Addicted Patients Research Articles

Pattern of chest diseases among addicts in Poison Control Center of Ain Shams University Hospitals

BackgroundDrug addiction results in serious pulmonary complications. Thoracic complications of drug addiction vary depending on the type and the route of administration of the drug that has been abused.AimTo study the pattern of chest diseases among addicts in Poison Control Center of Ain Shams University Hospitals.Patients and methodsA total of 200 addict patients were selected from Poison Control Center of Ain Shams University Hospitals in the duration between June 2016 and June 2018. All patients with pulmonary complications referred to Abbasia Chest Hospital were included.ResultsA total of 200 addict patients were enrolled in this study. Of them, 100 addicts with drug overdose with no pulmonary complications were excluded, and the other 100 patients were included, comprising 99 males and only one female, with mean age of 39.91±10.75 years. Overall, 63% of drug addicts were cannabis addicts, 27.0% were opiate addicts, 8.0% were polysubstance abusers, and 2.0% were alcohol addicts. Pulmonary tuberculosis was the most common pulmonary complication of all drug addicts. There was a statistically significant correlation between the type of drug addiction and the pulmonary complications. Pulmonary tuberculosis was the most common among cannabis addicts as well as polysubstance abusers. Parenchymal lung diseases (pneumonia and lung abscess) were the most common among opiate and intravenous drug addicts. There was no significant difference between different types of drugs and outcomes of the patients. Mortality represented 3.0% of all drug addicts.ConclusionMany pulmonary complications are associated with drug addiction. Achievement of early diagnosis and treatment can be obtained by proper counseling and therapeutic programs.

Construction and Validation of the Inventory of Addiction Awareness (ICE-A)

The development of an addiction considerably damages physical health, social functioning, and quality of life; however, people with substance use disorders act as if they were unaware of how drug and alcohol use contribute to their difficulties. This is one of the main reasons why they fail to address the problem and remain in a self-destructive spiral. The aim of this study was to construct and validate a diagnostic questionnaire for detecting an individual’s level of awareness of drug use, its consequences, and associated illnesses. Three sequential phases were carried out: theoretical (construction and production of adequately worded items), experimental (administration of the questionnaire to a sample of 124 patients with a substance use disorder), and analytical (factor analysis, temporal and internal reliability, discriminant validity, and sensitivity to change during treatment). The ICE-A showed a one-dimensional structure (all the items that make up the questionnaire measure a single variable that can be presented as a total score), an adequate level of internal consistency, and high temporal stability over a 1-month period. The scores obtained by the subjects at 12 months of treatment were significantly higher than those obtained by the same subjects at 6 months of treatment. This questionnaire could allow therapists to monitor the psychotherapeutic processes and outcomes of their addicted patients, assuming that the greater their awareness of their disease, the greater their self-care and improvement.

Examination of the mortality data of patients, treated by the "TÁMASZ" Addictological Out-patient Clinic in Józsefváros (in Budapest, Hungary), who deceased in 2001-2018

Introduction: The analysis of the mortality data of patients is important. Aim: Examination of data from patients treated in the Addictological Out-patient Clinic in Józsefváros and deceased between 2001 and 2018. Method: Patients' data originated from medical records. The national and Budapest data were from the publications of the Hungarian Central Statistical Office. Results: The age of patients was 52.85 ± 11.81 years for women and 51.99 ± 12.47 years for men. Two-thirds, regardless of gender, were alcoholic. There were many violent deaths. A new phenomenon was the high number of drug- and murder-associated deaths. The former group was dominated by men. The latter group showed female dominance. The completed suicide rate was 14.6%. Suicide attempts occurred in 22.4% of patients. The majority of patients were skilled workers. Conclusion: Data support the view that addict patients die earlier. Leading deaths, unlike previous investigations, were violent deaths. The rate of suicide was higher than the national rate, but it was the same as previously reported, indicating a high risk of this population. Gender differences were observed with regard to violent death, requiring further elucidation. Orv Hetil. 2019; 160(47): 1864-1871.

Gene Expression Survey of Serotonin Receptors (5HTR2A and 5HTR3A) and Monoamine Oxidases Enzyme After Treatment With Methadone in Addicted Individuals

Background : Addiction disrupts the nervous system of the reward system, stimulus, and memory in the brain. The disruption of these systems in the brain causes biological, physiological, social, and psychological complications. Addiction is considered a psychological, social, and economic disorder in terms of medicine, psychology, and sociology, as well as philosophy, law, ethics, and religion. The most important place of narcotic effect is the brain, and receptors affect these substances. Dopamine and serotonin receptors are among the most important receptors, in which drugs affect them. Methadone is also an opiate drug that is even more addictive than morphine and heroin and is often used as a preservative to control heroin and narcotic addiction. Methods : In this study, 3 genes of 5-Hydroxytryptamine Receptor 2 A (5HT2Ra), 5-Hydroxytryptamine Receptor 3 A (5HT3Ra), and Monoamine Oxidases A (MAOA), which play an important role in serotonin function, were examined in Peripheral Blood Mononuclear Cells (PBMCs) of heroin addicts, who had been quitting addiction with methadone for 3 months. Therefore, peripheral blood PBMCs were isolated. cDNA was synthesized from mRNA; then, the expression of the gene was measured by real-time Polymerase Chain Reaction (PCR). Results : The expression of MAOA gene in the PBMCs of the addicted patients with methadone was significantly reduced compared to the control group, while the expression of 5HT2Ra and 5HT3Ra genes showed no change in the two groups. Conclusion : These results suggest that Methadone Maintenance Treatment (MMT) may be moderated by 5HT2Ra and 5 HT3Ra serotonin receptors and returned to their previous efficacy, but MAOA was significantly reduced.

Clinical and Mechanistic Effects of Psilocybin in Alcohol Addicted Patients

Clinical and Mechanistic Effects of Psilocybin in Alcohol Addicted Patients

Pazienti addicted ad Elevata Complessità Socio-Sanitaria (ECoSS): dall'approccio intuitivo alla definizione di criteri scientifici. Studio retrospettivo osservazionale su una popolazione di 1.003 pazienti

Un paziente ad "Elevata Complessità SocioSanitaria" (ECoSS), rappresenta l'esito conclusivo di un investimento terapeutico e, tendenzialmente, non ha più possibilità di riabilitazione; quindi, impegnerà risorse del sistema di cura per tutta la durata della sua vita, costituendo un elemento da considerare in termini di programmazione e investimento delle risorse.  A fronte di queste considerazioni, si pongono diverse questioni. Quando è possibile definire un paziente ECoSS? Qual è la prevalenza dei pazienti che possono essere definiti ECoSS sul totale di quelli in cura? Quali caratteristiche specifiche hanno rispetto ai pazienti "non ECoSS" in cura e rispetto alla popolazione generale? Sono stati esaminati 1003 pazienti allo scopo di rispondere a queste domande.

Persone con alcol-dipendenza in trattamento in Toscana e in Friuli Venezia Giulia: uno studio epidemiologico

Obiettivi: Lo studio ha avuto l'obiettivo di approfondire la conoscenza su consumi alcolici, comorbilità somatiche e mentali, problemi sociali, e consumo dei servizi sanitari delle persone in trattamento per alcol-dipendenza (AD) e abuso alcolico in Toscana e in Friuli Venezia Giulia (FVG), confrontando le differenze tra le due regioni. Disegno e metodo: Ricerca trasversale, realizzata mediante intervista diretta con questionario strutturato. I dati risultanti sono stati analizzati mediante test del chi quadro e regressioni logistiche. Partecipanti: Lo studio è stato compiuto tra il luglio 2013 e febbraio 2014 su un campione di alcolisti in trattamento in Toscana (N=147) e in Friuli-Venezia Giulia (N=129).Risultati principali: I pazienti con dipendenza e abuso alcolico avevano condizioni socioeconomiche inferiori più in Toscana (47,9%) che nel FVG (35,7) (OR=1,75, Intervallo di confidenza [IC] 95% 1,06-2,86). I problemi di fegato, la depressione e l'ansia riferite erano maggiori in Toscana in confronto con il FVG: rispettivamente 35,4% vs 22,5% (OR=1,89, IC 95% 1,10-3,22); 58,6% vs 35,7, (OR=2,56, IC 95% 2,56-4,16); 58,9% vs 37,2% (OR=2,42, IC95% 1,49-3,93). Le probabilità che si presentassero gli 11 sintomi che per il DSM IV identificano la dipendenza e l'abuso, erano da 1,9 a 12 volte significativamente minori in Toscana che nel FVG. La probabilità di accesso al DEA (Dipartimento di Emergenza e Urgenza) è stata minore in Toscana rispetto al FVG (15,8% vs 33,3%, OR=0,37, IC95% 0,21- 0,67), mentre i contatti coi medici di medicina generale son stati più frequenti in Toscana che in FVG (51,7% vs 38,8%, OR=1,69, IC95% 1,05-2,73). Conclusione: Lo studio mostra che tra i pazienti con DSM-IV AD e abuso di alcol i problemi di salute percepiti e le condizioni socio-economiche inferiori sono maggiori in Toscana che nel FVG. Tali differenze potrebbero essere attribuite alle diverse attenzioni che le due regioni hanno nei confronti di tali co-morbilità.Inoltre si evidenzia una maggiore gravità della dipendenza e abuso alcolici nel FVG rispetto alla Toscana, con un superiore consumo di servizi ospedalieri forniti dal DEA, il che potrebbe corrispondere alla diversa cultura del bere nelle due regioni.

Addiction and the itch-scratch cycle. What do they have in common?

Itch is a multidimensional experience involving various brain regions associated with sensory perception and emotion, as well as an urge to scratch employing the motor system. Scratch temporarily relieves itch sensation in healthy subjects. However, in patients with chronic itch, rather than inhibit, scratch may aggravate itch. Patients with chronic itch, such as those with atopic dermatitis, experience severe itch and a strong desire to scratch. This urge to scratch is the driving force underlying the formation of the itch-scratch-cycle, an addictive and vicious cycle in chronic itch patients. This vicious itch-scratch behaviour and various types of addiction (henceforth, including recreational drug use) were shown to share common sensory mechanisms. Abnormalities have been observed in central neural circuits, including the reward, motivation/drive, control and learning/memory circuits, as well as other brain systems. Reward systems, including the ventral tegmental area (VTA), nucleus accumbens (NAc) and striatum, are important for brain processing of both addiction and itch. In addition to reward, addicted individuals can experience severe disruptions in motor control, cognitive awareness, executive function, learning/memory and even emotional functions. Findings showing that addiction and itch share a common neurobiological foundation could have important mechanistic and therapeutic implications. Here we propose that similar neuroadaptations exist in addiction and chronic itch patients.

Outcome of Primary PCI in STEMI Addict Patients

Outcome of Primary PCI in STEMI Addict Patients

A double blind randomized clinical trial of buprenorphine augmentation for treatment of psychotic symptoms in opioid addicted bipolar patients.

To assess the efficacy of buprenorphine augmentation in treatment of psychotic symptoms in bipolar disorder type I. Bipolar type I patients with manic or depressive episodes and psychotic feature and with opioid dependency comorbidity were randomly included and allocated. Both groups of buprenorphine (4 or 6 mg/d) and placebo were also treated with enough dosages of sodium valproate and risperidone. Psychosis as primary outcome and depressive and manic symptoms as secondary outcome were assessed at baseline and after 1 and 2 weeks. Data were analyzed through t test and repeated measure ANOVA. Twenty-four patients remained in each group. Both groups displayed significant reduction in psychotic, depressive, and manic symptoms during the 2 weeks of study, although there was not any significant difference between them. Buprenorphine did not add any efficacy to usual treatment of psychotic episodes of bipolar, although did not aggravate psychiatric symptoms.

Identification of Differentially Expressed Proteins from Smokeless Tobacco Addicted Patients Suffering from Oral Squamous Cell Carcinoma.

Oral squamous cell carcinoma (OSCC) is the eight most common malignancy worldwide with an incidence rate of 40% in south-east Asia. Lack of effective diagnostic tools at early stage and disease recurrence despite extensive treatments are main reasons for high mortality and low survival rates. The aim of current study was to identify differentially expressed proteins to explore potential candidate biomarkers having diagnostic significance. We performed comparative proteomic analysis of paired protein samples (cancerous buccal mucosa and adjacent normal tissue) from OSCC patients using a combination of two dimensional gel electrophoresis and Mass spectrometric analysis. On the basis of spot intensity, seventeen proteins were found to be consistently differentially expressed among most of the samples which were identified through mass spectrometry. For validation of identified proteins, expression level of stratifin was determined using immuno-histochemistry and Western blot analysis. All identified proteins were analyzed by STRING to explore their interaction. Among uniquely identified proteins in this study, at least two candidate markers (Ig Kappa chain C region and Isoform 2 of fructose bisphosphate aldolase A) were found to be novel with respect to OSCC which can be explored further. Results presented in current study are likely to contribute in understanding the involvement of these molecules in carcinogenesis apart from their plausible role as diagnostic/prognostic markers.

Basis of Tumor Microenvironment Relevant to Immunotherapies for Brain Metastases of NSCLC

脑是非小细胞肺癌(non-small cell lung cancer, NSCLC)最常见的远处转移部位，脑转移也是晚期肺癌致残致死的主要原因。近年来，小分子酪氨酸激酶抑制剂的应用和疗效奠定了驱动基因突变阳性的NSCLC脑转移的治疗基础。随着程序性死亡受体1(programmed cell death protein 1, PD-1)/程序性死亡受体配体1(programmed cell death protein ligand 1, PD-L1)抑制剂及相应联合疗法的不断发展，免疫治疗已成为驱动基因突变泛阴性的NSCLC脑转移患者的重要选择，相关生物标志物的价值也日益凸显。由于NSCLC脑转移肿瘤及其微环境的免疫病理特征具有一定的特殊性，本文旨在回顾相关研究进展，并为免疫治疗联合策略的探索与新型免疫疗法的开发提供参考。

Non-small-cell lung cancer: what are the benefits and challenges of treating it with immune checkpoint inhibitors?

Immune checkpoint inhibitors (ICIs) have transformed the treatment landscape of advanced non-small-cell lung cancer (NSCLC). It has improved the overall survival in the first- and second-line setting with manageable adverse events. Multiple challenges still impede the success of ICI in the whole population of NSCLC namely the lack of reliable predictive biomarkers, the scarcity of data regarding the optimal treatment duration with ICI and possibility of rechallenge with ICI as well as the efficacy of ICI in special subgroups of patients such as those with oncogenic addicted tumors or patients with brain metastases. In this framework, we review the benefits and challenges of ICI in NSCLC, in monotherapy and in combinations, in the advanced setting.

Opioids Use and Abuse: Prescription Practice, Attitude, and Beliefs among Doctors of Karachi.

BackgroundOpioid analgesics, also known as narcotics, are medicinal drugs used primarily for the management of pain secondary to any type of cancer, severe injury or surgery. Due to the ease of availability, opioids are commonly abused. In 2015, reported deaths exceeded 33,000 Americans from opioid overdose. A survey in 2013 revealed nearly 1.6 million Pakistanis abusing prescription opioids for non-medical needs. Although commonly prescribed by primary care physicians, most of them are diffident to stand by all the recommended strategies to reduce the incidence of opioid abuse.MethodsA cross-sectional study was conducted during the period of August through October 2018. A sample size of 365 was determined using a 95% confidence interval at a degree of precision of 5%. A 22-item questionnaire was given to doctors with at least two years practicing experience either from a private or a public healthcare setup. Doctors who had never prescribed opioids were excluded from the study. Out of the eligible participants, 15 refused to take part in the survey, and the co-operation rate was recorded as 95.8%. Collected data were analyzed using statistical package for social science (SPSS) version 22 for Windows. Frequencies, percentages, mean, standard deviation, and chi-square were used to explore the variables. The statistical significance level was considered at p < 0.5.ResultsOpioids were reported to be used mainly for treating acute pain (40.5%), chronic pain (24.7%) and both acute and chronic (34.8%). A minority of doctors (29%) screened their patients for opioid addiction. A significant association (p = 0.000) between the frequency of opioid prescription and prior screening for depression was determined. Surprisingly, only 23.2% clinicians frequently screened their patients for depression before prescribing opioids. The rate of counselling regarding drug tapering was found to be 71.6%. A majority, i.e., 88%, of the respondents anticipated the misuse of opioids they prescribe whereas 74% also held a belief that patients self-medicate their untreated pain. Participants reported addiction (54%) as the most common reason for abuse followed by the role of pharmaceutical companies (43%) and pharmacies (41%). About 80.2% clinicians believed that patients addicted to opioids could get well and return to their daily routine.ConclusionThe rising opioid epidemic is a major concern for doctors prescribing opioids. Adaptation of medical school curricula and appropriate training can equip doctors for better management of patients requiring opioids. This includes the screening of patients using standard risk assessment tools for opioid abuse leading to a more controlled opioid prescription practice. Dissemination of these tools will boost doctors' confidence and may help in reducing morbidity and mortality from opioid abuse.

Cerebral hemodynamic abnormalities of patients with ischemic stroke who are opium addicted: A study by transcranial doppler ultrasonography

Background: Ischemic stroke as the major cause of mortality and morbidity worldwide has different risk factors. One of its modifiable risk factors is opium addiction whose role is not clear yet. This study aimed at assessing the hemodynamic parameters in ischemic stroke patients addicted to opium using transcranial Doppler (TCD) ultrasonography and comparing them with non-addicted patients. Methods: This comparative cross-sectional study was conducted in an academic hospital in the north of Iran in 2016. All the patients diagnosed as ischemic stroke underwent cerebrovascular ultrasound in the first 4 days of symptoms onset. Frequency of hemodynamic abnormalities confirmed by pulsatility index (PI) and mean flow velocity (MFV) were determined and compared between the two groups. The data were analyzed by chi-square test, t-test, and multiple logistic regression models using SPSS software. Results: A total of 353 patients with ischemic stroke (92 addicted and 261 non-addicted patients) were enrolled in the study. Univariate analysis indicated that the PI and MFV differences were statistically significant between two groups of addicted and non-addicted patients (P = 0.0001). By multivariate logistic regression model, the age [odds ratio (OR) = 1.143], diabetes mellitus (DM) (OR = 3.875), hypertension (HTN) (OR = 2.557), and opium usage (OR = 9.615) had influence on PI and only opium usage (OR = 3.246) had influence on MFV. Conclusion: Opium usage affects the cerebral hemodynamic parameters and increases the chance of having abnormal PI as ten-fold and abnormal MFV as three-fold.

The association between the OPRM1 A118G polymorphism and addiction in a Turkish population.

Susceptibility to addiction has a complex genetic basis that includes genes associated with the action and metabolism of drugs of abuse. One important gene in that respect is OPRM1, which codes for the μ-opioid receptor and has an important role in mediating the rewarding effects of addiction substances. The aim of our study was to assess the prevalence of the OPRM1 A118G polymorphism (rs1799971) in Turkish population and to investigate its association with opioid and other substance addiction. In addition, we examined the association of rs1799971 in addicted patients who were also diagnosed with psychiatric disorders. The study included 103 patients addicted to opioids, cocaine, ecstasy, alcohol, lysergic acid diethylamide (LSD), cannabis, and sedative/hypnotic substances and 83 healthy volunteers with similar demographic features as controls. rs1799971 polymorphisms were identified with the polymerase chain reaction restriction fragment length polymorphism method (PCR-RFLP). The genotype frequencies were significantly higher in the addicted patients than controls (32.0 % vs 16.9 %, respectively; p=0.027). The prevalence of the G allele was 16.1 % in the addicted group and 8.4 % in the control group (p=0.031). Our study confirmed the association between the rs1799971(G) allele frequency and opioid and other substance addiction, but not with psychiatric disorders.

21st Century Approach: Using data and novel technologies to address the opioid crisis

ObjectiveTo use novel technologies to develop a rapid response framework to reach opioid overdose patients in an area which is challenging from both a geography and population distribution standpoint.IntroductionClark County, Indiana is geographically located in between the urban area of Louisville, Kentucky and Scott County, Indiana. Scott County is the site for the largest HIV outbreak in the history of the United States, directly related to high rates of IV drug abuse. The unique geographic location of Clark County in combination with the recent HIV and Hepatitis C outbreaks in Clark and neighboring counties has greatly informed the development of an effective response to overdoses and the opioid epidemic in general. Furthermore, Clark County has a unique population distribution, with a population of over 125,000 and a land area of over 300 square miles. Despite this large area, over 80% of the population lives within 9 miles of the southern border of the county. This leads to a mix of both urban and rural challenges. There are several areas of the county that have greater than 15 minute emergency response times, which is often the difference between life and death in an overdose situation. These factors led to the development of the Clark County Rapid Response Project. The rapid response project is a community-based, multidisciplinary framework to address the opioid addicted patient, from initial use to successful recovery. The project uses data driven technology to initiate the care of opiate overdose patients and administer lifesaving interventions.MethodsClark County has partnered with the Indiana State Department of Health utilizing the early notification system that monitors statewide overdose activity. Once an alert is sent out, the response involves the use of two early notification systems. Everbridge is a one touch notification system that allows rapid dissemination of information to various community partners to allow them to initiate the appropriate response. Pulse Point is a smart phone application that allows CPR and trained community laypeople to respond to a cardiac arrest or overdose patient in a public place. It provides directions to the patient as well as to the nearest AED. Clark County has also simultaneously instituted a county-wide CPR training initiative and offered Narcan training as well. This is a major paradigm shift, as prior methods of deployment of trained laypeople essentially relied on the chance that an overdose will be reached by a first responder.ResultsEverbridge has allowed for the rapid notification of county entities and deployment of resources to overdose ‘hot spot’ areas. The Pulse Point initiative has dramatically increased the number of CPR and Narcan trained responders and provided means of delivering them to the appropriate patient population in a timely manner. Both these technologies have dramatically increased the delivery of resources to the overdose patient and decreased response times to the delivery of care.ConclusionsUsing data driven technology to inform how Clark County Health Department and first responders collectively address the opioid crisis is a novel approach. Since January 2018, Clark County Health Department has used ESSENCE (Electronic Surveillance System for the Early Notification of Community-based Epidemics) to determine where and when an increase of drug overdose activity is occurring throughout the county. This affords county health officials the ability to inform in “near real-time” first responders, the emergency department and other community stakeholders, relevant information thus allowing for the rapid deployment of county resources to the areas most affected. Our collective efforts to save lives is further enhanced by the county using of novel technologies like Pulse Point which is used to deploy both CPR and Narcan trained laypersons directly to sites in the community where overdoses are occurring. In a community, which is in large part considered rural and, in many places, has a greater than 15 minute emergency response time, using Pulse Point and Everbridge technologies has uniquely positioned Clark County to be on the cutting edge of saving lives as we leverage data and technology to address the opioid epidemic in our communities. This has markedly improved access to treatment and response times to overdose patients in Clark County, Indiana.

Sensibilisation à l’addictologie et collaboration avec les personnels hospitaliers. L’expérience d’une équipe de liaison

ObjectivesAddictology needs the involvement of primary care professionals, but reality is far from this will. To resolve this problem, liaison-teams have been created in the hospitals two decades ago. Training and support of caregivers is their first mission, although not obvious because they are called usually to cure the most complex addict patients. Our aim is to describe what kind of relationship they build, when they are called to meet a patient, to improve the hospital caregivers’ implication in addictology care. Materials and methodsThis study is based on the practice of a liaison-team working in a universitary hospital, including emergency, medicine, surgery and obstetrical units, and called for every kind of addictions, except tobacco when used alone. ResultsAn attention is first devoted to caregivers, who can be in difficulty because of partial or false representations of addiction and its care, or because of their personal experience of addiction. The team has to meet them regularly, to take time to think together. It promotes an interdisciplinary approach, which gives every kind of profession a position in the care of addiction. It stands back their request, to understand where their difficulties are and give an adequate answer. Second, in front of patients with whom the relation is complex, the liaison-team has to boost the self confidence of the caregivers in their ability to care for them: some simple tools and technics can be given, and new others can be built together when necessary. It pays attention to the articulation between hospital acute treatment and long-term follow-up. Third the liaison-team works in a dynamics of network, which promotes cooperation rather than separation and split. ConclusionsThis study invites for more research on the link between addictologic network and primary care providers, and the way to develop it.

MP04: rEDirect: safety and compliance of an emergency department diversion protocol for mental health and addictions patients

Introduction: Transportation of patients better served at an alternative destinations (diversion) is part of a proposed solution to emergency department (ED) overcrowding. We evaluated the pilot implementation of the “Mental Health and Addiction Triage and Transport Protocol”. This is the first Canadian diversion protocol that allows paramedics to transport intoxicated or mental health patients to an alternative facility, bypassing the ED. Our aim was to implement a safe diversion protocol to allow patients to access more appropriate service without transportation to the emergency department. Methods: A retrospective analysis was conducted on patients presenting to EMS with intoxication or psychiatric issues. Study outcomes were protocol compliance, determined through missed protocol opportunities, noncompliance, and protocol failure (presentation to ED within 48 hours of appropriate diversion); and protocol safety, determined through patient morbidity (hospital admission within 48 hours of diversion) and mortality. Data was abstracted from EMS reports, hospital records, and discharge forms from alternative facilities. Data was analyzed qualitatively and quantitatively. Results: From June 1st, 2015 to May 31st, 2016 Greater Sudbury Paramedic Services responded to 1376 calls for mental health or intoxicated patients. 241 (17.5%) met diversion criteria, 158 (12.9%) patients were diverted and 83 (4.6%) met diversion criteria but were transported to the ED. Of the diverted patients 9 (5.6%) represented to the ED &amp;lt;48rs later and were admitted. Of the 158 diversions, 113 (72%) were transported to Withdrawal Management Services (WMS) and 45 (28%) were taken to Crisis Intervention (CI). There was protocol noncompliance in 77 cases, 69 (89.6%) were due to incomplete recording of vital signs; 6 (10.3%) were direct protocol violations of being transferred with vital sings outside the acceptable range. Conclusion: The Mental Health and Addiction Triage and Transport Protocol has the potential to safely divert 1 in 6 mental health or addiction patients to an alternative facility.

System Dynamics to Investigate Opioid Use and Chiropractic Care for Chronic Musculoskeletal Pain

ObjectiveThe purpose of this investigation was to create a system dynamics (SD) model, including published data and required assumptions, as a tool for future research identifying the role of chiropractic care in the management of chronic, nonmalignant pain in a Canadian population. MethodsWe present an illustrative case description of how we evaluated the feasibility of conducting a large-scale clinical trial to assess the impact of chiropractic care in mitigating excessive opioid use in Canada. We applied SD modeling using current evidence and key assumptions where such evidence was lacking. Modeling outcomes were highlighted to determine which potential factors were necessary to account for compelling study designs. ResultsResults suggest that a future clinical study diverting patients with nonmalignant musculoskeletal pain early to the chiropractic stream of care could be most effective. System dynamics modeling also highlighted design challenges resulting from unresearched assumptions that needed to be proxied for model completion. Assumptions included changing rates in opioid-associated deaths and rates of success in treatment management of addicted patients. ConclusionIn this case, SD modeling identified current research gaps and strong contenders for appropriate follow-up questions in a clinical research domain, namely the role of chiropractic care in the management of chronic, nonmalignant pain in a Canadian population.