Evaluating the Impact of Prescribed Versus Nonprescribed Benzodiazepine Use in Methadone Maintenance Therapy: Results From a Population-based Retrospective Cohort Study.

OBJECTIVES: Benzodiazepine (BZD) use is common in patients who are engaged in methadone as a treatment for opioid use disorder. BZD prescribing is generally discouraged for this patient population due to the increased risk of BZD dependence and BZD use disorder, medication-assisted treatment (MAT) discontinuation, and opioid-overdose death. However, some patients have concurrent mental health disorders, where BZD use may be clinically indicated. This study evaluates the impact of prescribed BZD on MAT outcomes. METHODS: Linking urine drug screening data (UDS) and prescribing information from single-payer health records, we conducted a retrospective Kaplan-Meier analysis between patients using prescribed and nonprescribed BZD with methadone treatment retention as the primary outcome. Data are from a network of 52 outpatient clinics in Ontario, Canada, between January 1, 2006 and June 30, 2013. RESULTS: We identified 3692 patients initiating methadone-assisted treatment for the first time; 76% were BZD-/UDS- (no BZD prescription and <30% screens positive for BZD); 13% were BZD+/UDS-; 6% BZD-/UDS+; and 6% BZD+/UDS+. Using 1-year treatment retention as a primary outcome, patients using nonprescribed BZD (BZD-/UDS+) were twice as likely (adjusted odds ratio 0.38, 95% confidence interval 0.27-0.53) to discontinue treatment as those not using BZD (BZD-/UDS-), or those using BZD in a prescribed manner (BZD+/UDS+). CONCLUSIONS: Our findings suggest that prescribed BZD can be used during methadone MAT without impacting a patient's retention in MAT, but nonprescribed BZD use is predictive of treatment discontinuation. Importantly, we urge both the physician and patient to seek alternative clinical options to BZD prescribing, due to the potential for developing physical dependence (and BZD use disorder) to BZD and the risks of negative interactions with opioids.

Characterizing the Use of Telepsychiatry for Patients with Opioid Use Disorder and Cooccurring Mental Health Disorders in Ontario, Canada.

Rural patients with opioid use disorder (OUD) face a variety of barriers when accessing opioid agonist therapy (OAT) and psychiatric services, due to the limited supply of physicians and the vast geographic area. The telemedicine allows for contact between patients and their physician-regardless of physical distance. Objective. We characterize the usage of telemedicine to deliver psychiatric services to patients with OUD in Ontario, as well as traits of treatment-seeking patients with opioid dependence and concurrent psychiatric disorders. Methodology. A retrospective cohort study was conducted using an administrative database for patients who received psychiatric services via telemedicine between 2008 and 2014 and who also had OUD. Results. We identified 9,077 patients with concurrent opioid use and other mental health disorders who had received psychiatric services via telemedicine from 2008 to 2014; 7,109 (78.3%) patients lived in Southern Ontario and 1,968 (21.7%) in Northern Ontario. Telemedicine was used more frequently to provide mental health services to patients residing in Northern Ontario than Southern Ontario. Conclusion. Telemedicine is increasingly being utilized throughout Ontario for delivering mental health treatment. There is an opportunity to increase access to psychiatric services for patients with opioid dependence and concurrent psychiatric disorders through the use of the telemedicine.

The opioid crisis: past, present and future policy climate in Ontario, Canada.

BACKGROUND: Addressing opioid use disorder has become a priority in Ontario, Canada, because of its high economic, social and health burden. There continues to be stigma and criticism relating to opioid use disorder and treatment options. The result has been unsystematic, partial, reactive policies and programs developed based on divergent points of view. The aim of this manuscript is to describe how past and present understandings, narratives, ideologies and discourse of opioid use, have impacted policies over the course of the growing opioid crisis. COMMENTARY: Assessing the impact of policy is complex. It involves consideration of conceptual issues of what impacts policy change. In this manuscript we argue that the development of polices and initiatives regarding opioids, opioid use disorder and opioid agonist treatment in the last decade, have been more strongly associated with the evolution of ideas, narratives and discourses rather than research relating to opioids. We formulate our argument using a framework by Sumner, Crichton, Theobald, Zulu, and Parkhurs. We use examples from the Canadian context to outline our argument such as: the anti- drug legislation from the Canadian Federal Conservative government in 2007; the removal of OxyContin™ from the drug formulary in 2012; the rapid expansion of opioid agonist treatment beginning in the early 2000s, the unilateral decision made regarding fee cuts for physicians providing opioid agonist treatment in 2015; and the most recent implementation of a narcotics monitoring system, which are all closely linked with the shifts in public opinion and discourse at the time of which these policies and programs are implemented. CONCLUSION: We conclude with recommendations to consider a multifactorial response using evidence and stakeholder engagement to address the opioid crisis, rather than a reactive policy approach. We suggest that researchers have an important role in shaping future policy by reframing ideas through knowledge translation, formation of values, creation of new knowledge and adding to the quality of public discourse and debate.

The impact of cannabis use on patients enrolled in opioid agonist therapy in Ontario, Canada.

BACKGROUND: With the Canadian government legalizing cannabis in the year 2018, the potential harms to certain populations-including those with opioid use disorder-must be investigated. Cannabis is one of the most commonly used substances by patients who are engaged in medication-assisted treatment for opioid use disorder, the effects of which are largely unknown. In this study, we examine the impact of baseline and ongoing cannabis use, and whether these are impacted differentially by gender. METHODS: We conducted a retrospective cohort study using anonymized electronic medical records from 58 clinics offering opioid agonist therapy in Ontario, Canada. One-year treatment retention was the primary outcome of interest and was measured for patients who did and did not have a cannabis positive urine sample in their first month of treatment, and as a function of the proportion of cannabis-positive urine samples throughout treatment. RESULTS: Our cohort consisted of 644 patients, 328 of which were considered baseline cannabis users and 256 considered heavy users. Patients with baseline cannabis use and heavy cannabis use were at increased risk of dropout (38.9% and 48.1%, respectively). When evaluating these trends by gender, only female baseline users and male heavy users are at increased risk of premature dropout. INTERPRETATION: Both baseline and heavy cannabis use are predictive of decreased treatment retention, and differences do exist between genders. With cannabis being legalized in the near future, physicians should closely monitor cannabis-using patients and provide education surrounding the potential harms of using cannabis while receiving treatment for opioid use disorder.

The impact of cocaine use in patients enrolled in opioid agonist therapy in Ontario, Canada.

BACKGROUND: Opioid agonist therapy is the gold standard of care for opioid use disorder; however, the efficacy of this treatment may be hindered by concurrent drug use, including the use of cocaine. This study examines the impact of cocaine use on treatment retention, while accounting for various risk factors, including geographic location, age, gender, and first-month cocaine use. METHODS: We conducted a retrospective cohort study using anonymized electronic medical records from 58 opioid agonist therapy clinics in Ontario between 2011 and 2013. One-year treatment retention was the primary outcome of interest and was measured by differing frequencies of cocaine use - as well as baseline use - with an additional focus on geographic location (Northern Ontario vs. Southern Ontario). RESULTS: Our cohort consisted of 3835 patients, with the average retention rate of 44%. Baseline cocaine users had a retention rate of 39% and non-users had a retention rate of 46%. Patients who were cocaine-negative on admission benefited from an increased median days retained (302 vs. 212 days). Patients who used cocaine at higher frequencies had decreased retention rates compared to those who used less often. Despite increased levels of cocaine use, Northern patients were better retained than Southern patients. CONCLUSION: Northern patients and patients from urban communities are more likely to be baseline cocaine users. Both baseline and continued cocaine use is predictive of treatment dropout in Northern and Southern patients. The higher the frequency of cocaine use, the more likely a patient is to terminate treatment. Patients in Northern Ontario are retained in treatment at higher rates than their Southern counterparts.

The impact of benzodiazepine use in patients enrolled in opioid agonist therapy in Northern and rural Ontario.

BACKGROUND: Benzodiazepine use is common among patients in opioid agonist therapy; this puts patients at an increased risk of overdose and death. In this study, we examine the impact of baseline and ongoing benzodiazepine use, and whether patients are more likely to terminate treatment with increasing proportion of benzodiazepine positive urine samples. We also study whether benzodiazepine use differs by geographic location. METHODS: We conducted a retrospective cohort study using anonymized electronic medical records from 58 clinics offering opioid agonist therapy in Ontario. One-year treatment retention was the primary outcome of interest and was measured for patients who did and did not have a benzodiazepine positive urine sample in their first month of treatment, and as a function of the proportion of benzodiazepine-positive urine samples throughout treatment. Cox proportional hazard model was used to characterize one-year retention. RESULTS: Our cohort consisted of 3850 patients, with the average retention rate of 43.4%. Baseline benzodiazepine users had a retention rate of 39.9% and non-users had a retention rate of 44%. Patients who were benzodiazepine negative on admission benefited from an increased median days retained of 265 vs. 215 days. Patients with more than 75% of urines positive for benzodiazepines were 175% more likely to drop out of treatment than those patients with little or no benzodiazepine use. CONCLUSIONS: Baseline benzodiazepine use is predictive of decreased retention. Patients who have a higher proportion of benzodiazepine-positive urine samples are more likely to drop out of treatment compared to those who have little or no benzodiazepine detection in their urine.