[Show abstract][Hide abstract] ABSTRACT: The non-medical use of prescription opioids (PO) has increased dramatically in North America. Special consideration for PO prescription is required for individuals in methadone maintenance treatment (MMT). Our objective is to describe the prevalence and correlates of PO use among British Columbia (BC) MMT clients from 1996 to 2007.
This study was based on a linked, population-level medication dispensation database. All individuals receiving 30 days of continuous MMT for opioid dependence were included in the study. Key measurements included the proportion of clients receiving >7 days of a PO other than methadone during MMT from 1996 to 2007. Factors independently associated with PO co-prescription during MMT were assessed using generalized linear mixed effects regression.
16,248 individuals with 27,919 MMT episodes at least 30 days in duration were identified for the study period. Among them, 5,552 individuals (34.2%) received a total of 290,543 PO co-prescriptions during MMT. The majority (74.3%) of all PO dispensations >7 days originated from non-MMT physicians. The number of PO prescriptions per person-year nearly doubled between 1996 and 2006, driven by increases in morphine, hydromorphone and oxycodone dispensations. PO co-prescription was positively associated with female gender, older age, higher levels of medical co-morbidity as well as higher MMT dosage, adherence, and retention.
A large proportion of MMT clients in BC received co-occurring PO prescriptions, often from physicians and pharmacies not delivering MMT. Experimental evidence for the treatment of pain in MMT clients is required to guide clinical practice. (Am J Addict 2014;23:257-264).
American Journal on Addictions 05/2014; 23(3):257-64. · 1.74 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective: Attention to knowledge translation (KT) has increased in the health care field in an effort to improve uptake and implementation of potentially beneficial knowledge. Weprovide an overview of the current state of KT literature and discuss the relevance of KT for health care professionals working in mental health.
Method: A systematic search was conducted using MEDLINE, PsycINFO, and CINAHL databases to identify review articles published in journals from 2007 to 2012. We selected articles on the basis of eligibility criteria and then added further articles deemed pertinent to the focus of our paper.
Results: After removing duplicates, we scanned 214 review articles for relevance and, subsequently, we added 46 articles identified through hand searches of reference lists or from other sources. A total of 61 papers were retained for full review. Qualitative synthesis identified 5 main themes: defining KT and development of KT science; effective KT strategies; factors influencing the effectiveness of KT; KT frameworks and guides; and relevance of KT to health care providers.
Conclusions: Despite limitations in existing evidence, the concept and practice of KT holds potential value for mental health care providers. Understanding of, and familiarity with, effective approaches to KT holds the potential to enhance providers’ treatment approaches and to promote the use of new knowledge in practice to enhance outcomes.
Canadian journal of psychiatry. Revue canadienne de psychiatrie 03/2014; 59(3):160. · 2.48 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Prescription opioid analgesic (POA) utilization has steeply increased globally, yet is far higher in established market economies than elsewhere. Canada features the world's second-highest POA consumption rates. Following increases in POA-related harm, several POA control interventions have been implemented since 2010.
We examined trends and patterns in POA dispensing in Canada by province for 2005-2012, including a focus on the potential effects of interventions. Data on annual dispensing of individual POA formulations - categorized into 'weak opioids' and 'strong opioids' - from a representative sub-sample of 5,700 retail pharmacies across Canada (from IMS Brogan's Compuscript) were converted into Defined Daily Doses (DDD), and examined intra- and inter-provincially as well as for Canada (total).
Total POA dispensing - driven by strong opioids - increased across Canada until 2011; four provinces indicated decreases in strong opioid dispensing; seven provinces indicated decreases specifically in oxycodone dispensing, 2011-2012. The dispensing ratio weak/strong opioids decreased substantively. Major inter-provincial differences in POA dispensing levels and qualitative patterns of POA formulations dispensed persisted. Previous increasing trends in POA dispensing were reversed in select provinces 2011-2012, coinciding with POA-related interventions.
Further examinations regarding the sustained nature, drivers and consequences of the recent trend changes in POA dispensing - including possible 'substitution effects' for oxycodone reductions - are needed.
BMC Health Services Research 02/2014; 14(1):90. · 1.77 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To determine the level and changes in public opinion between 2003 and 2009 among adult Canadians about implementation of supervised injection facilities (SIFs) in Canada.
Population-based, telephone survey data collected in 2003 and 2009 were analyzed to identify strong, weak, and intermediate support for SIFs.
Ontario, Canada PARTICIPANTS: Representative samples of adults aged 18 and over.
Analyses of the agreement with implementation of SIFs in relation to four individual SIF goals and a composite measure.
The final sample sizes for 2003 and 2009 were 1212 and 968, respectively. Between 2003 and 2009, there were increases in the proportion of participants who strongly agreed with implementing SIFs to: reduce neighbourhood problems (0.309 versus 0.556, respectively); increase contact of people who use drugs with health and social workers (0.257 versus .479, respectively); reduce overdose deaths or infectious disease among people who use drugs (0.269 versus 0.482, respectively); and encourage safer drug injection (0.213 versus 0.310, respectively). Analyses using a composite measure of agreement across goals showed 0.776 of participants had mixed opinions about SIFs in 2003, compared with only 0.616 in 2009. There was little change among those who strongly disagreed with all SIF goals (0.091 versus 0.113 in 2003 and 2009, respectively).
Support for implementation of supervised injection facilities in Ontario, Canada increased between 2003 and 2009, but at both time points a majority still held mixed opinions.
[Show abstract][Hide abstract] ABSTRACT: Crack use is prevalent among street drug users in Brazilian cities, yet despite recent help system reforms and investments, treatment utilization is low. Other studies have identified a variety of - often inconsistent - factors associated with treatment status among crack or other drug users. This study compared socio-economic, drug use, health and service use characteristics between samples of young adult crack users in- and out-of-treatment in Rio de Janeiro, Brazil.
Street-involved crack users (n = 81) were recruited by community-based methods, and privately assessed by way of an anonymous interviewer-administered questionnaire as well as biological methods, following informed consent. In-treatment users (n = 30) were recruited from a public service in-patient treatment facility and assessed based on the same protocol. Key indicators of interest were statistically cross-compared. Not-in-treatment users were less likely to: be white, educated, stably housed, to be involved in drug dealing, to report lifetime marijuana and current alcohol use, to report low mental health status and general health or addiction/mental health care; they were more likely to: be involved in begging and utilize social services, compared to the in-treatment sample (statistical significance for differences set at p < .05).
In-treatment and not-in-treatment crack users differed on several key characteristics. Overall, in-treatment users appeared to be more socio-economically integrated and connected to the health system, yet not acutely needier in terms of health or drug problems. Given overall low treatment utilization but high need, efforts are required to facilitate improved treatment access for marginalized crack users in Brazil.
[Show abstract][Hide abstract] ABSTRACT: Five years ago, we highlighted Canada's emerging problem of prescription opioid (PO)-related harms and emphasized the need for targeted surveillance, research and interventions. Overall levels of PO use in the Canadian population have grown by 70% since then, while at the same time levels of non-medical PO use (NMPOU) in general and in key risk populations have continued to be high; furthermore, PO-related harms - specifically morbidity (e.g., treatment admissions) and mortality (e.g., overdose deaths) - have risen substantively. Unfortunately, major knowledge gaps related to systematic monitoring of PO-related harms continue to exist; for example, no national morbidity or mortality statistics are available. Investigator-driven research has generated important insights into the epidemiology and impacts of PO-related harms: high correlations between population-level PO dispensing and/or PO dosing and harms; high rates of co-occurrence of NMPOU and co-morbidities; and distinct NMPOU-related risk dynamics among street drug users. Select policy measures have been implemented only recently at the federal and provincial levels; these interventions remain to be systematically evaluated, especially given preliminary indications of reductions in PO-related harms (e.g., NMPOU) unfolding prior to the interventions. For these purposes, improvements in surveillance tools and research resources devoted to the extensive public health problem of PO-related harms in Canada continue to be urgently needed.
[Show abstract][Hide abstract] ABSTRACT: Crack use is prevalent across the Americas, and specifically among marginalized urban street drug users in Brazil. Crack users commonly feature multiple physical and mental health problems, while low rates of and distinct barriers to help service use have been observed in these populations. This study examined profiles and determinants of social and health service utilization, and unmet service needs, in a bi-city sample of young (18-24 years), marginalized crack users in Brazil.
N = 160 study participants were recruited by community-based methods from impoverished neighborhoods in the cities of Rio de Janeiro (n = 81) and Salvador (n = 79). A mixed methods protocol was used. Participants' drug use, health, and social and health service utilization were assessed by an anonymous interviewer-administered questionnaire completed in a community setting; descriptive statistics on variables of interest were computed. Service needs and barriers were further assessed by way of several focus groups with the study population; narrative data were qualitatively analyzed. The study protocol was approved by institutional ethics review boards; data were collected between November 2010 and June 2011.
The majority of the sample was male, without stable housing, and used other drugs (e.g., alcohol, marijuana). About half the sample reported physical and mental health problems, yet most had not received medical attention for these problems. Only small minorities had utilized locally available social or health services; utilization appeared to be influenced by sex, race and housing characteristics in both sites. Participants cited limited service resources, lack of needs-specific professional skills, bureaucratic barriers and stigma as obstacles to better service access. However, most respondents stated strong interest and need for general social, health and treatment services designed for the study population, for which various key features were emphasized as important.
The study contributes substantive evidence to current discussions about the development and utilization of health and treatment interventions for crack use in Brazil. Based on our data, crack users' social, service needs are largely unmet; these gaps appear to partly root in systemic barriers of access to existing services, while improved targeted service offers for the target population seem to be needed also.
BMC Health Services Research 12/2013; 13(1):536. · 1.77 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Non-medical prescription opioid use (NMPOU) constitutes a substantial clinical and public health concern in North America. Although there is evidence of elevated rates of mental health problems among people with NMPOU, the extent of these correlations specifically in treatment samples has not been systematically assessed. A systematic review and meta-analysis were conducted for Axis-1 psychiatric diagnoses and symptoms with a principal focus on depression and anxiety disorders in substance use treatment samples reporting NMPOU at admission to treatment (both criteria within past 30days). 11 unique studies (all from either the United States or Canada) met inclusion criteria and were included in the meta-analysis. The pooled prevalence of 'any' mental health problems (both diagnosis and symptoms) among substance abuse treatment patients reporting NMPOU was 43% (95% CI: 32%-54%; I(2) for inter-study heterogeneity: 99.5%). The pooled prevalence of depression diagnosis among substance abuse treatment patients reporting NMPOU was 27% (95% CI: 9%-45%; I(2): 99.2%); the pooled prevalence of anxiety diagnosis in the sample was 29% (95% CI: 14%-44%; I(2): 98.7%). The prevalence rates of psychiatric problems (both diagnosis and symptoms), depression diagnosis and anxiety diagnosis are disproportionately high in substance use treatment samples reporting NMPOU relative to general population rates. Adequate and effective clinical strategies are needed to address co-occurring NMPOU and mental health in substance use treatment systems, especially given rising treatment demand for NMPOU. Efforts are needed to better understand the temporal and causal relationships among NMPOU, mental health problems, and treatment seeking in order to improve interventions.
[Show abstract][Hide abstract] ABSTRACT: Prescription opioid analgesic (POA)-related harms constitute a major public health problem in North America. Ontario features above-average POA use levels in Canada and has seen consistent increases in related mortality and morbidity. Recent studies documented strong correlations between POA dispensing levels and related harm outcomes on population levels. We examined correlations between POA dispensing and key POA-related mortality and morbidity indicators in Ontario, 2005-2011.
Correlations between (i) annual dispensing levels of four strong POA formulations (fentanyl, hydromorphone, morphine and oxycodone; from IMS Brogan's Compuscript converted to defined daily doses) and POA-related mortality (based on provincial coroner's data) and (ii) annual total POA dispensing and POA-related treatment caseload (from the Drug and Alcohol Treatment Information System) were examined for the study context.
Strong and significant correlations were observed between POA dispensing and mortality for three formulations, namely hydromorphone: 0.98 [95% confidence interval (CI) 0.89-1.00; P < 0.001], fentanyl: 0.93 (95% CI 0.58-0.99; P = 0.003) and oxycodone: 0.93 (95% CI 0.57-0.99; P = 0.003), but not morphine (-0.29; 95% CI-0.86-0.59; P = 0.523), as well as for treatment when examining congruent years [0.99 (95% CI 0.92-1.00); P < 0.001] and when using a 1-year offset (1.00; 95% CI 0.96-1.00; P < 0.001).
POA dispensing levels were found to be strongly correlated with mortality and morbidity (treatment) indicators. Targeted and sensible reductions of POA use level would likely constitute a primary measure to reduce POA-related harms on a population level, especially in a jurisdiction with high POA consumption levels. [Fischer B, Jones W, Urbanoski K, Skinner R, Rehm J. Correlations between prescription opioid analgesic dispensing levels and related mortality and morbidity in Ontario, Canada, 2005-2011. Drug Alcohol Rev 2013].
Drug and Alcohol Review 11/2013; · 1.55 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In Canada, hepatitis C virus (HCV) infection results in considerable morbidity, mortality and health-related costs. Within the next three to 10 years, it is expected that tolerable, short-duration (12 to 24 weeks) therapies capable of curing >90% of those who undergo treatment will be approved. Given that most of those already infected are aging and at risk for progressive liver disease, building research-based interdisciplinary prevention, care and treatment capacity is an urgent priority. In an effort to increase the dissemination of knowledge in Canada in this rapidly advancing field, the National CIHR Research Training Program in Hepatitis C (NCRTP-HepC) established an annual interdisciplinary Canadian Symposium on Hepatitis C Virus. The first symposium was held in Montreal, Quebec, in 2012, and the second symposium was held in Victoria, British Columbia, in 2013. The current article presents highlights from the 2013 meeting. It summarizes recent advances in HCV research in Canada and internationally, and presents the consensus of the meeting participants that Canada would benefit from having its own national HCV strategy to identify critical gaps in policies and programs to more effectively address the challenges of expanding HCV screening and treatment.
Canadian journal of gastroenterology = Journal canadien de gastroenterologie. 11/2013; 27(11):627-32.
[Show abstract][Hide abstract] ABSTRACT: Cannabis is the most widely used illicit drug worldwide, and the most commonly used illicit drug in Canada, among postsecondary student populations. This cross-sectional study qualitatively assessed 112 high-frequency, cannabis-using university students in Canada: It examined their subjective expectations regarding what they anticipated their cannabis use would look like in the short- and mid-term future and explored factors they saw potentially contributing to changes in their prospective drug use. Results indicated that participants believe that decisions about future cannabis use will be influenced by several contextual factors, including education and employment responsibilities, intimate relationships, and peer associations. These findings help illuminate the natural evolution of cannabis use and can guide the development of interventions for high-frequency cannabis users in the future.
Journal of Research on Adolescence 10/2013; · 1.99 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Opiate substitution treatment (OST) is the most widely used treatment for opioid dependence in Germany with substantial long-term benefits for the patient and for society. Due to lessened restrictive admission criteria, the number of registered OST patients in Germany has increased continuously in the recent years, whereas the number of physicians providing OST has remained constant. Previous data already indicated a deteriorating situation in the availability or quality of OST delivered and that structural barriers impede physicians in actively providing OST. The present survey among a sample of primary care physicians in Germany aimed to identify and assess potential structural barriers for the provision of health care in the context of OST.
An anonymous written questionnaire was sent out to a sample of 2,332 physicians across Germany providing OST. Physicians contacted were identified through databases of the Federal State Chambers of Physicians and/or of the Federal Associations of Statutory Health Insurance Physicians. Data obtained were analysed descriptively.
The response rate was 25,5% and the majority of 596 physicians sampled viewed substantial problems in terms of the regulatory framework of OST care in the German context. Furthermore, financial remuneration, insufficient qualification, as well as inadequate interdisciplinary cooperation in the treatment of comorbidities of opiate substituted patients were regarded as problematic. The number of physicians providing OST in Germany is expected to substantially decrease in the near future.
Despite less restrictive admission criteria for OST in Germany, the legal regulation framework for OST is still a limiting factor through raising concerns on the provider and consumer side to be unable to adhere to the strict rules. To avoid future shortages in the provision of OST care on the system level in Germany, revisions to the legal framework seem to be necessary. In regards to adequate care for drug use-related infectious diseases and psychiatric comorbidities commonly found in opiate substituted patients, efforts are required to improve professional qualifications of physicians providing OST as well as respective interdisciplinary collaboration.
[Show abstract][Hide abstract] ABSTRACT: Asians are the largest racial minority in Canada making up 11% of the population and represented over 60% of new immigrants between 2001 and 2006. We examined the experiences of community integration for first-generation (n = 27) and second-generation (n = 22) Asian Canadian men who have sex with men (MSM) in their ethnic and gay communities. Through focus group interviews, we explored their level of connectedness and the level of discrimination they experienced in the two communities. Findings indicate that Asian MSM in general perceived their ethnic community as homophobic, stemming from a combination of seeing sex as taboo, stereotypes about being gay, and the affiliation with religion. Although the literature indicates that immigrants rely on the support of their ethnic communities, our finding suggest that this is not the case for Asian immigrant MSM, who in our sample reported feeling less connected compared to their second-generation counterparts. For the gay community, our sample reported mixed experiences as some regarded it as welcoming, whereas others described it as racist. However, these experiences did not differ by generational status. Many were aware of explicit messages stating "No Asians" in dating contexts, while at the same time being aware that some older White men were interested in dating Asians exclusively. Barriers to integration in both communities may contribute to feelings of isolation. Theoretical implications are discussed. (PsycINFO Database Record (c) 2013 APA, all rights reserved).
Cultural Diversity and Ethnic Minority Psychology 07/2013; 19(3):248-56. · 1.36 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: AIMS: This paper aims to identify possible system-level factors contributing to the marked differences in the levels of non-medical prescription opioid use (NMPOU) and prescription opioid (PO)-related harms in North America (i.e. the United States and Canada) compared to other global regions. METHODS: Scientific literature and information related to relevant areas of health systems, policy and practice were reviewed and integrated. RESULTS: We identified several but different factors contributing to the observed differences. First, North American health-care systems consume substantially more Pos-even when compared to other high-income countries-than any other global region, with dispensing levels associated strongly with levels of NMPOU and PO-related harms. Secondly, North American health-care systems, compared to other systems, appear to have lesser regulatory access restrictions for, and rely more upon, community-based dispensing mechanisms of POs, facilitating higher dissemination level and availability (e.g. through diversion) of POs implicated in NMPOU and harms. Thirdly, we note that the generally high levels of psychotrophic drug use, dynamics of medical-professional culture (including patient expectations for 'effective treatment'), as well as the more pronounced 'for-profit' orientation of key elements of health care (including pharmaceutical advertising), may have boosted the PO-related problems observed in North America. CONCLUSIONS: Differences in the organization of health systems, prescription practices, dispensing and medical cultures and patient expectations appear to contribute to the observed inter-regional differences in non-medical prescription opioid use and prescription opioid-related harms, although consistent evidence and causal analyses are limited. Further comparative examination of these and other potential drivers is needed, and also for evidence-based intervention and policy development.
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Crack use constitutes a major problem in cities across Brazil. While existing data suggest that crack use is generally concentrated among disenfranchised young people with extensive health problems and crime involvement, extensive data gaps exist. To address this issue, this study aimed to assess key characteristics of young crack users in two Brazilian cities. METHODS: N=160 regular and young adult (ages 18-24) crack users were recruited by community-based methods in the cities of Rio de Janeiro (Southeast) and Salvador (Northeast). Assessments included an interviewer-administered questionnaire on key social, drug use, health and service use characteristics, as well as serological testing of HBV, HCV and HIV status, and were conducted anonymously between November 2010 and June 2011. Participants provided informed consent and received transportation vouchers following assessment completion. The study was approved by institutional ethics review boards. RESULTS: The majority of participants were: male, with less than high school education, unstably housed (Rio only); gained income from legal or illegal work; arrested by police in past year (Salvador only); had numerous daily crack use episodes and shared paraphernalia (Salvador only); co-used alcohol, tobacco, cannabis and cocaine; had no injection history; rated physical and mental health as 'fair' or lower (Salvador only); had unprotected sex; were never HIV tested; were not HIV, HBV or HCV positive; and did not use existing social or health services, but desired access to crack user specific services. CONCLUSION: Crack users in the two Brazilian sites featured extensive socio-economic marginalization, crack and poly-drug use as well as sexual risk behaviours, and compromised health status. Social and health service utilization are low, yet needs are high. There is an urgent need for further research and for targeted interventions for crack use in Brazil.
The International journal on drug policy 04/2013; · 2.54 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Non-medical prescription opioid use (NMPOU) and prescription opioid (PO) related harms have become major substance use and public health problems in North America, the region with the world's highest PO use levels. In Ontario, Canada's most populous province, NMPOU rates, PO-related treatment admissions and accidental mortality have risen sharply in recent years. A series of recent policy interventions from governmental and non-governmental entities to stem PO-related problems have been implemented since 2010. FINDINGS: We compared the prevalence of NMPOU in the Ontario general adult population (18 years+) in 2010 and 2011 based on data from the 'Centre for Addiction and Mental Health (CAMH) Monitor' (CM), a long-standing annual telephone interview-based representative population survey of substance use and health indicators. While 'any PO use' (in past year) changed non-significantly from 26.6% to 23.9% (Chi2 =2.511; df = 1; p = 0.113), NMPOU decreased significantly from 7.7% to 4.0% (Chi2 =14.786; df = 1; p < 0.001) between 2010 and 2011. Over-time changes varied by age group but not by sex. CONCLUSIONS: The observed substantial decrease in NMPOU in the Ontario adult population could be related to recent policy interventions, alongside extensive media reporting, focusing on NMPOU and PO-related harms, and may mean that these interventions have shown initial effects. However, other factors could have been involved. Thus, it is necessary to systematically examine whether the observed changes will be sustained, and whether other key PO-related harm indicators (e.g., treatment admissions, accidental mortality) change correspondingly in order to more systematically assess the impact of the policy measures.