'Planning for a healthy baby and a healthy pregnancy': A critical analysis of Canadian clinical practice guidelines for the treatment of opioid dependence during pregnancy

As opioid fatalities rise in North America, the need to improve the supports available to those who are dependent on opioids and pregnant has become more urgent. This paper discusses the social organisation of drug treatment supports for those who are pregnant, using Canadian clinical practice guidelines (CPGs) for methadone maintenance treatment (MMT) as a case study. Pregnant patients are a priority population for MMT, both in Canada and internationally; the regulatory bodies that oversee MMT in Canada are the provincial Colleges of Physician and Surgeons and Health Canada. The paper analyses MMT CPGs published by these agencies, comparing their general recommendations to those specific to pregnant patients. We demonstrate that the guidelines address few treatment considerations for pregnant patients, other than improved birth outcomes and child welfare, despite acknowledging their more complex needs. Drawing on social science studies of gender and drugs, we argue that MMT CPGs therefore perpetuate the intensified surveillance and foetal prioritisation that have long generated barriers to care for opiate-dependent pregnant patients. We also discuss how and why the CPGs ultimately only reinforced these current limitations in the drug treatment sector.

What motivates students to decrease or cease substance use?: A scoping review

OBJECTIVE

The association between illicit substance use by third-level education students and their mental and physical health is well documented. The aim of this scoping review was to determine factors that contribute to student motivations to reduce or stop their use of illicit substances, and to elaborate on factors that may be pertinent for student-focused behaviour change interventions for substance use.

METHOD

We searched eight databases in March 2021 using search terms based on 'students', 'illicit substance use', and 'motivations'. We identified 86 research articles that reported on third-level education students' illicit substance use and included reasons or motives for their use.

RESULTS

After full-text screening, three studies were eligible for inclusion in the qualitative synthesis. The majority of studies described motives for abstention but did not describe motivation for reducing or stopping current patterns of use of illicit substances.

CONCLUSION

Few studies have examined motivations of third-level education students to decrease or cease substance use. Promising avenues for research on motivations to change substance use behaviour include the social contextual factors, perceived effects on social relationships, and actions of friends and family to prompt contemplations of change.

Immortalized striatal precursor neurons from Huntington's disease patient-derived iPS cells as a platform for target identification and screening for experimental therapeutics

We have previously established induced pluripotent stem cell (iPSC) models of Huntington's disease (HD), demonstrating CAG-repeat-expansion-dependent cell biological changes and toxicity. However, the current differentiation protocols are cumbersome and time consuming, making preparation of large quantities of cells for biochemical or screening assays difficult. Here, we report the generation of immortalized striatal precursor neurons (ISPNs) with normal (33) and expanded (180) CAG repeats from HD iPSCs, differentiated to a phenotype resembling medium spiny neurons (MSN), as a proof of principle for a more tractable patient-derived cell model. For immortalization, we used co-expression of the enzymatic component of telomerase hTERT and conditional expression of c-Myc. ISPNs can be propagated as stable adherent cell lines, and rapidly differentiated into highly homogeneous MSN-like cultures within 2 weeks, as demonstrated by immunocytochemical criteria. Differentiated ISPNs recapitulate major HD-related phenotypes of the parental iPSC model, including brain-derived neurotrophic factor (BDNF)-withdrawal-induced cell death that can be rescued by small molecules previously validated in the parental iPSC model. Proteome and RNA-seq analyses demonstrate separation of HD versus control samples by principal component analysis. We identified several networks, pathways, and upstream regulators, also found altered in HD iPSCs, other HD models, and HD patient samples. HD ISPN lines may be useful for studying HD-related cellular pathogenesis, and for use as a platform for HD target identification and screening experimental therapeutics. The described approach for generation of ISPNs from differentiated patient-derived iPSCs could be applied to a larger allelic series of HD cell lines, and to comparable modeling of other genetic disorders.

Putting Pain to Paper: Endometriosis and the Documentation of Suffering

Although the elusive and subjective nature of pain has been examined in compelling ways in health studies, the implications for systems of pain documentation and measurement remain relatively unexplored. Two systems for the documentation of pain symptoms in women with endometriosis are examined, one developed by a gynaecological association and the other by a woman with the disease. All pain documentation systems must contend with a fundamental problem: that they permit the comparison only of accounts of pain, not of pains themselves. These two instruments shift attention away from the pain itself to evaluations of the perspectives of those accounting for and evaluating pain. It is argued that systems of pain measurement and documentation, rather than offering objective readings of pain, must be seen as the products of epistemological communities with particular interests, aims and methods which affect the construction of pain and its subjects.

Sociomateriality: a theoretical framework for studying distributed medical education

Distributed medical education (DME) is a type of distance learning in which students participate in medical education from diverse geographic locations using Web conferencing, videoconferencing, e-learning, and similar tools. DME is becoming increasingly widespread in North America and around the world.Although relatively new to medical education, distance learning has a long history in the broader field of education and a related body of literature that speaks to the importance of engaging in rigorous and theoretically informed studies of distance learning. The existing DME literature is helpful, but it has been largely descriptive and lacks a critical "lens"-that is, a theoretical perspective from which to rigorously conceptualize and interrogate DME's social (relationships, people) and material (technologies, tools) aspects.The authors describe DME and theories about distance learning and show that such theories focus on social, pedagogical, and cognitive considerations without adequately taking into account material factors. They address this gap by proposing sociomateriality as a theoretical framework allowing researchers and educators to study DME and (1) understand and consider previously obscured actors, infrastructure, and other factors that, on the surface, seem unrelated and even unimportant; (2) see clearly how the social and material components of learning are intertwined in fluid, messy, and often uncertain ways; and (3) perhaps think differently, even in ways that disrupt traditional approaches, as they explore DME. The authors conclude that DME brings with it substantial investments of social and material resources, and therefore needs careful study, using approaches that embrace its complexity.

Investing in prospective cohorts for etiologic study of occupational exposures

Prospective cohorts have played a major role in understanding the contribution of diet, physical activity, medical conditions, and genes to the development of many diseases, but have not been widely used for occupational exposures. Studies in agriculture are an exception. We draw upon our experience using this design to study agricultural workers to identify conditions that might foster use of prospective cohorts to study other occupational settings. Prospective cohort studies are perceived by many as the strongest epidemiologic design. It allows updating of information on exposure and other factors, collection of biologic samples before disease diagnosis for biomarker studies, assessment of effect modification by genes, lifestyle, and other occupational exposures, and evaluation of a wide range of health outcomes. Increased use of prospective cohorts would be beneficial in identifying hazardous exposures in the workplace. Occupational epidemiologists should seek opportunities to initiate prospective cohorts to investigate high priority, occupational exposures.

The OxyContin crisis: problematisation and responsibilisation strategies in addiction, pain, and general medicine journals

BACKGROUND

OxyContin(®) (Purdue Pharma, L.P., Stamford, CT) is now widely regarded as a drug of abuse fueling a larger opioid health crisis. While coverage in the North American press about OxyContin overwhelmingly focused upon the problems of related crime and addiction/misuse and the perspectives of law enforcement officials and police, coverage in those fields of medicine most intimately concerned with OxyContin-pain medicine and addiction medicine-was more nuanced.

METHODS

In this article, we draw upon the constructivist social problems tradition and Hunt's theory of moral regulation in a qualitative analysis of 24 medical journal articles. We compare and contrast pain medicine and addiction medicine representations of the OxyContin problem, the agents responsible for it, and proposed solutions.

RESULTS

While there are some significant differences, particularly concerning the nature of the problem and the agents responsible for it, both pain medicine and addiction medicine authors 'take responsibility' in ways that attempt to mitigate the potential appropriation of the issue by law enforcement and regulatory agencies.

CONCLUSIONS

The responses of pain medicine and addiction medicine journal articles represent strategic moves to recapture lost credibility, to retain client populations and tools necessary to their jobs, and to claim a seat at the table in responding to the OxyContin crisis.

Representations of OxyContin in North American newspapers and medical journals

BACKGROUND

There are public concerns regarding OxyContin (Purdue Pharma, Canada) and charges within the pain medicine community that media coverage of the drug has been biased.

OBJECTIVE

To analyze and compare representations of OxyContin in medical journals and North American newspapers in an attempt to shed light on how each contributes to the 'social problem' associated with OxyContin.

METHODS

Using searches of newspaper and medical literature databases, two samples were drawn: 924 stories published between 1995 and 2005 in 27 North American newspapers, and 197 articles published between 1995 and 2007 in 33 medical journals in the fields of addiction/substance abuse, pain/anesthesiology and general/internal medicine. The foci, themes, perspectives represented and evaluations of OxyContin presented in these texts were analyzed statistically.

RESULTS

Newspaper coverage of OxyContin emphasized negative evaluations of the drug, focusing on abuse, addiction, crime and death rather than the use of OxyContin for the legitimate treatment of pain. Newspaper stories most often conveyed the perspectives of law enforcement and courts, and much less often represented the perspectives of physicians. However, analysis of physician perspectives represented in newspaper stories and in medical journals revealed a high degree of inconsistency, especially across the fields of pain medicine and addiction medicine.

CONCLUSION

The prevalence of negative representations of OxyContin is often blamed on biased media coverage and an ignorant public. However, the proliferation of inconsistent messages regarding the drug from physicians plays a role in the drug's persistent status as a social problem.

'No one agrees except for those of us who have it': endometriosis patients as an epistemological community

This paper contributes to the literature on patients' claims-making work by analysing the epistemological strategies and standards used by members of an endometriosis patient community. It draws upon focus group research with members of a support group for endometriosis sufferers, and an open-ended survey of an e-mail list for women with the disease. Lynn Hankinson Nelson's (1993) concept of epistemological community is used to examine standards and practices for developing and evaluating knowledge used by women with endometriosis. Particular attention is paid to the use and centrality of the notion of experience within this community.

Large outbreak of E. coli O157 in 2005, Ireland

In October/November 2005, the largest outbreak of verotoxin-producing Escherichia coli (VTEC) ever recorded in Ireland occurred. Eighteen E. coli O157 culture-positive cases, phage type 32, verotoxin 2 positive, were identified in a small rural area of mid-west Ireland. Half of these patients were asymptomatic. Two children were admitted to hospital with haemolytic uraemic syndrome, one of whom required peritoneal dialysis, and both recovered. All 18 culture-positive patients had indistinguishable or closely related pulsed field gel electrophoresis (PFGE) patterns. Nine of the VTEC O157 culture-positive individuals were in preschool children attending two local crèches. Several culture-positive individuals apparently had exposure to a vulnerable private group water scheme (GWS) in an agricultural area. No microbiological evidence of VTEC was found in food or water. One veterinary sample (an animal rectal swab) was positive for E. coli O157 and the PFGE strain was indistinguishable from the outbreak strain. A case control study showed analytical epidemiological evidence of risk related to potential exposure to the GWS but not related to reported consumption of that water. Selection of cases and controls proved challenging. Transmission occurred primarily in childcare and family settings, with significant person-to-person spread. Control measures included voluntary closure of the crèches, exclusion of culture-positive individuals in risk groups until microbiological clearance was achieved and the issuing of a ‘boil water’ advisory for drinking water pending upgrading of disinfection facilities.

The association between childhood feeding problems and maternal eating disorder: a community study

BACKGROUND

A possible association between childhood feeding problems and maternal eating disorder has been suggested by a clinic-based self-report questionnaire study. A community study was conducted, using standardized psychiatric interviews, to investigate the strength and specificity of this putative association.

METHODS

Four-year-old children were screened using a self-report version of the Behaviour Screening Questionnaire, completed by mothers, and the Pre-School Behaviour Checklist, completed by teachers. Three groups of children were identified for follow-up: children with feeding problems (N = 42), children with a non-feeding form of disturbance (i.e. shyness, fearfulness or behavioural disturbance; N = 79), and a random sample of children with no disturbance (N = 29). The presence of feeding problems was confirmed by assessment of a filmed family meal, with ratings made blind to child group and maternal mental state. Maternal current and past affective disorder and current and past eating disorder were systematically assessed, blind to child status, using the Anxiety Disorders Interview Schedule and the Eating Disorder Examination respectively.

RESULTS

Compared with the mothers of the two comparison groups of children, the mothers of the children with feeding problems had no raised rate of any affective disorder, either current or past, but they did have a markedly raised rate of both current and past DSM-IV eating disorder. The odds ratio of maternal eating disorder for the children with feeding problems was significantly raised at 11.1 (CI 1.4-91.8).

CONCLUSION

There is a strong and specific association between childhood feeding problems and maternal eating disorder.

Chair dental anaesthesia: a survey of current and intended practice in Mersey Region

We performed a questionnaire survey to establish the current and intended practice of chair dental anaesthesia amongst recently appointed consultants, and senior registrars within the Mersey Region. Only 26% of the consultants surveyed practised chair dental anaesthesia, however, more consultants would have had their anaesthetic sessions allowed. Consultants performed 4.62 +/- 3.5 sessions per month and anaesthetised 8.0 +/- 2.27 patients per session. Cases were mostly performed in community dental centres. The most common reason for discontinuing the practice of chair dental anaesthesia was the Poswillo report and its implications. Sixty-eight per cent of senior registrars declared an interest in chair dental anaesthesia. This group had received significantly more training (p < 0.005) in dental anaesthesia than those with no interest. Most anaesthetists (52/71) felt that chair dental anaesthesia was acceptable in centres approved to Poswillo standards; 16 anaesthetists felt that it should be confined to a hospital environment and three felt that it should not be performed at all.

Lack of effect of ageing on the stereochemical disposition of propranolol

The elderly are more resistant to the effects of propranolol than the young. To determine whether the decreased sensitivity in the elderly could be due to stereoselective alteration in propranolol metabolism, we investigated the effect of age on the oral clearance of (-)- and (+)-propranolol. Six young (aged 24-32, mean 27.3 +/- 1.3 years) and six elderly (65-80, mean 71.3 +/- 2.7 years) white male volunteers were given a single 80 mg oral dose of racemic propranolol. The mean peak plasma concentrations of both (+)- and (-)-propranolol were significantly higher (P less than 0.05) in the elderly (105.7 +/- 19.7 and 165.0 +/- 29.7 nmol l-1) compared with the young subjects (68.6 +/- 10.1 and 115.7 +/- 18.1 nmol l-1). The oral clearances of both (+)- and (-)-propranolol were significantly higher (P less than 0.05) in the young (6933 +/- 598 and 4554 +/- 372 ml min-1) than in the elderly (4548 +/- 712 and 2941 +/- 473 ml min-1). Age had no effect on the relative concentration of the two isomers. Thus, the ratio of (+)-propranolol to (-)-propranolol was 0.67 +/- 0.05 in the young compared with 0.65 +/- 0.02 in the elderly.

Effect of i.v. anaesthesia with propofol on drug distribution and metabolism in the dog

We have studied the effect of i.v. anaesthesia with propofol in the emulsion (Intralipid) formulation on drug distribution and metabolism in six dogs using dual-route administration of propranolol as a model compound. Each dog was studied on two consecutive days: day 1 awake and day 2 during propofol anaesthesia (6 mg kg-1 followed by an infusion of 0.8 mg kg-1 min-1). Propofol anaesthesia was associated with reduced intrinsic clearance by 40% (P less than 0.05) but no significant difference in systemic clearance or hepatic plasma flow. Propofol produced marked changes in drug distribution; volume of distribution (Vss) of propranolol increased 54% from 82.5 (SEM 7.3) litre awake to 127.3 (27) litre during propofol anaesthesia (P less than 0.05). This change was accompanied by an increase (P less than 0.05) in the free fraction of propranolol from 8.5 (0.7) % in awake to 14.0 (0.7) % in propofol-anaesthetized dogs. The combination of the effects of both drug clearance and protein binding resulted in a 65% decrease in the intrinsic clearance of unbound drug (P less than 0.05). In contrast with the effects of propofol on drug distribution, infusion of Intralipid alone in another group of six dogs had no significant effects on drug distribution, protein binding or drug metabolism. We conclude that propofol is a modest inhibitor of drug metabolism, but has major effects on propranolol distribution, possibly by changing plasma protein binding.

Halothane inhibition of propranolol metabolism is stereoselective

Propranolol, like many drugs, is used clinically as a racemic mixture. The major pharmacodynamic effects of propranolol, however, are mediated by the (-)-isomer, which is 100 times as potent as the (+)-isomer. The two isomers also differ in their pharmacokinetic characteristics. To determine whether halothane anesthesia stereo-selectively inhibits the metabolism of racemic propranolol, eight male mongrel dogs were studied. On the first day of the study, 40 mg racemic propranolol was infused into the portal vein and arterial blood samples were obtained over the following 4 h for the measurements of (+)- and (-)-propranolol concentrations by HPLC. The study was repeated 24 h later during 2 MAC halothane anesthesia, when the intrinsic clearance of total propranolol was decreased by 67.5 +/- 5%, from 6.14 +/- 1.1 1/min to 1.84 +/- 0.4 1/min (P less than 0.05). The decrease in intrinsic clearance was stereoselective, (-)-propranolol being affected to a greater extent than (+)-propranolol; thus, the decrease in the clearance of (-)-propranolol, from 10.96 +/- 2.71/min to 2.6 +/- 0.71/min (73 +/- 5%) was significantly (P less than 0.05) greater than the decrease in the clearance of (+)-propranolol, (62 +/- 3%) from 4.3 +/- 0.8 1/min to 1.5 +/- 0.3 1/min. Furthermore, the ratio of the intrinsic clearance of (-)-propranolol to the intrinsic clearance of (+)-propranolol was significantly (P less than 0.05) reduced by halothane anesthesia, from 2.42 +/- 0.29 to 1.69 +/- 0.11. Stereoselective inhibition of propranolol metabolism results in proportionally higher concentrations of (-)-propranolol during halothane anesthesia than are present in awake dogs.(ABSTRACT TRUNCATED AT 250 WORDS)

Lack of effect of spinal anesthesia on drug metabolism

The effect of spinal anesthesia on drug disposition was determined in six dogs with chronically implanted vascular catheters using propranolol as a model compound. On the first study day, 40 mg of unlabeled propranolol and 200 microCi of [3H]propranolol were injected into the portal and femoral veins respectively. Arterial blood samples were taken for 4 hr for measurement of plasma concentrations of labeled and unlabeled propranolol by high-pressure liquid chromatography (HPLC) and of [3H]propranolol by liquid scintillation counting of the HPLC eluant corresponding to each propranolol peak. Twenty-four hr later, spinal anesthesia was induced with tetracaine (mean dose 20.7 +/- 0.6 mg) with low sacral to midthoracic levels and the propranolol infusions and sampling were then repeated. Spinal anesthesia had no significant effect on either the intrinsic clearance of propranolol (2.01 +/- 0.75 L/min before and 1.9 +/- 0.7 L/min during spinal anesthesia), or on mean hepatic plasma flow (2.01 +/- 0.5 L/min before and 1.93 +/- 0.5 L/min during spinal anesthesia). The systemic clearance and elimination half-life of propranolol were also unchanged by spinal anesthesia (0.9 +/- 0.23 L/min on the first day, 0.7 +/- 0.1 L/min during spinal anesthesia; and 101 +/- 21 min on the first day, 115 +/- 16 min during spinal anesthesia, respectively). The volume of distribution (Vd) of propranolol was similarly unaffected by spinal anesthesia.(ABSTRACT TRUNCATED AT 250 WORDS)

Operations postponed by anaesthetists: a prospective study

A prospective study was carried out in one District Health Authority over a twelve month period to investigate the principal reasons for the postponement of operations on the advice of anaesthetic staff. A mean of 1.4% of all cases listed for general anaesthesia were postponed. The clinical indications for this are described and possible methods for reducing this figure are discussed.

Venous plethysmography values in patients with spinal cord injury

To determine whether venous hemodynamics differ fundamentally between patients with spinal cord injury (SCI) and the abled-bodied population, quantitation of lower extremity venous plethysmography values was performed in 14 SCI patients and ten able-bodied subjects. The control group had an average maximum venous outflow (MVO) of 59.3 +/- 2.75 mL/min/100mL of tissue, mean +/- SE, and an average venous capacitance (VC) of 3.2 +/- 0.13mL/100mL. In contrast, the SCI patients had an average MVO of 32.5 +/- 2.57mL/min/100mL and an average VC of 2.3 +/- 0.17mL/100mL. The differences between the two groups were statistically significant, suggesting that the standard venous function index of plethysmography values used in the general population may not be applicable to the SCI population and that, therefore, a new standard for SCI patients derived from a larger data base should be sought.

Acquisition and performance difference between normal and mentally handicapped adults on a complex assembly task

Several single studies concerned with work training with the mentally handicapped have been reported in the literature (Bitter & Bolanovich, 1966; Huddle, 1967; Gold, 1969; Screven, Straka & Lafond, 1971). Most have been concerned with issues of acquisition and motivation to perform. No studies have been reported which focus on the evaluation of different techniques of training or which assess rate of acquisition against that of non-handicapped controls. The aim of this experiment is twofold. It uses a complex task, analysed by MTM-2, to enable comparison between the performances of mentally handicapped adults and adults from a 'normal' population, in the acquisition of new work skills. Various strategies of training were compared and the increase in the rate and quality of performance following acquisition was measured for both, in terms of speed and accuracy of production. Results add further support for the notion that the potential of mentally handicapped individuals is commonly underestimated. It is hoped that the findings provide a basis from which further experiments can be developed and evaluated.

The Highlands Dependency Questionnaire (HDQ). An administered version for use with mothers of school children

A questionnaire concerned with dependency, mainly in the mother–child relationship, and intended for use in child psychiatry, is described. It was administered to the mothers of 116 randomly selected junior and secondary school children in the general population, stratified into age, sex, social class, and school groupings. Two meaningful dimensions were revealed by principal component factor analyses: one concerned with reliance on mother and the other reflecting sociability. Reliability and validity were found to be satisfactory.