Prescribed safer supply during dual public health emergencies: a qualitative study examining service providers perspectives on early implementation

BACKGROUND

Within North America and worldwide, drug related overdoses have increased dramatically over the past decade. COVID-19 escalated the need for a safer supply to replace unregulated substances and to reduce toxicity and overdoses. Service providers play an integral role in the delivery of safer supply but there is little empirical evidence that conceptualizes effective safer supply from their perspectives. This study explored early implementation and impacts of a safer supply program, capturing the perspectives of an interdisciplinary team of service providers on tensions and issues encountered in the development of the SAFER program.

METHODS

Using a community-based participatory approach, we conducted individual interviews with program providers (n = 9). The research team was composed of researchers from a local drug user organization, a local harm reduction organization, and academic researchers. The Consolidated Framework for Implementation Research (CFIR) informed the interview guide. Data was analyzed using thematic analysis.

RESULTS

There are six themes describing early implementation: (1) risk mitigation prescribing as context for early implementation; (2) developing SAFER specific clinical protocols; (3) accessibility challenges and program innovations; (4) interdisciplinary team and wraparound care; (5) program tensions between addiction medicine and harm reduction; (6) the successes of safer supply and future visions.

CONCLUSION

Early implementation issues and tensions included prescriber concerns about safer supply prescribing in a highly politicized environment, accessibility challenges for service users such as stigma, encampment displacement, OAT requirements, program capacity and costs, and tensions between addiction medicine and harm reduction. Navigating these tensions included development of clinical protocols, innovations to reduce accessibility challenges such as outreach, wraparound care, program coverage of medication costs and prescribing safer supply with/without OAT. These findings contribute important insights for the development of prescribed safer supply programs.

Reduction in mortality risk with opioid agonist therapy: a systematic review and meta-analysis

INTRODUCTION

Opioid agonist therapies are effective medications that can greatly improve the quality of life of individuals with opioid use disorder. However, there is significant uncertainty about the risks of cause-specific mortality in and out of treatment.

OBJECTIVE

This systematic review and meta-analysis explored the association between methadone and buprenorphine with cause-specific mortality among opioid-dependent persons.

METHODS

We searched six online databases to identify relevant cohort studies, calculating all-cause and overdose-specific mortality rates during periods in and out of treatment. We pooled mortality estimates using multivariate random effects meta-analysis of the crude mortality rate per 1000 person-years of follow-up as well as relative risks comparing mortality in vs. out of treatment.

RESULTS

A total of 32 cohort studies (representing 150 235 participants, 805 423.6 person-years, and 9112 deaths) met eligibility criteria. Crude mortality rates were substantially higher among methadone cohorts than buprenorphine cohorts. Relative risk reduction was substantially higher with methadone relative to buprenorphine when time in-treatment was compared to time out-of-treatment. Furthermore, the greatest mortality reduction was conferred during the first 4 weeks of treatment. Mortality estimates were substantially heterogeneous and varied significantly by country, region, and by the nature of the treatment provider.

CONCLUSION

Precautions are necessary for the safer implementation of opioid agonist therapy, including baseline assessments of opioid tolerance, ongoing monitoring during the induction period, education of patients about the risk of overdose, and coordination within healthcare services.

Neurotic Personality Traits and Risk for Adverse Alcohol Outcomes: Chained Mediation through Emotional Disorder Symptoms and Drinking to Cope

BACKGROUND

Rates of alcohol abuse are high on Canadian postsecondary campuses. Individual trait differences have been linked to indices of alcohol use/misuse, including neurotic traits like anxiety sensitivity (AS) and hopelessness (HOP). We know little, though, about how these traits confer vulnerability. AS and HOP are related to anxiety and depression, respectively, and to drinking to cope with symptoms of those disorders. Neurotic personality may therefore increase risk of alcohol use/abuse via (1) emotional disorder symptoms and/or (2) coping drinking motives.

OBJECTIVES

Allan and colleagues (2014) found chained mediation through AS-generalized anxiety-coping motives-alcohol problems and AS-depression-coping motives-alcohol problems. We sought to expand their research by investigating how emotional disorder symptoms (anxiety, depression) and specific coping motives (drinking to cope with anxiety, depression) may sequentially mediate the AS/HOP-to-hazardous alcohol use/drinking harms relationships among university students.

METHODS

This study used cross-sectional data collected in Fall 2014 as part of the Movember-funded Caring Campus Project (N = 1,883). The survey included the SURPS, adapted DMQ-R SF, and AUDIT-3.

RESULTS

AS and HOP were both related to hazardous alcohol and drinking harms via emotional disorder symptoms and, in turn, coping drinking motives. All indirect pathways incorporating both mediators were statistically significant, and additional evidence of partial specificity was found. Conclusions/Importance: The study's results have important implications for personality-matched interventions for addictive disorders.

Reducing stigma in high school youth

OBJECTIVE

We evaluated 21 contact-based education interventions in 5047 Canadian high school students and identified student characteristics associated with success.

METHODS

We used a one-group pretest/posttest design with standardized instruments to measure changes in behavioural intent. Variability across interventions was assessed using meta-analysis, and a mixed-effects logistic regression was used to identify student characteristics.

RESULTS

Interventions were heterogeneous (I(2)  = 62.4%) but generally successful. The odds of getting an A grade was 2.57 times greater on the posttest than the pretest (95% CI = 2.18, 3.03). Males were less likely to achieve a passing score overall; however, males who self-disclosed a mental illness were more likely to pass. Three percent of students experienced a large drop in social acceptance following the intervention. These were more likely to be male [OR = 1.5 (95% CI = 1.0, 2.1)].

CONCLUSION

Contact-based education is a promising practice for reducing stigma in high school students, although the field would benefit from fidelity criteria to reduce variation across interventions. Males and females react differently to antistigma programming; particularly those with self-reported mental illnesses and a small proportion may become more intolerant.

Reducing the stigma of mental illness

This paper presents a narrative review of anti-stigma programming using examples from different countries to understand and describe current best practices in the field. Results highlight the importance of targeting the behavioural outcomes of the stigmatization process (discrimination and social inequity), which is consistent with rights-based or social justice models that emphasize social and economic equity for people with disabilities (such as equitable access to services, education, work, etc.). They also call into question large public education approaches in favour of more targeted contact-based interventions. Finally, to add to the research base on best practices, anti-stigma programs are encouraged to create alliances with university researchers in order to critically evaluate their activities and build better, evidence informed practices.

Images of psychiatry and psychiatrists

OBJECTIVE

This study surveyed medical teaching faculty to determine their attitudes toward psychiatry and psychiatrists.

METHOD

We conducted a multisite survey of a probability sample of 1057 teaching medical faculty members from 15 academic teaching centers in the United Kingdom, Europe, and Asia stratified by early, middle, and late career stage. The average response rate across countries was 65%.

RESULTS

The outstanding findings were that 90% of respondents considered that psychiatrists were not good role models for medical students, 84% thought psychiatric patients were unsuitable to be treated outside of specialized facilities, and 73% thought psychiatric patients were emotionally draining. We noted statistically significant differences by country, gender, career stage, and specialty.

CONCLUSION

These results highlight why recruitment into psychiatry is problematic in many countries and suggest that greater attention should be given to improving the perception of psychiatrists as good role models and the efficacy of psychiatric treatments.

Community attitudes toward people with schizophrenia

OBJECTIVE

We surveyed public attitudes toward people with schizophrenia as part of a pilot project for the World Psychiatric Association's Global Campaign to Fight Stigma and Discrimination Because of Schizophrenia.

METHODS

We conducted random-digit telephone surveys with 1653 respondents (aged 15 years or over) residing in 2 adjacent rural and urban health regions (71.9% response rate). A brief interview collected information on experiences with people with a mental illness or schizophrenia, knowledge of causes and treatments for schizophrenia, and levels of social distance felt toward people with schizophrenia.

RESULTS

One-half of the sample had known someone treated for schizophrenia or another mental illness. Of those able to identify a cause of schizophrenia (two-thirds), most identified a biological cause, usually a brain disease. Social distance increased with the level of intimacy required. One in 5 respondents thought they would be unable to maintain a friendship with, one-half would be unable to room with, and three-quarters would be unable to marry, someone with schizophrenia. Those over 60 were least knowledgeable or enlightened and the most socially distancing. Greater knowledge was associated with less-distancing attitudes. When other factors were controlled, exposure to the mentally ill was not correlated with knowledge or attitudes, even among those who had worked in agencies providing services to the mentally ill.

CONCLUSIONS

Most respondents were relatively well informed and progressive in their reported understanding of schizophrenia and its treatment. Clear subgroup differences were apparent with respect to age and knowledge. Knowledge of schizophrenia, not exposure to the mentally ill, was a central modifiable correlate of stigma.

The Canadian Criminal Code provisions for mentally disordered offenders: a survey of experiences, attitudes, and knowledge

OBJECTIVE

To systematically survey Alberta psychiatrists and lawyers regarding their knowledge of, attitudes toward, and experiences with the Criminal Code provisions regarding mentally disordered offenders to better understand the lack of impact in practice patterns.

METHOD

A survey design was used, and 2 questionnaires, 1 for lawyers and 1 for psychiatrists, were developed and mailed out.

RESULTS

Out of 245 surveys sent to psychiatrists, 141 were returned, giving a response rate of 57%. The number of lawyers practising criminal law could not be determined, and 5273 surveys were sent to all lawyers on the Law Society of Alberta mailing list. Of these, 564 were returned, giving an overall response rate of 11%. The response rate for lawyers practising criminal law is unknown. Overall, lawyers were younger than psychiatrists. Most of the respondents in both groups were men. Overall, attitudes toward offenders with mental illness were very similar among lawyers and psychiatrists. Compared with lawyers, psychiatrists had significantly more correct responses to the items assessing knowledge. With a highest possible knowledge score of 27, the average score was 16 (SD 5.7) for psychiatrists and 13 (SD 7.23) for lawyers.

CONCLUSIONS

The lack of familiarity with many of the key provisions among psychiatrists and lawyers is worrisome and suggests the need for educational materials to improve knowledge of the Criminal Code provisions governing mentally disordered offenders.

Access to physician treatment for a mental disorder: a regional analysis

BACKGROUND

This study examined (1) disparities in the proportion of persons who accessed a physician for treatment of a diagnosed mental disorder across 17 health regions in Alberta, Canada, and (2) the extent to which regional disparities in physician access could be explained by differences in regional demographies, population needs, or physician supply.

METHODS

The study illustrates the use of ecological comparisons for regional health system performance evaluations. Regional characteristics were aggregated from four sources of data: the health insurance registry file (population denominators and regional demographies), physician claims data (treatment access), census data (social indicators of population need), and the medical directory of the College of Physicians of Surgeons (physician supply).

RESULTS

Regional variability in needs-adjusted measures of access to physician-based treatment services were comparatively small (varying by a factor of 1.6). Models containing adjustments for demography, need, and physician supply explained 41% of regional variation in access. Of the total variation explained, physician supply explained a smaller proportion (39%) in comparison to social demography and needs (61%). Few large regional imbalances were noted when needs-adjusted and supply-adjusted estimates were compared. Only two areas appeared to be underserviced in comparison to their local needs, reflecting approximately 6% of the provincial population.

CONCLUSIONS

While all three study factors proved important, findings support the broad conclusion that social demography and social risk (a proxy for need) will remain the key determinants predicting access to physician services for treatment of mental disorders in publicly funded health systems.

Congenital methaemoglobinaemia detected by preoperative pulse oximetry

Methaemoglobinaemia is an unusual cause of cyanosis whether it is congenital or acquired. Hence, the diagnosis may not be immediately obvious and appropriate treatment may be delayed. The case described shows that it should be considered when pulse oximetry and arterial blood gas analysis appear to give conflicting results. A healthy 24-yr-old woman was found to have a pulse oximeter reading of 82% prior to induction of anaesthesia for minor surgery. Clinical examination confirmed cyanosis but no other abnormality was detected. She had no important medical history and was not receiving any medications. Arterial blood gas analysis with the patient breathing air showed PaO2 12.03 kPa (90 mmHg). Co-oximeter analysis of this sample revealed a methaemoglobin content of 13.4% and she was subsequently found to have congenital methaemoglobin reductase deficiency. Anaesthesia was induced and maintained with incremental doses of propofol and fentanyl. A spontaneously breathing technique with oxygen in nitrous oxide was employed uneventfully. No specific treatment for methaemoglobinaemia was given. Perioperative pulse oximetry is one of the major advances in patient monitoring in recent years but unexpected results should not be accepted uncritically. A knowledge of the working principles of oximetry is essential to enable appropriate management in the presence of dyshaemoglobins.