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Although opioid-related harms have reached new heights across North America, the size of the gap in opioid agonist therapy (OAT) delivery for opioid-related health problems is unknown in most jurisdictions. This study sought to characterize the gap in OAT treatment using a cascade of care framework, and determine factors associated with engagement and retention in treatment.A population-based retrospective cohort study.Ontario, Canada.Individuals who sought medical care for opioid-related health problems or died from an opioid-related cause between 2005 and 2019.Monthly treatment status for buprenorphine/naloxone or methadone OAT between 2013 and 2019 (i.e., "off OAT", "retained on OAT6 months", "retained on OAT ≥6 months").Out of 122,811 individuals in the cohort, 97,516 (79.4%) received OAT at least once during the study period. There was decreasing 6-month treatment retention over time. Model results indicated that males had higher odds of being on OAT each month (odds ratio [OR]=1.26, 95% confidence interval [CI]: 1.23-1.28) but lower odds of OAT retention (OR=0.90, 95% CI: 0.88-0.92), while the reverse was observed for older individuals (monthly: OR=0.76 per 10-year increase, 95% CI: 0.76-0.77; retention: OR=1.36 per 10-year increase, 95% CI: 1.34-1.38) and individuals with higher neighbourhood income (e.g., highest income quintile, monthly: OR=0.79, 95% CI: 0.77-0.82; highest income quintile, retention: OR=1.15, 95% CI: 1.11-1.20). Individuals residing in rural areas and with a history of mental health diagnoses had poorer outcomes overall, including lower odds of being on OAT each month (rural: OR=0.75, 95% CI: 0.73-0.78; mental health: OR=0.89, 95% CI: 0.87-0.92) and OAT retention (rural: OR=0.79, 95% CI: 0.77-0.82; mental health: OR=0.81, 95% CI: 0.78-0.83), as well as higher risk of starting/stopping OAT (rural, starting OAT: HR=1.07, 95% CI: 1.05-1.10; mental health, starting OAT: HR=1.20, 95% CI: 1.18-1.23; rural, stopping OAT: HR=1.24, 95% CI: 1.22-1.26; mental health, stopping OAT: HR=1.11, 95% CI: 1.09-1.13). Individuals with a history of mental health diagnoses also had a higher risk of death, regardless of OAT status (off OAT death: HR=1.49, 95% CI: 1.33-1.66; on OAT death: HR=1.20, 95% CI: 1.09-1.31).Factors influencing engagement and declining retention in treatment with opioid agonist therapy in Ontario's health system include age, sex and neighbourhood income, as well as mental health diagnoses or residing in rural regions..

In Western countries, Blacks experience various challenges and problems such as discrimination, racism, unemployment, low income that can contribute to substance use. This scoping review seeks to m...

This systematic review aims to identify, appraise and synthesize the best available evidence on the effectiveness of methadone maintenance treatment or buprenorphine therapy in reducing sex- and drug-related HIV risk among African, Caribbean and black people.Substance use plays an important role in HIV transmission and acquisition among African, Caribbean and black people by increasing risky sexual behavior and the risk of HIV acquisition. Pharmacological interventions targeting drug use, injection-related risk behaviors and HIV risk behaviors have been found to be effective measures in minimizing HIV transmission attributable to opioid addiction.This review will consider studies that have evaluated the impact of methadone maintenance treatment or buprenorphine therapy on sex- and drug-related HIV risks. All interventions conducted in any clinical setting will be included.Multiple sources of published and gray literature will be searched, including Embase, MEDLINE, PsycINFO, Cochrane Central Register of Controlled Trials, OpenGrey, Grey Matters, New York Academy of Medicine's Grey Literature Report, ClinicalTrials.gov and WHO International Clinical Trials Registry Platform. All titles and abstracts identified will be reviewed independently by two reviewers and potentially relevant studies will be retrieved in full. Papers selected for retrieval will be assessed by two independent reviewers for methodological validity. Data will be extracted from papers and will include details about the interventions, populations, study methods and outcomes.PROSPERO CRD42019126954.

Objective The objective of this systematic review is to identify, appraise, and synthesize the best available evidence on the effectiveness of opioid substitution treatment in reducing HIV risk behavior among African, Caribbean, and Black people. Introduction Substance use plays an important role in HIV transmission among Black people by increasing risky sexual behavior and the risk of HIV acquisition. Opioid substitution treatment, such as methadone maintenance treatment and buprenorphine therapy, has been found to be an effective measure to minimize HIV transmission attributable to opioid addiction. Inclusion criteria The current review considered studies that included African Caribbean and Black adult patients, aged 18 years or over, who have used methadone maintenance treatment or buprenorphine therapies as part of the intervention for opioid use disorders and have been evaluated for sex- and drug-related HIV risk behaviors. This review considered studies that have evaluated the impact of methadone maintenance treatment or buprenorphine therapy on sex- and drug-related HIV risk behaviors. Methods Multiple databases were searched, including Embase, MEDLINE, PsycINFO, Cochrane Central Register of Controlled Trials, Open Grey, Grey Matters, New York Academy of Medicine Grey Literature Report, ClinicalTrials.gov, and WHO International Clinical Trials Registry Platform. Two reviewers independently assessed all titles and abstracts, and potentially relevant studies were retrieved in full. Papers selected for retrieval were assessed by two independent reviewers for methodological validity. Data were then extracted from papers. Statistical pooling of quantitative data and meta-analysis was not possible due to heterogeneity of data. Results In total, 565 articles were retrieved from databases and unpublished/gray literature searches; 150 duplicates were removed, leaving 415 records. After reviewing titles and abstracts, 368 did not meet our eligibility criteria. Thus, 47 articles were retrieved for full-text assessment of which 42 were excluded, leaving five articles to be included in this review: three randomized control trials, one cohort, and one quasi-experimental study. Four studies focused on methadone maintenance treatment.and one study discussed the effectiveness of buprenorphine intervention. All studies were from the USA. One study enrolled participants in methadone maintenance treatment for heroin injectors, of which 10% of the sample was HIV positive. These papers included studies that reported a significant reduction in sex-related HIV behavior, including having multiple sexual partners, frequency of sexual intercourse, condom use, prostitution and sex trade. Of the five studies, two reported on drug-related HIV risk behaviors, citing a reduction in drug-related HIV risk behaviors. Also, these papers showed unexpected outcomes relating to frequency of sexual intercourse, prostitution, and sex trade. One study reported a significantly higher number of sexual encounters among those not participating in treatment. One study reported decreasing prostitution and sex trade among individuals receiving methadone maintenance treatment intervention. Conclusion Methadone maintenance treatment or buprenorphine therapy can be effective in reducing sex- and drug-related HIV risk among African, Caribbean, and Black people. However, due to the weaknesses in the body of evidence and the quality of evidence, it is not possible to make strong conclusions about these interventions. Rigorous studies are necessary to generate more findings and reinforce the body of literature. Systematic review registration PROSPERO CRD42019126954.

Additional file 1: Appendix S1. Eligibility screening questionnaires.

Objective 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.

OBJECTIVE The objectives of this systematic review are: i) to identify, appraise, and synthesize the best available evidence on individuals' experiences of the integration of substance use/addiction and HIV/AIDS services in community settings, and ii) to identify barriers to and facilitators of the integration of the services. INTRODUCTION The integration of drug use treatment and HIV services has shown to improve HIV prevention, decrease HIV infection and progression, while improving access to social and support services among substance users. Combined pharmacological and behavioral drug use treatments have been proven to diminish behaviors that increase HIV risk, decrease incidence of the disease, and improve adherence to antiretroviral therapy among individuals who use drugs and are HIV-positive. INCLUSION CRITERIA The populations of interest in this review include patients who have experienced integrated substance use/addiction and HIV services, as well as health care professionals and policy makers who have been involved in developing or implementing integrated substance use/addiction and HIV/AIDS services. Eligible studies will focus on the views, attitudes, understandings, and perceptions of patients, health care professionals, and policy makers resulting from experience in developing or implementing strategies that have or could inform the integration of substance use/addiction and HIV/AIDS services in community settings. METHODS Searches will be conducted in MEDLINE, Embase, PsycINFO, and CINHAL. The search for unpublished studies will include OpenGrey, Grey Matters, New York Academy of Medicine's Grey Literature Report, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform. Selected studies will be critically appraised by two independent reviewers for methodological quality. Data will be extracted and then synthesized following the JBI meta-aggregative approach. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO CRD42020185858.

Background Despite concerns surrounding high patient volumes in methadone clinics, little is known about the practice patterns of opioid maintenance therapy (OMT) providers in Ontario. We examined the distribution of these services and how physician characteristics differ based on prescribing volume. Methods We conducted a cross-sectional study among prescribers of methadone or buprenorphine to Ontario public drug beneficiaries in 2014 by stratifying physicians into low- (lower 50%), moderate- (51–89%) and high-volume (top 10%) prescribers. We summarized the distribution of OMT prescription days dispensed and urine drug screens (UDS) ordered using Lorenz curves and examined physician characteristics using descriptive statistics. Results We identified 893 OMT prescribers in 2014. Physicians were mostly male (67.5%; N = 603), and middle-aged (median was 50). High-volume methadone providers (N = 57) prescribed approximately 56% (N = 4,115,322) of the total days of methadone (Gini coefficient = 0.76, 95% CI 0.74–0.79) while high-volume buprenorphine providers (N = 64) prescribed 61% (N = 589,463) of the total days of buprenorphine (Gini coefficient = 0.78, 95% CI 0.75–0.80). On average, each high-volume methadone prescriber treated 435 OMT patients and billed 43 UDS per patient, while each high-volume buprenorphine prescriber treated 64 OMT patients and billed 22 UDS per patient. Daily OMT patient volume was on average 74 for high-volume methadone prescribers and 6 for high-volume buprenorphine prescribers. Conclusions OMT services are highly concentrated among a small portion of OMT providers who carry high daily patient volumes. Future research should examine the quality of primary care received by their patients to better elucidate the possible consequences of this highly unequal distribution of services.

OBJECTIVE: To determine access to opioid agonist therapy (OAT) for those entering residential treatment for opioid use disorder; to report on treatment outcomes for those taking OAT and those not taking OAT; and to determine the association between OAT use and residential treatment completion. DESIGN: Retrospective cohort study. SETTING: Ontario. PARTICIPANTS: Patients with opioid use disorder admitted to publicly funded residential treatment programs in the province of Ontario between January 1, 2013, and December 31, 2016. MAIN OUTCOME MEASURES: Access to OAT during residential treatment using descriptive statistics. Treatment outcomes (ie, completed the program, voluntarily left early, involuntary discharged, and other) for the entire cohort and for the OAT and non-OAT groups using descriptive statistics. Association between OAT use at admission and treatment completion (a binary outcome) using bivariate and multivariate models. RESULTS: Among an identified cohort of 1910 patients with opioid use disorder, 52.8% entered programs that permitted access to OAT. Overall, 56.8% of patients completed treatment, 23.3% voluntarily left early (eg, were no-shows, dropped out), 17.0% were involuntarily discharged, and 2.9% were discharged early for other reasons. Those taking OAT were as likely to complete treatment as those not taking OAT (53.9% vs 57.5%, respectively; adjusted odds ratio of 1.07, 95% CI 0.77 to 1.38). CONCLUSION: This study demonstrates 2 large gaps in care for patients with opioid use disorder. First, these patients have poor access to OAT—the first-line treatment of opioid use disorder—while in publicly funded residential treatment programs; and second, many are involuntarily discharged from treatment. Additionally, this study indicates that patients taking OAT have similar likelihood of completing residential treatment as those not taking OAT do. Limitations of this study are that it is based on observational data for patients who self-selected before admission to use OAT or not, and it is likely not all confounders were accounted for.

IntroductionPrevious research demonstrated that substance use continues to be one of the most complex and prevalent problems among African, Caribbean and Black (ACB) people. A number of studies were conducted to characterise substance use patterns in this population. To our knowledge, this is the first known review in Canada characterising substance use disorders on ACB people.This scoping review seeks to answer the following research questions: What characterises substance use disorders among ACB people in Canada? What are the different types and prevalence of substance use among ACB people in Canada? Do ACB people in Canada use more than one substance? What factors are associated with substance use among ACB people in Canada? What are the health and social impacts of substance use in ACB people in Canada?Methods and analysesThis study will use the methodological framework for scoping reviews developed by Arksey and O’Malley. We will search electronic bibliographic databases including Ovid MEDLINE, PsycINFO and CINAHL. We will limit our search to English articles published between 2000and2019. In addition, we will conduct a grey literature search. Two investigators will independently screen citations and full-text articles. Our findings will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis for scoping reviews guidelines. We will provide a descriptive summary of the studies and summarise the findings with respect to the outcomes and report any gaps that might require further investigation.Ethics and disseminationOur proposed study does not involve human participants; therefore, research ethics approval is not required. This study will provide evidence that will inform the development of strategies for appropriate interventions, as well as policy and further research. The results will be disseminated through publications in open access peer-reviewed journals, presentations at scientific meetings and to the lay public.

Objectives Ultrasound is a critical diagnostic imaging tool in obstetrics and gynecology (Ob/Gyn). Obstetric ultrasound is taught during residency, but we suspected a gap in Gyn ultrasound education. Proficiency in Gyn ultrasound allows real-time interpretation and management of pelvic disease and facilitates technical skill development for trainees learning blinded procedures. This study sought to evaluate ultrasound education in Canada's Ob/Gyn residency programs and assess whether residents and physicians perceived a need for a formalized Gyn ultrasound curriculum. Methods We distributed a needs assessment survey to residents enrolled in Canadian Ob/Gyn residency programs and to all obstetrician/gynecologists registered as members of the Society of Obstetricians and Gynaecologists of Canada. Residents were asked to specify their current training in ultrasound and to rate the adequacy of their curriculum. All respondents rated the importance of proficiency in pelvic ultrasound for practicing obstetrician/gynecologists as well as the perceived need for formalized ultrasound training in Ob/Gyn residency programs. Results Eighty-two residents and 233 physicians completed the survey. Extents and types of ultrasound training varied across residency programs. Most residents reported inadequate exposure to Gyn ultrasound, and most residents and physicians agreed that it is important for obstetrician/gynecologists to be proficient in Gyn ultrasound and that the development of a standardized Gyn ultrasound curriculum for residency programs is important. Conclusions Current ultrasound education in Ob/Gyn varies across Canadian residency programs. Training in Gyn ultrasound is lacking, and both trainees and physicians confirmed the need for a standardized Gyn ultrasound curriculum for residency programs in Canada.

Objective To describe obstetrical and neonatal outcomes including neonatal abstinence syndrome (NAS) in a Canadian cohort of methadone-maintained pregnant women. Methods We conducted a retrospective chart review at three integrated care programs in Vancouver, Toronto, and Montreal. Pregnant women on methadone maintenance treatment (MMT) who attended for care between 1997 and 2009 were included in this multisite study. Maternal and neonatal outcomes in each of the three contributing centres were compared. Results A total of 94 pregnant methadone-maintained women were included in the final analysis: 36 from Toronto, 36 from Vancouver, and 22 from Montreal. Maternal demographics showed inter-site differences in ethnicity and marital status. Obstetrical complications were not frequent; the most frequent was antenatal hemorrhage, which occurred in 14% of the total cohort. The incidence of premature labour was significantly higher in Vancouver and Montreal than in Toronto. The mean gestational age at delivery for the entire cohort was 38weeks; mean birth weight was 2856 grams. The average length of hospital stay for babies with NAS was 19days, with 27% of neonates requiring pharmacological treatment for NAS. Approximately 60% of neonates were discharged from hospital to the care of their mother. Conclusion Integrated care programs resulted in satisfactory obstetrical and neonatal outcomes for pregnant women on MMT. Policies promoting maternal–newborn contact, rooming-in, and breastfeeding may help to decrease the severity of NAS and the need for pharmacological treatment of NAS. We strongly recommend the development of similar programs across Canada to address gaps in services.

Opioid use affects up to 30% of pregnancies in Northwestern Ontario. Health care providers in Northwestern Ontario have varying comfort levels providing care to substance-involved pregnant women. Furthermore, health care practitioners, social service agencies and community groups in Northwestern Ontario often work in isolation with little multidisciplinary communication and collaboration. This article describes two workshops that brought together health and social service providers, community organizations, as well as academic institutions and professional organizations involved in the care of substance-involved pregnant and parenting women. The initial workshop presented best practices and local experience in the management of opioid dependence in pregnancy while the second workshop asked participants to apply a local Indigenous worldview to the implementation of clinical, research and program priorities that were identified in the first workshop. Consensus statements developed by workshop participants identified improved transitions in care, facilitated access to buprenorphine treatment, stable funding models for addiction programs and a focus on Indigenous-led programming. Participants identified a critical need for a national strategy to address the effects of opioid use in pregnancy from a culturally safe, trauma-informed perspective that takes into account the health and well-being of the woman, her infant, her family and her community.

Several strategies for preventing, identifying, and responding to aberrant opioid-related behaviors are recommended in pain management guidelines. This systematic review evaluated data supporting basic strategies for addressing aberrant opioid-related behaviors. Risk reduction strategies were identified via a review of available guidelines. Systematic literature searches of PubMed (May 1, 2007-January 18, 2013) identified articles with evidence relevant to nine basic strategies. Reference lists from relevant articles were reviewed for additional references of interest. Levels of evidence for articles identified were graded on a four-point scale (strongest evidence = level 1; weakest evidence = level 4) using Oxford Centre for Evidence-Based Medicine Levels of Evidence criteria. Weak to moderate evidence supports the value of thorough patient assessment, risk-screening tools, controlled-substance agreements, careful dose titration, opioid dose ceilings, compliance monitoring, and adherence to practice guidelines. Moderate to strong evidence suggests that prescribing tamper-resistant opioids may help prevent misuse but may also have the unintended consequence of prompting a migration of users to other marketed opioids, heroin, or other substances. Similarly, preliminary evidence suggests that although recent regulatory and legal efforts may reduce misuse, they also impose barriers to the legitimate treatment of pain. Despite an absence of consistent, strong supporting evidence, clinicians are advised to use each of the available risk-mitigation strategies in combination in an attempt to minimize the risk of abuse in opioid treatment patients. Physicians must critically evaluate their opioid prescribing and not only increase their efforts to prevent substance abuse but also not compromise pain management in patients who benefit from it.

To advise physicians on which treatment options to recommend for specific patient populations: abstinence-based treatment, buprenorphine-naloxone maintenance, or methadone maintenance.PubMed was searched and literature was reviewed on the effectiveness, safety, and side effect profiles of abstinence-based treatment, buprenorphine-naloxone treatment, and methadone treatment. Both observational and interventional studies were included.Both methadone and buprenorphine-naloxone are substantially more effective than abstinence-based treatment. Methadone has higher treatment retention rates than buprenorphine-naloxone does, while buprenorphine-naloxone has a lower risk of overdose. For all patient groups, physicians should recommend methadone or buprenorphine-naloxone treatment over abstinence-based treatment (level I evidence). Methadone is preferred over buprenorphine-naloxone for patients at higher risk of treatment dropout, such as injection opioid users (level I evidence). Youth and pregnant women who inject opioids should also receive methadone first (level III evidence). If buprenorphine-naloxone is prescribed first, the patient should be promptly switched to methadone if withdrawal symptoms, cravings, or opioid use persist despite an optimal buprenorphine-naloxone dose (level II evidence). Buprenorphine-naloxone is recommended for socially stable prescription oral opioid users, particularly if their work or family commitments make it difficult for them to attend the pharmacy daily, if they have a medical or psychiatric condition requiring regular primary care (level IV evidence), or if their jobs require higher levels of cognitive functioning or psychomotor performance (level III evidence). Buprenorphine-naloxone is also recommended for patients at high risk of methadone toxicity, such as the elderly, those taking high doses of benzodiazepines or other sedating drugs, heavy drinkers, those with a lower level of opioid tolerance, and those at high risk of prolonged QT interval (level III evidence).Individual patient characteristics and preferences should be taken into consideration when choosing a first-line opioid agonist treatment. For patients at high risk of dropout (such as adolescents and socially unstable patients), treatment retention should take precedence over other clinical considerations. For patients with high risk of toxicity (such as patients with heavy alcohol or benzodiazepine use), safety would likely be the first consideration. However, the most important factor to consider is that opioid agonist treatment is far more effective than abstinence-based treatment.

To evaluate established opioid addiction treatment programs that use traditional healing in combination with buprenorphine-naloxone maintenance treatment in 6 First Nations communities in the Sioux Lookout region of northwestern Ontario.Retrospective cohort study.Six First Nations communities in northwestern Ontario.A total of 526 First Nations participants in opioid-dependence treatment programs.Buprenorphine-naloxone substitution therapy and First Nations healing programming.Retention rates and urine drug screening (UDS) results.Treatment retention rates at 6, 12, and 18 months were 84%, 78%, and 72%, respectively. We estimate that the rate at 24 months will also be more than 70%. The UDS programming varied and was implemented in only 1 community. Initially urine testing was voluntary and it then became mandatory. Screening with either method found the proportion of urine samples with negative results for illicit opioids ranged between 84% and 95%.The program's treatment retention rates and negative UDS results were higher than those reported for most methadone and buprenorphine-naloxone programs, despite a patient population where severe posttraumatic stress disorder is endemic, and despite the programs' lack of resources and addiction expertise. Community-based programs like these overcome the initial challenge of cultural competence. First Nations communities in other provinces should establish their own buprenorphinenaloxone programs, using local primary care physicians as prescribers. Sustainable core funding is needed for programming, long-term aftercare, and trauma recovery for such initiatives.

Objective To improve awareness and knowledge of problematic substance use in pregnancy and to provide evidence-based recommendations for the management of this challenging clinical issue for all health care providers. Options This guideline reviews the use of screening tools, general approach to care, and recommendations for clinical management of problematic substance use in pregnancy. Outcomes Evidence-based recommendations for screening and management of problematic substance use during pregnancy and lactation. Evidence Medline, PubMed, CINAHL, and The Cochrane Library were searched for articles published from 1950 using the following key words: substance-related disorders, mass screening, pregnancy complications, pregnancy, prenatal care, cocaine, cannabis, methadone, opioid, tobacco, nicotine, solvents, hallucinogens, and amphetamines. Results were initially restricted to systematic reviews and randomized control trials/controlled clinical trials. A subsequent search for observational studies was also conducted because there are few RCTs in this field of study. Articles were restricted to human studies published in English. Additional articles were located by hand searching through article reference lists. Searches were updated on a regular basis and incorporated in the guideline up to December 2009. Grey (unpublished) literature was also identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Values The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on the Preventive Health Care. Recommendations for practice were ranked according to the method described in that report (Table 1). Benefits, harms, and costs This guideline is intended to increase the knowledge and comfort level of health care providers caring for pregnant women who have substance use disorders. Improved access to health care and assistance with appropriate addiction care leads to reduced health care costs and decreased maternal and neonatal morbidity and mortality.

Resume Objectif Accroitre la sensibilisation a la consommation problematique de substances psychoactives pendant la grossesse et les connaissances a ce sujet, et formuler des recommandations factuelles pour la prise en charge de ce difficile probleme clinique a l'intention de tous les fournisseurs de soins de sante Options La presente directive clinique analyse l'utilisation d'outils de depistage, l'approche generale envers les soins et les recommandations pour la prise en charge clinique de la consommation problematique de substances psychoactives pendant la grossesse Issues Recommandations factuelles pour le depistage et la prise en charge de la consommation problematique de substances psychoactives pendant la grossesse et la lactation Resultats Des recherches ont ete menees dans Medline, PubMed, CINAHL et The Cochrane Library en vue d'en tirer les articles publies depuis 1950 au moyen des mots cles suivants : « substance-related disorders », « mass screening », « pregnancy complications », « pregnancy », « prenatal care », « cocaine », « cannabis », « methadone », « opioid », « tobacco », « nicotine », « solvents », « hallucinogens » et « amphetamines ».Les resultats ont ete restreints aux analyses systematiques et aux essais comparatifs randomises / essais cliniques comparatifs.Des recherches subsequentes visant les etudes observationnelles ont egalement ete menees en raison de la rarete des ECR dans ce domaine d'etude.Les articles ont ete restreints aux etudes menees chez l'homme publiees en anglais.Des articles additionnels ont ete identifies manuellement par l'analyse des listes de references des articles selectionnes.Les recherches ont ete mises a jour de facon reguliere et leurs resultats ont ete incorpores a la directive clinique jusqu'en decembre 2009.La litterature grise (non publiee) a ete identifiee par l'intermediaire de recherches menees dans les sites Web d'organismes s'interessant a l'evaluation des technologies dans le domaine de la sante et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et aupres de societes de specialite medicale nationales et internationales. Valeurs La qualite des resultats a ete evaluee au moyen des criteres decrits dans le rapport du Groupe d'etude canadien sur les soins de sante preventifs.Les recommandations visant la pratique ont ete classees conformement a la methode decrite dans ce rapport (Tableau 1). Avantages, desavantages et couts La presente directive clinique a pour but d'accroitre les connaissances et le degre d'aisance des fournisseurs de soins de sante aux femmes enceintes qui presentent des troubles lies a la consommation de substances psychoactives L'amelioration de l'acces aux soins de sante et a une aide pour l'obtention d'un traitement adequat de l'assuetude mene a une baisse des couts de sante et des taux maternels et neonatals de morbidite et de mortalite. Recommendations 1. Toutes les femmes enceintes et les femmes en âge de procreer devraient periodiquement faire l'objet d'un depistage de la consommation d'alcool, de tabac, de medicaments d'ordonnance et de drogues illicites. (III-A) 2. Lorsque le depistage de la consommation de substances psychoactives s'avere cliniquement indique, le depistage de drogue dans l'urine constitue la methode a privilegier. (II-2A) Le consentement eclaire de la patiente devrait etre obtenu avant que la tenue d'un depistage toxicologique maternel ne soit demandee. (III-B) 3. Les politiques et les obligations juridiques liees au depistage toxicologique chez les nouveau-nes peuvent varier d'un territoire de competence a l'autre, et les fournisseurs de soins devraient se familiariser avec les reglements en vigueur dans leur region. (III-A) 4. Les fournisseurs de soins de sante devraient utiliser une approche flexible envers les soins a offrir aux femmes qui connaissent des problemes de consommation de substances psychoactives. De plus, ils devraient favoriser l'utilisation de toutes les ressources communautaires disponibles. (II-2B) 5. Les femmes devraient se voir offrir des conseils au sujet des risques qu'occasionne la consommation de drogues pendant les periodes periconceptionnelle, antepartum et postpartum. (III-B) 6. Le counseling visant l'abandon du tabagisme devrait etre considere comme etant l'intervention de premiere intention pour ce qui est des femmes enceintes qui fument. (I-A) Le recours a la therapie de remplacement de la nicotine et/ou a la pharmacotherapie peut etre envisage lorsque le counseling echoue. (I-A) 7. Le traitement de substitution a la methadone devrait constituer la norme de diligence pour ce qui est des femmes qui presentent une dependance aux opioides pendant la grossesse. (II-IA) L'utilisation d'autres preparations opioides a liberation prolongee peut etre envisagee lorsque la methadone n'est pas disponible. (II-2B) 8. La desintoxication visant les opioides ne devrait etre mise en oeuvre qu'aupres de certaines femmes, et ce, en raison du risque eleve de rechute. (II-2B) 9. Les femmes qui presentent une dependance aux opiaces devraient etre avisees que les nouveau-nes exposes a l'heroine, aux opioides d'ordonnance, a la methadone ou a la buprenorphine pendant la grossesse font l'objet d'une etroite surveillance visant a deceler les symptomes du sevrage neonatal (syndrome d'abstinence neonatale). (II-2B) Les hopitaux offrant des soins obstetricaux devraient elaborer un protocole pour l'evaluation et la prise en charge des nouveau-nes exposes aux opiaces pendant la grossesse. (III-B) 10. La planification prenatale de l'analgesie intrapartum et postpartum peut etre offerte a toutes les femmes, en consultation avec les fournisseurs de soins appropries. (III-B) 11. Les risques et les avantages de l'allaitement devraient etre ponderes de facon personnalisee, puisque le traitement de substitution a la methadone ne constitue pas une contre-indication a l'allaitement. (II-3B)

Objective To improve awareness and knowledge of problematic substance use in pregnancy and to provide evidence-based recommendations for the management of this challenging clinical issue for all health care providers Options This guideline reviews the use of screening tools, general approach to care, and recommendations for clinical management of problematic substance use in pregnancy. Outcomes Evidence-based recommendations for screening and management of problematic substance use during pregnancy and lactation. Evidence Medline, PubMed, CINAHL, and The Cochrane Library were searched for articles published from 1950 using the following key words: substance-related disorders, mass screening, pregnancy complications, pregnancy, prenatal care, cocaine, cannabis, methadone, opioid, tobacco, nicotine, solvents, hallucinogens, and amphetamines. Results were initially restricted to systematic reviews and randomized control trials/controlled clinical trials. A subsequent search for observational studies was also conducted because there are few RCTs in this field of study. Articles were restricted to human studies published in English Additional articles were located by hand searching through article reference lists. Searches were updated on a regular basis and incorporated in the guideline up to December 2009. Grey (unpublished) literature was also identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Values The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on the Preventive Health Care Recommendations for practice were ranked according to the method described in that report (Table 1) Benefits, harms, and costs This guideline is intended to increase the knowledge and comfort level of health care providers caring for pregnant women who have substance use disorders Improved access to health care and assistance with appropriate addiction care leads to reduced health care costs and decreased maternal and neonatal morbidity and mortality. Recommendations 1. All pregnant women and women of childbearing age should be screened periodically for alcohol, tobacco, and prescription and illicit drug use. (III-A) 2. When testing for substance use is clinically indicated, urine drug screening is the preferred method. (II-2A) Informed consent should be obtained from the woman before maternal drug toxicology testing is ordered. (III-B) 3. Policies and legal requirements with respect to drug testing of newborns may vary by jurisdiction, and caregivers should be familiar with the regulations in their region. (III-A) 4. Health care providers should employ a flexible approach to the care of women who have substance use problems, and they should encourage the use of all available community resources. (II-2B) 5. Women should be counselled about the risks of periconception, antepartum, and postpartum drug use. (III-B) 6. Smoking cessation counselling should be considered as a first-line intervention for pregnant smokers. (I-A) Nicotine replacement therapy and/or pharmacotherapy can be considered if counselling is not successful. (I-A) 7. Methadone maintenance treatment should be standard of care for opioid-dependent women during pregnancy. (II-IA) Other slow-release opioid preparations may be considered if methadone is not available. (II-2B) 8. Opioid detoxification should be reserved for selected women because of the high risk of relapse to opioids. (II-2B) 9. Opiate-dependent women should be informed that neonates exposed to heroin, prescription opioids, methadone, or buprenorphine during pregnancy are monitored closely for symptoms and signs of neonatal withdrawal (neonatal abstinence syndrome). (II-2B) Hospitals providing obstetric care should develop a protocol for assessment and management of neonates exposed to opiates during pregnancy. (III-B) 10. Antenatal planning for intrapartum and postpartum analgesia may be offered for all women in consultation with appropriate health care providers. (III-B) 11. The risks and benefits of breastfeeding should be weighed on an individual basis because methadone maintenance therapy is not a contraindication to breastfeeding. (II-3B)

Background: Use of a symptom-triggered scale to measure the severity of alcohol withdrawal could reduce the rate of seizures and other complications. The current standard scale, the Clinical Institute of Withdrawal Assessment (CIWA), takes a mean (±SD) of 5 minutes to complete, requiring 30 minutes of nursing time per patient when multiple measures are required. Objectives: The objective was to assess the feasibility and reliability of a brief scale of alcohol withdrawal severity. Methods: The SHOT is a brief scale designed to assess alcohol withdrawal in the emergency department (ED). It includes four items: sweating, hallucinations, orientation, and tremor (SHOT). It was developed based on a literature review and a consensus process by emergency and addiction physicians. The SHOT was first piloted in one ED, and then a prospective observational study was conducted at a different ED to measure its feasibility and reliability. Subjects included patients who were in alcohol withdrawal. One nurse administered the SHOT and CIWA, and the physician repeated the SHOT independently. The SHOT was done only at baseline, before treatment was administered. Results: In the pilot study (12 patients), the SHOT took 1 minute to complete on average, and the CIWA took 5 minutes. Sixty-one patients participated in the prospective study. For the SHOT and the CIWA done by the same nurse, the kappa was 0.88 (95% confidence interval [CI] = 0.52 to 1.0; p

There is a high prevalence of alcohol use, abuse, and dependence in methadone maintenance treatment (MMT) programs. There have been reports that this may be a result of entry into methadone maintenance. Through a systematic review, this article attempts to determine whether alcohol consumption is affected during the course (from prior to treatment initiation to once on maintenance) of MMT. A literature search for publications addressing the issue of alcohol use while on MMT was conducted. Of 15 heterogeneous clinical studies that met inclusion criteria, three studies supported an increase in alcohol use, three supported a decrease in alcohol use, and nine supported no change in alcohol use. The studies varied in their methodology and in their definition of problematic alcohol use. This review found that alcohol use, although often problematic in methadone-using patients, likely does not change upon entering MMT. We recommend routine screening and treatment for problematic alcohol use in patients on MMT.

Objective To assess: (1) physicians’ knowledge and clinical confidence regarding problematic substance use in pregnancy compared to folic acid, and (2) physicians’ desire for education in this area and their preferred learning modalitiestools. Design Self-administered survey. Setting Family Medicine Forum 2004 in Toronto, Canada. Participants Physicians attending Family Medicine Forum2004 in Toronto who provide antenatal care. Main Outcome Measures Knowledge of folic acid, smoking and alcohol in pregnancy. Clinical confidence and interest in resources regarding problematic substance use in pregnancy. Results Sixty-six surveys completed. Physicians answered 92.3% of folic acid questions correctly, compared to 82.0% for nicotine and 57.1% for alcohol. Scores were higher on questions about effects of nicotine and alcohol use in pregnancy than on questions about treatment options. A perceived inability to influence clinical outcomes and a lack of professional resources regarding substance use in pregnancy were also identified. Physicians were interested in learning more about problematic substance use in pregnancy, particularly from continuing medical education events, websites and pocket cards. Conclusion Participants’ level of knowledge regarding substance use in pregnancy was significantly lower than their knowledge of folic acid, as was their clinical confidence. This lack of knowledge was not attributable to disinterest and clearly more educational resources are needed to address this topic.

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.

Tamper-resistant formulations, designed to make drugs harder to crush, snort or inject, are being promoted in Canada and the United States as a strategy to prevent opioid-related harms such as overdose and addiction. In a research article published in CMAJ Open , Gomes and colleagues[1][1] examined

Aim. This paper presents the findings of a staff survey conducted at a 350-bed acute care facility located on the periphery of Toronto, Canada. Background. Toronto's severe acute respiratory syndrome (SARS) crisis resulted in trauma-like effects at hospitals hardest hit by the disease. A systematic examination of the impact on staff working in hospitals that saw relatively few cases, while maintaining the precautions associated with elevated alert levels, has not been undertaken. Methods. A questionnaire was distributed for 1 month commencing 17 April 2003 and 300 completed responses were obtained (approximately one in six staff members). The data collected included demographic and occupational information, in addition to perceptions of SARS’ impact on patient care, factors contributing to adverse impacts on patient care, working conditions, decision-making, communication and relations, sources of support, and the impact on workers’ lives outside work. Items for these sections were developed by a multi-disciplinary team of health care workers and hospital administrators. Results. In the absence of pre-SARS normative data for the survey, demographic and occupational variables were used to look for patterns of differences between relevant subgroups of respondents. Statistically significant differences were found for gender (73·9% women), nurses (24·7%) vs. others, doctors (20·3%) vs. others, older (40 years or older, 60·0%) vs. younger persons, emergency or intensive care unit workers (8·0%) vs. others, and those employed fewer years at the hospital (less than 5 years: 46·2%) vs. five or more years. These differences varied across the following domains: factors adversely affecting patients, communications, support, working conditions, decision-making and, to a lesser extent, impact on life outside work. While all groups found SARS stressful, nurses reported a greater impact on morale and job satisfaction. Nurses relied more on peer support than doctors, felt less informed and less involved in decision-making than doctors felt, and were more likely to report that infection control procedures were not strict enough. Conclusions. The between-group differences and the pattern of these differences clearly illustrate the polarizing and stressful impact SARS had at a hospital with only a small number of probable or suspect cases. The clear differences between groups defined by demographics, professions and clinical roles suggest a subtle and pervasive secondary impact of the SARS outbreak, with repercussions health care facilities must contend with while maintaining increased levels of vigilance in the wake of SARS.

Fifty-six second-year family medicine residents completed a survey on their knowledge and beliefs about problem drinkers. Most residents felt responsible for screening and counseling, were confident in their clinical skills in these areas, and scored well on related knowledge questions. However, only 18% felt that problem drinkers would often respond to brief counseling sessions with physicians while 36% felt that moderate drinking was a reasonable goal for patients with severe alcohol dependence. Residents were then visited by unannounced simulated patients (SPs) presenting with alcohol-induced hypertension or insomnia. Residents detected the SP in 45 out of 104 visits. In the 59 undetected SP visits, residents asked about alcohol consumption in 47 visits (80%), discussed the relationship between alcohol use and the presenting complaint in 37 visits (63%), and recommended a specific weekly consumption in 35 visits (59%). Only 31% offered reduced drinking strategies, and most did not ask about features of alcohol dependence. These results suggest that residents have the fundamental clinical skills required to manage the problem drinker who gives a clear history and is receptive to advice. Educational efforts with residents should focus on the importance of systematic screening, taking an alcohol history under more challenging conditions, identifying the subtler presentations of alcohol problems, counselling the less receptive patient at an earlier stage of change, distinguishing the problem drinker from the alcohol-dependent patient, and offering specific behavioral strategies for the problem drinker.

The Canadian guideline’s[1][1] key recommendations are flawed. Based on three small studies on highly select patients,[2][2] the guideline recommends tapering for all patients taking dosages at or above 90 mg morphine equivalents daily regardless of their clinical response to the opioid. The

To offer preliminary guidance on prescribing smoked cannabis for chronic pain before the release of formal guidelines.We reviewed the literature on the analgesic effectiveness of smoked cannabis and the harms of medical and recreational cannabis use. We developed recommendations on indications, contraindications, precautions, and dosing of smoked cannabis, and categorized the recommendations based on levels of evidence. Evidence is mostly level II (well conducted observational studies) and III (expert opinion).Smoked cannabis might be indicated for patients with severe neuropathic pain conditions who have not responded to adequate trials of pharmaceutical cannabinoids and standard analgesics (level II evidence). Smoked cannabis is contraindicated in patients who are 25 years of age or younger (level II evidence); who have a current, past, or strong family history of psychosis (level II evidence); who have a current or past cannabis use disorder (level III evidence); who have a current substance use disorder (level III evidence); who have cardiovascular or respiratory disease (level III evidence); or who are pregnant or planning to become pregnant (level II evidence). It should be used with caution in patients who smoke tobacco (level II evidence), who are at increased risk of cardiovascular disease (level III evidence), who have anxiety or mood disorders (level II evidence), or who are taking higher doses of opioids or benzodiazepines (level III evidence). Cannabis users should be advised not to drive for at least 3 to 4 hours after smoking, for at least 6 hours after oral ingestion, and for at least 8 hours if they experience a subjective "high" (level II evidence). The maximum recommended dose is 1 inhalation 4 times per day (approximately 400 mg per day) of dried cannabis containing 9% delta-9-tetrahydrocannabinol (level III evidence). Physicians should avoid referring patients to "cannabinoid" clinics (level III evidence).Future guidelines should be based on systematic review of the literature on the safety and effectiveness of smoked cannabis. Further research is needed on the effectiveness and long-term safety of smoked cannabis compared with pharmaceutical cannabinoids, opioids, and other standard analgesics.

Nonmedical use of prescription opioids is a growing problem in Canada; in 2011, it had the highest per capita consumption of oxycodone in the world.[1][1] When a woman with opioid dependence becomes pregnant, adequate management of the addiction is of critical importance for the well-being of both

To review the clinical features and complications of at-risk cannabis use and cannabis use disorder, and to outline an office-based protocol for screening, identifying, and managing this disorder.PubMed was searched for controlled trials, observational studies, and reviews on cannabis use among adolescents and young adults; cannabis-related medical and psychiatric harms; cannabis use disorder and its treatment; and lower-risk cannabis use guidelines.Physicians should ask all patients about cannabis use. They should ask adolescents and young adults and those at highest risk of cannabis-related harms (those with concurrent psychiatric or substance use disorders) more frequently. Physicians should also ask about cannabis use in patients who have problems that could be caused by cannabis, such as mood disorders, psychosis, and respiratory symptoms. In patients who report cannabis use, physicians should inquire about frequency and amount, tolerance and withdrawal symptoms, attempts to reduce use, and cannabis-related harms. Lower-risk cannabis users smoke, inhale, or ingest cannabis occasionally without evidence of school, work, or social dysfunction; those with problematic use often use cannabis daily or almost daily, have difficulty reducing their use, and have impaired school, work, or social functioning. Physicians should offer all patients with problematic use brief advice and counseling, focusing on the health effects of cannabis and setting a goal of abstinence (some higher-risk groups should not use cannabis at all) or reduced use, and they should provide practical strategies to reduce cannabis use. Physicians should incorporate simple motivational interviewing techniques into the counseling sessions. They should refer those patients who are unable to reduce use or who are experiencing harms from cannabis use to specialized care, while ensuring those patients remain connected to primary care. As well, physicians should give information on lower-risk cannabis use to all cannabis users.Physicians should screen all patients in their practices at least once for cannabis use, especially those who have problems that might be caused by cannabis. Physicians should screen those at higher risk more often, at least annually. Lower-risk cannabis use should be distinguished from problematic use. Brief counseling should be provided to those with problematic use; these patients should be referred to specialists if they are unable to reduce or cease use.

To examine the effects of an intensive 2-day course on physicians' prescribing of opioids.Population-based retrospective observational study.College of Physicians and Surgeons of Ontario (CPSO) in Toronto.Ontario physicians who took the course between April 1, 2000, and May 30, 2008.A 2-day opioid-prescribing course with a maximum of 12 physician participants. Educational methods included didactic presentations, case discussions, and standardized patients. A detailed syllabus and office materials were provided.Participants were matched with control physicians using specific variables. The primary outcome was the rate of opioid prescribing, expressed as milligrams of morphine equivalent per quarter.One hundred thirty-eight course participants (120 family physicians, 15 specialists, and 3 physicians whose status was uncertain) were eligible for analysis. Of these, 68.1% were self-referred and 31.9% were referred by the CPSO. Overall, among physicians referred by the CPSO, the rate of opioid prescribing decreased dramatically in the year before course participation compared with matched control physicians. The course had no added effect on the rate of physicians' opioid prescribing in the subsequent 2 years. There was no statistically significant effect on the rate of opioid prescribing observed among the self-referred physicians. Among 15 of the self-referred physicians who, owing to the high quantities of opioids they prescribed, were not matched with control physicians, the rate of opioid prescribing decreased by 43.9% in the year following course completion.Physicians markedly reduced the quantities of opioids they prescribed after medical regulators referred them to an opioid-prescribing course. The course itself did not lead to significant additional reductions; however, a subgroup of physicians who prescribed high quantities of opioids might have responded to what was taught in the course.

MacDonald and colleagues suggest that physicians are reluctant to prescribe opioids because of fears about addiction.[1][1] Evidence suggests otherwise. Canada and the United States are the biggest consumers of opioids in the world.[2][2] Canadian per-capita opioid consumption more than doubled from

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.

To provide family physicians with a practical clinical summary of opioid prescribing for specific populations based on recommendations from the Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain.Researchers for the guideline conducted a systematic review of the literature, focusing on reviews of the effectiveness and safety of opioids in specific populations.Family physicians can minimize the risks of overdose, sedation, misuse, and addiction through the use of strategies tailored to the age and health status of patients. For patients at high risk of addiction, opioids should be reserved for well-defined nociceptive or neuropathic pain conditions that have not responded to first-line treatments. Opioids should be titrated slowly, with frequent dispensing and close monitoring for signs of misuse. Suspected opioid addiction is managed with structured opioid therapy, methadone or buprenorphine treatment, or abstinence-based treatment. Patients with mood and anxiety disorders tend to have a blunted analgesic response to opioids, are at higher risk of misuse, and are often taking sedating drugs that interact adversely with opioids. Precautions similar to those for other high-risk patients should be employed. The opioid should be tapered if the patient's pain remains severe despite an adequate trial of opioid therapy. In the elderly, sedation, falls, and overdose can be minimized through lower initial doses, slower titration, benzodiazepine tapering, and careful patient education. For pregnant women taking daily opioid therapy, the opioids should be slowly tapered and discontinued. If this is not possible, they should be tapered to the lowest effective dose. Opioid-dependent pregnant women should receive methadone treatment. Adolescents are at high risk of opioid overdose, misuse, and addiction. Patients with adolescents living at home should store their opioid medication safely. Adolescents rarely require long-term opioid therapy.Family physicians must take into consideration the patient's age, psychiatric status, level of risk of addiction, and other factors when prescribing opioids for chronic pain.

A pocket guide on management of substance use during pregnancy was developed by a group of Canadian care providers. One hundred and fifteen family medicine residents in 6 Canadian teaching sites were randomized to receive either the pocket guide or a paper summary on similar clinical topics, based on UpToDate, a comprehensive Web-based resource. At baseline, both groups completed a survey containing questions on beliefs, attitudes, experience, and training on pregnancy and substance use. Participants then answered 28 multiple choice questions about substance use in pregnancy, using either the pocket guide or UpToDate. Finally participants were asked to rate ease of use for the 2 resources. The results showed that the pocket guide group had higher knowledge scores than the UpToDate group overall and at each study site (61.27% vs. 42.86%, P < .001). The residents found the pocket guide easier to use than UpToDate (mean = 2.73 vs. 4.36, P < .001), and were more likely to want to use it again (96% for pocket card, 78% for UpToDate, P = .005). It is concluded that the pocket guide is a practical source of clinical information at point of care, particularly for “orphan” subjects such as substance use in pregnancy.

To improve awareness and knowledge of problematic substance use in pregnancy and to provide evidence-based recommendations for the management of this challenging clinical issue for all health care providers.This guideline reviews the use of screening tools, general approach to care, and recommendations for clinical management of problematic substance use in pregnancy.Evidence-based recommendations for screening and management of problematic substance use during pregnancy and lactation.Medline, PubMed, CINAHL, and The Cochrane Library were searched for articles published from 1950 using the following key words: substance-related disorders, mass screening, pregnancy complications, pregnancy, prenatal care, cocaine, cannabis, methadone, opioid, tobacco, nicotine, solvents, hallucinogens, and amphetamines. Results were initially restricted to systematic reviews and randomized control trials/controlled clinical trials. A subsequent search for observational studies was also conducted because there are few RCTs in this field of study. Articles were restricted to human studies published in English. Additional articles were located by hand searching through article reference lists. Searches were updated on a regular basis and incorporated in the guideline up to December 2009. Grey (unpublished) literature was also identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on the Preventive Health Care. Recommendations for practice were ranked according to the method described in that report (Table 1).This guideline is intended to increase the knowledge and comfort level of health care providers caring for pregnant women who have substance use disorders. Improved access to health care and assistance with appropriate addiction care leads to reduced health care costs and decreased maternal and neonatal morbidity and mortality.

In Canada, the qualification of physicians is the jurisdiction of the College of Family Physicians and the Royal College of Physicians and Surgeons. The Colleges have promoted the training of “generalists” in family medicine and “sophisticated generalists” among the traditional specialties, and the development of subspecialties has not been encouraged. Nevertheless, due to the increasing number of family physicians and specialists practicing a range of new subspecialties, including addiction medicine, the College of Family Physicians has recognized special interest or focused practices, whereas the Royal College has recognized, in psychiatry, 3 subspecialties (child, geriatric, forensic) requiring an extra year of training and may offer others a diploma recognition. These new opportunities will shape the training requirements of addiction medicine leading to available certification through the International and American Medical Societies of Addiction Medicine.

To improve awareness and knowledge of problematic substance use in pregnancy and to provide evidence-based recommendations for the management of this challenging clinical issue for all health care providers.This guideline reviews the use of screening tools, general approach to care, and recommendations for clinical management of problematic substance use in pregnancy.Evidence-based recommendations for screening and management of problematic substance use during pregnancy and lactation.Medline, PubMed, CINAHL, and The Cochrane Library were searched for articles published from 1950 using the following key words: substance-related disorders, mass screening, pregnancy complications, pregnancy, prenatal care, cocaine, cannabis, methadone, opioid, tobacco, nicotine, solvents, hallucinogens, and amphetamines. Results were initially restricted to systematic reviews and randomized control trials/controlled clinical trials. A subsequent search for observational studies was also conducted because there are few RCTs in this field of study. Articles were restricted to human studies published in English. Additional articles were located by hand searching through article reference lists. Searches were updated on a regular basis and incorporated in the guideline up to December 2009. Grey (unpublished) literature was also identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on the Preventive Health Care. Recommendations for practice were ranked according to the method described in that report (Table 1).This guideline is intended to increase the knowledge and comfort level of health care providers caring for pregnant women who have substance use disorders. Improved access to health care and assistance with appropriate addiction care leads to reduced health care costs and decreased maternal and neonatal morbidity and mortality.1. All pregnant women and women of childbearing age should be screened periodically for alcohol, tobacco, and prescription and illicit drug use. (III-A) 2. When testing for substance use is clinically indicated, urine drug screening is the preferred method. (II-2A) Informed consent should be obtained from the woman before maternal drug toxicology testing is ordered. (III-B) 3. Policies and legal requirements with respect to drug testing of newborns may vary by jurisdiction, and caregivers should be familiar with the regulations in their region. (III-A) 4. Health care providers should employ a flexible approach to the care of women who have substance use problems, and they should encourage the use of all available community resources. (II-2B) 5. Women should be counselled about the risks of periconception, antepartum, and postpartum drug use. (III-B) 6. Smoking cessation counselling should be considered as a first-line intervention for pregnant smokers. (I-A) Nicotine replacement therapy and/or pharmacotherapy can be considered if counselling is not successful. (I-A) 7. Methadone maintenance treatment should be standard of care for opioid-dependent women during pregnancy. (II-IA) Other slow-release opioid preparations may be considered if methadone is not available. (II-2B) 8. Opioid detoxification should be reserved for selected women because of the high risk of relapse to opioids. (II-2B) 9. Opiate-dependent women should be informed that neonates exposed to heroin, prescription opioids, methadone, or buprenorphine during pregnancy are monitored closely for symptoms and signs of neonatal withdrawal (neonatal abstinence syndrome). (II-2B) Hospitals providing obstetric care should develop a protocol for assessment and management of neonates exposed to opiates during pregnancy. (III-B) 10. Antenatal planning for intrapartum and postpartum analgesia may be offered for all women in consultation with appropriate health care providers. (III-B) 11. The risks and benefits of breastfeeding should be weighed on an individual basis because methadone maintenance therapy is not a contraindication to breastfeeding. (II-3B).