Architecture and Development Framework for a Web-Based Risk Assessment and Management Platform Developed on WordPress to Address Opioid Overdose

The number of overdose-related fatalities continues to reach historic levels across Canada, despite ongoing efforts by authorities. To reduce mortality, a clinical trajectory ranging from preventative measures to crisis intervention, skill training to treatment, and risk assessment to risk management needs to be supported. The web-based Risk Assessment and Management Platform (RAMP) was developed to realize this concept and to empower people who use drugs through an integrated tool that allows them to better understand and manage their risk of overdose. This paper outlines the architecture and development of RAMP, which is built on the WordPress platform. WordPress components are mapped onto a 3-tier architecture that consists of presentation, application, and database layers. The architecture facilitates the development of a modular software that includes several features that are independent in functionality but interact with each other in an integrated platform. The relatively low coupling and high coherence of the features may reduce the cost of maintenance and increase flexibility of future developments. RAMP's architecture comprises a user interface, conceptual framework, and backend layers. The RAMP front end effectively uses some of the WordPress' features such as HTML5, CSS, and JavaScript to create a mobile, friendly, and scalable user interface. The RAMP backend uses several standard and custom WordPress plug-ins to support risk assessment and monitoring, with the goal of mitigating the impacts and eliminating risks together. A rule-based decision support system has been hard-coded to suggest relevant modules and goals to complement each user's lifestyle and goals based on their risk assessment. Finally, the backend uses the MySQL database management system and communicates with the RAMP framework layer via the data access layer to facilitate a timely and secure handling of information. Overall, RAMP is a modular system developed to identify and manage the risk of opioid overdose in the population of people who use drugs. Its modular design uses the WordPress architecture to efficiently communicate between layers and provide a base for external plug-ins. There is potential for the current system to adopt and address other related fields such as suicide, anxiety, and trauma. Broader implementation will support this concept and lead to the next level of functionality.

Shifting drug markets in North America - a global crisis in the making?

Understanding drug market dynamics and their underlying driving factors is paramount to developing effective responses to the overdose crisis in North America. This paper summarises the distinct drug market trends observed locally and internationally over the past decade to extrapolate future drug market trajectories. The emergence of fentanyl on North American street markets from 2014 onwards led to a shift of street drug use patterns. Previously perceived as contaminants, novel synthetic opioids became the drugs of choice and a trend towards higher potency was observed across various substance classes. The diversification of distribution strategies as well as the regionalisation and industrialisation of production followed basic economic principles that were heavily influenced by prosecution and policy makers. Particularly, the trend towards higher potency is likely most indicative of what to expect from future illicit drug market developments. Nitazenes and fentanyl-analogues, several times more potent than fentanyl itself, are increasingly detected in toxicological testing and have the potential of becoming the drugs of choice in the future. The dynamic of drug import and local production is less clear and influenced by a multitude of factors like precursor availability, know-how, infrastructure, and the success of local drug enforcement strategies. Drug market dynamics and the current trajectory towards ultrapotent opioids need to be recognised by legislation, enforcement, and the health care system to prepare effective responses. Without significant improvements in treatment access, the implementation of preventative approaches and early warning systems, the mortality rate will continue to increase. Furthermore, there is no mechanism in place preventing the currently North American focused overdose crisis to spread to other parts of the globe, particularly Europe. A system of oversight, research, and treatment is needed to address mortality rates of historic proportions and prevent further harm.

Quality of life of patients treated with opium tincture or methadone: A randomized controlled trial

OBJECTIVE

Quality of life (QoL) is an increasingly recognized patient-centered treatment outcome in individuals with opioid use disorder. There is a gap in literature on the impact of opium tincture (OT) on patients' QoL compared to standard treatment options such as methadone. This study aimed to compare the QoL of participants with opioid use disorder receiving OAT using OT or methadone and identify the factors associated with their QoL during treatment.

METHODS

The opium trial was a multicenter non-inferiority randomized clinical trial in four private OAT outpatient clinics in Iran. The study assigned patients to either OT (10 mg/ml) or methadone sirup (5 mg/ml) for a follow-up of 85 days. QoL was assessed using the brief version of the World Health Organization Quality of Life instrument (WHOQOL- BREF).

RESULTS

A total of 83 participants, 35 (42.2%) in the OT arm and 48 (57.8%) in the methadone arm, completed the WHOQOL-BREF in full and were included in the primary analysis. The mean score of patients' QoL showed improvement compared to baseline, but differences were not statistically significant between OT and methadone arms (p = 0.786). Improvements were mainly observed within the first 30 days of receiving treatment. Being married and lower psychological distress were associated with an improved QoL. Within the social relationships domain, male gender showed significantly higher QoL compared to females.

CONCLUSION

OT shows promise as an OAT medication, comparable to methadone in improving patients' QoL. There is a need to incorporate psychosocial interventions to further sustain and improve the QoL in this population. Identifying other social determinants of health which affect QoL and the cultural adaptation of assessments for individuals from various ethnocultural backgrounds are critical areas of inquiry.

Opium tincture versus methadone for opioid agonist treatment: a randomized controlled trial

AIM

To test if opium tincture (OT) was non-inferior to methadone in retaining participants in opioid agonist treatment (OAT).

DESIGN

A Phase III, multi-centre, parallel-group, non-inferiority, double-blind randomized controlled trial with an allocation ratio of 1:1. Participants were provided treatment and followed for a period of 85 days.

SETTING

Four OAT clinics in Iran.

PARTICIPANTS

Two hundred and four participants with opioid use disorder [mean age (standard deviation) = 37.4 (9.3); female 11.3%] recruited between July 2017 and January 2018.

INTERVENTIONS

Participants were assigned to either OT (102) or methadone (102) using a patient-centred flexible dosing strategy.

MEASUREMENTS

Treatment retention over 85 days was the primary outcome. Self-reported opioid use outside treatment and occurrence of adverse events (AEs) were the secondary outcomes.

FINDINGS

Remaining in treatment at the end of the follow-up were 68.6% in the methadone arm and 59.8% in the OT arm. The relative retention rate of methadone to OT was 1.15 (0.97, 1.36) in both intent-to-treat and per-protocol analyses; non-inferiority was not supported statistically, as the upper bound of the confidence interval exceeded our pre-specified non-inferiority margin (1.25). Opioid use outside treatment was reported by 30.3% of OT (n = 152) and 49.4% of methadone (n = 168) patients, a difference in proportions of -19%: 90% confidence interval (-28%, -10%). The total count of AEs in the OT arm (22 among nine individuals) was significantly higher (P = 0.04) than that in the methadone arm (three among two individuals). Nausea was the most common side effect.

CONCLUSION

While this study could not conclude the non-inferiority of opium tincture (OT) to methadone for retaining patients in opioid agonist treatment, OT retained 60% of participants to end of follow-up (85 days) and was superior to methadone in reducing self-reported opioid use outside treatment.

OGC P48 Improving documentation in Surgical Operation Notes in An Upper GI Surgery Tertiary Unit: A Quality Improvement Project

Background

Good Surgical Practice are a set of guidelines that surgeons should adhere by to ensure efficiency of services, patient's quality of care and safety. One of the standards focuses on good medical record keeping; within this standard, it is dictated that there should be operative notes for every procedure, where each note should include the following: D

date and time, elective/emergency procedure, names of the operating surgeon and assistant, name of the theatre anaesthetist, operative procedure carried out, incision, operative diagnosis, operative findings, any problems/complications, any extra procedure performed and the reason why it was performed, details of tissue removed, added or altered, identification of any prosthesis used, including the serial numbers of prostheses and other implanted materials, details of closure technique, anticipated blood loss, antibiotic prophylaxis (where applicable), DVT prophylaxis, detailed postoperative care instructions and signature.

Methods

Surgical operative notes of 97 patients within our tertiary Upper GI Surgery Unit were retrospectively reviewed to investigate how many of the criteria listed in RCS guidelines were adhered to. These 97 operative notes were recorded using two different template forms on the trust's electronic system.39 of the operations were recorded using an old operation notes template in 2019; the documentation details of these were compared to 58 operation notes that were recorded using the newly implemented template in 2021.

Results

We found that documentation was excellent with use of both templates when including date of surgery (100% vs 100%), name of surgeon (100% vs 100%), name of assistant (100% vs 100%), operative procedure (100% vs 100%), incision type (100% vs 100%), operative findings (100% vs 100%), details of tissue removed, added, or altered (100% vs 100%), details of closure technique (100% vs 100%), DVT prophylaxis (100% vs 100%) and detailed postoperative care instructions (100% vs 100%). Documentation was poor in both the 2019 and 2021 operative notes when specifying whether procedure was elective or emergency (5% vs 12%), when specifying whether any complications/problems occurred (10% vs 43%) and whether an extra procedure was performed (8% vs 52%). However, there was notable improvement in documentation with the implementation of the new procedural note template; this was especially true for time of operation (3% vs 100%) and estimated blood loss (15% vs 100%).

Conclusions

Documentation detail was generally good in the 97 operative notes reviewed, with notable improvement seen after the implementation of a more comprehensive template. There is, however, still room for improvement; this could be achieved by creating a new template to include separate text boxes allowing the surgeon to describe whether the procedure was elective/emergency, whether there were any complications/problems to declare and if there were any additional procedures to declare. Further actions would be to present these results to the local surgical department and re-review these operation notes in 6 months’ time after implementation of new template.

Towards an International Consensus on the Prevention, Treatment, and Management of High-Risk Substance Use and Overdose among Youth

Background and Objectives: Now more than ever, there is an obvious need to reduce the overall burden of disease and risk of premature mortality that are associated with mental health and substance use disorders among young people. However, the current state of research and evidence-based clinical care for high-risk substance use among youth is fragmented and scarce. The objective of the study is to establish consensus for the prevention, treatment, and management of high-risk substance use and overdose among youth (10 to 24 years old). Materials and Methods: A modified Delphi technique was used based on the combination of scientific evidence and clinical experience of a group of 31 experts representing 10 countries. A semi-structured questionnaire with five domains (clinical risks, target populations, intervention goals, intervention strategies, and settings/expertise) was shared with the panelists. Based on their responses, statements were developed, which were subsequently revised and finalized through three iterations of feedback. Results: Among the five major domains, 60 statements reached consensus. Importantly, experts agreed that screening in primary care and other clinical settings is recommended for all youth, and that the objectives of treating youth with high-risk substance use are to reduce harm and mortality while promoting resilience and healthy development. For all substance use disorders, evidence-based interventions should be available and should be used according to the needs and preferences of the patient. Involuntary admission was the only topic that did not reach consensus, mainly due to its ethical implications and resulting lack of comparable evidence. Conclusions: High-risk substance use and overdoses among youth have become a major challenge. The system’s response has been insufficient and needs substantial change. Internationally devised consensus statements provide a first step in system improvement and reform.

Treatment approaches and outcome trajectories for youth with high-risk opioid use: A narrative review

AIM

First use of opioids often happens in adolescence and an increasing number of opioid overdoses are being reported among youth. The purpose of this narrative review was to present the treatment approaches for youth with high-risk opioid use, determine whether the literature supports the use of opioid agonist treatment among youth and identify evidence for better treatment outcomes in the younger population.

METHODS

A search of the literature on PubMed using MeSH terms specific to youth, opioid use and treatment approaches generated 1436 references. Following a screening process, 137 papers were found to be relevant to the treatment of high-risk opioid use among youth. After full-text review, 19 eligible studies were included: four randomized controlled trials, nine observational studies and six reviews.

RESULTS

Research for the different treatment options among youth is limited. The available evidence shows better outcomes in terms of retention in care and cost-effectiveness for opioid agonist treatment than abstinence-based comparisons. Integrating psychosocial interventions into the continuum of care for youth can be an effective way of addressing comorbid psychiatric conditions and emotional drivers of substance use, leading to improved treatment trajectories.

CONCLUSIONS

From the limited findings, there is no evidence to deny youth with high-risk opioid use the same treatment options available to adults. A combination of pharmacological and youth-specific psychosocial interventions is required to maximize retention and survival. There is an urgent need for more research to inform clinical strategies toward appropriate treatment goals for such vulnerable individuals.

The aquaculture supply chain in the time of covid-19 pandemic: Vulnerability, resilience, solutions and priorities at the global scale

The COVID-19 global pandemic has had severe, unpredictable and synchronous impacts on all levels of perishable food supply chains (PFSC), across multiple sectors and spatial scales. Aquaculture plays a vital and rapidly expanding role in food security, in some cases overtaking wild caught fisheries in the production of high-quality animal protein in this PFSC. We performed a rapid global assessment to evaluate the effects of the COVID-19 pandemic and related emerging control measures on the aquaculture supply chain. Socio-economic effects of the pandemic were analysed by surveying the perceptions of stakeholders, who were asked to describe potential supply-side disruption, vulnerabilities and resilience patterns along the production pipeline with four main supply chain components: a) hatchery, b) production/processing, c) distribution/logistics and d) market. We also assessed different farming strategies, comparing land- vs. sea-based systems; extensive vs. intensive methods; and with and without integrated multi-trophic aquaculture, IMTA. In addition to evaluating levels and sources of economic distress, interviewees were asked to identify mitigation solutions adopted at local / internal (i.e., farm-site) scales, and to express their preference on national / external scale mitigation measures among a set of a priori options. Survey responses identified the potential causes of disruption, ripple effects, sources of food insecurity, and socio-economic conflicts. They also pointed to various levels of mitigation strategies. The collated evidence represents a first baseline useful to address future disaster-driven responses, to reinforce the resilience of the sector and to facilitate the design reconstruction plans and mitigation measures, such as financial aid strategies.

Chronic Pain among Individuals Experiencing Homelessness and Its Interdependence with Opioid and Other Substance Use and Mental Illness

Chronic pain and substance use disorders are serious conditions that are prevalent among homeless populations. The aim of this study was to examine the association between chronic pain and substance use among individuals experiencing homelessness and mental illness. We analyzed cross-sectional data from two sites of the At Home/Chez Soi study (Vancouver and Toronto) using bivariate statistics and multivariate logistic regression. Substance use and chronic pain parameters were assessed with the Maudsley Addiction Profile and purpose-designed short instruments. The sample comprised 828 participants. Mean age was 42.4 years and 54% reported chronic pain. In bivariate analysis, chronic pain was significantly associated with use of opioids and stimulants, daily substance use, polysubstance use and injecting as route of administration. In multivariate analysis, only daily substance use (OR: 1.46, 95% CI: 1.02-2.09) and injecting (OR: 1.81, 95% CI: 1.08-3.05) remained as significant associated factors, whereas neither use of opioids nor use of stimulants specifically were significantly associated with chronic pain. Among participants with chronic pain, daily substance users (50% vs. 22%, p < 0.001) and injectors (66% vs. 24%, p < 0.001) were more likely to use non-prescribed medication for pain. Participants with daily substance use were less likely to receive professional treatment (52% vs. 64%, p = 0.017) and prescribed pain medication (42% vs. 54%, p = 0.023). Our findings suggest an association of chronic pain with patterns related to severity of substance use rather than to specific substance use in homeless persons with mental illness. Interventions aiming at prevention and treatment of chronic pain in this population should consider severity of substance use and associated risk behavior over use of specific substances.

Shifting North American drug markets and challenges for the system of care

Drug markets are dynamic systems which change based on demand, competition, legislation and revenue. Shifts that are not met with immediate and appropriate responses from the healthcare system can lead to public health crises with tragic levels of morbidity and mortality, as experienced Europe in the early 1990s and as is the case in North America currently. The major feature of the current drug market shift in North America is towards highly potent synthetic opioids such as fentanyl and fentanyl analogues. An additional spike in stimulant use further complicates this issue. Without understanding the ever-changing dynamics of drug markets and consequent patterns of drug use, the healthcare system will continue to be ineffective in its response, and morbidity and mortality will continue to increase. Economic perspectives are largely neglected in research and clinical contexts, but better treatment alternatives need to consider the large-scale macroeconomic conditions of drug markets as well as the behavioural economics of individual substance use. It is important for policy makers, health authorities, first responders and medical providers to be aware of the clinical implications of drug market changes in order to best serve people who use drugs. Only with significant clinical research, a comprehensive reorganization of the system of care across all sectors, and an evidence-driven governance, will we be successful in addressing the challenges brought on by the recent shifts in drug markets.

Early childhood trauma, substance use and complex concurrent disorders among adolescents

PURPOSE OF REVIEW

To highlight the interdependence between early childhood trauma, substance use and complex concurrent disorders among adolescents and discuss the delayed response and gaps in the healthcare system.

RECENT FINDINGS

High-risk behavior such as suicidality, self-harm and hazardous substance use including overdose and the use of psychotropic substances for self-medication of mental health challenges is a growing concern. These symptoms are often related to early childhood trauma, substance use and complex concurrent disorders. Most countries do not have a youth mental healthcare system, there are no specific guidelines and only few programs addressing high-risk substance use are in place.

SUMMARY

In addition to the significance of traumatic experience for high-risk substance use and addiction, most parts of the system of care ignore the trauma aspect in treatment of substance use and focus on abstinence. There are hardly any early intervention programs, broader prevention strategies or evidence-based or target-group-oriented treatment offers.

Opium tincture for opioid substitution treatment

Introduction

Opium tincture (OT) is widely used for opioid substitution treatment (OST) in Iran.

Objectives

To determine if OT is a safe and effective medication for OST.

Methods

Opium Trial was a multicenter, double‐blind, noninferiority randomized controlled trial, with 204 participants with opioid dependence in Iran. Participants were then randomized to OT or methadone arms with an allocation ratio of 1:1 and were followed for 12 weeks. The primary outcome was retention in treatment, compared between the two groups using both intention-To-Treat (ITT) and Per-Protocol (PP) analyses.

Results

A total of 70 participants (IT: 68.6%, PP: 69.3%) in methadone arm and 61 participants (ITT: 59.8%, PP: 60.4%) in OT arm remained in the treatment. The relative retention rate was 1.15 (0.97, 1.36) in both analyses in favour of methadone. A total of 46 out of 152 (30.3%) participants in OT arm and 83 out of 168 (49.4%) participants in methadone arm reported opioid use outside the treatment. The difference in these two proportions (OT - methadone) was 19%: (10%, 28%) in favour of OT. The proportion of patients with adverse events were not different between the two arms (P = 0.06). There was no serious AE in OT arm.

Conclusions

Opium tincture is a clinically effective and safe medication, but this study could not conclude if it was as equally effective as methadone in retaining participants in treatment, but it showed that OT was superior to methadone in reducing opioid use outside the treatment.

Disclosure

No significant relationships.

The impact of employment on recovery among individuals who are homeless with severe mental illness in the Vancouver At Home/Chez Soi trial

OBJECTIVE

To assess impact of employment on recovery in a sample of adults from Vancouver At Home (VAH) study, who were homeless and were diagnosed with severe mental disorders.

METHODS

The VAH included two randomized controlled trials investigating the effect of housing first with support intervention in vulnerable population. Employment was assessed at baseline and during the follow-up using Demographics, Housing, Vocational, and Service Use History (DSHH), and Vocational Timeline Follow-Back (VTLFB) self-report questionnaires, respectively. Recovery was examined using Recovery Assessment Scale (RAS) at baseline and at 24-month follow-up visit. Multivariable regression models were built to examine: (1) the effect of current employment at baseline on RAS score at baseline, and RAS score at 24-month follow-up visit; and (2) and to examine the cumulative effect of recent employment over 8 follow-up visits on RAS score at 24-month visit. Cumulative effect of employment over the follow-up visits was weighted by recency using a pre-specified weighting function.

RESULTS

Employment at baseline was associated with an increase in recovery score at baseline [8.06 (95% CI 1.21, 14.91); p = 0.02], but not with recovery score at 24-month follow-up visit [3.78 (-4.67, 12.24); p = 0.37]. Weighted cumulative effect of employment over 8 follow-up visits was associated with increase in RAS score at 24-month follow-up visit [8.33 (1.68, 14.99) p = 0.01].

CONCLUSION

Employment is associated with an increase in recovery. Our result suggests a dual effect of employment on recovery, an immediate effect through current employment, and a long-term effect of cumulative employment.

Electronic Mental Health as an Option for Egyptian Psychiatry: Cross-Sectional Study

BACKGROUND

Egypt is a country of nearly 100 million citizens, and there are less than 1000 registered psychiatrists. The mental health care system is under resourced and nearly inaccessible for the majority of the population. In addition, youth under the age of 25 years represent 50% of Egyptian citizens; however, there are no specific services addressing their unique needs. How can the needs of the largest population in the Middle East be effectively addressed? Is a web-based framework an option for Egyptian psychiatrists to serve the population?

OBJECTIVE

The aims of this study were to better understand the opinions of psychiatrists on the current state of mental health care services in Egypt and their current knowledge on electronic mental health (EMH); assess the attitudes of Egyptian psychiatrists toward web-based interventions and telemedicine for mental health; and identify perceived advantages and barriers of EMH development in Egypt.

METHODS

A cross-sectional survey was conducted online among 640 Egyptian psychiatrists. It included a total of 36 items within a set of 16 questions asking about EMH literacy, integrating EMH into the mental health care system, and the perceived priorities and barriers of EMH. The sampling was supported by Tanta University, a large academic institution close to Cairo. Statistical analysis was performed using SPSS 25 (IBM Corp). Descriptive statistics, the chi-square test, the independent sample t test, and analysis of variance were applied.

RESULTS

A total of 188 participants responded (response rate of 29.4%), of which 54.2% (102/188) were female and 54.3% (102/188) were between 30 and 45 years old. Less than half of the participants thought that the current health care system was efficient for adults (69/155, 44.4%), and even less thought it was efficient for youth (44/155, 28.3%). Almost all participants agreed that EMH would be beneficial for patient care (147/155, 94.8%) and that integrating EMH into the current health care system would be a good idea (118/155, 76.2%). The highest rated utility of web-based solutions was documentation, followed by psychoeducation and communication with professionals. The main advantages were to improve access to care in rural areas of the country and its convenience.

CONCLUSIONS

There is scarcity of mental health resources in Egypt. Egyptian psychiatrists are interested in EMH and believe web-based platforms can become part of the solution for the Egyptian mental health care system.

Endometriosis and the Fallopian Tubes: Theories of Origin and Clinical Implications

Endometriosis is a common, oestrogen driven chronic condition, where endometrium-like epithelial and stromal cells exist in ectopic sites. At present, no curative treatments are available and the existing evidence for disease progression is conflicting. The pathogenesis is still unknown and evidently complex, as mechanisms of initiation may depend on the anatomical distribution of endometriotic lesions. However, amongst the numerous theories and plethora of mechanisms, contributions of the fallopian tubes (FT) to endometriosis are rarely discussed. The FT are implicated in all endometriosis associated symptomatology and clinical consequences; they may contribute to the origin of endometriotic tissue, determine the sites for ectopic lesion establishment and act as conduits for the spread of proinflammatory media. Here, we examine the available evidence for the contribution of the human FT to the origin, pathogenesis and symptoms/clinical consequences of endometriosis. We also examine the broader topic linking endometriosis and the FT epithelium to the genesis of ovarian epithelial cancers. Further studies elucidating the distinct functional and phenotypical characteristics of FT mucosa may allow the development of novel treatment strategies for endometriosis that are potentially curative.

History of parenting instability and lifetime suicidal behavior in people who inject drugs

Despite high rates of suicide in people who inject drugs, little is known about the risk factors for suicide related to childhood and family history in this population. We aimed to explore the relationship between the history of out-of-home care (OHC) and lifetime suicide attempts among people who inject opioids. Participants (N = 202) were current injection opioid users with at least one previous episode of opioid maintenance treatment. They were recruited into a double-blind randomized controlled trial for opioid substitution treatment. Secondary analysis of baseline data was conducted from the European Addiction Severity Index and basic demographics questionnaires. A total of 81 (40%) participants reported a history of living in OHC and 27% reported attempting suicide. Participants who reported living in OHC were more likely to report lifetime suicide attempts compared to those who did not live in OHC. History of OHC and suicidal ideation were significant risk factors for suicide attempts adjusting for depression and anxiety. Highest rates of lifetime attempts were among participants who lived in a group home, foster care, and/or psychiatric facility. Living in OHC during childhood was significantly associated with higher rates of suicide attempts in our sample. Greater efforts should be made to provide children from vulnerable families with environments where stable one-to-one relationships can be cultivated.

Mobile Apps for Medication Management: Review and Analysis

Background

Pharmacotherapy remains one of the major interventional strategies in medicine. However, patients from all age groups and conditions face challenges when taking medications, such as integrating them into the daily routine, understanding their effects and side effects, and monitoring outcomes. In this context, a reliable medication management tool adaptable to the patient’s needs becomes critical. As most people have a mobile phone, mobile apps offer a platform for such a personalized support tool available on the go.

Objective

This study aimed to provide an overview of available mobile apps, focusing on those that help patients understand and take their medications. We reviewed the existing apps and provided suggestions for future development based on the concept understand and manage, instead of the conventional adhere to medication. This concept aims to engage and empower patients to be in charge of their health, as well as see medication as part of a broader clinical approach, working simultaneously with other types of interventions or lifestyle changes, to achieve optimal outcomes.

Methods

We performed a Web search in the iOS Apple App Store and Android Google Play Store, using 4 search terms: medication management, pill reminder, medication health monitor, and medication helper. We extracted information from the app store descriptions for each eligible app and categorized into the following characteristics: features, author affiliation, specialty, user interface, cost, and user rating. In addition, we conducted Google searches to obtain more information about the author affiliation.

Results

A total of 328 apps (175 Android and 153 iOS) were categorized. The majority of the apps were developed by the software industry (73%, 11/15), a minority of them were codeveloped by health care professionals (15%, 3/20) or academia (2.1%; 7/328). The most prevalent specialty was diabetes (23 apps). Only 7 apps focused on mental health, but their content was highly comprehensive in terms of features and had the highest prevalence of the education component. The most prevalent features were reminder, symptom tracker, and ability to share data with a family member or doctor. In addition, we highlighted the features considered innovative and listed practical suggestions for future development and innovations.

Conclusions

We identified detailed characteristics of the existing apps, with the aim of informing future app development. Ultimately, the goal was to provide users with effective mobile health solutions, which can be expected to improve their engagement in the treatment process and long-term well-being. This study also highlighted the need for improved standards for reporting on app stores. Furthermore, it underlined the need for a platform to offer health app users an ongoing evaluation of apps by health professionals in addition to other users and to provide them with tools to easily select an appropriate and trustworthy app.

Living With Dual Diagnosis and Homelessness: Marginalized Within a Marginalized Group

Objective: Concurrent mental and substance use disorders or dual diagnosis are highly prevalent among individuals experiencing homelessness. Studies have indicated that dual diagnosis leads to poorer health outcomes and higher health service utilization among those affected. This study aims to estimate the prevalence of dual diagnoses among homeless populations in British Columbia (BC), Canada, and understand their characteristics and specific factors associated with dual diagnoses. Methods: The BC Health of the Homeless Survey is a cross-sectional study involving the homeless population of three cities in BC. The survey assessed addiction and concurrent disorders with standardized interviews-the Mini-International Neuropsychiatric Interview Plus, the Maudsley Addiction Profile, and the Brief Symptom Inventory-in a sample of 500 individuals who are homeless living in shelters or on the street. We characterized individuals after categorizing them into four groups: those without any current mental disorder, those with substance use disorders only, those with mental disorders only, and those with concurrent substance use and mental disorders. Focusing on the concurrent disorder group, we completed a multivariate analysis comparing individuals with dual diagnosis to those without concurrent disorders. Results: Consistent with previous studies, we found that individuals with dual diagnoses report more severe physical and psychological symptoms. Among the homeless, they were more likely to be Aboriginal and younger and more likely to not make it into a shelter. They also reported substantially more difficulties in getting the health care service that they need. Conclusions: Within this marginalized group, individuals with dual diagnosis were more likely to be from groups considered to be more vulnerable with more complex needs. They were having more problems accessing even basic support, such as shelters and health care. Without a systematic approach in providing appropriate care to individuals with dual diagnosis, the most vulnerable clients are not only the ones likely to suffer the most but also the ones having the most problems meeting their basic needs.

Comparing opium tincture and methadone for medication-assisted treatment of patients with opioid use disorder: Protocol for a multicenter parallel group noninferiority double-blind randomized controlled trial

OBJECTIVES

This is the first study to compare the safety and efficacy of opium tincture (OT) with methadone for treatment of opioid use disorder.

METHODS

In this multicenter, double-blind, noninferiority controlled trial, a stratified sample of 204 participants with opioid use disorder were recruited from community outreach, drop-in centers, and triangular clinics. Participants were excluded in case of active participation in another treatment program for opioid use disorder, hypersensitivity to trial medications, pregnancy, and certain serious medical conditions. They were randomized to receive either OT or methadone with an allocation ratio of 1:1 using a patient-centered flexible dosing strategy. Eligible participants were followed for a period of 12 weeks. Primary outcome is the difference in percentage of patients retained in the treatment. Secondary outcomes are craving, withdrawal symptoms, physical health, mental health, quality of life, and severity of substance use problems, cognitive function, safety profile, cost-effectiveness, and participants' satisfaction. Both intention-to-treat and per-protocol analyses will be conducted. The Ethics Board of the University of British Columbia and Tehran University of Medical Sciences approved the study. (clinicaltrials.gov; NCT02502175).

RESULTS

To be reported after final analysis.

CONCLUSIONS

If shown to be effective, OT will diversify the options for medication-assisted treatment of opioid use disorder.

A Process Evaluation of a Web-Based Mental Health Portal (WalkAlong) Using Google Analytics

BACKGROUND

Despite the increasing amount of research on Web-based mental health interventions with proven efficacy, high attrition rates decrease their effectiveness. Continued process evaluations should be performed to maximize the target population's engagement. Google Analytics has been used to evaluate various health-related Web-based programs and may also be useful for Web-based mental health programs.

OBJECTIVE

The objective of our study was to evaluate WalkAlong.ca, a youth-oriented mental health web-portal, using Google Analytics to inform the improvement strategy for the platform and to demonstrate the use of Google Analytics as a tool for process evaluation of Web-based mental health interventions.

METHODS

Google Analytics was used to monitor user activity during WalkAlong's first year of operation (Nov 13, 2013-Nov 13, 2014). Selected Google Analytic variables were overall website engagement including pages visited per session, utilization rate of specific features, and user access mode and location.

RESULTS

The results included data from 3076 users viewing 29,299 pages. Users spent less average time on Mindsteps (0 minute 35 seconds) and self-exercises (1 minute 08 seconds), which are important self-help tools, compared with that on the Screener tool (3 minutes 4 seconds). Of all visitors, 82.3% (4378/5318) were desktop users, followed by 12.7 % (677/5318) mobile phone and 5.0% (263/5318) tablet users. Both direct traffic (access via URL) and referrals by email had more than 7 pages viewed per session and longer than average time of 6 minutes per session. The majority of users (67%) accessed the platform from Canada.

CONCLUSIONS

Engagement and feature utilization rates are higher among people who receive personal invitations to visit the site. Low utilization rates with specific features offer a starting place for further exploration of users in order to identify the root cause. The data provided by Google Analytics, although informative, can be supplemented by other evaluation methods (ie, qualitative methods) in order to better determine the modifications required to improve user engagement. Google Analytics can play a vital role in highlighting the preferences of those using Web-based mental health tools.

Chronic Pain Among Homeless Persons with Mental Illness

Objective

Chronic pain is an important public health issue. However, characteristics and needs of marginalized populations have received limited attention. Studies on prevalence and correlates of chronic pain among homeless persons are lacking. We assessed chronic pain among homeless persons with mental illness in the At Home/Chez Soi study.

Design

Cross-sectional data from a randomized controlled trial on homelessness and mental health.

Setting

Data collected between 2009 and 2013 in three Canadian cities.

Subjects

One thousand two hundred eighty-seven homeless persons with mental illness.

Methods

Data on chronic pain and utilization of prescribed and nonprescribed interventions was assessed using a chronic pain screening instrument. Mental illness was diagnosed with the Mini-International Neuropsychiatric Interview.

Results

Forty-three percent reported moderate to severe chronic pain, interfering with general daily activities (80%), sleep (78%), and social interactions (61%). Multivariate analysis indicated that increasing age and diagnoses of major depressive disorder, mood disorder with psychotic features, panic disorder, and post-traumatic stress disorder (PTSD) were independent predictors of chronic pain. Chronic pain was further associated with increased suicidality. Among participants reporting chronic pain, 64% had sought medical treatment and 56% treated pain with prescribed drugs, while 38% used illicit drugs for pain relief.

Conclusions

Chronic pain is very common among homeless persons with mental illness and affects activities of daily living. Clinicians treating this population should be aware of the common connections between chronic pain, depression, panic disorder, PTSD, and substance use. While the data indicate the contribution of chronic pain to complex treatment needs, they also indicate a clear treatment gap.

Tincture of opium for treating opioid dependence: a systematic review of safety and efficacy

BACKGROUND AND AIMS

Recently, there has been a growing interest in using opium tincture (OT) for treating opioid dependence in certain regions. We aimed to assess the evidence on its safety and efficacy for this indication.

METHODS

We searched several databases (CENTRAL, Medline, EMBASE, Web of Science, PsychINFO, ProQuest Dissertation and Theses Database, Iran Medex, clinicaltrials.gov and who.int/trialsearch) with no language or publication date limitations. Two reviewers selected randomized controlled trials (RCT), cohort/case-control/cross-sectional studies and case-series on safety or efficacy of OT for treating opioid dependence and then extracted reported measures of mentioned outcomes from selected studies. We used the Effective Public Health Practice Project (EPHPP) Quality Assessment tool for appraisal.

RESULTS

From nine selected studies; in three RCTs and one cohort analytical analysis on detoxification, 110 patients were treated with 15-140 morphine equivalents/day (mEq/d) of OT; in four prospective and one retrospective uncontrolled case-series on long-term/maintenance treatment, 570 patients were treated with 100-400 mEq/d of OT. Only two studies on detoxification included a comparison: one concluded equal efficacy of OT and methadone in suppressing withdrawal symptoms (P = 0.32) and the other concluded OT to be less efficacious than buprenorphine/naloxone in suppressing withdrawal [OT = 12.20, 95% confidence interval (CI) = 11.00, 13.40]; control: 5.20 (95% CI = 4.69, 5.71) and craving (OT = 303.0, 95% CI = -144.664, 750.664; control: 0.0) but not significantly different (P = 0.26) in retaining participants in treatment. No major adverse events were reported.

CONCLUSIONS

Conclusive recommendations about the safety and efficacy of opium tincture for treating opioid dependence are not possible at this time.