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Hurtado SL, Simon-Arndt CM, Belding JN, Sanchez SS, Spevak C, Osik A. Evaluation of Two Educational Modalities for the Clinical Practice Guideline for Opioid Therapy for Chronic Pain for US Military Physicians. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2023; 43:241-246. [PMID: 36728977 PMCID: PMC10664779 DOI: 10.1097/ceh.0000000000000476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 09/30/2022] [Indexed: 06/18/2023]
Abstract
INTRODUCTION The Department of Veterans Affairs and Department of Defense Clinical Practice Guideline (CPG) for the Management of Opioid Therapy for Chronic Pain was updated in 2017 with targeted guidance to provide safe opioid use while mitigating the increasing levels of prescription opioid misuse among military personnel. The objective of this study was to determine the effectiveness of two educational training modalities for the CPG (an online training [OLT] module and a mobile app) on provider's knowledge, practices, and comfort with the CPG. The OLT was a self-paced interactive slide-based module that emphasized practical application, and the app provided information on the revised CPG and provider and patient resources. METHODS Active duty providers (N = 56) were randomly assigned to one of four groups (OLT only, app only, OLT and app combined, or neither OLT nor the app), and they completed a pre-test and an 8-week post-test. RESULTS Compared with those who received neither intervention, providers who received OLT only or the app only showed significant increases in knowledge over time. The combination of both OLT and app did not seem to significantly increase knowledge above either the OLT or the app alone. Neither the OLT, the app, nor their combination significantly increased either practices or comfort over time. DISCUSSION These results show that use of these educational tools, individually, was associated with an increase in provider knowledge, suggesting that these tools constitute a valuable addition to the available resources to optimize CPG implementation.
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Affiliation(s)
- Suzanne L. Hurtado
- Hurtado: Research Behavioral Health Scientist, Naval Health Research Center, San Diego, CA. Simon-Arndt: Senior Behavioral Health Scientist, Naval Health Research Center, Leidos, Inc, San Diego, CA. Dr. Belding: Behavioral Health Researcher, Naval Health Research Center, Leidos, Inc, San Diego, CA. Sanchez: Research Scientist, Naval Health Research Center, Leidos, Inc, San Diego, CA. Dr. Spevak: Director Pain Management Fellowship, Director Opioid Safety Program, National Capital Region Pain Initiative, Walter Reed National Military Medical Center, Bethesda, MD. Osik: Senior Program Manager, National Capital Region Pain Initiative, Walter Reed National Military Medical Center, Bethesda, MD
| | - Cynthia M. Simon-Arndt
- Hurtado: Research Behavioral Health Scientist, Naval Health Research Center, San Diego, CA. Simon-Arndt: Senior Behavioral Health Scientist, Naval Health Research Center, Leidos, Inc, San Diego, CA. Dr. Belding: Behavioral Health Researcher, Naval Health Research Center, Leidos, Inc, San Diego, CA. Sanchez: Research Scientist, Naval Health Research Center, Leidos, Inc, San Diego, CA. Dr. Spevak: Director Pain Management Fellowship, Director Opioid Safety Program, National Capital Region Pain Initiative, Walter Reed National Military Medical Center, Bethesda, MD. Osik: Senior Program Manager, National Capital Region Pain Initiative, Walter Reed National Military Medical Center, Bethesda, MD
| | - Jennifer N. Belding
- Hurtado: Research Behavioral Health Scientist, Naval Health Research Center, San Diego, CA. Simon-Arndt: Senior Behavioral Health Scientist, Naval Health Research Center, Leidos, Inc, San Diego, CA. Dr. Belding: Behavioral Health Researcher, Naval Health Research Center, Leidos, Inc, San Diego, CA. Sanchez: Research Scientist, Naval Health Research Center, Leidos, Inc, San Diego, CA. Dr. Spevak: Director Pain Management Fellowship, Director Opioid Safety Program, National Capital Region Pain Initiative, Walter Reed National Military Medical Center, Bethesda, MD. Osik: Senior Program Manager, National Capital Region Pain Initiative, Walter Reed National Military Medical Center, Bethesda, MD
| | - Sandra S. Sanchez
- Hurtado: Research Behavioral Health Scientist, Naval Health Research Center, San Diego, CA. Simon-Arndt: Senior Behavioral Health Scientist, Naval Health Research Center, Leidos, Inc, San Diego, CA. Dr. Belding: Behavioral Health Researcher, Naval Health Research Center, Leidos, Inc, San Diego, CA. Sanchez: Research Scientist, Naval Health Research Center, Leidos, Inc, San Diego, CA. Dr. Spevak: Director Pain Management Fellowship, Director Opioid Safety Program, National Capital Region Pain Initiative, Walter Reed National Military Medical Center, Bethesda, MD. Osik: Senior Program Manager, National Capital Region Pain Initiative, Walter Reed National Military Medical Center, Bethesda, MD
| | - Christopher Spevak
- Hurtado: Research Behavioral Health Scientist, Naval Health Research Center, San Diego, CA. Simon-Arndt: Senior Behavioral Health Scientist, Naval Health Research Center, Leidos, Inc, San Diego, CA. Dr. Belding: Behavioral Health Researcher, Naval Health Research Center, Leidos, Inc, San Diego, CA. Sanchez: Research Scientist, Naval Health Research Center, Leidos, Inc, San Diego, CA. Dr. Spevak: Director Pain Management Fellowship, Director Opioid Safety Program, National Capital Region Pain Initiative, Walter Reed National Military Medical Center, Bethesda, MD. Osik: Senior Program Manager, National Capital Region Pain Initiative, Walter Reed National Military Medical Center, Bethesda, MD
| | - Amy Osik
- Hurtado: Research Behavioral Health Scientist, Naval Health Research Center, San Diego, CA. Simon-Arndt: Senior Behavioral Health Scientist, Naval Health Research Center, Leidos, Inc, San Diego, CA. Dr. Belding: Behavioral Health Researcher, Naval Health Research Center, Leidos, Inc, San Diego, CA. Sanchez: Research Scientist, Naval Health Research Center, Leidos, Inc, San Diego, CA. Dr. Spevak: Director Pain Management Fellowship, Director Opioid Safety Program, National Capital Region Pain Initiative, Walter Reed National Military Medical Center, Bethesda, MD. Osik: Senior Program Manager, National Capital Region Pain Initiative, Walter Reed National Military Medical Center, Bethesda, MD
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Sachidanandan G, Sud A. From Two Dimensions to Multidimensions: A Mechanistic Model to Support Deliberate CPD Development, Coordination, and Evaluation. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2023:00005141-990000000-00099. [PMID: 37782259 DOI: 10.1097/ceh.0000000000000527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
INTRODUCTION The effectiveness of continuing professional development as an intervention to improve health professional behavior and patient health is variable and contentious. To clarify the causal relationships underlying program outcomes and facilitate a necessary shift from outcomes-only-based approaches to outcome-based and theory-based approaches in program development and evaluation, we developed a model of mechanisms mapped to relevant outcomes. METHODS Mechanisms identified in a prior realist synthesis of opioid agonist therapy continuing professional development programs were iteratively tested and refined using purposive and opportunistic sampling and realist approaches against two systematic reviews of programs in analgesic prescribing and palliative care. Further testing involved practical application within programs in sustainable health care and pain management. RESULTS Ninety reports on 75 programs and practical application to multiple additional programs informed the final model consisting of five distinct mechanisms: motivation transformation, expert influence, confidence development, self-efficacy facilitation, and community of practice expansion. The mechanisms and related analysis emphasize that continuing professional development is heterogeneous, complex, and context dependent. DISCUSSION Shifting toward outcome-based and theory-based approaches facilitates further conceptual shifts at intraprogram and interprogram and interintervention levels toward more deliberate program development and evaluation, increased program complementarity and subsequent collaboration. It clarifies opportunities for intercalation of continuing professional development with other intervention sciences. The model presents a resource for practitioners, researchers, and policymakers to advance continuing professional development planning, coordination, and evaluation.
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Affiliation(s)
- Grahanya Sachidanandan
- Ms. Sachidanandan: Medical Student, Temerty Faculty of Medicine, University of Toronto. Dr. Sud: Research Chair, Primary Care & Population Health Systems, Humber River Hospital, and Assistant Professor, Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto
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Shin D, Cho HJ, Alaiev D, Tsega S, Talledo J, Zaurova M, Chandra K, Alarcon P, Garcia M, Krouss M. Reducing daily dosing in opioid prescriptions in 11 safety net emergency departments. Am J Emerg Med 2023; 71:63-68. [PMID: 37343340 DOI: 10.1016/j.ajem.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/16/2023] [Accepted: 06/04/2023] [Indexed: 06/23/2023] Open
Abstract
BACKGROUND The United States continues to face a significant issue with opioid misuse, overprescribing, dependency, and overdose. Electronic health record (EHR) interventions have shown to be an effective tool to modify opioid prescribing behaviors. This quality improvement project describes an EHR intervention to reduce daily dosing in opioid prescriptions in 11 emergency departments (ED) across the largest safety net health system in the US. MEASURES The primary outcome measure was the rates of oxycodone-acetaminophen 5-325 mg prescriptions exceeding 50 morphine milligram equivalents per day (MMED) pre- vs. post-intervention; and stratified by individual hospitals and provider type. INTERVENTION The defaults for dose and frequency were uniformly changed to 'every 6 hours as needed' and '1 tablet', respectively, across 11 EDs. OUTCOMES The percentage of prescriptions greater than or equal to 50 MMED decreased from 46.0% (1624 of 3530 prescriptions) to 1.6% (52 of 3165 prescriptions) (96.4% relative reduction; p < 0.001). All 11 hospitals had a significant reduction in prescriptions exceeding 50 MMED. Nurse practitioners had the highest relative reduction of prescriptions exceeding 50 MMED at 100% (p < 0.001), and the attendings/fellows had the lowest relative reduction at 95.6% (p < 0.001). CONCLUSIONS/LESSONS LEARNED Default nudges are a simple yet powerful intervention that can strongly influence opioid prescribing patterns.
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Affiliation(s)
- Dawi Shin
- Icahn School of Medicine, New York, NY, USA; Department of Quality and Safety, NYC Health + Hospitals, New York, NY, USA
| | - Hyung J Cho
- Department of Quality and Safety, Brigham and Women's Hospital, Boston, MA, USA
| | - Daniel Alaiev
- Department of Quality and Safety, NYC Health + Hospitals, New York, NY, USA
| | - Surafel Tsega
- Department of Quality and Safety, NYC Health + Hospitals, New York, NY, USA
| | - Joseph Talledo
- Department of Quality and Safety, NYC Health + Hospitals, New York, NY, USA
| | - Milana Zaurova
- Department of Quality and Safety, NYC Health + Hospitals, New York, NY, USA
| | - Komal Chandra
- Department of Quality and Safety, NYC Health + Hospitals, New York, NY, USA
| | - Peter Alarcon
- Department of Quality and Safety, NYC Health + Hospitals, New York, NY, USA
| | - Mariely Garcia
- Icahn School of Medicine, New York, NY, USA; Department of Quality and Safety, NYC Health + Hospitals, New York, NY, USA
| | - Mona Krouss
- Department of Quality and Safety, NYC Health + Hospitals, New York, NY, USA; Department of Medicine, Icahn School of Medicine, New York, NY, USA.
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Narayan S, Rizzardo S, Hamilton MA, Cooper I, Maclure M, McCracken RK, Klimas J. Development and pilot evaluation of an educational session to support sparing opioid prescriptions to opioid naïve patients in a Canadian primary care setting. Fam Pract 2022; 39:1024-1030. [PMID: 35543305 PMCID: PMC9680661 DOI: 10.1093/fampra/cmac044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Prescribing rates of some analgesics decreased during the public health crisis. Yet, up to a quarter of opioid-naïve persons prescribed opioids for noncancer pain develop prescription opioid use disorder. We, therefore, sought to evaluate a pilot educational session to support primary care-based sparing of opioid analgesics for noncancer pain among opioid-naïve patients in British Columbia (BC). METHODS Therapeutics Initiative in BC has launched an audit and feedback intervention. Individual prescribing portraits were mailed to opioid prescribers, followed by academic detailing webinars. The webinars' learning outcomes included defining the terms opioid naïve and opioid sparing, and educating attendees on the (lack of) evidence for opioid analgesics to treat noncancer pain. The primary outcome was change in knowledge measured by four multiple-choice questions at the outset and conclusion of the webinar. RESULTS Two hundred participants attended four webinars; 124 (62%) responded to the knowledge questions. Community-based primary care professionals (80/65%) from mostly urban settings (77/62%) self-identified as family physicians (46/37%), residents (22/18%), nurse practitioners (24/19%), and others (32/26%). Twelve participants (10%) recalled receiving the individualized portraits. While the correct identification of opioid naïve definitions increased by 23%, the correct identification of opioid sparing declined by 7%. Knowledge of the gaps in high-quality evidence supporting opioid analgesics and risk tools increased by 26% and 35%, respectively. CONCLUSION The educational session outlined in this pilot yielded mixed results but appeared acceptable to learners and may need further refinement to become a feasible way to train professionals to help tackle the current toxic drugs crisis.
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Affiliation(s)
- Shawna Narayan
- Department of Family Practice, University of British Columbia, 3rd floor David Strangway Building, 5950 University Blvd., Vancouver, BC, V6T 2A1, Canada
| | - Stefania Rizzardo
- School of Occupational and Public Health, Ryerson University, 350 Victoria Street, Toronto, ON, M5B 2K3, Canada
| | - Michee-Ana Hamilton
- Department of Family Practice, Innovation Support Unit, University of British Columbia, 3rd floor David Strangway Building, 5950 University Blvd., Vancouver, BC, V6T 2A1, Canada
| | - Ian Cooper
- Department of Family Practice, Innovation Support Unit, University of British Columbia, 3rd floor David Strangway Building, 5950 University Blvd., Vancouver, BC, V6T 2A1, Canada
| | - Malcolm Maclure
- Department of Anesthesiology, Pharmacology and Therapeutics, Therapeutics Initiative, University of British Columbia, Vancouver, BC, V6T 2A1, Canada
| | - Rita K McCracken
- Department of Family Practice, Innovation Support Unit, University of British Columbia, 3rd floor David Strangway Building, 5950 University Blvd., Vancouver, BC, V6T 2A1, Canada
| | - Jan Klimas
- Department of Family Practice, University of British Columbia, 3rd floor David Strangway Building, 5950 University Blvd., Vancouver, BC, V6T 2A1, Canada
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Cordray H, Galvin J, Clark A, Alfonso K, Prickett KK. Opioid Prescribing Trends After Major Pediatric Ear Surgery: A 12-Year Analysis. Laryngoscope 2022. [PMID: 36054608 DOI: 10.1002/lary.30379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 07/28/2022] [Accepted: 08/12/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Postoperative opioid prescriptions tend to exceed children's analgesic needs, but awareness of the opioid epidemic may have driven changes in prescribing behaviors. This study evaluated opioid prescribing patterns after major pediatric ear surgery. METHODS This study reviewed all cases of tympanoplasty, tympanomastoidectomy, mastoidectomy, cochlear implantation, otoplasty, and aural atresia repair at a pediatric hospital during 2010-2021. Regressions were conducted to identify opioid prescribing trends over time. Potential covariates were assessed. Returns to the system were reviewed as a balancing measure. RESULTS Even without a targeted protocol, opioid prescribing declined significantly. After prescribing peaked in 2012-2013, significant negative trends yielded lower rates of opioid prescriptions, fewer doses per prescription, smaller patient-weight-standardized dose sizes, and less variability (all p < 0.001). In 2012, 96.1% of patients received opioid prescriptions; the rate fell to 13.5% by 2021. For patients ages, 0-6, the annual rate of opioid prescriptions dropped from a maximum of 96.3% in 2012 to 0.0% in 2021. The annual average supply of doses per prescription decreased by 68% between 2013 and 2021, reducing the total days' supply to an evidence-based 3.1 ± 1.6 days. Regressions did not detect changes in returns to the system. Pain-related returns were rare (0.9%) and did not vary by opioid prescriptions (p = 0.37). Prescribing trends were closely correlated with a tonsillectomy-focused protocol that our institution implemented in 2019. CONCLUSION Surgeon-driven opioid stewardship has improved with no resultant change in revisit rates. Procedure-specific quality improvement interventions may have broader off-target effects on prescribing behaviors. LEVEL OF EVIDENCE IV Laryngoscope, 2022.
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Affiliation(s)
- Holly Cordray
- Children's Healthcare of Atlanta, Atlanta, Georgia, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, Georgia, U.S.A
| | - John Galvin
- Emory University School of Medicine, Atlanta, Georgia, U.S.A
| | - Addison Clark
- Department of Biological and Environmental Sciences, Georgia College and State University, Milledgeville, Georgia, U.S.A
| | - Kristan Alfonso
- Children's Healthcare of Atlanta, Atlanta, Georgia, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, Georgia, U.S.A
| | - Kara K Prickett
- Children's Healthcare of Atlanta, Atlanta, Georgia, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, Georgia, U.S.A.,Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, U.S.A
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Sachidanandan G, Bechard LE, Hodgson K, Sud A. Education as drug policy: A realist synthesis of continuing professional development for opioid agonist therapy. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 108:103807. [PMID: 35930903 DOI: 10.1016/j.drugpo.2022.103807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 06/29/2022] [Accepted: 07/17/2022] [Indexed: 10/16/2022]
Abstract
BACKGROUND Continuing professional development (CPD) for opioid agonist therapy (OAT) has been identified as a key health policy strategy to improve care for people living with opioid use disorder (OUD) and to address rising opioid-related harms. To design and deliver effective CPD programs, there is a need to clarify how they work within complex health system and policy contexts. This review synthesizes the literature on OAT CPD programs and educational theory to clarify which interventions work, for whom, and in what contexts. METHODS A systematic review and realist synthesis of evaluations of CPD programs focused on OAT was conducted. This included record identification and screening, theory familiarization, data collection, analysis, expert consultation, and iterative context-intervention-mechanism-outcome (CIMO) configuration development. RESULTS Twenty-four reports comprising 21 evaluation studies from 5 countries for 3373 providers were reviewed. Through iterative testing of included studies with relevant theory, five CIMO configurations were developed. The programs were categorized by who drove the learning outcomes (i.e., system/policy, instructor, learner) and their spheres of influence (i.e., micro, meso, macro). There was a predominance of instructor-driven programs driving change at the micro level, with few policy-driven macro-influential programs, inconsistent with the promotion of CPD as a clear opioid crisis policy-level intervention. CONCLUSION OAT CPD is challenged by mismatches in program justifications, objectives, activities, and outcomes. Depending on how these program factors interact, OAT CPD can operate as a barrier or facilitator to OUD care. With more deliberate planning and consideration of program theory, programs more directly addressing diverse learner and system needs may be developed and delivered. OAT CPD as drug policy does not operate in isolation; programs may feed into each other and intercalate with other policy initiatives to have micro, meso, and macro impacts on educational and population health outcomes.
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Affiliation(s)
- Grahanya Sachidanandan
- Department of Health Sciences, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 3L8, Canada; Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health, 600 University Avenue, Toronto, Ontario, M5G 1X5, Canada
| | - Lauren E Bechard
- Department of Kinesiology and Health Sciences, Faculty of Health, University of Waterloo, 200 University Avenue West, Waterloo, Ontario, N2L 3G1, Canada
| | - Kate Hodgson
- Continuing Professional Development, Temerty Faculty of Medicine, University of Toronto, 500 University Avenue, 6th Floor, Toronto, Ontario, M5G 1V7, Canada
| | - Abhimanyu Sud
- Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health, 600 University Avenue, Toronto, Ontario, M5G 1X5, Canada; Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, 500 University Avenue, Toronto, Ontario, M5G 1V7, Canada; Humber River Hospital, 1235 Wilson Avenue, Toronto, Ontario, M3M 0B2, Canada.
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Sud A, Strang M, Buchman DZ, Spithoff S, Upshur REG, Webster F, Grundy Q. How the Suboxone Education Programme presented as a solution to risks in the Canadian opioid crisis: a critical discourse analysis. BMJ Open 2022; 12:e059561. [PMID: 35820738 PMCID: PMC9277368 DOI: 10.1136/bmjopen-2021-059561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES Pharmaceutical industry involvement in medical education, research and clinical practice can lead to conflicts of interest. Within this context, this study examined how the 'Suboxone Education Programme', developed and delivered by a pharmaceutical company as part of a federally regulated risk management program, was presented as a solution to various kinds of risks relating to opioid use in public documents from medical institutions across Canada. SETTING These documents were issued during the Canadian opioid crisis, a time when the involvement of industry in health policy was being widely questioned given industry's role in driving the overprescribing of opioid analgesics and contributing to population-level harms. DESIGN A critical discourse analysis of 69 documents collected between July 2020 and May 2021 referencing the Suboxone Education Program spanning 13 years (2007-2021) from medical, nursing and pharmacy institutions sourced from every Canadian province and territory. Discursive themes were identified through iterative and duplicate analyses using a semistructured data extraction instrument. RESULTS Documents characterised the Programme as addressing iatrogenic risks from overprescribing opioid analgesics, environmental risks from a toxic street drug supply and pharmacological risks relating to the dominant therapeutic alternative of methadone. The programme was identified as being able to address these risks by providing mechanisms to surveil healthcare professionals and to facilitate the prescribing of Suboxone. Medical institutions legitimised the Suboxone Education Programme by lending their regulatory, epidemiological and professional authority. CONCLUSIONS Addressing risk is considered as a central, moral responsibility of contemporary healthcare services. In this case, moral imperatives to address opioid crisis-related risks overrode other ethical concerns regarding conflicts of interest between industry and public welfare. Failing to address these conflicts potentially imperils efforts of mitigating population health harms by propagating an important driving force of the opioid crisis.
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Affiliation(s)
- Abhimanyu Sud
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Bridgepoint Collaboratory for Research and Innovation, Sinai Health System, Toronto, Ontario, Canada
| | - Matthew Strang
- Department of Sociology, York University, Toronto, Ontario, Canada
| | - Daniel Z Buchman
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Bioethics Program, University Health Network, Toronto, Ontario, Canada
| | - Sheryl Spithoff
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, Women's College Hospital, Toronto, Ontario, Canada
| | - Ross E G Upshur
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Bridgepoint Collaboratory for Research and Innovation, Sinai Health System, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Fiona Webster
- Arthur Labatt Family School of Nursing, Western University, London, Ontario, Canada
| | - Quinn Grundy
- Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
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