Centre For Addiction And Mental Health Research Articles

SU90 - GENOME-WIDE ASSOCIATION STUDY (GWAS) AND ANALYSIS OF VIOLENCE IN SCHIZOPHRENIA

Background Schizophrenia patients are at higher risk of engaging in violent behaviours than the general population. Schizophrenia is also regarded as a highly heritable disorder, and in 2014, a large genetic study by the Schizophrenia Working Group (SWG) of the Psychiatric Genomics Consortium (PGC) identified 108 risk loci for SCZ. The relationship between violence and these risk loci has not been studied, neither has there been any GWAS where Single-Nucleotide Polymorphisms (SNPs) were correlated with violence. This study aims to analyze the specific effect of genome-wide significant schizophrenia SNPs on violence in schizophrenia. Methods We recruited 87 subjects between the age of 18 to 75 from the Centre for Addiction and Mental Health (CAMH), who had a diagnosis of schizophrenia or schizoaffective disorder. We recorded physical violence scores indicating any violent actions to inflict pain, bodily harm, or death on another individual from the standardized scale, Modified Overt Aggression Scale (MOAS). We genotyped 2.5 million SNPs for each participant, and the DNA was analyzed using the whole genome analysis tool-set, PLINK. Results We found 13 SNPs which were associated with violence, and the highest correlation was with the SNP kgp11155273 on chromosome 10 (p=2.051E-7). Discussion This study found an association between violence and the kgp11155273 SNP on chromosome 10. Further studies using larger subject pools are required to probe further into the nature of this association, and determine the genetic basis of violence in schizophrenia.

The relationship between motor vehicle collisions and cigarette smoking in Ontario: Analysis of CAMH survey data from 2002 to 2016.

Research has shown that tobacco users have an increased risk of collisions compared to nonsmokers. Studies from 1967 through 2013 documented a crude relative risk of collision involvement of about 1.5 among smokers compared to nonsmokers. In January 2009, in response to concerns about the health risks associated with potentially high concentrations of secondhand smoke resulting from smoking in vehicles, the provincial government in Ontario, Canada, introduced legislation restricting smoking in vehicles where children and adolescents are present. We examined the association between reported smoking and involvement in a motor vehicle collision in a large representative sample of adult drivers in Ontario, Canada, from 2002 and 2016, with particular focus on 2002–2008 and 2010–2016, periods before and after the legislation. Data are based on the Centre for Addiction and Mental Health (CAMH) Monitor. Among licensed drivers, prevalence of self-reported collision involvement within the past year for 2002–2008 was 9.39% among those who currently smoked compared to 7.08% of nonsmokers. Following implementation of the legislation, for 2010–2016, the prevalence of collisions for smokers was 7.01% and for nonsmokers was 6.02%. The overall difference for both smokers and nonsmokers between the two time periods was statistically significant; however, the difference between the two groups for the pre-legislation period was significant even after adjusting for potential confounders, while post legislation the difference was not significant. Prior to the legislation, the prevalence of collision was higher among smokers than nonsmokers; following the introduction of the legislation the prevalence was similar for the two groups.

The CAMH Neuroinformatics Platform: A Hospital-Focused Brain-CODE Implementation.

Investigations of mental illness have been enriched by the advent and maturation of neuroimaging technologies and the rapid pace and increased affordability of molecular sequencing techniques, however, the increased volume, variety and velocity of research data, presents a considerable technical and analytic challenge to curate, federate and interpret. Aggregation of high-dimensional datasets across brain disorders can increase sample sizes and may help identify underlying causes of brain dysfunction, however, additional barriers exist for effective data harmonization and integration for their combined use in research. To help realize the potential of multi-modal data integration for the study of mental illness, the Centre for Addiction and Mental Health (CAMH) constructed a centralized data capture, visualization and analytics environment—the CAMH Neuroinformatics Platform—based on the Ontario Brain Institute (OBI) Brain-CODE architecture, towards the curation of a standardized, consolidated psychiatric hospital-wide research dataset, directly coupled to high performance computing resources.

Outcomes of an integrated care pathway for concurrent major depressive and alcohol use disorders: a multisite prospective cohort study

BackgroundIn 2013, an Integrated Care Pathway (ICP) for concurrent Major Depressive (MDD) and Alcohol Use (AUD) Disorders was developed at the Centre for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada. The ICP was further implemented at 8 other clinical sites across Ontario (the DA VINCI Project) in 2015–2017. The goal of this study was to systematically describe and analyze the main clinical outcomes of the project.MethodsData on a non-randomized cohort of patients receiving ICP-based treatment were collected prospectively at nine clinical sites in a variety of clinical settings. Statistical methods: descriptive statistics, t-test, chi-square, ANOVA, generalized linear models.ResultsTwo hundred forty-six patients were enrolled, 58.8% males, mean age was 45.6 years, 170 patients received treatment at academic health centres (AHC), 49 – at community hospitals (CH) and 27 – in family health teams (FHT). There were no major differences in anamnestic parameters and depression severity between the three settings, but there were differences in baseline drinking patterns between subgroups (F = 4.271, df = 2, p = 0.015). Overall completion rate was 70.7% with no significant variation between settings (χ2 = 3.35, df = 2, p = 0.19). Treatment duration in AHC was the longest, and completion rates were the highest. There was a statistically significant and clinically meaningful reduction in the number of drinking days per week (1.81, t = 8.78, p < 0.001). The cohort overall demonstrated significant and meaningful reduction in severity of cravings (Penn Alcohol Craving Scale: 4.42, t = 8.63, p < 0.001) and depressive symptoms (Quick Inventory of Depressive Symptomatology: 4.25, t = 11.26, p < 0.001). While some of the baseline patient characteristics and treatment parameters varied between the settings, the variation in clinical outcomes was mostly insignificant, though clinical improvement was more pronounced in academic setting and with individual therapy.ConclusionsThe study demonstrated that ICP is a feasible and effective treatment for concurrent AUD and MDD that delivers meaningful clinical improvement in a variety of settings. A randomized controlled study is needed to properly compare the treatment outcomes between ICP model and treatment as usual and to further explore the role of various factors on treatment outcomes.

Lessons Learned: Implementing UK-Developed Interprofessional Simulation Training Courses in a Canadian Setting

In response to the need for practitioners to improve their skills in integrating mental and physical healthcare, the Centre for Addiction and Mental Health (CAMH) (Canada) invited education specialists from Maudsley Simulation (UK) to pilot two of their existing interprofessional simulation courses on the mental-physical interface in Toronto. Participants' experiences as well as the courses' educational impact were evaluated. Participants completed pre-and post-course questionnaires, a 2-week follow-up questionnaire, and individual interviews 6months after course completion. Participants (n = 23) found the courses to be relevant and applicable to their practice. Over half of the participants interviewed (8/15) reported changing their practice as a result of the course. However, concerns regarding the sociological fidelity of these courses within the Canadian context were noted. The findings support the transferability of interprofessional simulation courses developed in other countries. It is important, however, to contextualize course material to fit local healthcare systems and to ensure sociological fidelity where professional roles may vary.

S191. INVESTIGATION OF THE PREVALENCE OF COPY NUMBER VARIANT SYNDROMES IN A LARGE SCHIZOPHRENIA COHORT

BackgroundMany rare genetic syndromes are known to phenotypically manifest with psychiatric symptoms that can be indistinguishable from primary psychiatric disorders. While the majority of ongoing research in psychiatric genetics has been dedicated to the identification and characterization of genes involved in primary psychiatric disorders, there has been a lack of research to determine the extent to which rare genetic variants contribute to the overall psychiatric disease load. In our study, we aim to investigate the prevalence of clinically well-characterized pathogenic copy number variant (CNV) syndromes that are associated with neuropsychiatric phenotypes in a large schizophrenia patient cohort.MethodsDNA from 348 schizophrenia patients recruited at the Centre for Addiction and Mental Health (CAMH) (Toronto, Canada) was run on the Affymetrix SNP Array 6. 0. CNVs were called using two algorithms (Canary Software and PennCNV) for deletions >200 kb and duplications >500 kb. CNVs called by both algorithms were included in further analysis. All CNVs were individually assessed to determine overlap with known, clinically well-characterized CNV syndromes with the use of the UCSC Genome Browser, DECIPHER GRCh37, and GeneReviews® databases.ResultsA total of 861 deletions and 171 duplications were called on 348 schizophrenia patients. In-depth analysis revealed a total of 16 schizophrenia patients with significant deletions. Microdeletions associated with known syndromes that were identified include: 16p11.2-p12.2 (n=1), 16p13.11 (n=3), 17p11.2 (n=2), 22q11.2 (n=5), 1p36 (n=4), and 5q35.3 (n=1). Analysis for pathogenic microduplications is ongoing.DiscussionWe observed a greater than expected number of syndromic microdeletions amongst the schizophrenia cohort (16/348, 4.6%), particularly CNVs already hypothesized or known to be associated with neurodevelopmental disorders. Screening for these rare genetic disorders could lead to better understanding of the pathophysiology of psychiatric disorders, as well as the prevalence of these syndromic CNVs within various psychiatric population subtypes. Correctly identifying syndromic CNVs within psychiatric populations can improve patient prognosis. Further analyses will be undertaken to define specific genes contained within the implicated CNV regions to better characterize potential genetic effects on the phenotypic presentation of SCZ patients.

Is there a link between motor vehicle collisions and being a cigarette smoker in Canada? Analysis of survey data from Ontario from 2002 to 2014

ABSTRACTObjective: Although most research on drugs and driving has focused on the use of alcohol and cannabis, research that has been conducted on cigarette smoking and collisions has found that smokers have an increased collision involvement. Studies dating from 1967 through 2013 have shown a crude relative risk of about 1.5 among smokers compared to nonsmokers. In Canada, the association between smoking and collisions has not been recently investigated. Studies that have examined the association between smoking and collisions often did not control for all confounding factors, such as alcohol use and driving exposure, which have been associated with increased collision rates. Additionally, a number of these studies were examined in countries and at times when prevalence of smoking was much higher than is currently the case in Canada. The purpose of this research is to examine the association between self-reported current smoking and past-year collision involvement, controlling for confounding factors, in a large representative sample of adult drivers in Ontario, Canada, from 2002 and 2014.Method: Data are based on the Centre for Addiction and Mental Health (CAMH) Monitor, an ongoing, rolling telephone survey of Ontario adults that provides epidemiological surveillance of indicators related to alcohol, tobacco, and other drug use, as well as physical and mental health. The survey uses random-digit-dialing methods via Computer-Assisted Telephone Interview, with response rates over 50%.Results: Prevalence of self-reported collision involvement within the past year for 2002–2014 was 8.6% among those who currently smoke compared to 6.5% of nonsmokers. Logistic regression analysis, controlling for the potential confounding effects of sociodemographics, driving exposure measures, drinking frequency, and hazardous alcohol use, found that the overall odds for collision involvement in the preceding year among current smokers for 2002–2014 was 1.27 (95% confidence interval [CI], 1.06–1.53) times that of nonsmokers.Conclusions: These findings indicate that despite a substantial reduction in overall prevalence of smoking in Canada, smokers still have a significantly increased odds of collision involvement, even when controlling for alcohol and exposure. Additionally, the results are consistent with the increased odds/risks of motor vehicle collisions found in other countries.

A method for co-creation of an evidence-based patient workbook to address alcohol use when quitting smoking in primary care: a case study

Plain English summaryThe purpose of this paper is to describe a patient engagement event designed to create an educational workbook with smokers who drink alcohol at harmful levels. The goal was to create a workbook that combined scientific evidence with patients’ values, preferences, and needs. Fourteen adult smokers who drink alcohol were invited to the Centre for Addiction and Mental Health (CAMH) to take part in a four-hour event to help design the workbook with the CAMH research team. Participants provided their opinions and ideas to create an outline for the workbook, including activities, images, and titles. The workbook – called Self-Awareness – is currently being offered in a smoking cessation program in 221 primary care clinics across Ontario to help smokers quit or reduce their harmful alcohol use. The patient engagement event was a useful way to co-create educational materials that incorporate both scientific research and patient needs.BackgroundEvidence-based medicine is the integration of best research evidence with clinical expertise and patient values. There are few methodologies on how to design evidence-based programs and resources to include patient values. The latter is an important aspect of patient-centered care, and is essential for patients to trust the recommendations and empower them as consumers to make informed choices. This manuscript describes a participatory research approach to design patient-facing educational materials that incorporate both evidence-based and community-sensitive principles. These materials are intended to support smokers to reduce or stop harmful alcohol consumption.MethodsAdult smokers who report consuming alcohol were invited to a co-creation meeting at the Centre for Addiction and Mental Health’s Nicotine Dependence Service to guide the adaptation of evidence-based materials. The four-hour event consisted of individual reflections, group discussions, and consensus-building interactions. Detailed notes were taken and then incorporated into the material.ResultsFourteen individuals participated in the event. The end product was a descriptive outline of an educational resource – entitled Self-Awareness – incorporating material from evidence-based workbooks and patient-driven features. Participants collaboratively selected the resource’s content, structure, and titles.ConclusionsThis model describes a participatory research method that emphasizes the value of the patient perspective; preliminary evidence finds this adaptation approach can increase the adoption of resources. The process described in this article could be replicated in other settings to co-create evidence-based resources, interventions, and programs that reflect the needs of the community.Trial registrationClinicalTrials.gov NCT03108144. Retrospectively registered 11 April 2017.

Substance Use, Health, and Functioning Characteristics of Medical Marijuana Program Participants Compared to the General Adult Population in Ontario (Canada)

ABSTRACTExistent profiles of Medical Marijuana Program (MMP) participants indicate common and co-morbid chronic diseases, yet evidence on disability or functioning as well as comparisons with general populations are largely lacking. This study compared health, substance use, and functioning status among formally approved MMP participants with the general adult population in Ontario (Canada). A community-recruited sample (n = 53) of MMP participants was compared to a sub-sample (n = 510) of the representative Centre for Addiction and Mental Health (CAMH) Monitor (2015 cycle) survey of Ontario general population adults (ages 18+) based on identical telephone-based interviews regarding substance use, health, and functioning measures. Means and standard deviations for all indicators were computed by sex, controlled for age and education, and compared by regression techniques. MMP participants were more likely to be male, younger, and less socio-economically integrated; they indicated more common psychoactive substance (e.g., tobacco, daily cannabis) and psychotropic medication use, as well as overall worse physical and mental health and functioning status. Marked differences between MMP participants and general population adults were observed. MMPs appear to attract individuals with complex chronic health problems; however, little is known about the impact of MMP participation on these.

Capacity Building through a Professional Development Framework for Clinical Nurse Specialist Roles: Addressing Addiction Population Needs in the Healthcare System

The impact of substance use disorders on the Canadian healthcare system is large, contributing to high use of hospital resources. At the Centre for Addiction and Mental Health (CAMH), Canada's largest mental health and addictions academic teaching hospital, substance use disorders constitute the primary diagnosis of 31% of annual inpatient admissions. Clinical nurse specialists (CNSs) with expertise in addictions are ideally prepared to promote competency development among baccalaureate-prepared nurses who are caring for this population. Despite recent advocacy to advance the addictions nursing workforce in Canada, recruitment of graduate-level CNSs in this field remains a challenge owing to a shortage of candidates with addictions expertise. Healthcare organizations specializing in substance use treatment must use innovative professional development strategies to foster nursing leadership that addresses the complex needs of this clinical population. In this paper, we describe the implementation of an innovative competency-based professional development framework designed to build capacity of CNSs at CAMH.

Clozapine administration in clinical practice: once-daily versus divided dosing.

While it is recommended that clozapine be administered in a divided dosing regimen, it is unclear whether this recommendation is followed in real-world clinical practice. In two large datasets, we examined clozapine dosing frequency and patient characteristics across different dosing regimens. We conducted a cross-sectional survey, collecting data on patients receiving clozapine in August/September 2015 from the Centre for Addiction and Mental Health (CAMH) in Toronto, Canada, and The Zucker Hillside Hospital (ZHH) in New York, United States. Of 676 and 308 patients included in CAMH and ZHH datasets, clozapine was prescribed once daily in 75.1% and 74.4%, even though doses exceeding 200 mg/day were administered in 88.6% and 84.4% of the respective samples. No significant difference was found in the rates of positive symptom remission between once-daily vs. divided dosing (79.7% vs. 80.5%, P = 1.00). Higher clozapine dose and use of anticholinergic medications were significantly associated with divided dosing in both datasets. Older age or male gender was related to divided dosing in CAMH or ZHH dataset respectively. Despite the product monograph recommendation, clozapine is frequently prescribed once daily in North America. Further studies are needed to compare clinical outcomes between once-daily vs. divided clozapine dosing.

Gender Differences in Alcohol Use and Risk Drinking in Ontario Ethnic Groups

This article examines prevalence and gender differences of alcohol use and risk drinking in a representative sample of Ontario adults. Data were drawn from the Centre for Addiction and Mental Health (CAMH) Monitor survey of Ontario adults aged 18 and older collected between January 2005 and December 2010. The prevalence of self-reported lifetime, current, and high-risk drinking were all higher among the Canadian and the European-origin groups compared with other ethnic groups. Within-group gender differences were evident for all ethnic groups. The narrowest gender gap was observed within the North European group and the widest in the South Asian group. The non-European ethnic groups had higher rates of abstinence and lower alcohol consumption rates; nevertheless, a considerable proportion of people from these groups may be at risk of alcohol-related harm due to risky and harmful alcohol consumption patterns. Future research should continue to investigate alcohol use in these groups and identify subgroups at risk and factors that increase or decrease their vulnerability to risky and problem drinking.

Development and Implementation of an Ambulatory Integrated Care Pathway for Major Depressive Disorder and Alcohol Dependence.

Integrated care pathways (ICPs) provide an approach for delivering evidence-based treatment in a hospital setting. This column describes the development and pilot implementation in a clinical setting of an ICP for patients with concurrent major depressive disorder and alcohol dependence at the Centre for Addiction and Mental Health (CAMH), an academic tertiary care hospital, in Toronto, Canada. The ICP methodology includes evidence reviews, knowledge translation, process reengineering, and change management. Pilot results indicate high patient satisfaction, evidence of symptom improvement, and excellent retention.

Developing a holistic policy and intervention framework for global mental health.

There are significant gaps in the accessibility and quality of mental health services around the globe. A wide range of institutions are addressing the challenges, but there is limited reflection and evaluation on the various approaches, how they compare with each other, and conclusions regarding the most effective approach for particular settings. This article presents a framework for global mental health capacity building that could potentially serve as a promising or best practice in the field. The framework is the outcome of a decade of collaborative global health work at the Centre for Addiction and Mental Health (CAMH) (Ontario, Canada). The framework is grounded in scientific evidence, relevant learning and behavioural theories and the underlying principles of health equity and human rights. Grounded in CAMH's research, programme evaluation and practical experience in developing and implementing mental health capacity building interventions, this article presents the iterative learning process and impetus that formed the basis of the framework. A developmental evaluation (Patton M.2010. Developmental Evaluation: Applying Complexity Concepts to Enhance Innovation and Use. New York: Guilford Press.) approach was used to build the framework, as global mental health collaboration occurs in complex or uncertain environments and evolving learning systems. A multilevel framework consists of five central components: (1) holistic health, (2) cultural and socioeconomic relevance, (3) partnerships, (4) collaborative action-based education and learning and (5) sustainability. The framework's practical application is illustrated through the presentation of three international case studies and four policy implications. Lessons learned, limitations and future opportunities are also discussed. The holistic policy and intervention framework for global mental health reflects an iterative learning process that can be applied and scaled up across different settings through appropriate modifications.

Alcohol use among immigrants in Ontario, Canada.

This study examined prevalence of alcohol consumption among immigrants and the Canadian-born populations of Ontario by ethnic origin, and the association between ethnicity, country of birth, age at arrival, length of residence in Canada and drinking measures. Data were derived from the Centre for Addiction and Mental Health (CAMH) Monitor, a cross-sectional survey of Ontario adults, conducted between January 2005 and December 2010 (n = 13,557). The prevalence of alcohol consumption and risk drinking was generally lower among foreign-born than Canadian-born respondents, but significant variations across ethnic groups were found. In general, foreign-born respondents of European descent reported higher rates of alcohol use and risk drinking than foreign-born respondents from other ethnic groups. We also observed that ethnicity effects varied by whether or not respondents were born in Canada, and by the age at which they arrived in Canada. While previous studies generally found an increase in immigrants' alcohol consumption with years in Canada, our data suggest that longer duration of residence may have either positive or negative effects on immigrants' alcohol use, depending on the country of origin/traditional drinking pattern. More research is needed to explore determinants of alcohol use and risk drinking among immigrants and to identify those groups at highest risk.

Integrated Care Pathway (ICP), an Inter-professional Outline of Evidence Informed Care in Mental Health and Addictions: an Innovative Treatment Approach From Concept to Results

One of the challenges in mental health is the overwhelming number of clinical guidelines, yet the apparent lack of standardization in treatment. Patients expect that clinical decisions will be made on the basis of evidence with access to standardized treatment. The mental health system is constantly challenged by simultaneous needs to both improve quality of care and increase efficiency, without any significant increase in staffing or funding. ICP is the innovative solution to address these challenges. The Centre for Addiction and Mental Health (CAMH) ICPs has three key components: a specific medication algorithm, non-pharmacological interventions, and team effectiveness interventions. Our methodology to develop ICPs includes: evidence reviews, process redesign and knowledge translation. An ICP specifically details what to do, when to do it and who will do it. Three ICP pilots have been implemented and currently 100 patients have been treated and are being evaluated. The overall intent of the initiative is to develop practical ways of changing the delivery of services to improve patient experience and outcomes. The benefits of forming an ICP have manifested themselves early in development. The discussions that have taken place during the development of the pathway have encouraged closer team working alliances and a greater appreciation of existing treatment variability. This presentation will review the lessons learned in the development, implementation and evaluation of ICPs at the (CAMH), including early findings from our teams and early outcomes from patients. Key elements of success that are fundamental components of a pathway will be demonstrated.

New APA Award Recognizes Emerging Field of Pharmacogenomics

New APA Award Recognizes Emerging Field of Pharmacogenomics

Personalized medicine hits primary practice as genetic testing is being done for the first time in family practice to better select psychiatric medications for patients: an interview with Dr. Nicholas Voudouris

For the first time in Canada, genetic testing done at the Centre for Addiction and Mental Health (CAMH) in Toronto is being made available to family physicians. This leading-edge research started just over a year ago at the Thornhill Medical Centre in Thornhill, Ontario. The aim of the research is to use genetic testing to better select psychiatric drugs and dosages to improve efficacy and reduce side effects in patients suffering from mental illness. Dr. Nicholas Voudouris, a family physician at the Thornhill Medical Centre who is heavily involved in this project, describes it as leading-edge science that has the possibility of having profound impact on personalized medicine at the primary care level. I spoke with Dr. Voudouris to learn more about him, this project, and the future implications genetic testing could have on personalized medicine and reducing health care spending.

Featuring: Tim Tripp

Tell us about your current position I’ve been in my current role only a few months now, so I’m still learning about it! The Centre for Addiction and Mental Health (CAMH) and its library is a fascinating place to work. There’s much that you would find typical in a library for an academic teaching hospital, but there’s much that’s unique as well. Focussing on a patient population that has mental health and addiction issues is a real eye-opener. I find it’s totally changing my perspective on much of news and even pop culture once your awareness has been raised around issues of stigma, language, trauma, etc., you can’t help but place a different lens over everything that you look at. It’s been a while since I’ve worked in an actual library, so it’s fun getting re-acquainted with that world. There’s the more mundane we just completed our annual subscription cancellation, er, I mean renewal, process. And then there’s the truly exciting we’ve just kicked off planning for brand new space in a building that is yet to be built. We’ll spend three years planning and then three years building, and if all goes according to plan, we’ll be moving into a brand new space at CAMH’s Queen Street West campus in downtown Toronto in 2020. The new space should be amazing we’ll be sharing ground floor space right on Queen St. West with the new student centre, conference centre, and Workman Arts theatre. There really is a transformation happening all across CAMH. It’s impacting everything from the physical spaces to clinical practice. I think the next decade here is going to be a blast! Your previous positions have been quite information technology (IT) intensive. What made you decide to move into a new role? How does your previous IT experience inform your work as the Director of Library Services at CAMH? The last 13 years I’ve been in a ‘‘nontraditional’’ role, that’s true, but I’ve always thought I’d return to the library world at some point. I’ve always loved the field, which is why I maintained my connections, primarily through my involvement in CHLA, with health librarians across the country. It’s not often an opportunity like this comes along, so I jumped at the chance. I think having IT experience is a definite benefit. So much of what we do is dependent upon technology that it really streamlines things when your IT folk know that you understand their language and their constraints. Having that background allows me to participate in other projects that are going on within Education at CAMH. There are a number of technology heavy projects around portal development and mobile app development that I’m just starting to get involved with, but I think the variety of work that I’m going to be getting involved with is incredible.

Harm reduction: A canadian perspective

Maintenance Therapy (MMT) found that they not only dispensed, but "almost half (48%) provided information on drug interactions with OST [Opioid Substitution Therapy] medication; side effects of medication (38%); accessing support services (30%); smoking cessation (30%); blood-borne virus exposure risks (10%); vein care (8%); and other services or information (12%), including dental hygiene, general health, practical parenting advice, internet-based resources and counselling." 4