. Punitive state prenatal drug use laws may counteract priority access laws by impeding treatment seeking. Findings highlight the need to allocate additional resources to drug treatment for pregnant and postpartum people.
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Affiliation(s)
- Sarah A White
- Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, Baltimore, Maryland.
| | - Alexander McCourt
- Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, Baltimore, Maryland
| | - Sachini Bandara
- Johns Hopkins Bloomberg School of Public Health, Department of Mental Health, Baltimore, Maryland
| | - Daisy J Goodman
- Dartmouth-Hitchcock Medical Center, Department of Obstetrics and Gynecology, Lebanon, New Hampshire
| | - Esita Patel
- Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, Baltimore, Maryland
| | - Emma E McGinty
- Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, Baltimore, Maryland
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Ordean A, Tubman-Broeren M. Safety and Efficacy of Buprenorphine-Naloxone in Pregnancy: A Systematic Review of the Literature. PATHOPHYSIOLOGY 2023; 30:27-36. [PMID: 36810423 PMCID: PMC9944489 DOI: 10.3390/pathophysiology30010004] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 02/03/2023] [Accepted: 02/08/2023] [Indexed: 02/17/2023] Open
Abstract
The prevalence of opioid use among pregnant people has been increasing over the past few decades, with a parallel increase in the rate of neonatal abstinence syndrome. Opioid agonist treatment (OAT) including methadone and buprenorphine is the recommended management method for opioid use disorders during pregnancy. Methadone has been extensively studied during pregnancy; however, buprenorphine was introduced in the early 2000s with limited data on the use of different preparations during pregnancy. Buprenorphine-naloxone has been incorporated into routine practice; however, only a few studies have investigated the use of this medication during pregnancy. To determine the safety and efficacy of this medication, we conducted a systematic review of maternal and neonatal outcomes among buprenorphine-naloxone-exposed pregnancies. The primary outcomes of interest were birth parameters, congenital anomalies, and severity of neonatal abstinence syndrome. Secondary maternal outcomes included the OAT dose and substance use at delivery. Seven studies met the inclusion criteria. Buprenorphine-naloxone doses ranged between 8 and 20 mg, and there was an associated reduction of opioid use during pregnancy. There were no significant differences in gestational age at delivery, birth parameters, or prevalence of congenital anomalies between buprenorphine-naloxone-exposed neonates and those exposed to methadone, buprenorphine monotherapy, illicit opioids, or no opioids. In studies comparing buprenorphine-naloxone to methadone, there were reduced rates of neonatal abstinence syndrome requiring pharmacotherapy. These studies demonstrate that buprenorphine-naloxone is a safe and effective opioid agonist treatment for pregnant people with OUD. Further large-scale, prospective data collection is required to confirm these findings. Patients and clinicians may be reassured about the use of buprenorphine-naloxone during pregnancy.
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Affiliation(s)
- Alice Ordean
- Department of Family Medicine, St. Joseph’s Health Centre, Unity Health Toronto, Toronto, ON M6R 1B5, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON M5G 1V7, Canada
- Correspondence:
| | - Meara Tubman-Broeren
- Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC V5Z 1M9, Canada
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Albano GD, La Spina C, Pitingaro W, Milazzo V, Triolo V, Argo A, Malta G, Zerbo S. Intrauterine and Neonatal Exposure to Opioids: Toxicological, Clinical, and Medico-Legal Issues. TOXICS 2023; 11:toxics11010062. [PMID: 36668788 PMCID: PMC9866828 DOI: 10.3390/toxics11010062] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 12/27/2022] [Accepted: 01/05/2023] [Indexed: 06/01/2023]
Abstract
Opioids have a rapid transplacental passage (i.e., less than 60 min); furthermore, symptoms characterize the maternal and fetal withdrawal syndrome. Opioid withdrawal significantly impacts the fetus, inducing worse outcomes and a risk of mortality. Moreover, neonatal abstinence syndrome (NAS) follows the delivery, lasts up to 10 weeks, and requires intensive management. Therefore, the prevention and adequate management of NAS are relevant public health issues. This review aims to summarize the most updated evidence in the literature regarding toxicological, clinical, and forensic issues of intrauterine exposure to opioids to provide a multidisciplinary, evidence-based approach for managing such issues. Further research is required to standardize testing and to better understand the distribution of opioid derivatives in each specimen type, as well as the clinically relevant cutoff concentrations in quantitative testing results. A multidisciplinary approach is required, with obstetricians, pediatricians, nurses, forensic doctors and toxicologists, social workers, addiction specialists, and politicians all working together to implement social welfare and social services for the baby when needed. The healthcare system should encourage multidisciplinary activity in this field and direct suspected maternal and neonatal opioid intoxication cases to local referral centers.
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Ronan K, Hughes Driscoll C, Decker E, Gopalakrishnan M, El Metwally D. Resource utilization and convalescent care cost in neonatal opioid withdrawal syndrome. J Neonatal Perinatal Med 2022; 16:49-57. [PMID: 36530095 DOI: 10.3233/npm-221060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND: Neonatal opioid withdrawal syndrome (NOWS) is a growing public health problem associated with complex and prolonged medical care and a significant resource utilization burden. The objective of this study was to compare the cost of different convalescent care settings for infants with NOWS. METHODS: Retrospective comparison study of infants with NOWS discharged directly from NICU, transferred to an acute care pediatric floor (PPCU) or rehabilitation hospital (PRH). Primary outcomes were length of stay (LOS) and cost of stay (COS). RESULTS: Infants had 1.3 (95% CI: 1.1,1.6) times and 2.5 (95% CI: 2.1,3.1) times significantly longer mean LOS for PPCU and RH discharges compared to NICU discharges. NICU discharged infants had the lowest mean COS ($25,745.00) and PRH the highest ($60,528.00), despite PRH having a lower cost per day. PRH discharged infants had higher rates of methadone and benzodiazepine and less buprenorphine exposure than NICU/PPCU discharged. Infants born to mothers on marijuana and buprenorphine had a 28% lower mean COS compared to unexposed infants. Median treatment cumulative morphine doses were six-fold higher for PRH than NICU discharge. CONCLUSIONS: Infants transferred to convalescence care facilities had longer and more costly admissions and received more medication. However, there may be a role for earlier transfer of a subset of infants at-risk for longer LOS as those exposed to methadone and/or benzodiazepines. Further studies exploring differences in resource utilization, convalescent care delivery and cost expenditure are recommended.
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Affiliation(s)
- K. Ronan
- Department of Pediatrics. University of Maryland School of Medicine, MD, USA
- Women’s and Babies Hospital, Lancaster, PA, USA
| | | | - E. Decker
- Department of Pediatrics. University of Maryland School of Medicine, MD, USA
- The College of Physicians and Surgeons at Columbia University, NY, USA
| | - M. Gopalakrishnan
- Center for Translational Medicine, University of Maryland School of Pharmacy, MD, USA
| | - D. El Metwally
- Department of Pediatrics. University of Maryland School of Medicine, MD, USA
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Suarez EA, Huybrechts KF, Straub L, Hernández-Díaz S, Jones HE, Connery HS, Davis JM, Gray KJ, Lester B, Terplan M, Mogun H, Bateman BT. Buprenorphine versus Methadone for Opioid Use Disorder in Pregnancy. N Engl J Med 2022; 387:2033-2044. [PMID: 36449419 PMCID: PMC9873239 DOI: 10.1056/nejmoa2203318] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
BACKGROUND Opioid agonist therapy is strongly recommended for pregnant persons with opioid use disorder. Buprenorphine may be associated with more favorable neonatal and maternal outcomes than methadone, but existing data are limited. METHODS We conducted a cohort study involving pregnant persons who were enrolled in public insurance programs in the United States during the period from 2000 through 2018 in which we examined outcomes among those who received buprenorphine as compared with those who received methadone. Exposure to the two medications was assessed in early pregnancy (through gestational week 19), late pregnancy (gestational week 20 through the day before delivery), and the 30 days before delivery. Risk ratios for neonatal and maternal outcomes were adjusted for confounders with the use of propensity-score overlap weights. RESULTS The data source for the study consisted of 2,548,372 pregnancies that ended in live births. In early pregnancy, 10,704 pregnant persons were exposed to buprenorphine and 4387 to methadone. In late pregnancy, 11,272 were exposed to buprenorphine and 5056 to methadone (9976 and 4597, respectively, in the 30 days before delivery). Neonatal abstinence syndrome occurred in 52.0% of the infants who were exposed to buprenorphine in the 30 days before delivery as compared with 69.2% of those exposed to methadone (adjusted relative risk, 0.73; 95% confidence interval [CI], 0.71 to 0.75). Preterm birth occurred in 14.4% of infants exposed to buprenorphine in early pregnancy and in 24.9% of those exposed to methadone (adjusted relative risk, 0.58; 95% CI, 0.53 to 0.62); small size for gestational age in 12.1% and 15.3%, respectively (adjusted relative risk, 0.72; 95% CI, 0.66 to 0.80); and low birth weight in 8.3% and 14.9% (adjusted relative risk, 0.56; 95% CI, 0.50 to 0.63). Delivery by cesarean section occurred in 33.6% of pregnant persons exposed to buprenorphine in early pregnancy and 33.1% of those exposed to methadone (adjusted relative risk, 1.02; 95% CI, 0.97 to 1.08), and severe maternal complications developed in 3.3% and 3.5%, respectively (adjusted relative risk, 0.91; 95% CI, 0.74 to 1.13). Results of exposure in late pregnancy were consistent with results of exposure in early pregnancy. CONCLUSIONS The use of buprenorphine in pregnancy was associated with a lower risk of adverse neonatal outcomes than methadone use; however, the risk of adverse maternal outcomes was similar among persons who received buprenorphine and those who received methadone. (Funded by the National Institute on Drug Abuse.).
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Affiliation(s)
- Elizabeth A Suarez
- From the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.A.S., K.F.H., L.S., H.M.), and the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology (K.J.G.), Brigham and Women's Hospital, the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.A.S., K.F.H., L.S., H.M.), and the Department of Psychiatry (H.S.C.), Harvard Medical School, the Department of Epidemiology, Harvard T.H. Chan School of Public Health (S.H.-D.), and the Department of Pediatrics, Tufts Medical Center and the Tufts Clinical and Translational Science Institute (J.M.D.), Boston, and the Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont (H.S.C.) - all in Massachusetts; UNC Horizons and the Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill (H.E.J.); the Center for the Study of Children at Risk, Departments of Psychiatry and Pediatrics, Warren Alpert Medical School of Brown University, and Women and Infants Hospital - both in Providence, RI (B.L.); Friends Research Institute, Baltimore (M.T.); and the Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA (B.T.B.)
| | - Krista F Huybrechts
- From the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.A.S., K.F.H., L.S., H.M.), and the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology (K.J.G.), Brigham and Women's Hospital, the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.A.S., K.F.H., L.S., H.M.), and the Department of Psychiatry (H.S.C.), Harvard Medical School, the Department of Epidemiology, Harvard T.H. Chan School of Public Health (S.H.-D.), and the Department of Pediatrics, Tufts Medical Center and the Tufts Clinical and Translational Science Institute (J.M.D.), Boston, and the Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont (H.S.C.) - all in Massachusetts; UNC Horizons and the Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill (H.E.J.); the Center for the Study of Children at Risk, Departments of Psychiatry and Pediatrics, Warren Alpert Medical School of Brown University, and Women and Infants Hospital - both in Providence, RI (B.L.); Friends Research Institute, Baltimore (M.T.); and the Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA (B.T.B.)
| | - Loreen Straub
- From the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.A.S., K.F.H., L.S., H.M.), and the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology (K.J.G.), Brigham and Women's Hospital, the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.A.S., K.F.H., L.S., H.M.), and the Department of Psychiatry (H.S.C.), Harvard Medical School, the Department of Epidemiology, Harvard T.H. Chan School of Public Health (S.H.-D.), and the Department of Pediatrics, Tufts Medical Center and the Tufts Clinical and Translational Science Institute (J.M.D.), Boston, and the Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont (H.S.C.) - all in Massachusetts; UNC Horizons and the Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill (H.E.J.); the Center for the Study of Children at Risk, Departments of Psychiatry and Pediatrics, Warren Alpert Medical School of Brown University, and Women and Infants Hospital - both in Providence, RI (B.L.); Friends Research Institute, Baltimore (M.T.); and the Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA (B.T.B.)
| | - Sonia Hernández-Díaz
- From the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.A.S., K.F.H., L.S., H.M.), and the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology (K.J.G.), Brigham and Women's Hospital, the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.A.S., K.F.H., L.S., H.M.), and the Department of Psychiatry (H.S.C.), Harvard Medical School, the Department of Epidemiology, Harvard T.H. Chan School of Public Health (S.H.-D.), and the Department of Pediatrics, Tufts Medical Center and the Tufts Clinical and Translational Science Institute (J.M.D.), Boston, and the Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont (H.S.C.) - all in Massachusetts; UNC Horizons and the Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill (H.E.J.); the Center for the Study of Children at Risk, Departments of Psychiatry and Pediatrics, Warren Alpert Medical School of Brown University, and Women and Infants Hospital - both in Providence, RI (B.L.); Friends Research Institute, Baltimore (M.T.); and the Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA (B.T.B.)
| | - Hendrée E Jones
- From the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.A.S., K.F.H., L.S., H.M.), and the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology (K.J.G.), Brigham and Women's Hospital, the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.A.S., K.F.H., L.S., H.M.), and the Department of Psychiatry (H.S.C.), Harvard Medical School, the Department of Epidemiology, Harvard T.H. Chan School of Public Health (S.H.-D.), and the Department of Pediatrics, Tufts Medical Center and the Tufts Clinical and Translational Science Institute (J.M.D.), Boston, and the Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont (H.S.C.) - all in Massachusetts; UNC Horizons and the Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill (H.E.J.); the Center for the Study of Children at Risk, Departments of Psychiatry and Pediatrics, Warren Alpert Medical School of Brown University, and Women and Infants Hospital - both in Providence, RI (B.L.); Friends Research Institute, Baltimore (M.T.); and the Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA (B.T.B.)
| | - Hilary S Connery
- From the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.A.S., K.F.H., L.S., H.M.), and the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology (K.J.G.), Brigham and Women's Hospital, the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.A.S., K.F.H., L.S., H.M.), and the Department of Psychiatry (H.S.C.), Harvard Medical School, the Department of Epidemiology, Harvard T.H. Chan School of Public Health (S.H.-D.), and the Department of Pediatrics, Tufts Medical Center and the Tufts Clinical and Translational Science Institute (J.M.D.), Boston, and the Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont (H.S.C.) - all in Massachusetts; UNC Horizons and the Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill (H.E.J.); the Center for the Study of Children at Risk, Departments of Psychiatry and Pediatrics, Warren Alpert Medical School of Brown University, and Women and Infants Hospital - both in Providence, RI (B.L.); Friends Research Institute, Baltimore (M.T.); and the Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA (B.T.B.)
| | - Jonathan M Davis
- From the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.A.S., K.F.H., L.S., H.M.), and the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology (K.J.G.), Brigham and Women's Hospital, the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.A.S., K.F.H., L.S., H.M.), and the Department of Psychiatry (H.S.C.), Harvard Medical School, the Department of Epidemiology, Harvard T.H. Chan School of Public Health (S.H.-D.), and the Department of Pediatrics, Tufts Medical Center and the Tufts Clinical and Translational Science Institute (J.M.D.), Boston, and the Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont (H.S.C.) - all in Massachusetts; UNC Horizons and the Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill (H.E.J.); the Center for the Study of Children at Risk, Departments of Psychiatry and Pediatrics, Warren Alpert Medical School of Brown University, and Women and Infants Hospital - both in Providence, RI (B.L.); Friends Research Institute, Baltimore (M.T.); and the Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA (B.T.B.)
| | - Kathryn J Gray
- From the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.A.S., K.F.H., L.S., H.M.), and the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology (K.J.G.), Brigham and Women's Hospital, the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.A.S., K.F.H., L.S., H.M.), and the Department of Psychiatry (H.S.C.), Harvard Medical School, the Department of Epidemiology, Harvard T.H. Chan School of Public Health (S.H.-D.), and the Department of Pediatrics, Tufts Medical Center and the Tufts Clinical and Translational Science Institute (J.M.D.), Boston, and the Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont (H.S.C.) - all in Massachusetts; UNC Horizons and the Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill (H.E.J.); the Center for the Study of Children at Risk, Departments of Psychiatry and Pediatrics, Warren Alpert Medical School of Brown University, and Women and Infants Hospital - both in Providence, RI (B.L.); Friends Research Institute, Baltimore (M.T.); and the Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA (B.T.B.)
| | - Barry Lester
- From the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.A.S., K.F.H., L.S., H.M.), and the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology (K.J.G.), Brigham and Women's Hospital, the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.A.S., K.F.H., L.S., H.M.), and the Department of Psychiatry (H.S.C.), Harvard Medical School, the Department of Epidemiology, Harvard T.H. Chan School of Public Health (S.H.-D.), and the Department of Pediatrics, Tufts Medical Center and the Tufts Clinical and Translational Science Institute (J.M.D.), Boston, and the Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont (H.S.C.) - all in Massachusetts; UNC Horizons and the Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill (H.E.J.); the Center for the Study of Children at Risk, Departments of Psychiatry and Pediatrics, Warren Alpert Medical School of Brown University, and Women and Infants Hospital - both in Providence, RI (B.L.); Friends Research Institute, Baltimore (M.T.); and the Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA (B.T.B.)
| | - Mishka Terplan
- From the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.A.S., K.F.H., L.S., H.M.), and the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology (K.J.G.), Brigham and Women's Hospital, the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.A.S., K.F.H., L.S., H.M.), and the Department of Psychiatry (H.S.C.), Harvard Medical School, the Department of Epidemiology, Harvard T.H. Chan School of Public Health (S.H.-D.), and the Department of Pediatrics, Tufts Medical Center and the Tufts Clinical and Translational Science Institute (J.M.D.), Boston, and the Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont (H.S.C.) - all in Massachusetts; UNC Horizons and the Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill (H.E.J.); the Center for the Study of Children at Risk, Departments of Psychiatry and Pediatrics, Warren Alpert Medical School of Brown University, and Women and Infants Hospital - both in Providence, RI (B.L.); Friends Research Institute, Baltimore (M.T.); and the Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA (B.T.B.)
| | - Helen Mogun
- From the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.A.S., K.F.H., L.S., H.M.), and the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology (K.J.G.), Brigham and Women's Hospital, the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.A.S., K.F.H., L.S., H.M.), and the Department of Psychiatry (H.S.C.), Harvard Medical School, the Department of Epidemiology, Harvard T.H. Chan School of Public Health (S.H.-D.), and the Department of Pediatrics, Tufts Medical Center and the Tufts Clinical and Translational Science Institute (J.M.D.), Boston, and the Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont (H.S.C.) - all in Massachusetts; UNC Horizons and the Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill (H.E.J.); the Center for the Study of Children at Risk, Departments of Psychiatry and Pediatrics, Warren Alpert Medical School of Brown University, and Women and Infants Hospital - both in Providence, RI (B.L.); Friends Research Institute, Baltimore (M.T.); and the Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA (B.T.B.)
| | - Brian T Bateman
- From the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.A.S., K.F.H., L.S., H.M.), and the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology (K.J.G.), Brigham and Women's Hospital, the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.A.S., K.F.H., L.S., H.M.), and the Department of Psychiatry (H.S.C.), Harvard Medical School, the Department of Epidemiology, Harvard T.H. Chan School of Public Health (S.H.-D.), and the Department of Pediatrics, Tufts Medical Center and the Tufts Clinical and Translational Science Institute (J.M.D.), Boston, and the Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont (H.S.C.) - all in Massachusetts; UNC Horizons and the Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill (H.E.J.); the Center for the Study of Children at Risk, Departments of Psychiatry and Pediatrics, Warren Alpert Medical School of Brown University, and Women and Infants Hospital - both in Providence, RI (B.L.); Friends Research Institute, Baltimore (M.T.); and the Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA (B.T.B.)
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A review of the safety of buprenorphine in special populations. Am J Med Sci 2022; 364:675-684. [PMID: 35843298 DOI: 10.1016/j.amjms.2022.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 04/17/2022] [Accepted: 06/29/2022] [Indexed: 01/25/2023]
Abstract
Rates of opioid misuse and opioid use disorder have been increasing in recent years. Buprenorphine has emerged as an appealing medication for its use not only as treatment for opioid use disorder, but also as an opioid for chronic pain that has a ceiling effect on risks associated with opioid therapy. As other opioid prescribing decreases, buprenorphine prescribing continues to increase. As a result, it is imperative to understand the safety and efficacy of its use in special populations. This review article will explore the safety and efficacy of buprenorphine when used in subjects with hepatic and renal impairment, the elderly, and pregnant women. While manufacturer labeling for buprenorphine products may caution against their use in these populations, further examination of available data indicates that buprenorphine can be used safely and effectively for both chronic pain and/or opioid use disorder in all four of these populations.
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McCOURT ALEXANDERD, WHITE SARAHA, BANDARA SACHINI, SCHALL THEO, GOODMAN DAISYJ, PATEL ESITA, McGINTY EMMAE. Development and Implementation of State and Federal Child Welfare Laws Related to Drug Use in Pregnancy. Milbank Q 2022; 100:1076-1120. [PMID: 36510665 PMCID: PMC9836249 DOI: 10.1111/1468-0009.12591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 07/01/2022] [Accepted: 07/07/2022] [Indexed: 12/15/2022] Open
Abstract
Policy Points Over the past several decades, states have adopted policies intended to address prenatal drug use. Many of these policies have utilized existing child welfare mechanisms despite potential adverse effects. Recent federal policy changes were intended to facilitate care for substance-exposed infants and their families, but state uptake has been incomplete. Using legal mapping and qualitative interviews, we examine the development of state child welfare laws related to substance use in pregnancy from 1974 to 2019, with a particular focus on laws adopted between 2009 and 2019. Our findings reveal policies that may disincentivize treatment-seeking and widespread implementation challenges, suggesting a need for new treatment-oriented policies and refined state and federal guidance. CONTEXT Amid increasing drug use among pregnant individuals, legislators have pursued policies intended to reduce substance use during pregnancy. Many states have utilized child welfare mechanisms despite evidence that these policies might disincentivize treatment-seeking. Recent federal changes were intended to facilitate care for substance-exposed infants and their families, but implementation of these changes at the state level has been slowed and complicated by existing state policies. We seek to provide a timeline of state child welfare laws related to prenatal drug use and describe stakeholder perceptions of implementation. METHODS We catalogued child welfare laws related to prenatal drug use, including laws that defined child abuse and neglect and established child welfare reporting standards, for all 50 states and the District of Columbia (DC), from 1974 to 2019. In the 19 states that changed relevant laws between 2009 and 2019, qualitative interviews were conducted with stakeholders to capture state-level perspectives on policy implementation. FINDINGS Twenty-four states and DC have passed laws classifying prenatal drug use as child abuse or neglect. Thirty-seven states and DC mandate reporting of suspected prenatal drug use to the state. Qualitative findings suggested variation in implementation within and across states between 2009 and 2019 and revealed that implementation of changes to federal law during that decade, intended to encourage states to provide comprehensive social services and linkages to evidence-based care to drug-exposed infants and their families, has been complicated by existing policies and a lack of guidance for practitioners. CONCLUSIONS Many states have enacted laws that may disincentivize treatment-seeking among pregnant people who use drugs and lead to family separation. To craft effective state laws and support their implementation, state policymakers and practitioners could benefit from a treatment-oriented approach to prenatal substance use and additional state and federal guidance.
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Affiliation(s)
- ALEXANDER D. McCOURT
- Johns Hopkins University Bloomberg School of Public HealthBaltimoreMarylandUnited States
| | - SARAH A. WHITE
- Johns Hopkins University Bloomberg School of Public HealthBaltimoreMarylandUnited States
| | - SACHINI BANDARA
- Johns Hopkins University Bloomberg School of Public HealthBaltimoreMarylandUnited States
| | - THEO SCHALL
- Johns Hopkins University Bloomberg School of Public HealthBaltimoreMarylandUnited States
| | - DAISY J. GOODMAN
- Dartmouth Geisel School of Medicine, The Dartmouth Institute for Health Policy and Clinical PracticeHanoverNew HampshireUnited States
| | - ESITA PATEL
- Johns Hopkins University Bloomberg School of Public HealthBaltimoreMarylandUnited States
| | - EMMA E. McGINTY
- Division of Health Policy and EconomicsDepartment of Population Health SciencesWeill Cornell MedicineNew York, New YorkUnited States
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Lim G, Soens M, Wanaselja A, Chyan A, Carvalho B, Landau R, George RB, Klem ML, Osmundson SS, Krans EE, Terplan M, Bateman BT. A Systematic Scoping Review of Peridelivery Pain Management for Pregnant People With Opioid Use Disorder: From the Society for Obstetric Anesthesia and Perinatology and Society for Maternal Fetal Medicine. Anesth Analg 2022; 135:912-925. [PMID: 36135926 PMCID: PMC9588509 DOI: 10.1213/ane.0000000000006167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The prevalence of pregnant people with opioid use disorder (OUD), including those receiving medications for opioid use disorder (MOUD), is increasing. Challenges associated with pain management in people with OUD include tolerance, opioid-induced hyperalgesia, and risk for return to use. Yet, there are few evidence-based recommendations for pain management in the setting of pregnancy and the postpartum period, and many peripartum pain management studies exclude people with OUD. This scoping review summarized the available literature on peridelivery pain management in people with OUD, methodologies used, and identified specific areas of knowledge gaps. PubMed and Embase were comprehensively searched for publications in all languages on peripartum pain management among people with OUD, both treated with MOUD and untreated. Potential articles were screened by title, abstract, and full text. Data abstracted were descriptively analyzed to map available evidence and identify areas of limited or no evidence. A total of 994 publications were imported for screening on title, abstracts, and full text, yielding 84 publications identified for full review: 32 (38.1%) review articles, 14 (16.7%) retrospective studies, and 8 (9.5%) case reports. There were 5 randomized controlled trials. Most studies (64%) were published in perinatology (32; 38.1%) journals or anesthesiology (22; 26.2%) journals. Specific areas lacking trial or systematic review evidence include: (1) methods to optimize psychological and psychosocial comorbidities relevant to acute pain management around delivery; (2) alternative nonopioid and nonpharmacologic analgesia methods; (3) whether or not to use opioids for severe breakthrough pain and how best to prescribe and monitor its use after discharge; (4) monitoring for respiratory depression and sedation with coadministration of other analgesics; (5) optimal neuraxial analgesia dosing and adjuncts; and (6) benefits of abdominal wall blocks after cesarean delivery. No publications discussed naloxone coprescribing in the labor and delivery setting. We observed an increasing number of publications on peripartum pain management in pregnant people with OUD. However, existing published works are low on the pyramid of evidence (reviews, opinions, and retrospective studies), with a paucity of original research articles (<6%). Opinions are conflicting on the utility and disutility of various analgesic interventions. Studies generating high-quality evidence on this topic are needed to inform care for pregnant people with OUD. Specific research areas are identified, including utility and disutility of short-term opioid use for postpartum pain management, role of continuous wound infiltration and truncal nerve blocks, nonpharmacologic analgesia options, and the best methods to support psychosocial aspects of pain management.
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Affiliation(s)
- Grace Lim
- University of Pittsburgh Department of Anesthesiology & Perioperative Medicine, Pittsburgh, PA
- University of Pittsburgh Department of Obstetrics & Gynecology, UPMC Magee-Women’s Hospital, Pittsburgh, PA
| | - Mieke Soens
- Brigham & Women’s Hospital, Department of Anesthesiology & Perioperative Medicine, Boston, MA
| | - Anne Wanaselja
- University of Pittsburgh Department of Anesthesiology & Perioperative Medicine, Pittsburgh, PA
| | - Arthur Chyan
- Brigham & Women’s Hospital, Department of Anesthesiology & Perioperative Medicine, Boston, MA
| | - Brendan Carvalho
- Stanford University Department of Anesthesiology, Perioperative & Pain Medicine, Palo Alto, CA
| | - Ruth Landau
- Columbia University Department of Anesthesiology & Perioperative Medicine, New York City, NY
| | - Ronald B. George
- University of California San Francisco Department of Anesthesiology & Perioperative Care, San Francisco, CA
| | - Mary Lou Klem
- University of Pittsburgh Health Sciences Library System, Pittsburgh, PA
| | - Sarah S. Osmundson
- Vanderbilt University, Department of Obstetrics & Gynecology, Nashville, TN
| | - Elizabeth E. Krans
- University of Pittsburgh Department of Obstetrics & Gynecology, UPMC Magee-Women’s Hospital, Pittsburgh, PA
| | | | - Brian T. Bateman
- Stanford University Department of Anesthesiology, Perioperative & Pain Medicine, Palo Alto, CA
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20
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Rates of substance and polysubstance use through universal maternal testing at the time of delivery. J Perinatol 2022; 42:1026-1031. [PMID: 35177791 PMCID: PMC9356969 DOI: 10.1038/s41372-022-01335-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 01/10/2022] [Accepted: 01/27/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To report substance and polysubstance use at the time of delivery. STUDY DESIGN A cross-sectional study was performed on mothers consented for universal drug testing (99%) during hospital admission at six delivery hospitals in Cincinnati, Ohio. Mass spectrometry urinalysis detected positivity rates of 46 substances. Rates of positive drug tests for individual and common co-occurring substances measured were reported. RESULTS 2531 maternal samples were tested (88%) and 33% contained cotinine, 11.3% THC, 7.2% opioids, 3.8% cocaine, and 1.9% methamphetamines. Polysubstance use prevalence was as high as 15%. Among mothers testing positive for methadone or buprenorphine, 93% also tested positive for cotinine and 39% tested positive for a third substance in addition to cotinine. CONCLUSIONS Substance use at delivery is more prevalent than previously reported. Many mothers testing positive for opioids also test positive for other substances, which may increase overdose risk and exacerbate neonatal opioid withdrawal syndrome (NOWS).
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Kinsella M, Capel Y, Nelson SM, Kearns RJ. Opioid substitution in pregnancy a narrative review: contemporary evidence for use of methadone and buprenorphine in pregnancy. JOURNAL OF SUBSTANCE USE 2022. [DOI: 10.1080/14659891.2022.2106600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Affiliation(s)
- M. Kinsella
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Y. Capel
- Foundation Programme, NHS Greater Glasgow and Clyde, Glasgow, UK
| | | | - R. J. Kearns
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
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22
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Chhabra N, Smith DL, Maloney CM, Archer J, Sharma B, Thompson HM, Afshar M, Karnik NS. The Identification of Subphenotypes and Associations with Health Outcomes in Patients with Opioid-Related Emergency Department Encounters Using Latent Class Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19148882. [PMID: 35886733 PMCID: PMC9321801 DOI: 10.3390/ijerph19148882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 07/17/2022] [Accepted: 07/19/2022] [Indexed: 02/05/2023]
Abstract
The emergency department (ED) is a critical setting for the treatment of patients with opioid misuse. Detecting relevant clinical profiles allows for tailored treatment approaches. We sought to identify and characterize subphenotypes of ED patients with opioid-related encounters. A latent class analysis was conducted using 14,057,302 opioid-related encounters from 2016 through 2017 using the National Emergency Department Sample (NEDS), the largest all-payer ED database in the United States. The optimal model was determined by face validity and information criteria-based metrics. A three-step approach assessed class structure, assigned individuals to classes, and examined characteristics between classes. Class associations were determined for hospitalization, in-hospital death, and ED charges. The final five-class model consisted of the following subphenotypes: Chronic pain (class 1); Alcohol use (class 2); Depression and pain (class 3); Psychosis, liver disease, and polysubstance use (class 4); and Pregnancy (class 5). Using class 1 as the reference, the greatest odds for hospitalization occurred in classes 3 and 4 (Ors 5.24 and 5.33, p < 0.001) and for in-hospital death in class 4 (OR 3.44, p < 0.001). Median ED charges ranged from USD 2177 (class 1) to USD 2881 (class 4). These subphenotypes provide a basis for examining patient-tailored approaches for this patient population.
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Affiliation(s)
- Neeraj Chhabra
- Division of Medical Toxicology, Department of Emergency Medicine, Cook County Health, Chicago, IL 60612, USA
- Department of Emergency Medicine, Rush Medical College, Rush University, Chicago, IL 60612, USA
- Correspondence:
| | - Dale L. Smith
- Addiction Data Science Laboratory, Department of Psychiatry & Behavioral Science, Rush University Medical Center, Chicago, IL 60612, USA; (D.L.S.); (B.S.); (H.M.T.); (N.S.K.)
- Department of Psychology, Olivet Nazarene University, Bourbonnais, IL 60914, USA
| | - Caitlin M. Maloney
- Doctor of Medicine Program, Rush Medical College, Rush University, Chicago, IL 60612, USA;
| | - Joseph Archer
- School of Medicine and Public Health, University of Wisconsin, Madison, WI 53715, USA;
| | - Brihat Sharma
- Addiction Data Science Laboratory, Department of Psychiatry & Behavioral Science, Rush University Medical Center, Chicago, IL 60612, USA; (D.L.S.); (B.S.); (H.M.T.); (N.S.K.)
| | - Hale M. Thompson
- Addiction Data Science Laboratory, Department of Psychiatry & Behavioral Science, Rush University Medical Center, Chicago, IL 60612, USA; (D.L.S.); (B.S.); (H.M.T.); (N.S.K.)
| | - Majid Afshar
- Department of Medicine, University of Wisconsin-Madison, Madison, WI 53715, USA;
| | - Niranjan S. Karnik
- Addiction Data Science Laboratory, Department of Psychiatry & Behavioral Science, Rush University Medical Center, Chicago, IL 60612, USA; (D.L.S.); (B.S.); (H.M.T.); (N.S.K.)
- Institute for Juvenile Research, Department of Psychiatry, University of Illinois Chicago, Chicago, IL 60612, USA
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23
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Liu J, Grewen K, Gao W. Evidence for the Normalization Effects of Medication for Opioid Use Disorder on Functional Connectivity in Neonates with Prenatal Opioid Exposure. J Neurosci 2022; 42:4555-4566. [PMID: 35552232 PMCID: PMC9172285 DOI: 10.1523/jneurosci.2232-21.2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 03/30/2022] [Accepted: 04/19/2022] [Indexed: 11/21/2022] Open
Abstract
Altered functional connectivity has been reported in infants with prenatal exposure to opioids, which significantly interrupts and influences endogenous neurotransmitter/receptor signaling during fetal programming. Better birth outcomes and long-term developmental outcomes are associated with medication for opioid use disorder (MOUD) during pregnancy, but the neural mechanisms underlying these benefits are largely unknown. We aimed to characterize effects of prenatal opioid/other drug exposure (PODE) and the neural basis for the reported beneficial effects of MOUD by examining neonatal brain functional organization. A cohort of 109 human newborns, 42 PODE, 39 with prenatal exposure to drugs excluding opioids (PDE), 28 drug-free controls (males and females) underwent resting-state fMRI at 2 weeks of age. To examine neural effects of MOUD, PODE infants were separated into subgroups based on whether mothers received MOUD (n = 31) or no treatment (n = 11). A novel heatmap analysis was designed to characterize PODE-associated functional connectivity alterations and MOUD-related effects, and permutation testing identified regions of interest with significant effects. PODE neonates showed alterations beyond those associated with PDE, particularly in reward-related frontal-sensory connectivity. MOUD was associated with a significant reduction of PODE-related alterations in key regions of endogenous opioid pathways including limbic and frontal connections. However, significant residual effects in limbic and subcortical circuitry were observed. These findings confirm altered brain functional organization associated with PODE. Importantly, widespread normalization effects associated with MOUD reveal, for the first time, the potential brain basis of the beneficial effects of MOUD on the developing brain and underscore the importance of this treatment intervention for better developmental outcomes.SIGNIFICANCE STATEMENT This is the first study to reveal the potential neural mechanisms underlying the beneficial effects on the neonate brain associated with MOUD during pregnancy. We identified both normalization and residual effects of MOUD on brain functional architecture by directly comparing neonates prenatally exposed to opioids with MOUD and those exposed to opioids but without MOUD. Our findings confirm altered brain functional organization associated with prenatal opioid exposure and demonstrate that although significant residual effects remain in reward circuitry, MOUD confers significant normalization effects on functional connectivity of regions associated with socioemotional development and reward processing. Together, our results highlight the importance of MOUD intervention for better neurodevelopmental outcomes.
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Affiliation(s)
- Janelle Liu
- Cedars-Sinai Biomedical Imaging Research Institute, Los Angeles, California 90048
- Departments of Biomedical Sciences and Imaging, Cedars-Sinai Medical Center, Los Angeles, California 90048
| | - Karen Grewen
- Department of Psychiatry, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599
| | - Wei Gao
- Cedars-Sinai Biomedical Imaging Research Institute, Los Angeles, California 90048
- Departments of Biomedical Sciences and Imaging, Cedars-Sinai Medical Center, Los Angeles, California 90048
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24
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St Louis J, Barreto T, Taylor M, Kane C, Worringer E, Eden AR. Barriers to care for perinatal patients with opioid use disorder: family physician perspectives. Fam Pract 2022; 39:249-256. [PMID: 35325109 DOI: 10.1093/fampra/cmab154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND While barriers to care for pregnant patients with opioid use disorder (OUD) have been described, the experiences and challenges of the physicians providing care to these patients are poorly understood. OBJECTIVES To describe the experiences of family physicians providing comprehensive care to pregnant people with OUD and the challenges they face in providing such care. METHODS Qualitative thematic analysis of 17 semistructured interviews conducted from July 2019 to September 2020 with family physicians who possess a Drug Enforcement Administration "X" waiver and provide care to pregnant patients. RESULTS Seventeen family physicians practicing in the United States who care for pregnant people with OUD were interviewed. They described physician-, patient-, and systems-level barriers to providing and accessing care for this patient population. Of the 12 interrelated themes regarding challenges to delivering and accessing this care, 3 were particularly salient: the pervasive effects of social determinants of health, a lack of adequately trained providers, and social stigma associated with pregnant people with OUD. CONCLUSION A comprehensive, multilevel, and multidisciplinary approach is necessary to address these barriers and move towards health equity for this vulnerable patient population.
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Affiliation(s)
- Joshua St Louis
- Lawrence Family Medicine Residency, Lawrence, MA, United States
| | - Tyler Barreto
- Sea Mar Marysville Family Medicine Residency, Marysville, WA, United States
| | - Melina Taylor
- American Board of Family Medicine, Lexington, KY, United States
| | - Claire Kane
- Robert Graham Center for Policy Studies in Family Medicine, Washington, DC, United States
| | - Emma Worringer
- PCC Community Wellness Center, Oak Park, IL, United States
| | - Aimee R Eden
- American Board of Family Medicine, Lexington, KY, United States
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25
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Swain JE, Ho SS. Reduced Child-Oriented Face Mirroring Brain Responses in Mothers With Opioid Use Disorder: An Exploratory Study. Front Psychol 2022; 12:770093. [PMID: 35185679 PMCID: PMC8854864 DOI: 10.3389/fpsyg.2021.770093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 12/29/2021] [Indexed: 02/01/2023] Open
Abstract
While the prevalence of opioid use disorder (OUD) among pregnant women has multiplied in the United States in the last decade, buprenorphine treatment (BT) for peripartum women with OUD has been administered to reduce risks of repeated cycles of craving and withdrawal. However, the maternal behavior and bonding in mothers with OUD may be altered as the underlying maternal behavior neurocircuit (MBN) is opioid sensitive. In the regulation of rodent maternal behaviors such as licking and grooming, a series of opioid-sensitive brain regions are functionally connected, including the ventral pallidum (VP). In humans, these brain regions, interact with the supplementary motor area (SMA) to regulate maternal behaviors and are functionally dysregulated by opioids. It is unclear how these brain regions respond to the emotions of their child for mothers receiving BT. In this functional magnetic resonance imaging (fMRI) pilot study in 22 mothers within the first postpartum year, including six mothers receiving BT and 16 non-OUD mothers as a comparison group (CG), we devised a child face mirroring task in fMRI settings to assess maternal responses to pictures of facial expressions of own child and an unknown child in an empathic mirroring condition (Join) and a non-mirroring observation condition (Observe). In each condition, faces of neutral, ambiguous, distressed, and joyful expressions of each child were repeatedly displayed in a random order. The response of SMA during empathic mirroring (Join) vs. non-mirroring (Observe) of own child was reduced among BT/OUD vs. CG. Within MBN, the left VP, critical for parental sensitivity, had a similar deficit. This study outlines potential mechanisms for investigating the risks of deficits in the neural responses to actual maternal sensitivity and parenting behavior in mothers with OUD, and potential targets for interventions that reduce stress and augment maternal behavior and child outcome.
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Affiliation(s)
- James E. Swain
- Department of Psychiatry and Behavioral Health, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, United States
- Department of Psychology, Stony Brook University, Stony Brook, NY, United States
- Department of Obstetrics, Gynecology, and Reproductive Medicine, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, United States
- Program in Public Health, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, United States
- Department of Psychiatry and Psychology, Center for Human Growth and Development, University of Michigan, Ann Arbor, MI, United States
- *Correspondence: James E. Swain,
| | - S. Shaun Ho
- Department of Psychiatry and Behavioral Health, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, United States
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Aramjoo H, Yousefizadeh S, Aschner M, Roshanravan B, Farkhondeh T, Samarghandian S. Oxidative Stress Indices Changes in the Hearts of Rat Pups in Response to Maternal Buprenorphine Treatment during Gestation and Lactation. Cardiovasc Toxicol 2022; 22:29-34. [PMID: 34599474 DOI: 10.1007/s12012-021-09686-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 07/28/2021] [Indexed: 11/28/2022]
Abstract
This study aimed to assess the effects of Buprenorphine (BUP) on oxidative parameters in pups born to mothers exposed to the drug during gestation and lactation. Pregnant and lactating rats received BUP, 0.5 or 0.1 mg/kg subcutaneously for 21 and 28 days, respectively. At the end of the study, the pups were anesthetized, and the hearts were dissected out to measure oxidative stress indices, including the levels of Malondialdehyde (MDA), Nitric oxide (NO), Glutathione (GSH), and the activity of Superoxide dismutase (SOD). Our findings indicated that BUP did not alter MDA, NO, GSH levels, nor SOD activity in the cardiac tissue of pups exposed to this drug during the fetal period and through breast milk. We suggest performing additional studies to determine the association between BUP and oxidative modifications in cardiac tissues of pups born to mothers under BUP therapy during gestation and lactation.
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Affiliation(s)
- Hamed Aramjoo
- Student Research Committee, Birjand University of Medical Sciences, Birjand, Iran
| | - Shahnaz Yousefizadeh
- Department of Laboratory and Clinical Sciences, Faculty of Para-Veterinary, Ilam University, Ilam, Iran
| | - Michael Aschner
- Department of Molecular Pharmacology, Albert Einstein College of Medicine, Forchheimer 209, 1300 Morris Park Avenue, Bronx, NY, USA
| | - Babak Roshanravan
- Student Research Committee, Birjand University of Medical Sciences (BUMS), Birjand, Iran
| | - Tahereh Farkhondeh
- Cardiovascular Diseases Research Center, Birjand University of Medical Sciences, Birjand, Iran.
- Faculty of Pharmacy, Birjand University of Medical Sciences, Birjand, Iran.
| | - Saeed Samarghandian
- Noncommunicable Diseases Research Center, Neyshabur University of Medical Sciences, Neyshabur, Iran.
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27
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Histological Changes Observed in Placentas Exposed to Medication-Assisted Treatment. J Pregnancy 2021; 2021:2175026. [PMID: 34659831 PMCID: PMC8516570 DOI: 10.1155/2021/2175026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 09/06/2021] [Accepted: 09/11/2021] [Indexed: 11/22/2022] Open
Abstract
Introduction To compare the effects of medication-assisted treatment on the placenta in pregnant women with opioid use disorder and uncomplicated pregnancies. Methods This is a case-controlled study of pregnant women utilizing medication-assisted treatment, buprenorphine or methadone, which were matched to healthy uncomplicated controls by gestational age. Placental evaluations and neonatal outcomes were evaluated. Data analysis performed standard statistics and relative risk analysis with a p < 0.05 considered significant. Results There were 143 women who met the inclusion criteria: 103 utilizing MAT, 41 buprenorphine and 62 methadone, and 40 uncomplicated matched healthy controls. The incidence of delayed villous maturation was 36% in the medication-assisted group compared with 10% in controls (RR 3.6: 95% CI 1.37-9.43; p < 0.01). The placental weight was greater (541 ± 117 g versus 491 ± 117 g; p = 0.02), and the fetoplacental weight ratio was lower (5.70 ± 1.1 versus 7.13 ± 1.4; p < 0.01) in the medication-exposed pregnancies compared with controls. The mean birth weight of the MAT newborns was significantly lower than that of the healthy controls (3018 ± 536 g versus 3380 ± 492 g; p < 0.01). When evaluating the subgroups of the MAT newborns, the birth weight of the methadone-exposed newborns (2886 ± 514 g) was significantly lower than that of the buprenorphine-exposed newborns (3218 ± 512 g; p < 0.01). Conclusion Medication-exposed pregnancies have a greater incidence of delayed villous maturation, a larger placental size, and a decreased fetoplacental weight ratio compared to the healthy controls. Larger long-term follow-up studies to evaluate outcomes with the presence of delayed villous maturation are needed.
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28
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Chang CD, Saidinejad M, Atanelov Z, Dietrich AM, Lam SH, Rose E, Ruttan T, Shahid S, Stoner MJ, Sulton C, Chumpitazi CE. Emergency department strategies to combat the opioid crisis in children and adolescents. J Am Coll Emerg Physicians Open 2021; 2:e12512. [PMID: 34322681 PMCID: PMC8295033 DOI: 10.1002/emp2.12512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 04/20/2021] [Accepted: 06/11/2021] [Indexed: 11/07/2022] Open
Abstract
The opioid crisis has greatly affected not only adults but also children as well. As clinicians develop effective approaches to minimize pain and distress in children, the risks and benefits of opioids must be carefully considered. Children of parents with opioid use disorder are also at risk of living in unstable environments, performing poorly academically, engaging in future drug use, and having increased stress, which affects their development before entering adulthood. This statement focuses on the effects of the opioid crisis on children and adolescents and is intended to inform institutional policies, improve education, advocate for evidence-informed guidelines, and improve the care of children affected by the opioid epidemic who are seen in the emergency department.
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Affiliation(s)
- Cindy D. Chang
- Department of Emergency MedicineHarbor UCLA Medical CenterTorranceCaliforniaUSA
| | - Mohsen Saidinejad
- Department of Emergency MedicineHarbor UCLA Medical CenterTorranceCaliforniaUSA
| | - Zaza Atanelov
- North Florida Regional Medical Center Emergency DepartmentHCA/University of Central Florida College of Medicine ConsortiumOrlandoFloridaUSA
| | - Ann M. Dietrich
- Department of PediatricsOhio University Heritage College of Osteopathic MedicineDublinOhioUSA
| | - Samuel Hiu‐Fung Lam
- Department of Emergency MedicineSutter Medical Center SacramentoSacramentoCaliforniaUSA
| | - Emily Rose
- Department of Emergency MedicineKeck School of Medicine of the University of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Tim Ruttan
- Dell Children's Medical Center of Central TexasPediatric Emergency MedicineUniversity of Texas at AustinAustinTexasUSA
| | - Sam Shahid
- American College of Emergency PhysiciansDallasTexasUSA
| | - Michael J. Stoner
- Nationwide Children's HospitalThe Ohio State University College of MedicineColumbusOhioUSA
| | - Carmen Sulton
- Sedation ServicesChildren's Healthcare of Atlanta at EagletonEmory University School of MedicineAtlantaGeorgiaUSA
| | - Corrie E. Chumpitazi
- Department of PediatricsSection of Emergency MedicineBaylor College of MedicineHoustonTexasUSA
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Hakomäki H, Kokki H, Lehtonen M, Räsänen J, Voipio HM, Ranta VP, Kokki M. MATERNAL AND FETAL BUPRENORPHINE PHARMACOKINETICS IN PREGNANT SHEEP DURING TRANSDERMAL PATCH DOSING: Buprenorphine pharmacokinetics in pregnant sheep. Eur J Pharm Sci 2021; 165:105936. [PMID: 34273481 DOI: 10.1016/j.ejps.2021.105936] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 06/03/2021] [Accepted: 07/04/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Buprenorphine is used in the opioid maintenance treatment for opioid dependent patients, including pregnant women. Despite the wide use, limited data exists on buprenorphine pharmacokinetics and fetal exposure during pregnancy. The aim of our study was to determine the buprenorphine pharmacokinetics during transdermal patch dosing to pregnant sheep and, to determine the extent of transplacental transfer of buprenorphine to the fetus. METHODS Pregnant sheep in late gestation (n=50) received 20, 25 or 40 µg/h of buprenorphine as a 7-day extended-release transdermal patch. Plasma samples were collected from the ewe and the fetus on days 1 - 6, and buprenorphine and norbuprenorphine concentrations were determined. During the exposure period the sheep had a surgical procedure on the second day, a recovery phase, and an experimental procedure on the sixth day. In the experiment, hypoxia was induced under anesthesia for 18 sheep to investigate if decreased fetal pH would cause ion-trapping of buprenorphine in the fetus. The fetal/maternal plasma concentration ratio was determined on the second and on the sixth exposure day at baseline and during hypoxia. Maternal pharmacokinetics were modelled with a population pharmacokinetic method using the data from this study and our previous intravenous administration study. RESULTS The transdermal patch provided an extended release of buprenorphine throughout the exposure period, but the release rate declined approximately 20 h after patch placement. The median fetal/maternal plasma concentration ratio was 13 - 27 % throughout the exposure period at baseline. A ratio over 100 % was observed for four sheep on the sixth exposure day (102 - 269 %). A minor increase was seen in the median fetal/maternal-ratios during maternal hypoxia. Norbuprenorphine was undetected in all plasma samples. CONCLUSIONS The low transplacental passage of less than one fourth of the ewe's exposure supports buprenorphine as an alternative to methadone in opioid maintenance therapy during pregnancy.
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Affiliation(s)
| | - Hannu Kokki
- School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Marko Lehtonen
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Juha Räsänen
- Fetal Medicine Center, Department of Obstetrics and Gynecology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Hanna-Marja Voipio
- Department of Experimental Surgery, Oulu Laboratory Animal Centre, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Veli-Pekka Ranta
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Merja Kokki
- Department of Anesthesia and Intensive Care, Kuopio University Hospital, Kuopio, Finland
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Anesthetic management of the parturient with opioid addiction. Int Anesthesiol Clin 2021; 59:28-39. [PMID: 34100798 DOI: 10.1097/aia.0000000000000323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Buprenorphine and Naloxone Versus Buprenorphine for Opioid Use Disorder in Pregnancy: A Cohort Study. J Addict Med 2021; 14:185-192. [PMID: 31567599 DOI: 10.1097/adm.0000000000000562] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To compare maternal and fetal outcomes among dyads prescribed buprenorphine and naloxone or buprenorphine during pregnancy. METHODS Retrospective cohort study of patients with opioid use disorder obtaining care in a comprehensive, perinatal program. Patients utilized medication for opioid use disorder: a buprenorphine and naloxone combination product or buprenorphine monotherapy. The primary outcome was neonatal abstinence syndrome requiring treatment. Maternal secondary outcomes included: negative urine drug screen at delivery, obstetrical care attendance, primary cesarean delivery, and preterm delivery. Neonatal secondary outcomes included neonatal biometry, admission to neonatal intensive care, appropriate findings on cord toxicology, and length of stay. Univariate analyses included Chi square, Fisher exact, t-, or Mann-Whitney tests, as appropriate. Multivariate binary logistic regressions examined the association of type of buprenorphine product with diagnosis of neonatal abstinence syndrome requiring treatment and adjusted for variables significantly different in between-group comparisons and correlates of treatments and the primary outcome. RESULTS The rate of neonatal abstinence syndrome was significantly higher (P = 0.007) among infants exposed in utero to buprenorphine versus buprenorphine and naloxone: 59/108 (54.6%) versus 30/85 (35.3%), respectively. The combined product, relative to the monoproduct, was associated with lower odds of neonatal abstinence syndrome: odds ratio (OR) = 0.453 (95% confidence interval [CI] 0.253-0.813; P = 0.008). Adjusting for dose of buprenorphine product at delivery, year of expected delivery, type of prescriber, diagnosis of hepatitis C, and preterm delivery negated these results: adjusted OR = 0.627 (95% CI 0.309-1.275). Secondary outcomes were similar. CONCLUSION Compared with buprenorphine monotherapy, the combined buprenorphine and naloxone product was an acceptable alternative pharmacologic treatment for opioid use disorder during pregnancy.
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Abstract
BACKGROUND In the United States, drug addiction has become a nationwide health crisis. Recently, buprenorphine (BUP), a maintenance therapy approved by the Food and Drug Administration, has been increasingly used in pregnant women for the treatment of opioid use disorder. Pregnancy is associated with various anatomic and physiological changes, which may result in altered drug pharmacokinetics (PKs). Previously, we reported that dose-adjusted plasma concentrations of BUP are lower during pregnancy than after pregnancy. The mechanism(s) responsible for this difference has not yet been defined. Our study aimed to evaluate alterations in cytochromes P450 (CYP)- and uridine diphosphate glucunosyltransferases (UGT)-mediated metabolism of BUP during pregnancy to determine the mechanism(s) responsible for this observation. METHODS Data from 2 clinical studies were included in the current analysis. Study 1 was a prospective, open-labeled, nonrandomized longitudinal BUP PK study in pregnant women with a singleton gestation, stabilized on twice-daily sublingual BUP opioid substitution therapy. Each subject participated in up to 3 studies during and after pregnancy (the second, third trimester, and postpartum). The design of study 2 was similar to study 1, with patients evaluated at different time points during the pregnancy (first, second-half of pregnancy), as well as during the postpartum period. In addition, the dosing frequency of BUP study 2 participants was not restricted to twice-daily dosing. At each study visit, blood samples were collected before a BUP dose, followed by multiple collection times (10-12) after the dose, for up to 12 hours or till the end of the dosing interval. Plasma concentrations of BUP and 3 metabolites were quantified using validated ultraperformance liquid chromatography-tandem mass spectrometric assays. RESULTS In total, 19, 18, and 14 subjects completed the PK study during 1/2 trimester, third trimester, and postpartum, respectively. The AUC ratios of norbuprenorphine and norbuprenorphine glucuronide to buprenorphine, a measure of CYP3A mediated N-demethylation, were 1.89, 1.84, and 1.33 during the first and second, third trimesters, and postpartum, respectively. The AUC ratios of buprenorphine glucuronide to BUP, indicative of UGT activity, were 0.71, 2.07, and 0.3 at first/second trimesters, third trimester, and postpartum, respectively. Linear mixed-effect modeling analysis indicated that the AUC ratios of CYP- and UGT-mediated metabolism of BUP were significantly higher during pregnancy compared with postpartum. CONCLUSIONS The CYP and UGT activities were significantly increased as determined by the metabolic ratios of BUP during pregnancy compared with the postpartum period. The increased UGT activity appeared to account for a substantial part of the observed change in metabolic activity during pregnancy. This is in agreement with the need for BUP dose increment in pregnant women to reach similar BUP exposure and therapeutic effect as in nonpregnant subjects.
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Brokatzky S. Patientin mit Schwangerschaft, Borderline-Organisation und schwerer Polytoxikomanie. SUCHTTHERAPIE 2021. [DOI: 10.1055/a-1441-6646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Zusammenfassung
Zielsetzung Ziel dieser Arbeit war es, die Komplexität von Schwangerschaft und Sucht durch ein Fallbeispiel einer Patientin mit schwerer Polytoxikomanie, Borderline-Organisation sowie den Verlauf der Schwangerschaft und die frühe Phase nach der Geburt vorzustellen. Dabei ging es v. a. um die Frage, wie eine langfristige Behandlung mit einem mehrstufigen, multiprofessionellen und multimodalen Setting aussehen könnte. Die Arbeit zeigt zudem Konflikte an Schnittstellen auf und wie wichtig die Kommunikation innerhalb des Teams und fachübergreifend war.
Intervention Qualifizierte stationäre Entgiftungsbehandlung von Benzodiazepinen, Phenothiazin, Lyrica Venlafaxin und Reduktion von Methadon mit anschließender Umstellung auf Buprenorphin sowie ergänzender kombinierter ärztlicher, psychodynamischer Einzel- und Gruppentherapie und einem pflegerischen DBT-S Einzel- und Gruppensetting. Außerdem wurde schon während der Schwangerschaft zusätzlich zum stationären Behandlungsteam ein fächerübergreifendes Behandlungsteam aus Gynäkologen, Kinderärzten, Kinder- und Jugendpsychiatern sowie der Kinder- und Erwachsenenschutzbehörde (KESB, in Deutschland Jugendamt) zusammengestellt und schon zu Beginn wurde eine langfristige Behandlung mit stationärem, teilstationärem und ambulantem Intervall geplant.
Ergebnis Im Laufe der fast 3-jährigen Behandlung und 5 Jahre späteren katamnestischen Nachuntersuchung konnte zunächst unter 8 mg Buprenorphin eine Abstinenz von illegalen Substanzen erzielt werden. Im Verlauf sogar vollständige Abstinenz ohne Substitution. Dies konnte durch ein erneutes Interview und Drogenscreening im Jahr 2020 bestätigt werden. Außerdem konnte im Rahmen der fächerübergreifenden Arbeit ein stabiles soziales Umfeld und ein Wiedereinstieg ins Berufsleben erreicht werden.
Diskussion Trotz der anfänglich häufigen Rückfälle konnte durch den Erhalt der therapeutischen Beziehung (z. B. mittels Time-out auf die Akutstation, Verlängerung einer Wochenendbeurlaubung oder Neuverhandlung der Behandlungsvereinbarung) unter Fortsetzung der Einzelpsychotherapie und Bezugspflege mit Einbezug der Rückfälle, gegenseitiges Vertrauen und Wertschätzung geschaffen werden. Dafür war allerdings viel supervisorische Arbeit innerhalb des Teams, aber auch fächerübergreifend notwendig, da sich die extreme innerer Welt der Patientin häufig in unterschiedlicher Art und Weise im multiprofessionellen Team zeigte und dadurch zu Konflikten führte, die passager das Verlassen der Neutralität verlangten. Ferner waren für diese Art der Behandlung enorme Ressourcen notwendig sowohl zeitlich als auch personell.
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Affiliation(s)
- Stefan Brokatzky
- Klinik für Konsiliarpsychiatrie und Psychosomatik, Kantonsspital St. Gallen, Schweiz
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Wallin CM, Bowen SE, Brummelte S. Opioid use during pregnancy can impair maternal behavior and the Maternal Brain Network: A literature review. Neurotoxicol Teratol 2021; 86:106976. [PMID: 33812002 DOI: 10.1016/j.ntt.2021.106976] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 02/26/2021] [Accepted: 03/25/2021] [Indexed: 10/21/2022]
Abstract
Opioid Use Disorder (OUD) is a global epidemic also affecting women of reproductive age. A standard form of pharmacological treatment for OUD is Opioid Maintenance Therapy (OMT) and buprenorphine has emerged as the preferred treatment for pregnant women with OUD relative to methadone. However, the consequences of BUP exposure on the developing Maternal Brain Network and mother-infant dyad are not well understood. The maternal-infant bond is dependent on the Maternal Brain Network, which is responsible for the dynamic transition from a "nulliparous brain" to a "maternal brain". The Maternal Brain Network consists of regions implicated in maternal care (e.g., medial preoptic area, nucleus accumbens, ventral pallidum, ventral tegmentum area) and maternal defense (e.g., periaqueductal gray). The endogenous opioid system modulates many of the neurochemical changes in these areas during the transition to motherhood. Thus, it is not surprising that exogenous opioid exposure during pregnancy can be disruptive to the Maternal Brain Network. Though less drastic than misused opioids, OMTs may not be without risk of disrupting the neural and molecular structures of the Maternal Brain Network. This review describes the Maternal Brain Network as a framework for understanding how pharmacological differences in exogenous opioid exposure can disrupt the onset and maintenance of the maternal brain and summarizes opioid and OMT (in particular buprenorphine) use in the context of pregnancy and maternal behavior. This review also highlights future directions for evaluating exogenous opioid effects on the Maternal Brain Network in the hopes of raising awareness for the impact of the opioid crisis not only on exposed infants, but also on mothers and subsequent mother-infant bonds.
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Affiliation(s)
- Chela M Wallin
- Department of Psychology, Wayne State University, Detroit, MI 48202, USA.
| | - Scott E Bowen
- Department of Psychology, Wayne State University, Detroit, MI 48202, USA.
| | - Susanne Brummelte
- Department of Psychology, Wayne State University, Detroit, MI 48202, USA.
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Goetz TG, Becker JB, Mazure CM. Women, opioid use and addiction. FASEB J 2021; 35:e21303. [PMID: 33433026 DOI: 10.1096/fj.202002125r] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 12/01/2020] [Accepted: 12/08/2020] [Indexed: 12/22/2022]
Abstract
In the midst of the current coronavirus pandemic, the United States continues to struggle with an ongoing opioid epidemic, initially fueled by widespread prescribing of opioid medications during the 1990s. The primary reason for prescribing opioids is to treat pain. Women have more acute and chronic pain and have been prescribed these drugs in significantly greater numbers than men. Comparison of women and men with chronic pain also shows that women receive the majority of prescription opioids, and the use of these prescribed medications became the major pathway to misuse and addiction for women. Yet, recognition of the extent of women's exposure to opioids and the attendant consequences has been limited. Attempts to stem the overall tide of the epidemic focused on reducing the availability of prescription opioids. However, as these medications became more difficult to obtain and treatment opportunities were limited, many turned to other synthetic opioids, such as heroin and fentanyl. Thus, the public health crisis of opioid addiction has endured. This paper highlights the importance of understanding differences among women and men in opioid use and its biological and psychosocial effects to advance the gender-based treatment approaches and effective public health policy.
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Affiliation(s)
- Teddy G Goetz
- Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Jill B Becker
- Biopsychology Area Chair, University of Michigan, Ann Arbor, MI, USA
| | - Carolyn M Mazure
- Department of Psychiatry, Women's Health Research at Yale, Yale University School of Medicine, New Haven, CT, USA
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Coulson CC, Lorencz E, Rittenhouse K, Ramage M, Lorenz K, Galvin SL. Association of Maternal Buprenorphine or Methadone Dose with Fetal Growth Indices and Neonatal Abstinence Syndrome. Am J Perinatol 2021; 38:28-36. [PMID: 31421639 DOI: 10.1055/s-0039-1694729] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Our objective was to compare fetal growth and incidence of neonatal abstinence syndrome requiring treatment across pregnant women with opioid use disorders on two types and two dose categories of medication-assisted treatment. STUDY DESIGN A retrospective cohort study was conducted in a comprehensive, perinatal program in western North Carolina comparing growth percentiles on third-trimester ultrasound and at birth, and diagnosis of neonatal abstinence syndrome requiring treatment. Singletons were exposed in utero to low- to moderate-dose buprenorphine (≤16 mg/day; n = 70), high-dose buprenorphine (≥17 mg/day; n = 36), low- to moderate-dose methadone (≤89 mg/day; n = 41), or high-dose methadone (≥90 mg/day; n = 74). Multivariate analysis of variance with posthoc Bonferroni comparisons (p ≤ 0.01) and multinomial logistic regressions (adjusted odds ratio, 99% confidence interval) were conducted. RESULTS Differences in neonatal outcomes reached statistical significance for larger head circumference for buprenorphine doses (p = 0.01) and for longer length (p < 0.01) and lower odds of neonatal abstinence syndrome requiring treatment (p < 0.01) with low- to moderate-dose buprenorphine versus high-dose methadone. CONCLUSION Among pregnant women using medication-assisted treatment for opioid use disorders, low- to moderate-dose buprenorphine (≤16 mg/day) was associated with the most favorable neonatal outcomes. However, more rigorous control of confounders with a larger sample is necessary to determine if low- to moderate-dose buprenorphine is the better treatment choice.
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Affiliation(s)
- Carol C Coulson
- Department of Obstetrics and Gynecology, Mountain Area Health Education Center, Asheville, North Carolina.,Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Erin Lorencz
- Department of Obstetrics and Gynecology, Mountain Area Health Education Center, Asheville, North Carolina
| | - Katelyn Rittenhouse
- University of North Carolina School of Medicine-Asheville, Asheville, North Carolina
| | - Melinda Ramage
- Department of Obstetrics and Gynecology, Mountain Area Health Education Center, Asheville, North Carolina
| | - Kathleen Lorenz
- Department of Obstetrics and Gynecology, Mountain Area Health Education Center, Asheville, North Carolina
| | - Shelley L Galvin
- Department of Obstetrics and Gynecology, Mountain Area Health Education Center, Asheville, North Carolina.,Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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Use of Injectable Opioid Agonist Therapy in a In-Patient Setting for a Pregnant Patient With Opioid Use Disorder: A Case Report. J Addict Med 2020; 15:435-438. [PMID: 33234803 DOI: 10.1097/adm.0000000000000776] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND In the era of highly potent illicit opioids, such as fentanyl and carfentanil, injectable opioid agonist treatment (iOAT) is an effective treatment for those with severe and treatment-refractory opioid use disorder. Untreated opioid use disorder in pregnancy can lead to maternal and neonatal morbidity and mortality. There are currently limited reports on the use of iOAT in pregnant women. The in-patient setting may provide an opportunity to pregnant women for stabilization with iOAT where first line therapies have been ineffective. CASE SUMMARY We report a case of a pregnant individual who engaged in daily intravenous fentanyl who was admitted to the hospital at 29 weeks gestation for stabilization with iOAT, methadone, and slow-release oral morphine. Before admission, she endured 6 opioid overdoses in her pregnancy and continued to use illicit intravenous opioids in the community despite high dose methadone combined with slow-release oral morphine. Her withdrawal symptoms and cravings were ameliorated with hydromorphone 90 mg IM/IV BID, methadone 135 mg daily, and morphine sulfate sustained release 600 mg daily. With this regimen, she was able to reduce her intravenous fentanyl use to a single episode during her hospitalization. She completed her pregnancy in hospital, delivering a full-term live infant after receiving comprehensive prenatal care. DISCUSSION This case report highlights iOAT as an option during pregnancy and describes the in-patient setting as appropriate to retain high-risk patients in care. This approach may benefit those who are refractory to standard opioid agonist treatment, the numbers of whom may be rising as tolerance to the illicit supply increases.
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Minozzi S, Amato L, Jahanfar S, Bellisario C, Ferri M, Davoli M. Maintenance agonist treatments for opiate-dependent pregnant women. Cochrane Database Syst Rev 2020; 11:CD006318. [PMID: 33165953 PMCID: PMC8094273 DOI: 10.1002/14651858.cd006318.pub4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The prevalence of opiate use among pregnant women can range from 1% to 2% to as high as 21%. Just in the United States alone, among pregnant women with hospital delivery, a fourfold increase in opioid use is reported from 1999 to 2014 (Haight 2018). Heroin crosses the placenta, and pregnant, opiate-dependent women experience a six-fold increase in maternal obstetric complications such as low birth weight, toxaemia, third trimester bleeding, malpresentation, puerperal morbidity, fetal distress and meconium aspiration. Neonatal complications include narcotic withdrawal, postnatal growth deficiency, microcephaly, neuro-behavioural problems, increased neonatal mortality and a 74-fold increase in sudden infant death syndrome. This is an updated version of the original Cochrane Review first published in 2008 and last updated in 2013. OBJECTIVES To assess the effectiveness of any maintenance treatment alone or in combination with a psychosocial intervention compared to no intervention, other pharmacological intervention or psychosocial interventions alone for child health status, neonatal mortality, retaining pregnant women in treatment, and reducing the use of substances. SEARCH METHODS We updated our searches of the following databases to February 2020: the Cochrane Drugs and Alcohol Group Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, and Web of Science. We also searched two trials registers and checked the reference lists of included studies for further references to relevant randomised controlled trials (RCTs). SELECTION CRITERIA Randomised controlled trials which assessed the efficacy of any pharmacological maintenance treatment for opiate-dependent pregnant women. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by Cochrane. MAIN RESULTS We found four trials with 271 pregnant women. Three compared methadone with buprenorphine and one methadone with oral slow-release morphine. Three out of four studies had adequate allocation concealment and were double-blind. The major flaw in the included studies was attrition bias: three out of four had a high dropout rate (30% to 40%), and this was unbalanced between groups. Methadone versus buprenorphine: There was probably no evidence of a difference in the dropout rate from treatment (risk ratio (RR) 0.66, 95% confidence interval (CI) 0.37 to 1.20, three studies, 223 participants, moderate-quality evidence). There may be no evidence of a difference in the use of primary substances between methadone and buprenorphine (RR 1.81, 95% CI 0.70 to 4.68, two studies, 151 participants, low-quality evidence). Birth weight may be higher in the buprenorphine group in the two trials that reported data MD;-530.00 g, 95%CI -662.78 to -397.22 (one study, 19 particpants) and MD: -215.00 g, 95%CI -238.93 to -191.07 (one study, 131 participants) although the results could not be pooled due to very high heterogeneity (very low-quality of evidence). The third study reported that there was no evidence of a difference. We found there may be no evidence of a difference in the APGAR score (MD: 0.00, 95% CI -0.03 to 0.03, two studies,163 participants, low-quality evidence). Many measures were used in the studies to assess neonatal abstinence syndrome. The number of newborns treated for neonatal abstinence syndrome, which is the most critical outcome, may not differ between groups (RR 1.19, 95% CI 0.87 to1.63, three studies, 166 participants, low-quality evidence). Only one study which compared methadone with buprenorphine reported side effects. We found there may be no evidence of a difference in the number of mothers with serious adverse events (AEs) (RR 1.69, 95% CI 0.75 to 3.83, 175 participants, low-quality evidence) and we found there may be no difference in the numbers of newborns with serious AEs (RR 4.77, 95% CI 0.59, 38.49,131 participants, low-quality evidence). Methadone versus slow-release morphine: There were no dropouts in either treatment group. Oral slow-release morphine may be superior to methadone for abstinence from heroin use during pregnancy (RR 2.40, 95% CI 1.00 to 5.77, one study, 48 participants, low-quality evidence). In the comparison between methadone and slow-release morphine, no side effects were reported for the mother. In contrast, one child in the methadone group had central apnoea, and one child in the morphine group had obstructive apnoea (low-quality evidence). AUTHORS' CONCLUSIONS Methadone and buprenorphine may be similar in efficacy and safety for the treatment of opioid-dependent pregnant women and their babies. There is not enough evidence to make conclusions for the comparison between methadone and slow-release morphine. Overall, the body of evidence is too small to make firm conclusions about the equivalence of the treatments compared. There is still a need for randomised controlled trials of adequate sample size comparing different maintenance treatments.
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Affiliation(s)
- Silvia Minozzi
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Laura Amato
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Shayesteh Jahanfar
- Department of Public Health, School of Population and Public Health, University of British Columbia, Vancouver, Canada
- School of Health Sciences, Central Michigan University, Mount Pleasant, Michigan, USA
- MPH Program, School of Public Health, Central Michigan University, Michigan, USA
| | - Cristina Bellisario
- CPO Piemonte, Dipartimento Interaziendale di Prevenzione Secondaria dei Tumori S.C. Epidemiologia dei Tumori, AO Città della Salute e della Scienza di Torino Via San Francesco da Paola 31, Torino, Italy
| | - Marica Ferri
- Best practices, knowledge exchange and economic issues, European Monitoring Centre for Drugs and Drug Addiction, Lisbon, Portugal
| | - Marina Davoli
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
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Abstract
Prenatal opioid exposure adversely impacts upon fetal growth and places the newborn at risk of neonatal opioid withdrawal. The severity and duration of opioid withdrawal cannot be predicted in the individual baby and may be contributed to by other drugs including benzodiazepines and alcohol as well as cigarette smoking. Mitigating factors include breastfeeding, rooming in and absence of maternal polypharmacy. Less well recognised are a variety of other complications associated with prenatal opioid exposure including epigenetic changes, effects on neurophysiological function and structural alterations to the developing brain. The visual system is significantly affected, with changes to both clinical and electrophysiological function persisting at least to mid-childhood. Longer term neurodevelopmental and behavioural outcomes are confounded by multiple factors including poverty, parent-child interaction and small study numbers, but systematic reviews consistently demonstrate poorer outcomes for those children and young people prenatally exposed to opioids. Crucially, manifestation of neonatal withdrawal is not a prerequisite for important long term problems including behavioural, emotional or motor function disorder, sensory or speech disorder, strabismus and nystagmus. A body of evidence supports an independent adverse effect of prenatal opioid exposure upon fetal brain development, mediated via a systemic neuro-inflammatory process. Children prenatally exposed to opioids should remain under appropriate follow up, at least until school entry, as difficulties may only become apparent in mid-childhood. Future studies of the management of opioid use disorder in pregnancy, including maintenance methadone, must include longer term outcomes for the baby.
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Affiliation(s)
- Helen Mactier
- Princess Royal Maternity, Glasgow, UK; College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK.
| | - Ruth Hamilton
- College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK; Department of Clinical Physics and Bio-engineering, Royal Hospital for Children, NHS Greater Glasgow & Clyde, Glasgow, UK
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Bryan MA, Smid MC, Cheng M, Fortenberry KT, Kenney A, Muniyappa B, Pendergrass D, Gordon AJ, Cochran G. Addressing opioid use disorder among rural pregnant and postpartum women: a study protocol. Addict Sci Clin Pract 2020; 15:33. [PMID: 33129355 PMCID: PMC7603672 DOI: 10.1186/s13722-020-00206-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 10/23/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Opioid use disorder (OUD) among women delivering at a hospital has increased 400% from 1999-2014 in the United States. From the years 2007 to 2016, opioid-related mortality during pregnancy increased over 200%, and drug-overdose deaths made up nearly 10% of all pregnancy-associated mortality in 2016 in the US. Disproportionately higher rates of neonatal opioid withdrawal syndrome (NOWS) have been reported in rural areas of the country, suggesting that perinatal OUD is a pressing issue among these communities. There is an urgent need for comprehensive, evidence-based treatment services for pregnant women experiencing OUD. The purpose of this article is to describe a study protocol aimed at developing and evaluating a perinatal OUD curriculum, enhancing evidence-based perinatal OUD treatment in a rural setting, and evaluating the implementation of such collaborative care for perinatal OUD. METHODS This two-year study employed a one group, repeated measures, hybrid type-1 effectiveness-implementation design. This study delivered interventions at 2 levels, both targeting improvement of care for pregnant women with OUD. The first area of focus was at the community healthcare provider-level, which aimed to evaluate the acceptability and feasibility of perinatal OUD education across time and to improve provider education by increasing knowledge specific to: MOUD provision; screening, brief intervention, and referral to treatment (SBIRT) utilization; and NOWS treatment. The second area of intervention focus was at the patient-level, which assessed the preliminary effect of perinatal OUD provider education in promoting illicit opioid abstinence and treatment engagement among pregnant women with OUD. We adopted constructs from the Consolidated Framework for Implementation Research (CFIR) to assess contextual factors that may influence implementation, and the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) model to comprehensively evaluate implementation outcomes. DISCUSSION This article presents the protocol of an implementation study that is employing the CFIR and RE-AIM frameworks to implement and evaluate a perinatal OUD education and service coordination program in two rural counties. This protocol could serve as a model for clinicians and researchers seeking to implement improvements in perinatal care for women with OUD in other rural communities. Trial registration NCT04448015 clinicaltrials.gov.
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Affiliation(s)
- M Aryana Bryan
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA.
| | - Marcela C Smid
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA.,Department of Obstetrics and Gynecology, University of Utah School of Medicine, Division of Maternal Fetal Medicine, Salt Lake City, UT, 84132, USA
| | - Melissa Cheng
- Department of Family and Preventive Medicine, University of Utah School of Medicine, 375 Chipeta Way Ste. A, Salt Lake City, UT, 84108, USA
| | - Katherine T Fortenberry
- Department of Family and Preventive Medicine, University of Utah School of Medicine, 375 Chipeta Way Ste. A, Salt Lake City, UT, 84108, USA
| | - Amy Kenney
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA
| | - Bhanu Muniyappa
- Department of Pediatrics, University of Utah School of Medicine, Division of General Pediatrics, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | | | - Adam J Gordon
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA.,Greater Intermountain Node (GIN), NIH NIDA Clinical Trials Network, University of Utah, Salt Lake City, UT, USA.,Informatics, Decision-Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Gerald Cochran
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA.,Greater Intermountain Node (GIN), NIH NIDA Clinical Trials Network, University of Utah, Salt Lake City, UT, USA
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41
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Wouldes TA, Woodward LJ. Neurobehavior of newborn infants exposed prenatally to methadone and identification of a neurobehavioral profile linked to poorer neurodevelopmental outcomes at age 24 months. PLoS One 2020; 15:e0240905. [PMID: 33064777 PMCID: PMC7567379 DOI: 10.1371/journal.pone.0240905] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 10/05/2020] [Indexed: 11/25/2022] Open
Abstract
The abuse of prescription opioids and heroin by women of childbearing age over the past decade has resulted in a five-fold increase in the number of infants born opioid-dependent. Daily opioid substitution treatment with methadone is associated with less maternal illicit opioid use and improved antenatal care. However, research on the neurobehavioral effects of daily prenatal exposure to methadone on the infant is limited. Using the NICU Network Neurobehavioral Scale (NNNS), we compared the neurobehavior at birth of 86 infants born to opioid-dependent mothers receiving methadone treatment (MMT) with 103 infants unexposed to methadone. Generalized linear models, adjusted for covariates, showed methadone exposed infants had significantly poorer attention, regulation, and quality of movement. They were also significantly more excitable, more easily aroused, exhibited more non-optimal reflexes, hypertonicity, and total signs of stress abstinence. Maternal MMT was also associated with more indices of neonatal abstinence, including: CNS, visual, genitourinary (GI), and state. Latent profile analysis of the NNNS summary scores revealed four distinct neurobehavioral profiles with infants characterized by the most disturbed neurobehavior at birth having the poorest clinical outcomes at birth, and poorer cognitive and motor development at 24 months of age.
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Affiliation(s)
- Trecia A. Wouldes
- Department of Psychological Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Lianne J. Woodward
- School of Health Sciences, University of Canterbury, Christchurch, New Zealand
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42
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Pottie K, Kendall CE, Aubry T, Magwood O, Andermann A, Salvalaggio G, Ponka D, Bloch G, Brcic V, Agbata E, Thavorn K, Hannigan T, Bond A, Crouse S, Goel R, Shoemaker E, Wang JZJ, Mott S, Kaur H, Mathew C, Hashmi SS, Saad A, Piggott T, Arya N, Kozloff N, Beder M, Guenter D, Muckle W, Hwang S, Stergiopoulos V, Tugwell P. Lignes directrices de pratique clinique pour les personnes sans-abri, logées précairement, ou ayant connu l’itinérance. CMAJ 2020; 192:E1225-E1241. [PMID: 33051325 PMCID: PMC7588247 DOI: 10.1503/cmaj.190777-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Kevin Pottie
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont.
| | - Claire E Kendall
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Tim Aubry
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Olivia Magwood
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Anne Andermann
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Ginetta Salvalaggio
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - David Ponka
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Gary Bloch
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Vanessa Brcic
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Eric Agbata
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Kednapa Thavorn
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Terry Hannigan
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Andrew Bond
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Susan Crouse
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Ritika Goel
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Esther Shoemaker
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Jean Zhuo Jing Wang
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Sebastian Mott
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Harneel Kaur
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Christine Mathew
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Syeda Shanza Hashmi
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Ammar Saad
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Thomas Piggott
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Neil Arya
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Nicole Kozloff
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Michaela Beder
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Dale Guenter
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Wendy Muckle
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Stephen Hwang
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Vicky Stergiopoulos
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Peter Tugwell
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
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Andersen N, Lund IO. Mapping the literature on parents with mental illness, across psychiatric sub-disciplines: a bibliometric review. BMC Psychiatry 2020; 20:468. [PMID: 32993578 PMCID: PMC7523296 DOI: 10.1186/s12888-020-02825-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 08/19/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Research on parental mental illness is often carried out in disorder specific research silos. Drawing on the different research areas, it is possible to leverage and combine existing knowledge, and identify insights that can be transferred across research areas. In this study, we identify the overarching structure of research on parents with psychiatric disorders, and the structure of the different research areas, as defined by psychiatric disorder groups in ICD-10, and identify both topics that are commonly examined, and topics that received attention in only a few of the research areas. METHODS We use bibliometric science mapping to examine keywords in 16,734 articles, showing the overarching structure of research on parents with mental illness, both overall and within ICD-10 psychiatric disorder categories. The search was conducted using the Scopus database for journal articles published between 1999 and 2018, with no restrictions on language. RESULTS Co-occurrence analysis of the keywords in the 16,734 articles on parental mental illnesses in different psychiatric disorder categories, indicate there are six general themes in the literature: 'expectant mothers and early motherhood', 'substance use and abuse', 'Socio-economic status' (SES) and support practices', 'biomedical research', 'diagnoses, symptoms and treatment', and 'child-parent interaction and context'. Although the same themes are covered in different areas, the contexts, in terms of content and relation to other topics, vary between the research areas. Some topics are heavily researched in some areas, but seem to be neglected in others. CONCLUSIONS This study provides data both in interactive maps and an extensive table, allowing readers to dive deep into their topic of interest, and examine how this connects to other topics, which may in turn guide identification of important gaps in the literature, and ultimately inspire and generate novel research avenues.
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Affiliation(s)
- Njål Andersen
- grid.413074.50000 0001 2361 9429Department of Leadership and Organizational Behaviour, BI Norwegian Business School, 0442 Oslo, Norway
| | - Ingunn Olea Lund
- Department of Mental Disorders, The Norwegian Institute of Public Health, Postboks 222 Skøyen, 0213, Oslo, Norway. .,Ludwig Boltzmann Gesellschaft, Research Group Village in cooperation with the Department of Psychiatry, Psychotherapy and Psychosomatics, Division of Psychiatry I, Medical University of Innsbruck, Tirol Kliniken GmbH, Schöpfstraße 23a, 6020, Innsbruck, Austria.
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"I didn't want to be on Suboxone at first…" - Ambivalence in Perinatal Substance Use Treatment. J Addict Med 2020; 13:264-271. [PMID: 30585875 DOI: 10.1097/adm.0000000000000491] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The objectives of this article are to present findings from recent qualitative research with patients in a combined perinatal substance use treatment program in Central Appalachia, and to describe and analyze participants' ambivalence about medication-assisted treatment for opioid use disorder (OUD), in the context of widespread societal stigma and judgement. METHODS We conducted research in a comprehensive outpatient perinatal substance use treatment program housed in a larger obstetric practice serving a large rural, Central Appalachian region. The program serves patients across the spectrum of substance use disorders but specifically offers medication-assisted treatment to perinatal patients with OUD. We purposively and opportunistically sampled patients receiving prescriptions for buprenorphine or buprenorphine-naloxone dual product, along with prenatal care and other services. Through participant-observation and semi-structured interviews, we gathered qualitative data from 27 participants, in a total of 31 interviews. We analyzed transcripts of interviews and fieldnotes using modified Grounded Theory. RESULTS Participants in a combined perinatal substance use treatment program value supportive, non-judgmental care but report ambivalence about medication, within structural and institutional contexts of criminalized, stigmatized substance use and close scrutiny of their pregnancies. Women are keenly aware of the social and public consequences for themselves and their parenting, if they begin or continue medication treatment for OUD. CONCLUSIONS Substance use treatment providers should consider the social consequences of medication treatment, as well as the clinical benefits, when presenting treatment options and recommendations to patients. Patient-centered care must include an understanding of larger social and structural contexts.
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Winhusen T, Lofwall M, Jones HE, Wilder C, Lindblad R, Schiff DM, Wexelblatt S, Merhar S, Murphy SM, Greenfield SF, Terplan M, Wachman EM, Kropp F, Theobald J, Lewis M, Matthews AG, Guille C, Silverstein M, Rosa C. Medication treatment for opioid use disorder in expectant mothers (MOMs): Design considerations for a pragmatic randomized trial comparing extended-release and daily buprenorphine formulations. Contemp Clin Trials 2020; 93:106014. [PMID: 32353544 PMCID: PMC7184985 DOI: 10.1016/j.cct.2020.106014] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 04/16/2020] [Accepted: 04/24/2020] [Indexed: 01/17/2023]
Abstract
Opioid use disorder (OUD) in pregnant women has increased significantly in recent years. Maintaining these women on sublingual (SL) buprenorphine (BUP) is an evidence-based practice but BUP-SL is associated with several disadvantages that an extended-release (XR) BUP formulation could eliminate. The National Drug Abuse Treatment Clinical Trials Network (CTN) is conducting an intent-to-treat, two-arm, open-label, pragmatic randomized controlled trial, Medication treatment for Opioid-dependent expectant Mothers (MOMs), to compare mother and infant outcomes of pregnant women with OUD treated with BUP-XR, relative to BUP-SL. A second aim is to determine the relative economic value of utilizing BUP-XR. Approximately 300 pregnant women with an estimated gestational age (EGA) of 6-30 weeks, recruited from 12 sites, will be randomized in a 1:1 ratio to BUP-XR or BUP-SL, balancing on site, EGA, and BUP-SL status (taking/not taking) at the time of randomization. Participants will be provided with study medication and attend weekly medication visits through 12 months postpartum. Participants will be invited to participate in two sub-studies to evaluate the: 1) mechanisms by which BUP-XR may improve mother and infant outcomes; and 2) effects of prenatal exposure to BUP-XR versus BUP-SL on infant neurodevelopment. This paper describes the key design decisions for the main trial made during protocol development. This Investigational New Drug (IND) trial uniquely uses pragmatic features where feasible in order to maximize external validity, hence increasing the potential to inform clinical practice guidelines and address multiple knowledge gaps for treatment of this patient population.
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Affiliation(s)
- Theresa Winhusen
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH 45229, USA; Center for Addiction Research, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH 45229, USA.
| | - Michelle Lofwall
- Departments of Behavioral Science and Psychiatry, University of Kentucky College of Medicine, Center on Drug and Alcohol Research, 845 Angliana Avenue, Lexington, KY 40508, USA
| | - Hendrée E Jones
- UNC Horizons and Department of Obstetrics and Gynecology, University of North Carolina Chapel Hill, 410 North Greensboro St., Carrboro, NC 27510, USA
| | - Christine Wilder
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH 45229, USA; Center for Addiction Research, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH 45229, USA
| | - Robert Lindblad
- The Emmes Company, LLC, 401 N Washington Street, Suite 700, Rockville, MD 20850, USA
| | - Davida M Schiff
- Division of General Academic Pediatrics, MassGeneral Hospital for Children, 125 Nashua St Suite 860, Boston, MA 02114, USA
| | - Scott Wexelblatt
- Perinatal Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA; Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH 45229, USA
| | - Stephanie Merhar
- Perinatal Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA; Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH 45229, USA
| | - Sean M Murphy
- Department of Healthcare Policy & Research, Weill Cornell Medical College, 425 East 61st Street Suite 301, New York, NY 10065, USA
| | - Shelly F Greenfield
- Department of Psychiatry, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA; Division of Alcohol, Drug and Addictions and the Division of Women's Mental Health, McLean Hospital, 115 Mill Street, Belmont, MA 02478, USA
| | - Mishka Terplan
- Friends Research Institute,1040 Park Ave Suite 103, Baltimore, MD 21201, USA
| | - Elisha M Wachman
- Department of Pediatrics, Boston Medical Center, 801 Albany Street, Boston, MA 02119, USA
| | - Frankie Kropp
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH 45229, USA; Center for Addiction Research, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH 45229, USA
| | - Jeff Theobald
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH 45229, USA; Center for Addiction Research, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH 45229, USA
| | - Mitra Lewis
- The Emmes Company, LLC, 401 N Washington Street, Suite 700, Rockville, MD 20850, USA
| | - Abigail G Matthews
- The Emmes Company, LLC, 401 N Washington Street, Suite 700, Rockville, MD 20850, USA
| | - Connie Guille
- Department of Psychiatry and Behavioral Science, Medical University of South Carolina, 67 President St., MSC 861, Charleston, SC 29425, USA
| | - Michael Silverstein
- Department of Pediatrics, Boston Medical Center, Boston University School of Medicine, 88 East Newton Street, Boston, MA 02118, USA
| | - Carmen Rosa
- Center for the Clinical Trials Network, National Institute on Drug Abuse, 6001 Executive Blvd, Bethesda, MD 20892, USA
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Thakrar S, Lee J, Martin CE, Butterworth Iv J. Buprenorphine management: a conundrum for the anesthesiologist and beyond - a one-act play. Reg Anesth Pain Med 2020; 45:656-659. [PMID: 32371499 DOI: 10.1136/rapm-2020-101294] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 03/25/2020] [Accepted: 04/01/2020] [Indexed: 11/04/2022]
Abstract
We have witnessed a worldwide upsurge of streamlined enhanced recovery after surgery (ERAS) pathways advocating for consistency and compliance within their guidelines. At a recent national conference, two experts defended their institutional policies on perioperative management of buprenorphine, one defending its continuation, while the other suggesting its discontinuation. The moderator diplomatically proclaimed the need to have guidance at the institutional level and following it for favorable patient outcomes. Unfortunately, perioperative management of buprenorphine remains an understudied topic with a lack of national guidelines leading to variations at a local level despite its increased use nationally in the current opioid crisis. Although the moderator made a valid statement, we demonstrate via our one-act play the importance of recognizing a subset of the population within an ERAS pathway that necessitates multidisciplinary discussion, communication, and patient-centric care to formulate a perioperative plan coordinating a patient's care. More robust research is needed to minimize variability in current practices and to further develop comprehensive evidence-based guidelines that encompass risk factors and anticipated postsurgical and peripartum pain for patients on buprenorphine.
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Affiliation(s)
- Shilen Thakrar
- Department of Anesthesiology, VCU Medical Center, West Hospital,1200 E. Broad Street, 7th Floor. North Wing, Richmond, Virginia, USA
| | - Josh Lee
- Department of Anesthesiology, VCU Medical Center, West Hospital,1200 E. Broad Street, 7th Floor. North Wing, Richmond, Virginia, USA
| | - Caitlin E Martin
- Department of Obstetrics and Gynecology, Virginia Commonwealth University, Richmond, Virginia, USA.,Institute for Drug and Alcohol Studies, Virginia Commonwealth University, Richmond, VA, USA
| | - John Butterworth Iv
- Department of Anesthesiology, VCU Medical Center, West Hospital,1200 E. Broad Street, 7th Floor. North Wing, Richmond, Virginia, USA
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47
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Garrison-Desany HM, Nawa N, Kim Y, Ji Y, Susan Chang HY, Hong X, Wang G, Pearson C, Zuckerman BS, Wang X, Surkan PJ. Polydrug Use During Pregnancy and Preterm Birth in a Low-Income, Multiethnic Birth Cohort, Boston, 1998-2018. Public Health Rep 2020; 135:383-392. [PMID: 32311304 DOI: 10.1177/0033354920915437] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE The opioid epidemic in the United States increasingly affects women of reproductive age and has resulted in a rise in concurrent polydrug use. The objective of this study was to investigate the effect of this polydrug use on preterm birth in a multiethnic birth cohort. METHODS We analyzed data from 8261 mothers enrolled in the Boston Birth Cohort from 1998 to 2018 in Boston, Massachusetts. We grouped substances used during pregnancy based on their primary effects (stimulant or depressant) and assessed independent and combined associations with smoking on preterm birth. RESULTS Of 8261 mothers, 131 used stimulant drugs and 193 used depressant drugs during pregnancy. The preterm birth rate was 27.5% (2271 of 8261) in the sample. Mothers who smoked had 35% increased odds of preterm birth across adjusted models. Mothers who used stimulant drugs without smoking were not at increased risk of preterm delivery compared with mothers who used neither (odds ratio [OR] = 0.69; 95% confidence interval [CI], 0.19-1.98), whereas mothers who used depressant drugs without smoking had more than twice the odds of having preterm delivery (OR = 2.31; 95% CI, 1.19-4.44), and infants were at risk of a 1-week reduction in gestational age (OR = -1.05; 95% CI, -2.07 to -0.03). Concurrently smoking and using depressant drugs was associated with increased odds of preterm birth (OR = 1.83; 95% CI, 1.28-2.61), as was concurrently smoking and using stimulant drugs (OR = 1.73; 95% CI, 1.14-2.59). CONCLUSIONS Using stimulant drugs and depressant drugs during pregnancy is a risk factor for preterm birth. The individual and combined effects of using these drugs with smoking must be considered together to reduce the risk of preterm birth in the United States.
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Affiliation(s)
- Henri M Garrison-Desany
- 25802 Center on Early Life Origins of Disease, Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.,1466 Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Nobutoshi Nawa
- 25802 Center on Early Life Origins of Disease, Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Yoona Kim
- 25802 Center on Early Life Origins of Disease, Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.,1466 Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Yuelong Ji
- 25802 Center on Early Life Origins of Disease, Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Hsing-Yuan Susan Chang
- 25802 Center on Early Life Origins of Disease, Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Xiumei Hong
- 25802 Center on Early Life Origins of Disease, Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Guoying Wang
- 25802 Center on Early Life Origins of Disease, Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Colleen Pearson
- 1836 Department of Pediatrics, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Barry S Zuckerman
- 1836 Department of Pediatrics, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Xiaobin Wang
- 25802 Center on Early Life Origins of Disease, Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.,25802 Division of General Pediatrics & Adolescent Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Pamela J Surkan
- 25802 Center on Early Life Origins of Disease, Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.,1466 Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
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48
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Kroelinger CD, Addison D, Rodriguez M, Rice ME, Frey MT, Hickner HR, Weber MK, Mueller T, Velonis A, Uesugi K, Romero L, Akbarali S, Foster N, Ko JY, Pliska E, Mackie C, Cox S, Fehrenbach SN, Barfield WD. Implementing a Learning Collaborative Framework for States Working to Improve Outcomes for Vulnerable Populations: The Opioid Use Disorder, Maternal Outcomes, and Neonatal Abstinence Syndrome Initiative Learning Community. J Womens Health (Larchmt) 2020; 29:475-486. [PMID: 32176568 DOI: 10.1089/jwh.2020.8303] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The opioid crisis has impacted vulnerable populations, specifically pregnant and postpartum women, and infants prenatally exposed to substances, including infants with Neonatal Abstinence Syndrome. Lack of access to clinical and social services; potential stigma or discrimination; and lack of resources for provision of services, including screening and treatment, have impacted the health of these populations. In 2018, using a systems change approach, the Association of State and Territorial Health Officials (ASTHO) and the Centers for Disease Control and Prevention (CDC) convened an Opioid use disorder, Maternal outcomes, Neonatal abstinence syndrome Initiative Learning Community (OMNI LC) that included other federal agencies, national clinical and nonclinical organizations, and 12 state leadership groups. The purpose of the OMNI LC was to determine areas of focus and identify strategies and best practices for implementing systems change to improve maternal and infant outcomes associated with opioid use disorder (OUD) during the perinatal period. Activities included in-person convenings with policy goal action plan development, virtual learning sessions, intensive technical assistance (TA), and temporary field placements. The OMNI LC partnering agencies and state teams met bimonthly for the first year of the initiative. At the in-person convening, state teams identified barriers to developing and implementing systems change in activity-specific action plans within five areas of focus: financing and coverage; access to and coordination of quality services; provider training and awareness; ethical, legal, and social considerations; and data, monitoring, and evaluation. State teams also identified stakeholder partnerships as a necessary component of strategy development in all areas of focus. Four virtual learning sessions were conducted on the areas of focus identified by state teams, and ASTHO conducted three intensive TA opportunities, and five states were identified for temporary field placement. To successfully address the impact of the opioid crisis on pregnant and postpartum women and infants, states developed innovative strategies focused on increasing support, services, and resources. Moving forward, state teams will participate in two additional in-person meetings, continue to identify barriers to the work, refine and customize action plans, and set new goals, to effect broad-ranging systems change for these vulnerable populations.
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Affiliation(s)
- Charlan D Kroelinger
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Donna Addison
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia.,United States Public Health Service, Commissioned Corps, Atlanta, Georgia
| | - Mirelys Rodriguez
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | | | - Meghan T Frey
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Hadley R Hickner
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Mary Kate Weber
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Trish Mueller
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Alisa Velonis
- Division of Community Health Sciences, University of Illinois at Chicago, Chicago, Illinois
| | - Keriann Uesugi
- Division of Epidemiology and Biostatistics, University of Illinois at Chicago, Chicago, Illinois
| | - Lisa Romero
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Sanaa Akbarali
- Association of State and Territorial Health Officials, Arlington, Virginia
| | - Natalie Foster
- Association of State and Territorial Health Officials, Arlington, Virginia
| | - Jean Y Ko
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia.,United States Public Health Service, Commissioned Corps, Atlanta, Georgia
| | - Ellen Pliska
- Association of State and Territorial Health Officials, Arlington, Virginia
| | - Christine Mackie
- Association of State and Territorial Health Officials, Arlington, Virginia
| | - Shanna Cox
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - S Nicole Fehrenbach
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Wanda D Barfield
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia.,United States Public Health Service, Commissioned Corps, Atlanta, Georgia
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49
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Pottie K, Kendall CE, Aubry T, Magwood O, Andermann A, Salvalaggio G, Ponka D, Bloch G, Brcic V, Agbata E, Thavorn K, Hannigan T, Bond A, Crouse S, Goel R, Shoemaker E, Wang JZJ, Mott S, Kaur H, Mathew C, Hashmi SS, Saad A, Piggott T, Arya N, Kozloff N, Beder M, Guenter D, Muckle W, Hwang S, Stergiopoulos V, Tugwell P. Clinical guideline for homeless and vulnerably housed people, and people with lived homelessness experience. CMAJ 2020; 192:E240-E254. [PMID: 32152052 PMCID: PMC7062440 DOI: 10.1503/cmaj.190777] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Kevin Pottie
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont.
| | - Claire E Kendall
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Tim Aubry
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Olivia Magwood
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Anne Andermann
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Ginetta Salvalaggio
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - David Ponka
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Gary Bloch
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Vanessa Brcic
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Eric Agbata
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Kednapa Thavorn
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Terry Hannigan
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Andrew Bond
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Susan Crouse
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Ritika Goel
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Esther Shoemaker
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Jean Zhuo Jing Wang
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Sebastian Mott
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Harneel Kaur
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Christine Mathew
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Syeda Shanza Hashmi
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Ammar Saad
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Thomas Piggott
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Neil Arya
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Nicole Kozloff
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Michaela Beder
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Dale Guenter
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Wendy Muckle
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Stephen Hwang
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Vicky Stergiopoulos
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Peter Tugwell
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
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Magwood O, Salvalaggio G, Beder M, Kendall C, Kpade V, Daghmach W, Habonimana G, Marshall Z, Snyder E, O’Shea T, Lennox R, Hsu H, Tugwell P, Pottie K. The effectiveness of substance use interventions for homeless and vulnerably housed persons: A systematic review of systematic reviews on supervised consumption facilities, managed alcohol programs, and pharmacological agents for opioid use disorder. PLoS One 2020; 15:e0227298. [PMID: 31945092 PMCID: PMC6964917 DOI: 10.1371/journal.pone.0227298] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 12/16/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Substance use is disproportionately high among people who are homeless or vulnerably housed. We performed a systematic overview of reviews examining the effects of selected harm reduction and pharmacological interventions on the health and social well-being of people who use substances, with a focus on homeless populations. METHODS AND FINDINGS We searched MEDLINE, EMBASE, PsycINFO, Joanna Briggs Institute EBP, Cochrane Database of Systematic Reviews and DARE for systematic reviews from inception to August 2019. We conducted a grey literature search and hand searched reference lists. We selected reviews that synthesized evidence on supervised consumption facilities, managed alcohol programs and pharmacological interventions for opioid use disorders. We abstracted data specific to homeless or vulnerably housed populations. We assessed certainty of the evidence using the GRADE approach. Our search identified 483 citations and 30 systematic reviews met all inclusion criteria, capturing the results from 442 primary studies. This included three reviews on supervised consumption facilities, 24 on pharmacological interventions, and three on managed alcohol programs. Supervised consumption facilities decreased lethal overdoses and other high risk behaviours without any significant harm, and improved access to care. Pharmaceutical interventions reduced mortality, morbidity, and substance use, but the impact on retention in treatment, mental illness and access to care was variable. Managed alcohol programs reduced or stabilized alcohol consumption. Few studies on managed alcohol programs reported deaths. CONCLUSIONS Substance use is a common chronic condition impacting homeless populations. Supervised consumption facilities reduce overdose and improve access to care, while pharmacological interventions may play a role in reducing harms and addressing other morbidity. High quality evidence on managed alcohol programs is limited.
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Affiliation(s)
- Olivia Magwood
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada
| | | | - Michaela Beder
- St. Michael’s Hospital, University of Toronto Dept of Psychiatry, Toronto, ON, Canada
| | - Claire Kendall
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada
- Departments of Family Medicine & School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Victoire Kpade
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Wahab Daghmach
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada
| | - Gilbert Habonimana
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada
| | - Zack Marshall
- School of Social Work, McGill University, Montreal, QC, Canada
| | - Ellen Snyder
- Public Health and Preventative Medicine Residency Program, University of Ottawa, Ottawa, ON, Canada
| | - Tim O’Shea
- Department of Medicine, Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Robin Lennox
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - Helen Hsu
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Peter Tugwell
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Kevin Pottie
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada
- Departments of Family Medicine & School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
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