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Awareness of Fentanyl Exposure and the Associated Overdose Risks Among People Who Inject Drugs in a Canadian Setting

Peer reviewed: 
Yes, item is peer reviewed.
Date created: 
2021-02-18
Abstract: 

Introduction and Aims:

Illicitly-manufactured fentanyl continues to fuel the opioidoverdose crisis throughout the United States and Canada. However, little is known about factors associated with knowingly or unknowingly using fentanyl. Therefore, we sought to identify the prevalence and correlates of suspected/known and unknown exposure to fentanyl (excluding the prescribed one) among people who inject drugs (PWID), including associated overdose risks.

 

Design and Methods:

Data were derived from three prospective cohort studies of community-recruited people who use drugs in Vancouver, Canada in 2016–2017. Multivariable logistic regression was used to identify correlates of suspected/known exposure (i.e., urine drug screen positive [UDS+] and self-reporting past three-day exposure) and unknown exposure to fentanyl (i.e., UDS+ and self-reporting no past three day exposure), respectively.

 

Results:

Among 590 PWID, 296 (50.2%) tested positive for fentanyl. Of those, 143 (48.3%) had suspected/known and 153 (51.7%) had unknown exposure to fentanyl. In multivariable analyses, using supervised injection sites and possessing naloxone were associated with both suspected/known and unknown exposure (all p<0.05). Injecting drugs alone (Adjusted Odds Ratio [AOR]: 3.26; 95% Confidence Interval [CI]: 1.72–6.16) was associated with known exposure, but not with unknown exposure.

 

Discussion and Conclusions:

We found a high prevalence of fentanyl exposure in our sample of PWID, with one half of those exposed consuming fentanyl unknowingly. While those exposed to fentanyl appeared more likely to utilize some overdose prevention services, PWID with suspected/known fentanyl exposure were more likely to inject alone, indicating a need for additional overdose prevention efforts for this group.

Document type: 
Article
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Sharpening Our Public Health Lens: Advancing Im/Migrant Health Equity During COVID-19 and Beyond

Peer reviewed: 
Yes, item is peer reviewed.
Date created: 
2021-02-08
Abstract: 

Background:  Differential impacts of the COVID-19 pandemic have brought deeply rooted inequities to the forefront, where increasing evidence has shown that racialized immigrant and migrant (im/migrant) populations face a disproportionate burden of COVID-19. Im/migrant communities may be worst affected by lockdowns and restrictive measures, face less opportunity to physically distance or stay home sick within ‘essential’ jobs, and experience severe barriers to healthcare. Insufficient attention to experiences of racialized im/migrants in current pandemic responses globally highlights an urgent need to more fulsomely address unmet health needs through an anti-racist, equity-oriented lens. This commentary aims to highlight the need for public health and clinical training, research, and policy to thoughtfully prioritize im/migrant health equity during and beyond the COVID-19 pandemic.

Main text:  Global pandemic responses have neglected im/migrants by continuing to ignore or insufficiently address inequities, exacerbating COVID transmission, xenophobia, and occupational injustice. Deaths, illness, stress, and other negative outcomes of the overlapping epidemics of COVID-19 and structural racism disproportionately borne by racialized im/migrants suggest the urgent need for action. As evidence mounts about how im/migrants have been left behind in times of crises, we need enhanced focus on health equity within COVID-19 research and interventions, including research that examines and pursues structural interventions necessary to mitigate these impacts, and that identifies patterns and harms of xenophobic policy, structural racism, and white supremacy in shaping im/migrant health outcomes. We must also strengthen anti-racist and equity-oriented curriculum within health education, and ensure sufficient attention to the needs of im/migrant communities within public health, clinical, and research training.

Conclusion:  The COVID-19 pandemic has exacerbated and rendered more visible the deeply rooted health and social inequities faced by racialized im/migrants across diverse settings. We argue for a greater emphasis on equity-focused and anti-racist im/migrant health research, interventions, and training. Policymakers and practitioners must ensure that healthcare policies and practices do not exacerbate inequities, and instead meaningfully address unmet needs of communities, including racialized im/migrants. Ethical and respectful community engagement, commitment and collaboration with global, national, and local communities, policymakers, academics, and educators, as well as accountability across sectors, is critical.

Document type: 
Article
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An Economic Analysis of the Health-Related Benefits Associated With Bicycle Infrastructure Investment in Three Canadian Cities

Peer reviewed: 
Yes, item is peer reviewed.
Date created: 
2021-02-08
Abstract: 

Objectives

Decision-makers are increasingly requesting economic analyses on transportation-related interventions, but health is often excluded as a determinant of value. We assess the health-related economic impact of bicycle infrastructure investments in three Canadian cities (Victoria, Kelowna and Halifax), comparing a baseline reference year (2016) with the future infrastructure build-out (2020).

Methods

The World Health Organization’s Health Economic Assessment Tool (HEAT; version 4.2) was used to quantify the economic value of health benefits associated with increased bicycling, using a 10-year time horizon. Outputs comprise premature deaths prevented, carbon emissions avoided, and a benefit:cost ratio. For 2016–2020, we derived cost estimates for bicycle infrastructure investments (including verification from city partners) and modelled three scenarios for changes in bicycling mode share: ‘no change’, ‘moderate change’ (a 2% increase), and ‘major change’ (a 5% increase). Further sensitivity analyses (32 per city) examined how robust the moderate scenario findings were to variation in parameter inputs.

Results

Planned bicycle infrastructure investments between 2016 and 2020 ranged from $28–69 million (CAD; in 2016 prices). The moderate scenario benefit:cost ratios were between 1.7:1 (Victoria) and 2.1:1 (Halifax), with the benefit estimate incorporating 9–18 premature deaths prevented and a reduction of 87–142 thousand tonnes of carbon over the 10-year time horizon. The major scenario benefit:cost ratios were between 3.9:1 (Victoria) and 4.9:1 (Halifax), with 19–43 premature deaths prevented and 209–349 thousand tonnes of carbon averted. Sensitivity analyses showed the ratio estimates to be sensitive to the time horizon, investment cost and value of a statistical life inputs.

Conclusion

Within the assessment framework permitted by HEAT, the dollar value of health-related benefits exceeded the cost of planned infrastructure investments in bicycling in the three study cities. Depending on the decision problem, complementary analyses may be required to address broader questions relevant to decision makers in the public sector.

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Article
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Helping children cope with trauma

Peer reviewed: 
No, item is not peer reviewed.
Date created: 
2021
Abstract: 

Background: Experiencing adverse experiences during childhood can lead to the development of mental disorders. We therefore set out to identify that effectively help children who have experienced trauma.

Methods: We used systematic review methods to identify randomized controlled trials (RCTs) evaluating prevention interventions for children after serious adverse experiences. After applying our rigorous inclusion criteria, we accepted five RCTs – evaluating three psychosocial interventions delivered to children who had been maltreated, and one medication for children who had sustained physical injuries.

Results: It’s My Turn Now, Fostering Healthy Futures, and Multisystemic Therapy showed benefits for children who had a history of maltreatment, including reducing symptoms of mental disorders. In contrast, Propranolol failed to show benefit for children who had sustained injuries.

Conclusions: Preventing childhood adversities wherever possible is crucial and recognizes children’s rights to safety. Yet it is possible to prevent mental health symptoms from developing even after children have experienced serious adversity.

Helping young people with psychosis

Peer reviewed: 
No, item is not peer reviewed.
Date created: 
2020
Abstract: 

Background: Psychotic disorders are associated with a high degree of impairment making early intervention crucial for youth. We therefore set out to identify effective psychosis interventions for young people.

Methods: We used systematic review methods to identify randomized controlled trials (RCTs) evaluating treatment interventions. After applying our rigorous inclusion criteria, we accepted eight RCTs – evaluating five different medications and three psychosocial interventions.

Results: Aripiprazole and olanzapine showed benefits in two trials each, although both led to adverse events that require close monitoring. Cognitive Remediation Therapy, Computer-Assisted Cognitive Remediation and the Think Program showed secondary benefits of improved cognitive skills and reduced emergency room visits which can be helpful when used along with antipsychotic medications.

Conclusions: Antipsychotics should be used prudently, after careful assessment and diagnosis, and psychosocial interventions should be offered as well. Further research is needed on early interventions to help young people with psychosis.

Association of “Hypertriglyceridemic Waist” With Increased 5-Year Risk of Subclinical Atherosclerosis in a Multi-Ethnic Population: A Prospective Cohort Study

Peer reviewed: 
Yes, item is peer reviewed.
Date created: 
2021-02-02
Abstract: 

Background

Hypertriglyceridemic waist (HTGW), which incorporates measures of waist circumference and levels of triglyceride in blood, could act as an early-stage predictor to identify the individuals at high-risk for subclinical atherosclerosis. Previous studies have explored the cross-sectional association between HTGW and atherosclerosis; however, understanding how this association might change over time is necessary. This study will assess the association between HTGW with 5-year subclinical carotid atherosclerosis.

Methods

517 participants of Aboriginal, Chinese, European, and South Asian ethnicities were examined for baseline HTGW and 5-year indices of subclinical atherosclerosis (intima media thickness (mm), total area (mm2), and plaque presence). Family history of cardiovascular disease, sociodemographic measures (age, sex, ethnicity, income level, maximum education), and traditional risk factors (systolic blood pressure, smoking status, total cholesterol, high-density lipoprotein cholesterol, body mass index) were incorporated into the models of association. These models used multiple linear regression and logistic regression.

Results

Baseline HTGW phenotype is a statistically significant and clinically meaningful predictor of 5-year intima media thickness (β = 0.08 [0.04, 0.11], p < 0.001), total area (β = 0.20 [0.07, 0.33], p = 0.002), and plaque presence (OR = 2.17 [1.13, 4.19], p = 0.02) compared to the non-HTGW group independent of sociodemographic factors and family history. However, this association is no longer significant after adjusting for the traditional risk factors of atherosclerosis (p = 0.27, p = 0.45, p = 0.66, respectively). Moreover, change in status of HTGW phenotype does not correlate with change in indices of atherosclerosis over 5 years.

Conclusions

Our results suggest that when the traditional risk factors of atherosclerosis are known, HTGW may not offer additional value as a predictor of subclinical atherosclerosis progression over 5 years.

 

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Article
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The Scope and Nature of Sexual Orientation and Gender Identity and Expression Change Efforts: A Systematic Review Protocol

Peer reviewed: 
Yes, item is peer reviewed.
Date created: 
2021-01-08
Abstract: 

Background

Sexual orientation and gender identity and expression change efforts (SOGIECE) are a set of scientifically discredited practices that aim to deny and suppress the sexual orientations, gender identities, and/or gender expressions of sexual and gender minorities (SGM). SOGIECE are associated with significant adverse health and social outcomes. SOGIECE continue to be practiced around the world, despite denouncements from professional bodies and survivors, as well as calls for legislative advocacy to prohibit SOGIECE and protect SGM. There are substantial gaps in the availability of consolidated international research to support and refine legislative proposals related to SOGIECE, including those currently underway to enforce bans in Canada and elsewhere.

We therefore propose the first systematic review of international data on SOGIECE that will outline the scope and nature of these practices worldwide. Specifically, we aim to estimate how many SGM have been exposed to SOGIECE, which sub-groups of SGM experience higher rates of SOGIECE, and how estimates of SOGIECE vary over time and place. In addition, we aim to describe when, where, how, and under what circumstances SGM are exposed to SOGIECE.

Methods

To locate an interdisciplinary swath of papers, nine (9) bibliographic databases will be searched: Medline (OVID), Embase (OVID), PsycInfo and Social Work Abstracts via EBSCO, CINAHL, Web of Science Core Collection, LGBTQ+ Source, and Proquest Dissertations & Theses Global and Sociology Collection (ProQuest). A gold standard search will be developed for Medline and adapted to the other databases. Grey literature will be searched at relevant websites, and reference harvesting will be performed in relevant SOGIECE scientific consensus statements. Two authors will independently screen abstracts/titles, screen full texts, abstract data, and apply risk of bias assessments. A narrative synthesis will be implemented to summarize findings.

Discussion

This review will address the gap in synthesized data regarding the prevalence of SOGIECE, social correlates of SOGIECE, variations of SOGIECE over time and place, and the circumstances, settings, and time-points of SOGIECE exposure. Findings from this review will directly inform ongoing and new legislative efforts to ban SOGIECE and other interventions that aim to stem SOGIECE practices and support SOGIECE survivors.

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Article
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Crowdfunding for Complementary and Alternative Medicine: What Are Cancer Patients Seeking?

Peer reviewed: 
Yes, item is peer reviewed.
Date created: 
2020-11-20
Abstract: 

Background

Complementary and alternative medicine (CAM) is increasingly being integrated into conventional medical care for cancer, used to counter the side effects of conventional cancer treatment, and offered as an alternative to conventional cancer care. Our aim is to gain a broader understanding of trends in CAM interventions for cancer and crowdfunding campaigns for these interventions.

Methods

GoFundMe campaigns fundraising for CAM were retrieved through a database of crowdfunding campaign data. Search terms were drawn from two National Institutes of Health lists of CAM cancer interventions and a previous study. Campaigns were excluded that did not match these or related search terms or were initiated outside of June 4th, 2018 to June 4th, 2019.

Results

1,396 campaigns were identified from the US (n = 1,037, 73.9%), Canada (n = 165, 11.8%), and the UK (n = 107, 7.7%). Most common cancer types were breast (n = 344, 24.6%), colorectal (n = 131, 9.4%), and brain (n = 98, 7.0%). CAM interventions sought included supplements (n = 422, 30.2%), better nutrition (n = 293, 21.0%), high dose vitamin C (n = 276, 19.8%), naturopathy (n = 226, 16.2%), and cannabis products (n = 211, 15.1%). Mexico (n = 198, 41.9%), and the US (n = 169, 35.7%) were the most common treatment destinations.

Conclusions

These findings confirm active and ongoing interest in using crowdfunding platforms to finance CAM cancer interventions. They confirm previous findings that CAM users with cancer tend to have late stage cancers, cancers with high mortality rates, and specific diseases such as breast cancer. These findings can inform targeted responses where facilities engage in misleading marketing practices and the efficacy of interventions is unproven.

Document type: 
Article
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Factors Associated with Drug Checking Service Utilization among People Who Use Drugs in a Canadian Setting

Peer reviewed: 
Yes, item is peer reviewed.
Date created: 
2020-12-14
Abstract: 

Background

The United States and Canada are amidst an opioid overdose crisis, with the Canadian province of British Columbia (BC) among the hardest hit. In response, drug checking services (DCS) have been introduced in this setting as a novel pilot harm reduction intervention though little is known about usage rates. Therefore, we sought to identify factors associated with drug checking uptake among people who use drugs (PWUD) in Vancouver, BC.

Methods

Data were derived from three ongoing prospective cohort studies of PWUD in Vancouver between June and November 2018. Multivariable logistic regression was used to determine factors associated with self-reported DCS utilization in the past 6 months among participants at high risk of fentanyl exposure (i.e., those self-reporting illicit opioid use or testing positive for fentanyl via urine drug screen).

Results

Among 828 eligible participants, including 451 (55%) males, 176 (21%) reported recent use of DCS. In multivariable analyses, factors significantly associated with DCS utilization included: homelessness (Adjusted Odds Ratio [AOR] 1.47; 95% Confidence Interval [CI] 1.01–2.13) and involvement in drug dealing (AOR 1.59; 95% CI 1.05–2.39).

Conclusions

In our sample of PWUD, uptake of DCS was low, although those who were homeless, a sub-population known to be at a heightened risk of overdose, were more likely to use the services. Those involved in drug dealing were also more likely to use the services, which may imply potential for improving drug market safety. Further evaluation of drug checking is warranted.

Document type: 
Article
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Understanding Cancer Survivors’ Reasons to Medicate With Cannabis: A Qualitative Study Based on the Theory of Planned Behavior

Peer reviewed: 
Yes, item is peer reviewed.
Date created: 
2020-10-17
Abstract: 

Background

Prior to nonmedical cannabis legalization in Canada, individuals were only able to access cannabis legally through licensed producers with medical authorization. Now with an additional legal access system designed for nonmedical purposes, it is unclear what factors influence cancer survivors’ decisions to medicate or not medicate cannabis as a complementary therapy to alleviate their cancer symptoms.

Methods

We recruited cancer survivors via social media. Interested individuals were purposively sampled to ensure maximization in terms of age, sex, and province of residence. Constructs of the Theory of Planned Behavior were explored during the telephone interviews as participants described what influenced their decisions to medicate or not medicate cannabis to manage their symptoms.

Results

Interviews were conducted with 33 cancer survivors. All individuals believed that cannabis would manage their cancer symptoms. Those that chose to medicate with cannabis provided a variety of reasons, including that cannabis was a more natural alternative; that it reduced their overall number of prescription drugs; and that safer products had become available with the legalization of nonmedical cannabis. Some individuals also indicated that support from physicians and validation from family and friends were important in their decision to medicate with cannabis. Individuals who opted not to medicate with cannabis raised concerns about the lack of scientific evidence and/or possible dependency issues. Some also felt their physician's disapproval was a barrier to considering cannabis use.

Conclusions

The findings revealed that recreational legalization made using cannabis appear safer and easier to access for some cancer survivors. However, physicians’ censure of cannabis use for symptom management was a barrier for survivors considering its use.

Document type: 
Article
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