Abstract Purpose: To determine knowledge of a national sample of medical students about substance withdrawal, screening and early intervention, medical and psychiatric complications of addiction, and treatment options. Methods: Based on learning objectives developed by medical faculty, twenty-two questions on addictions were included in the 1998 Canadian licensing examination. Results: The exam was written by 858 medical students. The average score on the addiction questions was 64%. Students showed strong knowledge of the clinical features of medical complications. Specific knowledge gaps were identified for withdrawal treatment protocols, low-risk drinking guidelines, taking an alcohol history, substance-induced psychiatric disorders, and Alcoholics Anonymous. Conclusion: Medical students are knowledge-deficient around key learning objectives in addictions. The deficiencies were in areas of basic knowledge that could be learnt with little difficulty.
To review the use of buprenorphine for opioid-addicted patients in primary care.The MEDLINE database was searched for literature on buprenorphine from 1980 to 2009. Controlled trials, meta-analyses, and large observational studies were reviewed.Buprenorphine is a partial opioid agonist that relieves opioid withdrawal symptoms and cravings for 24 hours or longer. Buprenorphine has a much lower risk of overdose than methadone and is preferred for patients at high risk of methadone toxicity, those who might need shorter-term maintenance therapy, and those with limited access to methadone treatment. The initial dose should be given only after the patient is in withdrawal. The therapeutic dose range for most patients is 8 to 16 mg daily. It should be dispensed daily by the pharmacist with gradual introduction of take-home doses. Take-home doses should be introduced more slowly for patients at higher risk of abuse and diversion (eg, injection drug users). Patients who fail buprenorphine treatment should be referred for methadone- or abstinence-based treatment.Buprenorphine is an effective treatment of opioid addiction and can be safely prescribed by primary care physicians.
To explore pharmacists' beliefs, practices, and experiences regarding opioid dispensing.Mailed survey.The province of Ontario.A total of 1011 pharmacists selected from the Ontario College of Pharmacists' registration list.Pharmacists' experiences with opioid-related adverse events (intoxication and aberrant drug-related behaviour) and their interactions with physicians.A total of 652 pharmacists returned the survey, for a response rate of 64%. Most (86%) reported that they were concerned about several or many of their patients who were taking opioids; 36% reported that at least 1 patient was intoxicated from opioids while visiting their pharmacies within the past year. Reasons for opioid intoxication included the patient taking more than prescribed (84%), the patient using alcohol or sedating drugs along with the opioid (69.9%), or the prescribed dose being too high (34%). Participants' most common concerns in the 3 months before the survey were patients coming in early for prescription refills, suspected double-doctoring, and requests for replacement doses for lost medication (reported frequently by 39%, 12%, and 16% of respondents, respectively). Pharmacists were concerned about physician practices, such as prescribing benzodiazepines along with opioids. Pharmacists reported difficulty in reaching physicians directly by telephone (43%), and indicated that physicians frequently did not return their calls promptly (28%). The strategies rated as most helpful for improving opioid dispensing were a provincial prescription database and opioid prescribing guidelines.Pharmacists commonly observe opioid intoxication and aberrant drug-related behaviour in their patients but have difficulty communicating their concerns to physicians. System-wide strategies are urgently needed to improve the safety of opioid prescribing and to enhance communication between physicians and pharmacists.
Abstract Purpose: To review the literature on methadone deaths and propose evidence-based dosing guidelines. Methods: A literature search was conducted on overdose deaths during the induction phase. Data on methadone deaths from the Ontario coroner's office, as well as prescribing guidelines from different countries and jurisdictions, were reviewed. The information was collectively considered and, using the best available evidence, translated into safe dosing guidelines for methadone induction. Results: A literature review found high death rates during the methadone induction period. Data from the Ontario coroner's office revealed that of deaths that were felt to be attributable to methadone overdose, the majority occurred in those who had consumed diverted methadone: of those deaths within a registered program, the majority occurred during the initial dosing phase. Despite high death rates during induction onto methadone treatment, many jurisdictions do not have prescribing guidelines that take this evid...
To measure physicians' experiences with opioid-related adverse events and their perceived level of confidence in their opioid prescribing skills and practices.Mailed survey. Setting The province of Ontario.A total of 1000 primary care physicians randomly selected from the College of Physicians and Surgeons of Ontario registration database.Opioid-related adverse events and concerns (eg, number of patients, type of opioid, cause of the event or concern); physicians' confidence, comfort, and satisfaction with opioid prescribing; physicians' opinions on strategies to optimize their prescribing; and physicians' perspectives of their interactions with pharmacists and nurses.The response rate was close to 66%, for a total of 658 participants. Almost all respondents reported prescribing opioids for chronic pain in the past 3 months. Eighty-six percent of respondents reported being confident in their prescribing of opioids, but 42% of respondents indicated that at least 1 patient had experienced an adverse event related to opioids in the past year, usually involving oxycodone, and 16.3% of respondents did not know if their patients had experienced any opioid-related adverse events. The most commonly cited factors leading to adverse events were that the patient took more than prescribed, the prescribed dose was too high, or the patient took alcohol or sedating drugs with the opioids. Most physicians had concerns about the opioid use of 1 or more of their patients; concerns included running out of opioids early, minimal access to pain and addiction treatment, and addiction and overdose. The reported number of physicians' patients taking opioids was positively associated with their confidence and comfort levels in opioid prescribing and negatively associated with their belief that many patients become addicted to opioids.Most physicians have encountered opioid-related adverse events. Comprehensive strategies are required to promote safe prescribing of opioids, including guidelines and comprehensive office-system materials.
To assess for long-term positive effects of buprenorphine treatment (BT) on opioid use disorder (OUD) at a Nishnawbe Aski Nation high school clinic.
Design
Postgraduation telephone survey of high school students between March 2017 and January 2018.
Setting
Dennis Franklin Cromarty High School in Thunder Bay, Ont.
Participants
All 44 students who had received BT in the high school clinic during its operation from 2011 to 2013 were eligible to participate.
Main outcome measures
Current substance use, BT status, and social and employment status.
Results
Thirty-eight of the 44 students who had received BT in the high school clinic were located and approached; 32 consented to participate in the survey. A descriptive analysis of the surveyed indicators was undertaken. Almost two-thirds (n = 20, 62.5%) of the cohort had graduated from high school, more than one-third (n = 12, 37.5%) were employed full time, and most (n = 29, 90.6%) rated their health as “good” or “OK.” A greater percentage of participants who continued taking BT after high school (n = 19, 61.3%) were employed full time (n = 8, 42.1% vs n = 4, 33.3%) and were abstinent from alcohol (n = 12, 63.2% vs n = 4, 33.3%). Participants still taking BT were significantly more likely to have obtained addiction counseling in the past year than those participants not in treatment (n = 9, 47.4% vs n = 1, 8.3%; P = .0464).
Conclusion
The study results suggest that offering OUD treatment to youth in the form of BT in a high school clinic might be an effective strategy for promoting positive long-term health and social outcomes. Clinical treatment guidelines currently recommend long-term opioid agonist treatment as the treatment of choice for OUD in the general population; they should consider adding youth to the population that might also benefit.
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Do not initiate opioids long-term for chronic pain until there has been a trial of available nonpharmacologic treatments and adequate trials of nonopioid medications.
Shared decision making (SDM), when initiating opioid therapy for long-term chronic pain, can be one of the most
