Understanding cannabis use in Singapore: profile of users and drug progression

INTRODUCTION@#Cannabis has consistently been the third most commonly abused drug among drug arrestees in Singapore over the past few years. Accordingly, this study aimed to understand the profile of cannabis users in Singapore and explore the effects of cannabis use on drug progression.@*METHODS@#A total of 450 participants who had used cannabis at least once in their lifetime were recruited from the National Addictions Management Service, prisons, the Community Rehabilitation Centre and halfway houses from August 2017 to May 2018. A face-to-face questionnaire was administered and descriptive analyses were conducted.@*RESULTS@#The mean participant age was 40.9 ± 14.51 years, and 93.1% of them were male. The participants generally initiated cannabis use during adolescence, at a mean onset age of 16.5 ± 4.46 years. Most (89.6%) were introduced to cannabis by peers. Approximately half of them (46.9%) had used cannabis before other illicit drugs and 42.1% of them had used heroin as the succeeding drug.@*CONCLUSION@#In Singapore, cannabis use is often initiated during adolescence, largely under peer influence. Cannabis users may progress to other illicit drugs, particularly heroin, later in life.

Favourable vaccine-induced SARS-CoV-2 specific T cell response profile in patients undergoing immune-modifying therapies

Patients undergoing immune-modifying therapies demonstrate a reduced humoral response after COVID-19 vaccination, but we lack a proper evaluation of the impact of such therapies on vaccine-induced T cell responses. Here, we longitudinally characterised humoral and Spike-specific T cell responses in inflammatory bowel disease (IBD) patients who are on antimetabolite therapy (azathioprine or methotrexate), TNF inhibitors and/or other biologic treatment (anti-integrin or anti-p40) after mRNA vaccination up to 3 months after completing two vaccine doses. We demonstrated that a Spike-specific T cell response is not only induced in treated IBD patients at levels similar to healthy individuals, but also sustained at higher magnitude, particularly in those treated with TNF inhibitor therapy. Furthermore, the Spike-specific T cell response in these patients is mainly preserved against mutations present in SARS-CoV-2 B.1.1.529 (Omicron) and characterized by a Th1/IL-10 cytokine profile. Thus, despite the humoral response defects, the favourable profile of vaccine-induced T cell responses might still provide a layer of COVID-19 protection to patients under immune-modifying therapies.

The Effects Of Practice Size On Quality Of Care In Primary Care Settings: A Systematic Review.

BACKGROUND: There is a trend towards the consolidation of small primary care practices into larger practices, which potentially have economies of scales for employment of staff and use of information technologies. However, the effects of practice size on quality of care remain unclear. OBJECTIVE: The objective of this review was to systematically appraise the effects of practice size on the quality of care in primary care. INCLUSION CRITERIA: All quantitative studies that focused on primary care practices or primary care practitioners were considered. Independent variables were team size or list size; outcome variables were measures of clinical processes, clinical outcomes, or patient reported outcomes. SEARCH STRATEGY: We searched the following databases: PubMed, CINAHL, EMBASE, Cochrane Library, CRD databases, Proquest Dissertations and Theses, Conference proceedings and Mednar from 1990 to 2010. Searches were restricted to English language. We also searched the reference lists of included studies. METHODOLOGICAL QUALITY: Methodological quality of the studies was assessed using a modified critical appraisal checklist from the Joanna Briggs Institute. Studies that did not fulfill or were unclear in any of the following criteria were excluded: 1) independent variable measured in a reliable way; 2) outcome variables measured in a reliable way; 3) use of appropriate statistical analysis; or 4) confounding factors adjusted for in analysis. DATA COLLECTION: Data was extracted using standardised data extraction forms from the Joanna Briggs Institute. DATA SYNTHESIS: A narrative synthesis of the results was conducted. RESULTS: The search yielded 371 articles. Of these, 34 articles were considered relevant and underwent quality assessment. This resulted in 17 articles (13 studies) being included in the review. All studies reviewed were cross-sectional in design. Eight examined the effects of practice size on clinical processes, one on clinical outcomes, two on patient reported outcomes, one on both clinical processes and outcomes, and one on both clinical processes and patient reported outcomes.Of the ten studies on the association between practice size and clinical processes, three found larger practices to have statistically significantly higher specialist referral rates for eating disorder (Rate ratio=1.11, 95% CI: 1.07-1.16, p<0.001), better adherence to American Academy of Pediatrics (AAP) guidelines (OR=2, 95% CI: 1.11-3.33), and better pneumococcal vaccination coverage (OR=1.45, p<0.0001). Three found statistically significant associations in only selected process measures, while four did not find any association between practice size and clinical processes. Of the latter seven studies, four may be underpowered.The two studies on clinical outcomes did not find any statistically significant association with practice size, although both studies may be underpowered. Of the three studies on patient reported outcomes, one reported statistically significant association between smaller practices and satisfaction with access, two found statistically significant associations in about half of the patient reported outcomes evaluated. However, one of the latter two studies may be underpowered. CONCLUSIONS: There is limited evidence available to support an association between practice size and quality of care in primary care. Although some studies showed that larger practices adhered to or implemented clinical processes better than smaller practices, other studies did not find any statistical significance between practice size and other process measures. None of the studies that examined clinical outcomes found statistically significant associations with practice size. For patient reported outcomes, there was some evidence that smaller practice size was associated with better patient reported access, however the evidence for other patient reported outcomes was inconsistent. IMPLICATIONS FOR PRACTICE: The findings of this review support the current evidence that smaller practices are comparable to larger practices in clinical performance. However, some evidence suggests that larger practices may perform better in certain process measures, while smaller practices may have better satisfaction in certain patient reported outcomes. With the trend towards larger primary care practices, there may be a trade-off between high quality clinical care and interpersonal care. IMPLICATIONS FOR RESEARCH: Further research needs to be done to ascertain an optimal practice size for primary care to retain the benefits that small and large practices can offer. Future studies should address common methodological limitations such as the lack of power due to small sample sizes, and to account for the effects of clustering and collinearity in statistical analyses.

Concomitant use of midazolam and buprenorphine and its implications among drug users in Singapore

<p><b>INTRODUCTION</b>The aim of this study was to determine the prevalence and characteristics of benzodiazepine (BZD) abuse among intravenous opioid users in Singapore.</p><p><b>MATERIALS AND METHODS</b>Eligibility criteria for inclusion in this study were all intravenous buprenorphine abusers, who presented to the Community Addictions Management Programme (CAMP) over a 1-year period from February 2005 to January 2006. One hundred and twenty subjects, who consented to the study, completed an interviewer-administered questionnaire and underwent blood test for blood-borne viral infections.</p><p><b>RESULTS</b>The age of the 120 subjects ranged from 20 to 64 years, with a mean age of 39.0 (SD 8.0) years. The majority of the participants were male (90.0%); 48.3% were Chinese. Ninety-eight (81.7%) patients were using BZDs concomitantly. Midazolam was the most commonly used BZD. Buprenorphine abusers who were concomitantly using BZDs were significantly younger and reported an earlier age of onset of illicit drug abuse as compared to those not using BZDs. Those abusing BZDs were more likely to share syringes (x 2 = 5.8, P = 0.02), and were more likely to be seropositive for hepatitis C virus (x 2 = 4.3, P = 0.04).</p><p><b>CONCLUSIONS</b>This study highlights the extreme caution that needs to be exercised in prescribing BZDs to all patients in general and patients with injecting drug use or histories of drug abuse in particular. At a public health level, general practitioners (GPs) who prescribe buprenorphine should have compulsory training which highlights the potential dangers of abuse and concomitant abuse of BZDs.</p>

Socio-demographic profile and help-seeking behaviour of buprenorphine abusers in Singapore

<p><b>INTRODUCTION</b>The US Food and Drug Administration (FDA) approved buprenorphine or Subutex for the treatment of opiate dependence in October 2002. Buprenorphine is a partial agonist of the mu-opioid receptor; although initial animal research suggested a low abuse potential for buprenorphine, it was subsequently shown to have an abuse potential similar to that of morphine or hydromorphone. The objectives of this study were to establish the sociodemographic profile and help-seeking behaviour of buprenorphine abusers attending the deaddiction treatment clinics of the Community Addictions Management Programme.</p><p><b>MATERIALS AND METHODS</b>One hundred and twenty subjects, all buprenorphine abusers fulfilling the diagnostic criteria for opiate dependence, who consented to the study, completed an interviewer-administered questionnaire.</p><p><b>RESULTS</b>The mean age of those participating in the study was 39.2 [standard deviation (SD) 8.0] years. The majority of the participants were male (90%), 52.5% were currently employed and 98% had at least primary education. A family history of drug abuse was reported by 27% of the subjects. Illicit drug abuse occurred at an early age with mean age of onset of illicit drug abuse being 16.9 (SD 4.8) years with gateway drugs like marijuana and glue.</p><p><b>CONCLUSIONS</b>It is vital for our medical profession to be aware of the trend in the local population to move from the abuse of illicit substances, to the abuse of prescriptive medications. It makes it necessary to increase the understanding of addictions both amongst our practising medical fraternity, and amongst those training to enter the profession. At the hospital level, it necessitates a higher level of vigilance among our emergency room physicians and those treating infectious diseases.</p>