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Background: This study reports on physicians’ experiences with chronic pain management. For over a decade prescription opioids have been a primary treatment for chronic pain in North America. However, the current opioid epidemic has complicated long-standing practices for chronic pain management which historically involved prescribing pain medication. Caring for patients with chronic pain occurs within a context in which a growing proportion of patients suffer from chronic rather than acute conditions alongside rising social inequities. Methods: Our team undertook an ethnographic approach known as institutional ethnography in the province of Ontario, Canada in order to explore the social organization of chronic pain management from the standpoint of primary care physicians. This paper reports on a subset of this study data, specifically interviews with 19 primary care clinicians and 8 nurses supplemented by 40 hours of observations. The clinicians in our sample were largely primary care physicians and nurses working in urban, rural and Northern settings. Findings: In their reflections on providing care for patients with chronic pain, many providers describe being most challenged by the work involved in helping patients who also struggled with poverty, mental health and addiction. These frustrations were often complicated by concerns that they could lose their license for inappropriate prescribing, thus shifting their work from providing treatment and care to policing their patients for malingering and opioid abuse. Interpretation: Our findings show that care providers find the treatment of patients with chronic pain–especially those patients also experiencing poverty–to be challenging at best, and at worst frustrating and overwhelming. In many instances, their narratives suggested experiences of depersonalization, loss of job satisfaction and emotional exhaustion in relation to providing care for these patients, key dimensions of burnout. In essence, the work that they performed in relation to their patients’ social rather than medical needs seems to contribute to these experiences. Their experiences were further exacerbated by the fact that restricting and reducing opioid dosing in patients with chronic pain has become a major focus of care provision. [ABSTRACT FROM AUTHOR]

There is a paucity of data on the reason for and the quantity of antimicrobials used in broiler chickens in Canada. To address this, the Canadian Integrated Program for Antimicrobial Resistance Surveillance (CIPARS) implemented surveillance of antimicrobial use (AMU) and antimicrobial resistance (AMR) in broiler chicken flocks in 2013. Shortly after this (2014), the poultry industry banned the preventive use of ceftiofur in broiler chickens. The objectives of this analysis were to describe antimicrobial use (AMU) in Canadian broiler chickens between 2013 and 2015 (n = 378 flocks), compare these results to other animal species in Canada, to highlight the utility of farm surveillance data to evaluate the impact of a policy change, and to explore how different antimicrobial use metrics might affect data interpretation and communication. The surveillance data indicated that the poultry industry policy resulted in lower antimicrobial use and resistance, and they successfully captured information on when, where, why, and how much antimicrobials were being used. The majority of antimicrobials were administered via the feed (95%). The relative frequency of antimicrobial classes used in broiler chickens differed from those used in swine or in food animal production in general. Coccidiostats were the most frequently used antimicrobial classes (53% of total kg). Excluding coccidiostats, the top three most frequently used antimicrobial classes were bacitracin (53% of flocks), virginiamycin (25%) and avilamycin (21%), mainly used for the prevention of necrotic enteritis. Depending on the AMU metric utilized, the relative rankings of the top antimicrobials changed; hence the choice of the AMU metric is an important consideration for any AMU reporting. When using milligrams/Population Correction Unit (mg/PCU) the top three antimicrobial classes used were bacitracins (76 mg/PCU), trimethoprim-sulfonamides (24 mg/PCU), and penicillins (15 mg/PCU), whereas when using a number of Defined Daily Doses in animals using Canadian standards /1,000 chicken-days at risk (nDDDvetCA/1,000 CD) the ranking was bacitracins (223 nDDDvetCA/1,000 CD), streptogramins (118 nDDDvetCA/1,000 CD), and trimethoprim-sulfonamides (87 nDDDvetCA/1,000 CD). The median animal treatment days in feed for one cycle (ATD/cycle) during the three-year study were 34 ATD/cycle; this was equal to the mean age of the flocks at pre-harvest sampling day (days at risk), indicating that the studied flocks except those that were raised without antibiotics and organic, were fed with medicated rations throughout the observation period. Overall, more than half (59%) of antimicrobials used in broiler chickens were in classes not used in human medicine, such as ionophores and chemical coccidiostats aimed to prevent coccidiosis. Compared to grower-finisher pigs and in production animal species (national sales data), the mg/PCU of antimicrobials used in broiler chickens was relatively lower. The findings of this paper highlighted the importance of farm-level AMU surveillance in measuring the impact of interventions to reduce antimicrobials in poultry. [ABSTRACT FROM AUTHOR]

In this study we explored nurse practitioner-provided medication abortion in Canada and identified barriers and enablers to uptake and implementation. Between 2020–2021, we conducted 43 semi-structured interviews with 20 healthcare stakeholders and 23 nurse practitioners who both provided and did not provide medication abortion. Data were analyzed using interpretive description. We identified five overarching themes: 1) Access and use of ultrasound for gestational dating; 2) Advertising and anonymity of services; 3) Abortion as specialized or primary care; 4) Location and proximity to services; and 5) Education, mentorship, and peer support. Under certain conditions, ultrasound is not required for medication abortion, supporting nurse practitioner provision in the absence of access to this technology. Nurse practitioners felt a conflict between wanting to advertise their abortion services while also protecting their anonymity and that of their patients. Some nurse practitioners perceived medication abortion to be a low-resource, easy-to-provide service, while some not providing medication abortion continued to refer patients to specialized clinics. Some participants in rural areas felt unable to provide this service because they were too far from emergency services in the event of complications. Most nurse practitioners did not have any training in abortion care during their education and desired the support of a mentor experienced in abortion provision. Addressing factors that influence nurse practitioner provision of medication abortion will help to broaden access. Nurse practitioners are well-suited to provide medication abortion care but face multiple ongoing barriers to provision. We recommend the integration of medication abortion training into nurse practitioner education. Further, widespread communication from nursing organizations could inform nurse practitioners that medication abortion is within their scope of practice and facilitate public outreach campaigns to inform the public that this service exists and can be provided by nurse practitioners. [ABSTRACT FROM AUTHOR]

Purpose: Women living with HIV experience high levels of trauma exposure before and after diagnosis. One of the most challenging outcomes following trauma exposure is posttraumatic stress disorder. Despite high exposure to traumatic events, the presence and contributors to posttraumatic stress disorder symptoms have not been examined in women living with HIV in Canada. Methods: The current study examines the presence of, contributors to, and geographical regions associated with self-reported posttraumatic stress symptoms (PTSS) among 1405 women enrolled in the Canadian HIV Women’s Sexual & Reproductive Health Cohort Study (CHIWOS). Results: Separate linear regression models were run for the three provinces in the cohort: British Columbia, Ontario and Québec. Scores consistent with posttraumatic stress disorder were reported by 55.9%, 39.1% and 54.1% of the participants in each province, respectively (F(2, 1402) = 13.53, p < .001). Conclusions: The results demonstrate that women living with HIV have high rates of PTSS, and that rates and variables associated with these symptoms vary by province. These results suggest the need for trauma-informed practices and care for women living with HIV in Canada, which may need to be tailored for the community and identities of the women. [ABSTRACT FROM AUTHOR]

Background: With the Canadian government legalizing cannabis in the year 2018, the potential harms to certain populations—including those with opioid use disorder—must be investigated. Cannabis is one of the most commonly used substances by patients who are engaged in medication-assisted treatment for opioid use disorder, the effects of which are largely unknown. In this study, we examine the impact of baseline and ongoing cannabis use, and whether these are impacted differentially by gender. Methods: We conducted a retrospective cohort study using anonymized electronic medical records from 58 clinics offering opioid agonist therapy in Ontario, Canada. One-year treatment retention was the primary outcome of interest and was measured for patients who did and did not have a cannabis positive urine sample in their first month of treatment, and as a function of the proportion of cannabis-positive urine samples throughout treatment. Results: Our cohort consisted of 644 patients, 328 of which were considered baseline cannabis users and 256 considered heavy users. Patients with baseline cannabis use and heavy cannabis use were at increased risk of dropout (38.9% and 48.1%, respectively). When evaluating these trends by gender, only female baseline users and male heavy users are at increased risk of premature dropout. Interpretation: Both baseline and heavy cannabis use are predictive of decreased treatment retention, and differences do exist between genders. With cannabis being legalized in the near future, physicians should closely monitor cannabis-using patients and provide education surrounding the potential harms of using cannabis while receiving treatment for opioid use disorder. [ABSTRACT FROM AUTHOR]

Background: In hospitals around the world, there has been no consensus regarding which clinical activities a pharmacist should focus on until recently. In 2011, a Canadian clinical pharmacy key performance indicator (cpKPI) collaborative was formed. The goal of the collaborative was to advance pharmacy practice in order to improve patient outcomes and enhance the quality of care provided to patients by hospital pharmacists. Following a literature review, which indicated that pharmacists can improve patient outcomes by carrying out specific activities, and an evidence-informed consensus process, a final set of eight cpKPIs were established. Canadian hospitals leading the cpKPI initiative are currently in the early stages of implementing these indicators. Objective: To explore pharmacists' perceptions of the barriers and facilitators to the implementation of cpKPIs. Methods: Clinical pharmacists employed by the Nova Scotia Health Authority were invited to participate in focus groups. Focus group discussions were audio-recorded and transcribed, and data was analyzed using thematic analysis. Findings: Three focus groups, including 26 pharmacists, were conducted in February 2015. Three major themes were identified. Resisting the change was comprised of documentation challenges, increased workload, practice environment constraints, and competing priorities. Embracing cpKPIs was composed of seeing the benefit, demonstrating value, and existing supports. Navigating the unknown was made up of quality versus quantity battle, and insights into the future. Conclusions: Although pharmacists were challenged by documentation and other changes associated with the implementation of cpKPIs, they demonstrated significant support for cpKPIs and were able to see benefits of the implementation. Pharmacists came up with suggestions for overcoming resistance associated with the implementation of cpKPIs and provided insights into the future of pharmacy practice. The identification of barriers and facilitators to cpKPI implementation will be used to inform the implementation process on a local and national level. [ABSTRACT FROM AUTHOR]

Background: Canadians pay amongst the highest generic drug prices in the world. In July 2010, the province of Ontario enacted a policy that halved reimbursement for generic drugs from the public drug plan, and substantially lowered prices for private purchases. We quantified the impact of this policy on overall generic drug expenditures in the province, and projected the impact in other provinces had they mimicked this pricing change. Methods: We used quarterly prescription generic drug dispensing data from the IMS-Brogan CompuScript Audit. We used the price per unit in both the pre- and post-policy period and two economics price indexes to estimate the expenditure reduction in Ontario. Further, we used the post-policy Ontario prices to estimate the potential reduction in other provinces. Results: We estimate that total expenditure on generic drugs in Ontario during the second half of 2010 was between $181 and $194 million below what would be expected if prices had remained at pre-policy level. Over half of the reduction in spending was due to savings on just 10 generic ingredients. If other provinces had matched Ontario's prices, their expenditures over during the latter half of 2010 would have been $445 million lower. Discussion: We found that if Ontario's pricing scheme were adopted nationally, overall spending on generic drugs in Canada would drop at least $1.28 billion annually--a 5% decrease in total prescription drug expenditure. Other provinces should seriously consider both changes to their generic drug prices and the use of more competitive bulk purchasing policies. [ABSTRACT FROM AUTHOR]