Background: Substance use is prevalent in Canada, yet treatment is inaccessible. The Rapid Access to Addiction Medicine (RAAM) clinic opened at the University Health Network (UHN) in January 2018 as part of a larger network of addictions clinics in Toronto, Ontario, to enable timely, low barrier access to medical treatment for substance use disorder (SUD). Patients attend on a walk-in basis without requiring an appointment or referral. We describe the RAAM clinic model, including referral patterns, patient demographics and substance use patterns. Secondary outcomes include retention in treatment and changes in both self-reported and objective substance use. Methods: The Electronic Medical Record at the clinic was reviewed for the first 26 weeks of the clinic's operation. We identified SUD diagnoses, referral source, medications prescribed, retention in care and self-reported substance use. Results: The clinic saw 64 unique patients: 66% had alcohol use disorder (AUD), 39% had opiate use disorder (OUD) and 20% had stimulant use disorder. Fifty-five percent of patients were referred from primary care providers, 30% from the emergency department and 11% from withdrawal management services. Forty-two percent remained ongoing patients, 23% were discharged to other care and 34% were lost to follow-up. Gabapentin (39%), naltrexone (39%), and acamprosate (15%) were most frequently prescribed for AUD. Patients with AUD reported a significant decrease in alcohol consumption at their most recent visit. Most patients (65%) with OUD were prescribed buprenorphine, and most patients with OUD (65%) had a negative urine screen at their most recent visit. Conclusion: The RAAM model provides low-barrier, accessible outpatient care for patients with substance use disorder and facilitates the prescription of evidence-based pharmacotherapy for AUD and OUD. Patients referred by their primary care physician and the emergency department demonstrated a reduction in median alcohol consumption and high rates of opioid abstinence.
The purpose of this study was to describe the design and evolution of a unique and successful Master of Science program in anatomical sciences at one Canadian post-secondary institution and to evaluate its long-term impact on student learning. This program prepares students to teach anatomy and design curricula in the anatomical sciences and is structured around three pillars of competency-content (disciplinary knowledge and transferable skills), pedagogy, and inquiry. Graduates of the program from the last ten years were surveyed, to better understand the knowledge, skills, and habits of mind they have adopted and implemented since completion. Interest was taken in identifying aspects of the program that students found particularly beneficial and areas that needed to be further developed. Based on the findings, this program has been a highly valuable experience for the graduates especially in helping them develop transferable skills, and grow as individuals. The hope is that other institutions that have similar programs in place or are considering developing them would benefit from this description of the program design and the sharing of the lessons learned.
Introduction: The opioid crisis persists, and in the context of this urgency and new practice guidelines, the practice of buprenorphine (BUP) prescription is expanding across Canadian emergency departments (EDs). The objective of this study was to identify current knowledge, attitudes and behaviours to managing opioid use disorder (OUD) in the ED, including barriers and facilitators to prescribing BUP. Methods: Forty ED staff physicians were randomly invited to participate from an urban Toronto ED which recently received continuing medical education in addictions, and whose hospital established an addictions follow-up clinic. Individual semi-structured interviews with the 19 physicians who self-selected to participate were grounded in phenomenology, allowing for in-depth accounts of participants’ lived experience and viewpoints on their role in addressing OUD. Thematic analysis was achieved through multiple readings; themes were coded using Dedoose software by two researchers. Themes were further organized as facilitators, barriers, and proposed solutions. Results: Opioid withdrawal management in the ED varied significantly between these practitioners in the same practice group. Facilitators to treating withdrawal and initiating BUP in the ED were rooted in three contributors to physician empowerment: knowledge about OUD and BUP, positive patient and provider experience with substitution therapy in the past, and exposure to physician champions to guide their practice. Systems-level facilitators included timely access to follow-up care and an available order set. Barriers included provider inexperience: missing subtle presentations of withdrawal, lacking feedback on treatment effectiveness, and reported uncertainty about the protocol from nursing staff. The ED environment also limits time to counsel effectively and discourages taking up a bed both to wait for withdrawal onset and for BUP induction. Other barriers were concerns about precipitating withdrawal, prescribing a chronic medication in acute care, and patient attitudes. Conclusion: This is the first study describing barriers and facilitators to addressing OUD and prescribing BUP in the ED. These findings suggest a role for home induction, involvement of allied health professionals in BUP counseling, and heightened continuing medical education. Results will inform departmental efforts across Canada to implement BUP prescribing as standard of care for patients in opioid withdrawal.
Both impulsivity and stress are risk factors for substance abuse, but it is not clear how these two processes interact to alter susceptibility for the disorder. The aim of this project was to examine the pharmacology of a stress-impulsivity interaction in rats. To do so, we tested the effects of yohimbine on impulsive action and then assessed whether behavioural changes could be reduced by antagonists at different receptor subtypes. Male Long-Evans rats were injected with various doses of yohimbine (0-5.0 mg/kg) before testing in the response-inhibition task. In subsequent experiments, yohimbine (2.5 mg/kg) was injected following pretreatment with the following receptor antagonists: corticotropin-releasing factor receptor 1, antalarmin (0-20 mg/kg); glucocorticoid, mifepristone (0-30 mg/kg); noradrenergic (NA) α1, prazosin (0-2 mg/kg); NA α2, guanfacine (0-0.5 mg/kg); NA β2, propranolol (0.5-2.0 mg/kg); dopamine D1/5, SCH 39166 (0-0.0625 mg/kg); μ opioid, naloxone (0-2 mg/kg); or 5-HT2A, M100907 (0.005-0.05 mg/kg). In all experiments, impulsive action was measured as increased premature responding. Yohimbine dose dependently increased impulsive action, but the effect was not reversed by antagonist pretreatment. None of the drugs altered any other behavioural measure. We conclude that stress-impulsivity interactions are likely mediated by a synergy of multiple neurotransmitter systems.
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