Cannabis use in patients treated for opioid use disorder pre- and post-recreational cannabis legalization in Canada

Background

As the legalization of recreational cannabis becomes more widespread, its impact on individuals with substance use disorders must be studied. Amidst an ongoing opioid crisis, Canada’s legalization of recreational cannabis in October 2018 provides an important setting for investigation. We examined changes to cannabis use patterns in patients receiving medication-assisted treatment (MAT) for opioid use disorder (OUD) following legalization.

Methods

This study includes cross-sectional data from 602 participants recruited 6 months pre-legalization and 788 participants recruited 6 months post-legalization, providing information on cannabis use. Regression analysis was used to estimate the association between legalization and cannabis use patterns. We collected longitudinal urine drug screens (UDSs) detecting cannabis-metabolites for 199 participants recruited pre-legalization and followed prospectively post-legalization. Conditional logistic regression was used to assess the association between legalization and UDS results.

Results

Past-month cannabis use was self-reported by 54.8 and 52.3% of participants recruited pre- and post-legalization, respectively. Legalization was not associated with changes in any measured cannabis characteristics: cannabis use (OR 0.91, 95% CI 0.73–1.13), days of use/month (B -0.42, 95% CI - 2.05-1.21), money spent, or cannabis source. There was no association between legalization and prevalence of cannabis use on UDS (OR 1.67, 95% CI 0.93–2.99) or percentage of cannabis-positive UDSs (OR 1.00, 95% CI 0.99–1.01). Participants overwhelmingly reported that legalization would have no impact on their cannabis use (85.7%).

Conclusions

Amongst patients treated for OUD, no significant change in cannabis use was observed following legalization; however, high rates of cannabis use are noted.

Are patients' goals in treatment associated with expected treatment outcomes? Findings from a mixed-methods study on outpatient pharmacological treatment for opioid use disorder

OBJECTIVES

Existing methods of measuring effectiveness of pharmacological treatment for opioid use disorder (OUD) are highly variable. Therefore, understanding patients' treatment goals is an integral part of patient-centred care. Our objective is to explore whether patients' treatment goals align with a frequently used clinical outcome, opioid abstinence.

DESIGN

Triangulation mixed-methods design.

SETTING AND PARTICIPANTS

We collected prospective data from 2030 participants who were receiving methadone or buprenorphine-naloxone treatment for a diagnosis of OUD in order to meet study inclusion criteria. Participants were recruited from 45 centrally-managed outpatient opioid agonist therapy clinics in Ontario, Canada. At study entry, we asked, 'What are your goals in treatment?' and used NVivo software to identify common themes.

PRIMARY OUTCOME MEASURE

Urine drug screens (UDS) were collected for 3 months post-study enrolment in order to identify abstinence versus ongoing opioid use (mean number of UDS over 3 months=12.6, SD=5.3). We used logistic regression to examine the association between treatment goals and opioid abstinence.

RESULTS

Participants had a mean age of 39.2 years (SD=10.7), 44% were women and median duration in treatment was 2.6 years (IQR 5.2). Six overarching goals were identified from patient responses, including 'stop or taper off of treatment' (68%), 'stay or get clean' (37%) and 'live a normal life' (14%). Participants reporting the goal 'stay or get clean' had lower odds of abstinence at 3 months than those who did not report this goal (OR=0.73, 95% CI 0.59 to 0.91, p=0.005). Although the majority of patients wanted to taper off or stop medication, this goal was not associated with opioid abstinence, nor were any of their other goals.

CONCLUSIONS

Patient goals in OUD treatment do not appear to be associated with programme measures of outcome (ie, abstinence from opioids). Future studies are needed to examine outcomes related to patient-reported treatment goals found in our study; pain management, employment, and stopping/tapering treatment should all be explored.

Treatment of alcohol use disorder among people of South Asian ancestry in Canada and the United States: A narrative review

To explore access and treatment for alcohol use disorders (AUDs) among people of South Asian ancestry living in Canada or the United State, EQUATOR guidelines were applied to 34 manuscripts identified through an English language literature search (1946-2017) for this narrative review. The population studied has poor access to and engagement with treatment for AUD. Early evidence suggests benefit from adopting language-specific materials, offering South Asian-specific therapy groups, and incorporating traditional healers. Specific engagement and therapy considerations may increase AUD treatment access and effectiveness among South Asians living in Canada or the United States.

Identifying patient-important outcomes in medication-assisted treatment for opioid use disorder patients: a systematic review protocol

INTRODUCTION

Illicit opioid use has become a national crisis in Canada, with over 65 000 people seeking treatment for opioid use disorder (OUD) in Ontario and British Columbia alone. Medication-assisted treatment (MAT) is a common treatment for OUD. There is substantial variability in treatment outcomes used to evaluate effectiveness of MAT, making it difficult to establish clinically and scientifically relevant treatment effect. Furthermore, patients are often excluded from the process of determining these outcomes. The primary objective of this review is to examine outcomes currently used to measure MAT effectiveness and to identify patient-relevant outcomes to enhance effectiveness of treatment options. This review refers to patient-important outcomes as those outcomes patients consider important to or markers of treatment success.

METHODS AND ANALYSIS

MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Web of Science, Cochrane Library, Cochrane Clinical Trials Registry, National Institutes for Health Clinical Trials Registry and WHO International Clinical Trials Registry Platform databases will be searched. We will search databases from inception to the date the search is ran. Studies of interest include those evaluating the effectiveness of MAT for patients with OUD, with or without consultation with patients regarding what they consider to be important as an indicator of treatment success. Results will be analysed using thematic analysis and qualitative analysis where possible. This will result in comprehensive synthesis of all outcomes and measures found related to OUD treatment effectiveness.

ETHICS AND DISSEMINATION

We are collaborating with Canadian Addiction Treatment Centres which provide MAT to patients with OUD who will participate in disseminating study results. Dissemination strategies will involve sharing study results through workshops, presentations, peer-reviewed publications, study reports, community presentations and resources in primary care settings.

PROSPERO REGISTRATION NUMBER

CRD42018095553.

Hospitalization among street-involved youth who use illicit drugs in Vancouver, Canada: a longitudinal analysis

Background

Street-involved youth who use illicit drugs are at high risk for health-related harms; however, the profile of youth at greatest risk of hospitalization has not been well described. We sought to characterize hospitalization among street-involved youth who use illicit drugs and identify the most frequent medical reasons for hospitalization among this population.

Methods

From January 2005 to May 2016, data were collected from the At-Risk Youth Study (ARYS), a prospective cohort study of street-involved youth in Vancouver, Canada. Multivariable generalized estimating equation (GEE) was used to identify factors associated with hospitalization.

Results

Among 1216 participants, 373 (30.7%) individuals reported hospitalization in the previous 6 months at some point during the study period. The top three reported medical reasons for hospital admission were the following: mental illness (37.77%), physical trauma (12.77%), and drug-related issues (12.59%). Factors significantly associated with hospitalization were the following: past diagnosis of a mental illness (adjusted odds ratio [AOR] = 1.85; 95% confidence interval [95% CI] 1.47–2.33), frequent cocaine use (AOR = 2.15; 95% CI 1.37–3.37), non-fatal overdose (AOR = 1.76; 95% CI 1.37–2.25), and homelessness (AOR = 1.40; 95% CI 1.16–1.68) (all p < 0.05).

Conclusions

Findings suggest that mental illness is a key driver of hospitalization among our sample. Comprehensive approaches to mental health and substance use in addition to stable housing offer promising opportunities to decrease hospitalization among this vulnerable population.

Barriers and facilitators to implementing addiction medicine fellowships: a qualitative study with fellows, medical students, residents and preceptors

Background

Although progress in science has driven advances in addiction medicine, this subject has not been adequately taught to medical trainees and physicians. As a result, there has been poor integration of evidence-based practices in addiction medicine into physician training which has impeded addiction treatment and care. Recently, a number of training initiatives have emerged internationally, including the addiction medicine fellowships in Vancouver, Canada. This study was undertaken to examine barriers and facilitators of implementing addiction medicine fellowships.

Methods

We interviewed trainees and faculty from clinical and research training programmes in addiction medicine at St Paul’s Hospital in Vancouver, Canada (N = 26) about barriers and facilitators to implementation of physician training in addiction medicine. We included medical students, residents, fellows and supervising physicians from a variety of specialities. We analysed interview transcripts thematically by using NVivo software.

Results

We identified six domains relating to training implementation: (1) organisational, (2) structural, (3) teacher, (4) learner, (5) patient and (6) community related variables either hindered or fostered addiction medicine education, depending on context. Human resources, variety of rotations, peer support and mentoring fostered implementation of addiction training. Money, time and space limitations hindered implementation. Participant accounts underscored how faculty and staff facilitated the implementation of both the clinical and the research training.

Conclusions

Implementation of addiction medicine fellowships appears feasible, although a number of barriers exist. Research into factors within the local/practice environment that shape delivery of education to ensure consistent and quality education scale-up is a priority.

Two birds with one stone: experiences of combining clinical and research training in addiction medicine

BACKGROUND

Despite a large evidence-base upon which to base clinical practice, most health systems have not combined the training of healthcare providers in addiction medicine and research. As such, addiction care is often lacking, or not based on evidence or best practices. We undertook a qualitative study to assess the experiences of physicians who completed a clinician-scientist training programme in addiction medicine within a hospital setting.

METHODS

We interviewed physicians from the St. Paul's Hospital Goldcorp Addiction Medicine Fellowship and learners from the hospital's academic Addiction Medicine Consult Team in Vancouver, Canada (N = 26). They included psychiatrists, internal medicine and family medicine physicians, faculty, mentors, medical students and residents. All received both addiction medicine and research training. Drawing on Kirkpatrick's model of evaluating training programmes, we analysed the interviews thematically using qualitative data analysis software (Nvivo 10).

RESULTS

We identified five themes relating to learning experience that were influential: (i) attitude, (ii) knowledge, (iii) skill, (iv) behaviour and (v) patient outcome. The presence of a supportive learning environment, flexibility in time lines, highly structured rotations, and clear guidance regarding development of research products facilitated clinician-scientist training. Competing priorities, including clinical and family responsibilities, hindered training.

CONCLUSIONS

Combined training in addiction medicine and research is feasible and acceptable for current doctors and physicians in training. However, there are important barriers to overcome and improved understanding of the experience of addiction physicians in the clinician-scientist track is required to improve curricula and research productivity.

Impact of incarceration on rates of methadone use in a community recruited cohort of injection drug users

BACKGROUND

Despite barriers to its use in many settings, opioid agonist therapy with methadone has become the standard of care for treating opioid (e.g. heroin) use disorder. Since people with opioid use disorders have an increased incidence of incarceration, we undertook the present study to evaluate the association between incarceration and methadone maintenance therapy among a cohort of injection drug users in a Canadian setting.

METHODS

A cohort of people who inject drugs was prospectively followed between May 1996 and May 2013 in Vancouver, Canada. We investigated the relationship between recent incarceration and methadone use using multivariate generalized estimating equation (GEE) logistic regression analysis.

RESULTS

Overall, 2758 individuals were recruited during the study period and followed for a median of 64 (interquartile range: 23-106) months. After adjusting for various potential confounders in the multivariate GEE model, being incarcerated remained independently associated with a lower likelihood of having received methadone treatment (Adjusted Odds Ratio: 0.87, 95% confidence interval: 0.81-0.93).

CONCLUSIONS

Our study demonstrates that incarceration was independently associated with a significantly lower likelihood of being on methadone. Given the role of methadone in reducing the harms of heroin use, including drug acquisitive crime and recidivism, these data suggest a need to scale-up methadone provision for incarcerated injection drug users.

Gender influences on hepatitis C incidence among street youth in a Canadian setting

PURPOSE

Few studies have examined gender-based differences in the risk of hepatitis C virus (HCV) infection among street-involved youth. We compared rates of HCV infection among male and female street-involved youth in a Canadian setting.

METHODS

The At-Risk Youth Study is a prospective cohort of drug-using street-involved youth. Study recruitment and follow-up occurred in Vancouver, Canada, between September 2005 and November 2011. Eligible participants were illicit drug-using youth aged 14-26 years at enrollment, recruited by street-based outreach. We evaluated rates of HCV antibody seroconversion, measured every 6 months during study follow-up, and used Cox proportional hazards regression to compare risk factors for HCV incidence between male and female street youth.

RESULTS

Among 512 HCV-seronegative youth contributing 836 person-years of follow-up, 56 (10.9%) seroconverted to HCV. Among female participants, the incidence density of HCV infection was 10.9 per 100 person-years, and in males, it was 5.1 per 100 person-years (p = .009). In multivariate analyses, female gender was independently associated with a higher rate of HCV seroconversion (adjusted hazard ratio, 2.01; 95% confidence interval, 1.18-3.44). Risk factors were similar in gender-stratified analyses and included heroin injection and crystal methamphetamine injection, although syringe sharing was only associated with HCV incidence among males.

CONCLUSIONS

Among street-involved youth in this setting, females had double the incidence of HCV seroconversion demonstrating the need for gender-focused HCV prevention interventions for this population.

A physician peer support writing group

BACKGROUND AND OBJECTIVES

Barriers to publication can be overcome through a peer support writing group in an academic department of family practice. This study describes the experience and outcomes of a writing group in a family practice department.

METHODS

A writing group was established to provide collaboration in identifying potential research and/or writing projects, to assist individual faculty to complete unfinished work for submission, to match journals appropriate to the individual group member's work, and to provide peer support for faculty members through attention to group process. Resource materials included instructions for authors for various journals and writing support literature. Minutes were taken at each meeting, and the manuscripts presented were tracked. Individual publication records in CVs and citations in Index Medicus were used to generate pre-group and post-group publication records for group participants and nonparticipants.

RESULTS

The writing group met 23 times in 36 months. Attendance ranged from 3 to 10 participants. Fifty writing projects were discussed, and 12 of the discussed manuscripts were published in indexed journals. The seven most frequent attendees increased their publications as first author from one publication over the 3 years prior to the writing group to 10 publications over the first 3 years of the writing group. Comparison of the attendees' publication records with nonparticipant members of the department demonstrated an increase in publication success for participants.

CONCLUSIONS

A peer support writing group, emphasizing group process and respectful collaboration, has increased the publication frequency of faculty in a Canadian department of family practice.

Alterations in electrical pain thresholds by use of acupuncture-like transcutaneous electrical nerve stimulation in pain-free subjects

Acupuncture-like transcutaneous electrical nerve stimulation (ALTENS) was compared with a placebo treatment in altering acute electrical pain thresholds. Ten pain-free subjects underwent, on different days, an acclimatization session, an ALTENS treatment, and a placebo treatment in a cross-over design. Electrical sensation and pain thresholds were measured from the tip of the index finger bilaterally at 15-minute intervals twice before, once during, and three times after a 30-minute treatment session. The ALTENS treatment was given at 4 Hz at an intensity just below pain threshold delivered to acupuncture points in the hand and wrist. The placebo treatment was similarly delivered, except that the intensity of stimulation was just above sensation threshold. Neither the ALTENS treatment nor the placebo treatment produced a significant change in pain threshold. There was no correlation between initial pain threshold and change in pain threshold. Implications for the modulation of pain are discussed.