Now showing 1 - 10 of 14
  • Publication
    Eligibility for heroin-assisted treatment (HAT) among people who inject opioids and are living with HIV in a Canadian setting
    Objectives: A growing body of evidence supports the effectiveness of injectable diacetylmorphine (i.e., heroin) for individuals with treatment-refractory opioid use disorder. Despite this evidence, and the increasing toll of opioid-associated morbidity and mortality, it remains controversial in some settings. To investigate the possible contribution of heroin-assisted treatment (HAT) to HIV treatment-related outcomes, we sought to estimate the proportion and characteristics of HIV-positive people who inject opioids that might be eligible for HAT in Vancouver, Canada. Methods: We used data from a prospective cohort of people living with HIV who use illicit drugs in Vancouver, Canada. Using generalized estimating equations (GEE), we assessed the longitudinal relationships between eligibility for HAT, using criteria from previous clinical trials and guidelines, with behavioural, social, and clinical characteristics. Results: Between 2005 and 2014, 478 participants were included in these analyses, contributing 1927 person-years of observation. Of those, 94 (19.7%) met eligibility for HAT at least once during the study period. In a multivariable GEE model, after adjusting for clinical characteristics, being eligible for HAT was positively associated with homelessness, female gender, high-intensity illicit drug use, drug dealing and higher CD4 count. Conclusions: In our study of HIV-positive people with a history of injection drug use, approximately 20% of participants were eligible for HAT at ≥ 1 follow-up period. Eligibility was linked to risk factors for sub-optimal HIV/AIDS treatment outcomes, such as homelessness and involvement in the local illicit drug trade, suggesting that scaling-up access to HAT might contribute to achieving optimal HIV treatment in this setting.
    Scopus© Citations 5  341
  • Publication
    Implementation of a regional quality improvement collaborative to improve care of people living with opioid use disorder in a Canadian setting
    Background: Although opioid agonist therapy is effective in treating opioid use disorders (OUD), retention in opioid agonist therapy is suboptimal, in part, due to quality of care issues. Therefore, we sought to describe the planning and implementation of a quality improvement initiative aimed at closing gaps in care for people living with OUD through changes to workflow and care processes in Vancouver, Canada. Methods: The Best-practice in Oral Opioid agoniSt Therapy (BOOST) Collaborative followed the Institute for Healthcare Improvement's Breakthrough Series Collaborative methodology over 18-months. Teams participated in a series of activities and events to support implementing, measuring, and sharing best practices in OAT and OUD care. Teams were assigned monthly implementation scores to monitor their progress on meeting Collaborative aims and implementing changes. Results: Seventeen health care teams from a range of health care practices caring for a total of 4301 patients with a documented diagnosis of OUD, or suspected OUD based on electronic medical record chart data participated in the Collaborative. Teams followed the Breakthrough Series Collaborative methodology closely and reported monthly on a series of standardized process and outcome indicators. The majority of (59%) teams showed some improvement throughout the Collaborative as indicated by implementation scores. Conclusions: Descriptive data from the evaluation of this initiative illustrates its success. It provides further evidence to support the implementation of quality improvement interventions to close gaps in OUD care processes and treatment outcomes for people living with OUD. This system-level approach has been spread across British Columbia and could be used by other jurisdictions facing similar overdose crises.
      266Scopus© Citations 6
  • Publication
    Excellent reliability and validity of the Addiction Medicine Training Need Assessment Scale across four countries
    Background: Addiction is a context specific but common and devastating condition. Though several evidence-based treatments are available, many of them remain under-utilized, among others due to the lack of adequate training in addiction medicine (AM). AM Training needs may differ across countries because of difference in discipline and level of prior AM training or contextual factors like epidemiology and availability of treatment. For appropriate testing of training needs, reliability and validity are key issues. The aim of this study was to evaluate the psychometric properties of the AM-TNA Scale: an instrument specifically designed to develop the competence-based curriculum of the Indonesian AM course. Methods: In a cross-sectional study in Indonesia, Ireland, Lithuania and the Netherlands the AM-TNA was distributed among a convenience sample of health professionals working in addiction care in The Netherlands, Lithuania, Indonesia and General Practitioners in-training in Ireland. 428 respondents completed the AM-TNA scale. To assess the factor structure, we used explorative factor analysis. Reliability was tested using Cronbach's Alpha, ANOVA determined the discriminative validity. Results: Validity: factor analysis revealed a two-factor structure: One on providing direct patient treatment and care (Factor 1: clinical) and one factor on facilitating/supporting direct patient treatment and care (Factor 2: non-clinical) AM competencies and a cumulative 76% explained variance. Reliability: Factor 1 α = 0.983 and Factor 2: α = 0.956, while overall reliability was (α = 0.986). The AM-TNA was able to differentiate training needs across groups of AM professionals on all 30 addiction medicine competencies (P =.001). Conclusions: In our study the AM-TNA scale had a strong two-factor structure and proofed to be a reliable and valid instrument. The next step should be the testing external validity, strengthening discriminant validity and assessing the re-test effect and measuring changes over time.
    Scopus© Citations 6  493
  • Publication
    Large Variation in Provincial Guidelines for Urine Drug Screening During Opioid Agonist Treatment in Canada
    Urine drug screening (UDS) is commonly used to detect or validate self-reported substance use, particularly when beginning and maintaining opioid agonist therapy. However, there is currently no summary of the published clinical practice guidelines for UDS in Canada, and no measure of the consistency with which different provinces suggest administering UDS. Therefore, we conducted a policy scan of UDS guidelines, examining the published clinical practice guidelines for each Canadian province and extracting all relevant data in March 2017. Our Canadian guideline and policy scan found that UDS frequency recommendations vary greatly among Provinces for persons receiving opioid agonist therapy for opioid use disorder.
      359Scopus© Citations 6
  • Publication
    Slow release oral morphine versus methadone for the treatment of opioid use disorder
    Objective: To assess the efficacy of Slow release oral morphine (SROM) as a treatment for opioid use disorder. Design: Systematic review and meta-analysis of randomized controlled trials (RCT). Data sources: Three electronic databases were searched through May 1st, 2018: the Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE. We also searched the following electronic registers for ongoing trials: ClinicalTrials.gov, World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), Current Controlled Trials, and the EU Clinical Trials Register. Eligibility criteria for selecting studies: We included RCTs of any duration, assessing the effect of SROM on measures of treatment retention, heroin use and craving in adults who met the diagnostic criteria for opioid use disorder. Data extraction and synthesis: Two independent reviewers extracted data and assessed risk of bias. Data were pooled using the random-effects model and expressed as Risk Ratios (RR) or mean differences (MDs) with 95% CIs. Heterogeneity was assessed (chi-squared statistic) and quantified (I2 statistic) and a sensitivity analysis was undertaken to assess the impact of particular high-risk trials. Results: Among 1315 records screened and four studies reviewed, four unique randomized trials met inclusion criteria (n = 471), and compared SROM with methadone. In the meta-analysis, we observed no significant differences between SROM and methadone in improving treatment retention (risk ratio [RR] = 0.98; 95% Confidence Interval [CI]: 0.94 - 1.02, p = 0.34), and heroin use (RR = 0.96; 95% CI: 0.61- 1.52, p = 0.86). Craving data was not amenable to meta-analysis. Available data implied no differences in adverse events, heroin, cocaine, or benzodiazepine use. Conclusions: Meta-analysis of existing randomized trials suggests SROM may be generally equal to methadone in retaining patients in treatment and reducing heroin use as methadone while potentially resulting in less craving. The methodological quality of the included RCTs was low-to-moderate.
    Scopus© Citations 37  294
  • Publication
    Closing the gap between training needs and training provision in addiction medicine
    Substance use disorders pose a significant global social and economic burden. Although effective interventions exist, treatment coverage remains limited. The lack of an adequately trained workforce is one of the prominent reasons. Recent initiatives have been taken worldwide to improve training, but further efforts are required to build curricula that are internationally applicable. We believe that the training needs of professionals in the area have not yet been explored in sufficient detail. We propose that a peer-led survey to assess those needs, using a standardised structured tool, would help to overcome this deficiency. The findings from such a survey could be used to develop a core set of competencies which is sufficiently flexible in its implementation to address the specific needs of the wide range of professionals working in addiction medicine worldwide.
    Scopus© Citations 7  286
  • Publication
    Factors associated with discontinuation of methadone maintenance therapy (MMT) among persons who also use alcohol in Vancouver, Canada
    Background We sought to examine the factors associated with discontinuation of MMT among persons on methadone who use alcohol. Methods We evaluated the impact of drug-related and other factors on discontinuation of MMT among persons enrolled in MMT and who reported any use of alcohol versus those who were enrolled in two community-recruited prospective cohorts of people who use illicit drugs (PWUD). Extended Cox models with time-dependent variables identified factors independently associated with time to first MMT discontinuation. Results Between December 2005 and 2015, 823 individuals on MMT who also reported using alcohol at least once were included in these analyses. During the study period, 391 (47.5%) discontinued methadone. Daily heroin injection (Adjusted Hazard Ratio [AHR] = 2.67, 95% Confidence Interval [CI]: 2.10–3.40) and homelessness (AHR = 1.42, 95% CI: 1.10–1.83) were positively associated with MMT discontinuation, whereas receiving other concurrent addiction treatment in addition to MMT (AHR = 0.07, 95% CI: 0.05–0.08), as well as >60 mg methadone dose (AHR = 0.48, 95% CI: 0.39–0.60), Hepatitis C virus seropositivity (AHR = 0.65, 95% CI: 0.47–0.90), and HIV seropositivity (AHR = 0.72, 95% CI: 0.57–0.91) were negatively associated with MMT discontinuation. Any/heavy alcohol use was not independently associated with MMT discontinuation. Conclusions This study reinforces the known risks of continued heroin injection and homelessness for MMT discontinuation among individuals who also consume alcohol and highlights the protective effect of both MMT dose and receipt of concurrent addiction treatment.
    Scopus© Citations 9  277
  • Publication
    In-hospital training in addiction medicine: A mixed-methods study of health care provider benefits and differences
    Background: Hospital-based clinical addiction medicine training can improve knowledge of clinical care for substance-using populations. However, application of structured, self-assessment tools to evaluate differences in knowledge gained by learners who participate in such training has not yet been addressed. Methods: Participants (n = 142) of an elective with the hospital-based Addiction Medicine Consult Team (AMCT) in Vancouver, Canada, responded to an online self-evaluation survey before and immediately after the structured elective. Areas covered included substance use screening, history taking, signs and symptoms examination, withdrawal treatment, relapse prevention, nicotine use disorders, opioid use disorders, safe prescribing, and the biology of substance use disorders. A purposefully selected sample of 18 trainees were invited to participate in qualitative interviews that elicited feedback on the rotation. Results: Of 168 invited trainees, 142 (84.5%) completed both pre- and post-rotation self-assessments between May 2015 and May 2017. Follow-up participants included medical students, residents, addiction medicine fellows, and family physicians in practice. Self-assessed knowledge of addiction medicine increased significantly post-rotation (mean difference in scores = 11.87 out of the maximum possible 63 points, standard deviation = 17.00; P < .0001). Medical students were found to have the most significant improvement in addiction knowledge (estimated mean difference = 4.43, 95% confidence interval = 0.76, 8.09; P = .018). Illustrative quotes describe the dynamics involved in the learning process among trainees. Conclusions: Completion of a hospital-based clinical elective was associated with improved knowledge of addiction medicine. Medical students appear to benefit more from the addiction elective with a hospital-based AMCT than other types of learners.
    Scopus© Citations 8  288
  • Publication
    What Are the Self-Assessed Training Needs of Early Career Professionals in Addiction Medicine? A BEME Focused Review
    (Association for Medical Education in Europe (AMEE), 2020-04-03) ; ; ; ; ;
    Background: Substance use disorders represent a significant social and economic burden globally. Accurate diagnosis and treatment by early career professionals in addiction medicine (ECPAM) falls short, in part, due to a lack of training programmes targeting this career stage. Prior research has highlighted the need to assess the specific training needs of ECPAM. Therefore, this focused review assessed self-reported training needs of ECPAM. Methods: Medical and medical education databases (Medline, EMBASE, CINAHL, ERIC, PSYCHInfo, BEI, and AEI) were searched to June 2018 for studies reporting self-reported training needs of ECPAM (trained at most five years before assessment occurred). Retrieved citations were screened for eligibility; two independent researchers reviewed included studies, assessed quality and extracted data. Experts reviewed study findings. Results: Of 1364 identified records, three cross-sectional studies were included, originating from China, USA and England. All studies surveyed ECPAM using self-reported questionnaires, with one study including face-to-face interviews. Participants included residents, physicians and social workers. All studies had a low risk of bias, and reported a wide range of training needs including rehabilitation, relapse prevention, buprenorphine treatment and risk assessment. Conclusions: There is little evidence for and substantial heterogeneity of training needs of ECPAM found in this review, particularly at the level of skills and knowledge. Study quality varies greatly. ECPAM training needs assessments are a priority.
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  • Publication
    Treatment of stimulant use disorder: A systematic review of reviews
    (Public Library of Science (PLoS), 2020-06-18) ; ; ; ;
    AIMS:Stimulant use disorder contributes to a substantial worldwide burden of disease, although evidence-based treatment options are limited. This systematic review of reviews aims to: (i) synthesize the available evidence on both psychosocial and pharmacological interventions for the treatment of stimulant use disorder; (ii) identify the most effective therapies to guide clinical practice, and (iii) highlight gaps for future study. METHODS:A systematic database search was conducted to identify systematic reviews and meta-analyses. Eligible studies were those that followed standard systematic review methodology and assessed randomized controlled trials focused on the efficacy of interventions for stimulant use disorder. Articles were critically appraised using an assessment tool adapted from Palmeteer et al. and categorized for quality as 'core' or 'supplementary' reviews. Evidence from the included reviews were further synthesized according to pharmacological or non-pharmacological management themes. RESULTS:Of 476 identified records, 29 systematic reviews examining eleven intervention modalities were included. The interventions identified include: contingency management, cognitive behavioural therapy, acupuncture, antidepressants, dopamine agonists, antipsychotics, anticonvulsants, disulfiram, opioid agonists, N-Acetylcysteine, and psychostimulants. There was sufficient evidence to support the efficacy of contingency management programs for treatment of stimulant use disorder. Psychostimulants, n-acetylcysteine, opioid agonist therapy, disulfiram and antidepressant pharmacological interventions were found to have insufficient evidence to support or discount their use. Results of this review do not support the use of all other treatment options. CONCLUSIONS:The results of this review supports the use of contingency management interventions for the treatment of stimulant use disorder. Although evidence to date is insufficient to support the clinical use of psychostimulants, our results demonstrate potential for future research in this area. Given the urgent need for effective pharmacological treatments for stimulant use disorder, high-quality primary research focused on the role of psychostimulant medications for the treatment of stimulant use disorder is needed.
    Scopus© Citations 96  271