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Laura Murphy,1– 3 Kori Leblanc,1,2,4 Souzi Badr,1,2 Emily Ching,1 Lynda Mao,1,2 Naomi Steenhof,1,2 Bassem Hamandi,1,2,4 Bonita Rubin,1,2 Ada Seto,1 Andrea D Furlan3,5,6 1Department of Pharmacy, University Health Network, Toronto, ON, Canada; 2Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada; 3KITE Research Institute, University Health Network, Toronto, ON, Canada; 4Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada; 5Department of Medicine, University of Toronto, Toronto, ON, Canada; 6Institute for Work & Health, Toronto, ON, CanadaCorrespondence: Laura Murphy, Department of Pharmacy, University Health Network, 550 University Ave, Toronto, ON, M5G 2A2, Canada, Tel +1 416-597-3422 x 3657, Fax +1 416-260-2658, Email laura.murphy@uhn.caBackground: Opioid utilization and management in an inpatient rehabilitation setting have not been widely described, despite the unique opportunities that exist in this setting to support opioid stewardship across transitions in care. We aimed to characterize opioid utilization and management by interprofessional teams across a large, inpatient rehabilitation setting after incorporation of opioid stewardship principles by pharmacists as part of their daily practice.Patients and methods: This was a retrospective chart review at Toronto Rehab, University Health Network, Toronto, Canada. Patients with admission orders for any opioid from November 2017 to February 2018 were included. Complex continuing care and palliative care patients were excluded. Descriptive statistics were primarily used to describe the data as well as univariate linear regression to compare associations with milligram morphine equivalent (MME) reduction.Results: A total of 448 patients were included. A reduction in total daily MME was seen in 49% (n=219) of the patients during their inpatient stay, with 73% (n=159) of these patients having a reduction of ≥ 50%. Sixty-nine percent (n=311) of the patients received an opioid prescription at discharge, with most scheduled (90%, n=98) with a supply of less than 30 days. Rehabilitation length of stay was correlated with a MME decrease during rehab (p< 0.01), suggesting that longer lengths of stay contributed to a greater reduction in MME. Patients with chronic opioid use prior to acute care admission (p=0.01), and those who started extended-release opioids during acute care (p=0.02) were significantly less likely to discontinue opioids during rehab stay.Conclusion: Opioid utilization and management in the setting of opioid stewardship across inpatient rehab and transitions of care were characterized. Opportunities exist for further quality improvement initiatives within inpatient rehabilitation and acute care settings to identify and support patients with complex pain management needs.Keywords: opioid, pain management, medication reconciliation, pharmacy practice, medication safety, discharge prescription

Laura Murphy,1,2 Karen WK Ng,1 Victoria CH Su,3 Sarah Woodworth-Giroux,4 Todd S Levy,1 Beth A Sproule,2,5 Andrea D Furlan1,6 1University Health Network, Toronto, ON, Canada; 2Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada; 3St Paul's Hospital, Lower Mainland Pharmacy Services, Vancouver, BC, Canada; 4Windsor Regional Hospital, Windsor, ON, Canada; 5Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada; 6Institute for Work and Health, Toronto, ON, Canada Abstract: This paper provides an overview of research, guidelines, and clinical considerations for the use of medications for chronic pain in the management of patients with an alcohol use disorder. A review of the literature identified randomized controlled trials, epidemiological cohort studies, consensus guidelines, and one systematic review and meta-analysis. Where gaps in the literature existed, clinical experience of the authors is included. Use of nonopioid medications should be given priority and may offer a more favorable risk profile as well as benefits beyond pain management, such as improvement in anxiety, depression, or insomnia. Pregabalin and gabapentin have additional benefits to decrease alcohol cravings or time to relapse after a period of abstinence from alcohol. Drug interactions between selected analgesics and alcohol, disulfiram, or naltrexone require careful consideration. Keywords: chronic pain, alcohol use disorder, opioids

STUDY DESIGN: Literature review. OBJECTIVE: To assess the influence of various factors in statistical heterogeneity of meta-analyses of interventions for low back pain. One of these factors was study design: randomized controlled trial (RCT) versus nonrandomized study (NRS). SUMMARY OF BACKGROUND DATA: The presence of statistical heterogeneity poses a challenge to the conduct and interpretation of meta-analyses. METHODS: We searched MEDLINE, EMBASE, and The Cochrane Library up to May 2005 for comparative studies of interventions for low back pain. The interventions with the highest number of NRSs were selected. All NRSs and RCTs of the same interventions were combined using meta-analysis. Subgroup analyses and meta-regression were performed according to study design and other factors that were selected by a panel of 20 experts. RESULTS: NRSs frequently either agree with RCTs or underestimate the effects compared with RCTs. The interventions and the respective factors that explained statistical heterogeneity were a) surgery versus conservative treatments (17 NRSs and 8 RCTs): study design (odds ratio, OR: 1.56 and 4.69 for nonrandomized and randomized studies, respectively), pain duration (OR: 1.75 and 3.55 for chronic and acute, respectively), and involvement of workers' compensation (OR: 1.85 and 5.07, with and without, respectively); b) surgery with fusion versus surgery without fusion (17 NRSs and 3 RCTs): spondylolisthesis (OR: 2.15 and 1.22, with and without, respectively); c) Instrumented fusion versus noninstrumented fusion (15 NRSs and 8 RCTs): previous surgery (OR: 2.89 and 1.36, with and without, respectively) and levels fused (OR: 1.50 and 2.98, single and multilevel, respectively). CONCLUSION: Comparisons between RCTs and NRSs may be influenced by various factors, including study design. However, other factors were more powerful explanatory variables than study design. These factors included pain duration, involvement of workers' compensation, presence of spondylolisthesis, previous surgery, and levels fused. [ABSTRACT FROM AUTHOR]

Background: Health issues caused and/or exacerbated by work are common in patients seeking primary health care. Yet, primary care providers generally receive little or no training in the assessment and management of occupational injuries and illnesses., Aims: To conduct a pilot project to develop, implement and evaluate a programme to teach occupational and environmental medicine to primary healthcare providers., Methods: We followed the Extensions for Community Healthcare Outcomes (ECHO) model to connect primary healthcare providers with experts in Occupational and Environmental Medicine (OEM). We employed an observational pre-post study design to assess changes in self-efficacy, knowledge, attitudes and beliefs towards OEM., Results: From September 2021 to June 2022, we offered two cycles of 12 sessions each. Participants came from medicine, nursing, psychology, occupational and physical therapy, chiropractic, kinesiology, social work, and pharmacy. Sixty-seven participants completed both pre- and post-ECHO questionnaires. Self-efficacy and knowledge ratings significantly increased after attendance at ECHO compared to the pre-ECHO responses. Attitudes and beliefs were unchanged in most of the items assessed. Participants rated their satisfaction with ECHO between 59% and 97%., Conclusions: Our pilot study demonstrated the challenges in implementing the first ECHO OEM in Canada. Findings show acceptability and satisfaction, improved self-efficacy, and small increases in knowledge, but not overall attitudes and beliefs. There is a need to understand barriers to participation and to target participants with less knowledge and experience in occupational and environmental medicine., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Society of Occupational Medicine.)

Background: Research on cannabis use motives has focused on youth. Little is known about motives among working adults, including how work may play a role. This study aimed to describe cannabis use motives and their connection to work, and identify the personal and work correlates of work-related motives among a sample of workers., Methods: A national, cross-sectional sample of Canadian workers were queried about their cannabis use. Workers reporting past-year cannabis use (n = 589) were asked their motives for using cannabis and whether each motive was related to work or helped them manage at work (i.e., work-related). Multinomial logistic regression analyses were conducted to estimate the associations of personal and work characteristics with work-related cannabis use motives (no work-related motives, < 50% of motives work-related, ≥ 50% of motives work-related)., Results: Use for relaxation (59.3%), enjoyment (47.2%), social reasons (35.3%), coping (35.1%), medical reasons (30.9%), and sleep (29.9%) were the most common motives. Almost 40% of respondents reported one or more of their cannabis use motives were work-related, with coping (19.9%) and relaxation (16.3%) most commonly reported as work-related. Younger age, poorer general health, greater job stress, having a supervisory role, and hazardous work were associated with increased odds of reporting at least some cannabis use motives to be work-related, while work schedule and greater frequency of alcohol use were associated with reduced odds of motives being primarily work-related., Conclusions: Cannabis use motives among workers are diverse and frequently associated with work. Greater attention to the role of work in motivating cannabis use is warranted., (© 2024. The Author(s).)

Objective: This study aimed to describe the characteristics associated with unmet rehabilitation needs in a sample of Canadians with long-term health conditions or disabilities during the first wave of the COVID-19 pandemic., Design: We used data from the Impacts of COVID-19 on Canadians Living With Long-Term Conditions and Disabilities, a national cross-sectional survey with 13,487 respondents. Unmet needs were defined as needing rehabilitation (ie, physiotherapy/massage/chiropractic, speech therapy, occupational therapy, counseling services, or support groups) but not receiving due to the pandemic. We used multivariable modified Poisson regression to examine the association between demographic, socioeconomic, and health-related characteristics and unmet rehabilitation needs., Results: More than half of the sample were 50 years and older (52.3%), female (53.8%), and 49.3% reported unmet rehabilitation needs. Those more likely to report unmet needs were females, those with lower socioeconomic status (receiving disability benefits or social assistance, job loss, increased work hours, decreased household income or earnings), and those with lower perceived general health or mental health status., Conclusions: Among Canadians with disabilities or chronic health conditions, marginalized groups are more likely to report unmet rehabilitation needs. Understanding the systemic and upstream determinants is necessary to develop strategies to minimize unmet rehabilitation needs and facilitate the delivery of equitable rehabilitation services., Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: The study aims to investigate the patient perspective on the pathway from healthcare practitioners' presentations of their cases at a Project ECHO (Extension for Community Healthcare Outcomes) tele-clinic to the management of those patients' chronic pain., Introduction: Managing patients with chronic and complex pain constitutes a prevalent, stressful challenge in the primary care setting. Primary care physicians typically have received little training in treating such patients and, until recently, have relied heavily on opioid and other pharmaceutical therapies as part of their regimen. Project ECHO Ontario Chronic Pain and Opioid Stewardship is an interprofessional telementoring program connecting pain specialists to primary care practitioners with the aim of supporting them in managing their patients with chronic pain, although the patients concerned do not generally participate in the telementoring sessions. While a number of papers have described the benefits accruing to healthcare professionals through participating in Project ECHO, there has been little exploration concerning patients' perceptions of their care subsequent to case presentation., Methods: Using data from in-depth interviews with 20 patients along with their associated case presentation forms and the recommendations following the presentation, we look at the alignment of patient and practitioner views and inquire about the patient's perceptions of how Project ECHO affects them., Results: Results suggest that the impact on patients is indirect but positive: most respondents express pleasure in contributing to research around chronic pain management, though only two of them identified a direct impact on their own treatment. They also appreciated their practitioner's efforts to bring expert attention to the patient's situation., Conclusions: Patients whose cases are presented to Project ECHO sessions experience positive emotions at being part of the process of research and quality improvement, regardless of changes in their own conditions. This study highlights the importance to patients of their practitioners' commitment to managing their chronic pain., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

Objective: We aimed to describe the prevalence of unmet rehabilitation needs among a sample of Canadians living with long-term conditions or disabilities during the first wave of the COVID-19 pandemic., Design: Cross-sectional survey., Setting: Individuals residing in Canada during the first wave of the COVID-19 pandemic., Participants: Eligible participants were Canadians living with long-term conditions or disabilities, 15 years or older living in 1 of the 10 provinces or 3 territories (n=13,487)., Interventions: Not applicable., Main Outcome Measure: We defined unmet rehabilitation needs as those who reported needing rehabilitation (ie, physiotherapy/massage therapy/chiropractic, speech, or occupational therapy, counseling services, support groups) but did not receive it because of the COVID-19 pandemic. We calculated the national, age, gender, and province/territory-specific prevalence and 95% confidence interval of unmet rehabilitation needs., Results: During the first wave of the pandemic, the prevalence of unmet rehabilitation needs among Canadians with long-term conditions or disabilities was 49.3% (95% confidence interval [CI]; 48.3, 50.3]). The age-specific prevalence was higher among individuals 15-49 years old (55.6%; 95% CI [54.2, 57.1]) than those 50 years and older (46.0%; 95% CI [44.5, 47.4]). Females (53.7%; 95% CI [52.6, 54.9]) had higher unmet needs than males (44.1%; 95% CI [42.3, 45.9]). Unmet rehabilitation needs varied across provinces and territories., Conclusions: In this sample, almost 50% of Canadians living with long-term conditions or disabilities had unmet rehabilitation needs during the first wave of the COVID-19 pandemic. This suggests that a significant gap between the needs for and delivery of rehabilitation care existed during the early phase of the pandemic., (Copyright © 2023 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Utilizing cannabis as a therapeutic option for chronic pain (CP) has increased significantly. However, data regarding the potential immunomodulatory effects of cannabis in CP patients remain scarce. We aimed at exploring the relationship between cannabis use and inflammatory cytokines and chemokines among a cohort of CP patients. Methods: Adult patients with a CP diagnosis and medical authorization of cannabis were enrolled. Patients completed validated clinical questionnaires and self-reported the effectiveness of cannabis for symptom management. Patients' blood and cannabis samples were analyzed for the presence of four major cannabinoids, two major cannabinoid metabolites, 29 different cytokines/chemokines, and cortisol. The multivariable linear regression model was used to identify cannabis and patient factors associated with immune markers. Results: Fifty-six patients (48±15 years; 64% females) were included, with dried cannabis (53%) being the most common type of cannabis consumed. Seventy percent of products were considered delta-9-tetrahydrocannabinol (Δ 9 -THC)-dominant. The majority of patients (96%) self-reported effective pain management, and 76% reported a significant decrease in analgesic medication usage ( p ≤0.001). Compared with males, female patients had higher plasma levels of cannabidiol (CBD), cannabidiolic acid, Δ 9 -THC, and 11-hydroxy-Δ 9 -tetrahydrocannabinol but lower concentrations of delta-9-tetrahydrocannabinolic acid and 11-nor-9-carboxy-Δ 9 -tetrahydrocannabinol (THC-COOH). Females had significantly lower eotaxin levels ( p =0.04) in comparison to male patients. The regression analysis indicated that high cannabis doses were related to increased levels of interleukin (IL)-12p40 ( p =0.02) and IL-6 ( p =0.01), whereas female sex was associated with decreased eotaxin ( p ≤0.01) concentrations. Blood CBD levels were associated with lower vascular endothelial growth factor ( p =0.04) concentrations, and THC-COOH was a factor related to decreased tumor necrosis factor alpha ( p =0.02) and IL-12p70 ( p =0.03). Conclusion: This study provides further support for the patient-perceived effectiveness of cannabis in managing CP symptoms and reducing analgesic medication consumption. The results suggest a potential sex difference in metabolizing cannabinoids, and the varying immune marker concentrations may support a possible immunomodulatory effect associated with patient sex and cannabis product type. These preliminary findings provide grounds for further validation using larger, well-designed studies with longer follow-up periods.

Introduction: In addition to shifting and expanding clinical responsibilities, rapidly evolving information and guidelines during the COVID-19 pandemic has made it difficult for health care workers (HCW) to synthesise and translate COVID-19 information into practice. This study evaluated whether a COVID-19-specific telemedicine education program (ECHO COVID) would impact health care workers' self-efficacy and satisfaction in the management of patients with COVID-19., Methods: A prospective mixed methods parallel-design study was conducted among ECHO COVID participants using pre-post questionnaires and a focus group discussion. Questionnaire results were examined for changes in health care workers' self-efficacy and satisfaction. Focus group discussion data were analysed to explore health care workers' experience in ECHO COVID and the context of their practice during the COVID-19 pandemic., Results: 239 health care workers registered in ECHO COVID and 114 (47.7%) completed questionnaires and attended at least one ECHO COVID session. Median self-efficacy scores increased from 5 (IQR 4-6) to 6 (IQR 6-6) ( p  < 0.0001), independent of profession, years in practice, age group, or practice environment. Participants were highly satisfied with ECHO COVID sessions with a median score of 4 (IQR 4-5). Focus group discussion data indicated that health care workers gained knowledge through ECHO COVID and revealed facilitators for ECHO COVID program success, including the transition to virtual care, the practicability of knowledge provided, and a 'perspective from the trenches.', Discussion: This study demonstrated that a telemedicine education program aimed to support health care workers in managing patients with COVID-19 had a positive impact on health care workers' self-efficacy and satisfaction. This impact was specifically mediated by the ECHO COVID program., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: Findings of previous studies examining the relationship between cannabis use and workplace injury have been conflicting, likely due to methodological shortcomings, including cross-sectional designs and exposure measures that lack consideration for timing of use. The objective was to estimate the association between workplace cannabis use (before and/or at work) and non-workplace use and the risk of workplace injury., Methods: Canadian workers participating in a yearly longitudinal study (from 2018 to 2020) with at least two adjacent years of survey data comprised the analytic sample (n = 2745). The exposure was past-year workplace cannabis use (no past-year use, non-workplace use, workplace use). The outcome was past-year workplace injury (yes/no). Absolute risks and relative risks (RR) with 95% confidence intervals (CIs) were estimated between workplace and non-workplace cannabis use at one time point and workplace injury at the following time point. Models were adjusted for personal and work variables and were also stratified by whether respondents' jobs were safety-sensitive., Results: Compared to no past-year cannabis use, there was no difference in workplace injury risk for non-workplace cannabis use (RR 1.09, 95%CI 0.83-1.44). However, workplace use was associated with an almost two-fold increased risk of experiencing a workplace injury (RR 1.97, 95%CI 1.32-2.93). Findings were similar for workers in safety-sensitive and non-safety-sensitive work., Conclusion: It is important to distinguish between non-workplace and workplace use when considering workplace safety impacts of cannabis use. Findings have implications for workplace cannabis use policies and substantiate the need for worker education on the risks of workplace cannabis use., (© 2023. The Author(s).)

Objectives: The rise in opioid prescriptions with a parallel increase in opioid use disorders remains a significant challenge in some developed countries (opioid epidemic). However, little is known about opioid consumption in low- and middle-income countries (LMICs). In this short report, we aim to discuss the increase in opioid consumption in LMICs by providing an update on the opioid perspective in Brazil., Methods: We analyzed opioid sales on the publicly available Brazilian Health Regulatory Agency (ANVISA) database from 2015 to 2020., Results: In Brazil, opioid sales increased 34.8 %, from 8,839,029 prescriptions in 2015 to 11,913,823 prescriptions in 2020, this represents an increase from 44 to 56 prescriptions for every 1,000 inhabitants. Codeine phosphate combined with paracetamol and tramadol hydrochloride were the most common opioids prescribed with an increase each year., Conclusions: The results suggest that opioid prescriptions are rising in Brazil in a 5 years period. Brazil may have a unique opportunity to learn from other countries and develop consistent policies and guidelines to better educate patients and prescribers and to prevent an opioid crisis., (© 2023 the author(s), published by De Gruyter, Berlin/Boston.)

Abstract: Interpatient variability is frequently observed among individuals with chronic low back pain (cLBP). This review aimed at identifying phenotypic domains and characteristics that account for interpatient variability in cLBP. We searched MEDLINE ALL (through Ovid), Embase Classic and EMBASE (through Ovid), Scopus, and CINAHL Complete (through EBSCOhost) databases. Studies that aimed to identify or predict cLBP different phenotypes were included. We excluded studies that focused on specific treatments. The methodological quality was assessed using an adaptation of the Downs and Black tool. Forty-three studies were included. Although the patient and pain-related characteristics used to identify phenotypes varied considerably across studies, the following were among the most identified phenotypic domains and characteristics that account for interpatient variability in cLBP: pain-related characteristics (including location, severity, qualities, and duration) and pain impact (including disability, sleep, and fatigue), psychological domains (including anxiety and depression), behavioral domains (including coping, somatization, fear avoidance, and catastrophizing), social domains (including employment and social support), and sensory profiling (including pain sensitivity and sensitization). Despite these findings, our review showed that the evidence on pain phenotyping still requires further investigation. The assessment of the methodological quality revealed several limitations. We recommend adopting a standard methodology to enhance the generalizability of the results and the implementation of a comprehensive and feasible assessment framework to facilitate personalized treatments in clinical settings., (Copyright © 2023 International Association for the Study of Pain.)

Objectives: Little is known about how workers use cannabis following a work-related injury/illness, including whether they receive clinical guidance. The objective was to compare characteristics of workers using and not using cannabis after a work-related injury/illness and describe use patterns., Design: Cross-sectional study., Setting and Participants: Workers who experienced a work-related physical injury/illness resulting in one or more days of lost time compensated by the workers' compensation authority in Ontario, Canada (n=1196)., Methods: Participants were interviewed 18 or 36 months after their injury/illness. Participants were asked about their past-year cannabis use, including whether use was for the treatment of their work-related condition. Sociodemographic, work and health characteristics were compared across cannabis groups: no past-year use; use for the work-related condition; use unrelated to the work-related condition. Cannabis use reasons, patterns, perceived impact and healthcare provider engagement were described., Results: In total, 27.4% of the sample reported using cannabis (14.1% for their work-related condition). Workers using cannabis for their condition were less likely to be working (58.0%) and more likely to have quite a bit/extreme pain interference (48.5%), psychological distress (26.0%) and sleep problems most/all the time (62.1%) compared with those not using cannabis (74.3%, 26.3%, 12.0% and 38.0%, respectively) and those using cannabis for other reasons (74.2%, 19.5%, 12.0% and 37.1%, respectively) (all p<0.0001). No significant differences were observed in medical authorisations for use among those using cannabis for their condition (20.4%) or unrelated to their condition (15.7%) (p=0.3021). Healthcare provider guidance was more common among those using cannabis for their condition (32.7%) compared with those using for other reasons (17.1%) (p=0.0024); however, two-thirds of this group did not receive guidance., Conclusions: Cannabis may be used to manage the consequences of work-related injuries/illnesses, yet most do not receive clinical guidance. It is important that healthcare providers speak with injured workers about their cannabis use., Competing Interests: Competing interests: ADF is a member of the Ontario Workplace Safety and Insurance Board’s Drug Advisory Committee., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: In a cohort of workers disabled by a work-related injury or illness, this study aimed to: (i) compare pre-injury prevalence estimates for common chronic conditions to chronic condition prevalence in a representative sample of working adults; (ii) calculate the incidence of chronic conditions post-injury; and (iii) estimate the association between persistent pain symptoms and the incidence of common chronic conditions., Methods: Eighteen months post-injury, 1832 workers disabled by a work-related injury or illness in Ontario, Canada, completed an interviewer-administered survey. Participants reported pre- and post-injury prevalence of seven physician-diagnosed chronic conditions, and demographic, employment, and health characteristics. Pre-injury prevalence estimates were compared to estimates from a representative sample of workers. Multivariable logistic regression was used to examine the association of persistent pain with post-injury chronic condition incidence., Results: Age-standardized pre-injury prevalence rates for diabetes, hypertension, arthritis, and back problems were similar to prevalence rates observed among working adults in Ontario, while prevalence rates for mood disorder, asthma and migraine were moderately elevated. Post-injury prevalence rates of mood disorder, migraine, hypertension, arthritis, and back problems were elevated substantially in this cohort. High persistent pain symptoms were strongly associated with the 18-month incidence of these conditions., Conclusions: The incidence of five chronic conditions over an 18-month follow-up period post injury was substantial. Persistent pain at 18 months was associated with this elevated incidence, with population attributable fraction estimates suggesting that 37-39% of incident conditions may be attributed to exposure to high levels of persistent pain.

Background: Patients with life-limiting cancers are commonly prescribed opioids to manage pain, dyspnea, and cough. Proper prescription opioid disposal is essential to prevent poisonings and deaths. Objective: We examined opioid disposal practices of patients referred to a Canadian outpatient palliative care clinic (OPCC). The primary objective was to determine the prevalence of OPCC patients who did not routinely dispose their opioids. The secondary objectives were to examine their methods of opioid disposal and to identify patient characteristics associated with routine disposal of opioids. Design and Setting: This cross-sectional study involved a retrospective chart review of new, adult patients who were seen in a Canadian OPCC (September 2018-August 2019) and completed a survey about opioid-related constructs: source of prescriptions, use, storage, disposal, and knowledge about associated harms. Results: Among the 122 study participants, half (58/111, 52.3%) reported that they did not routinely dispose their opioids. The most common method of disposal was by giving them to pharmacists (69/88, 78.4%). Cannabis use (odds ratio [OR]: 3.7, 95% confidence interval [CI]: 1.1-11.8) and neuropathic medication use (OR: 3.0, 95% CI: 1.2-7.2) were positively associated with routine disposal of opioids. Conversely, reports of an increased amount of opioid use in the past six months were negatively associated with routine disposal of opioids (OR: 0.38, 95% CI: 0.16-0.88). Conclusion: The high prevalence of people with life-limiting illnesses who do not routinely dispose their opioids requires increased attention. Interventions, such as education, are needed to reduce medication waste and opioid-related harms.

Importance: Opioid use for chronic nonmalignant pain can be harmful., Objective: To test whether a multicomponent, group-based, self-management intervention reduced opioid use and improved pain-related disability compared with usual care., Design, Setting, and Participants: Multicentered, randomized clinical trial of 608 adults taking strong opioids (buprenorphine, dipipanone, morphine, diamorphine, fentanyl, hydromorphone, methadone, oxycodone, papaveretum, pentazocine, pethidine, tapentadol, and tramadol) to treat chronic nonmalignant pain. The study was conducted in 191 primary care centers in England between May 17, 2017, and January 30, 2019. Final follow-up occurred March 18, 2020., Intervention: Participants were randomized 1:1 to either usual care or 3-day-long group sessions that emphasized skill-based learning and education, supplemented by 1-on-1 support delivered by a nurse and lay person for 12 months., Main Outcomes and Measures: The 2 primary outcomes were Patient-Reported Outcomes Measurement Information System Pain Interference Short Form 8a (PROMIS-PI-SF-8a) score (T-score range, 40.7-77; 77 indicates worst pain interference; minimal clinically important difference, 3.5) and the proportion of participants who discontinued opioids at 12 months, measured by self-report., Results: Of 608 participants randomized (mean age, 61 years; 362 female [60%]; median daily morphine equivalent dose, 46 mg [IQR, 25 to 79]), 440 (72%) completed 12-month follow-up. There was no statistically significant difference in PROMIS-PI-SF-8a scores between the 2 groups at 12-month follow-up (-4.1 in the intervention and -3.17 in the usual care groups; between-group difference: mean difference, -0.52 [95% CI, -1.94 to 0.89]; P = .15). At 12 months, opioid discontinuation occurred in 65 of 225 participants (29%) in the intervention group and 15 of 208 participants (7%) in the usual care group (odds ratio, 5.55 [95% CI, 2.80 to 10.99]; absolute difference, 21.7% [95% CI, 14.8% to 28.6%]; P < .001). Serious adverse events occurred in 8% (25/305) of the participants in the intervention group and 5% (16/303) of the participants in the usual care group. The most common serious adverse events were gastrointestinal (2% in the intervention group and 0% in the usual care group) and locomotor/musculoskeletal (2% in the intervention group and 1% in the usual care group). Four people (1%) in the intervention group received additional medical care for possible or probable symptoms of opioid withdrawal (shortness of breath, hot flushes, fever and pain, small intestinal bleed, and an overdose suicide attempt)., Conclusions and Relevance: In people with chronic pain due to nonmalignant causes, compared with usual care, a group-based educational intervention that included group and individual support and skill-based learning significantly reduced patient-reported use of opioids, but had no effect on perceived pain interference with daily life activities., Trial Registration: isrctn.org Identifier: ISRCTN49470934.

Background: Pharmacological interventions are the most used treatment for low back pain (LBP). Use of evidence from systematic reviews of the effects of pharmacological interventions for LBP published in the Cochrane Library, is limited by lack of a comprehensive overview., Objectives: To summarise the evidence from Cochrane Reviews of the efficacy, effectiveness, and safety of systemic pharmacological interventions for adults with non-specific LBP., Methods: The Cochrane Database of Systematic Reviews was searched from inception to 3 June 2021, to identify reviews of randomised controlled trials (RCTs) that investigated systemic pharmacological interventions for adults with non-specific LBP. Two authors independently assessed eligibility, extracted data, and assessed the quality of the reviews and certainty of the evidence using the AMSTAR 2 and GRADE tools. The review focused on placebo comparisons and the main outcomes were pain intensity, function, and safety., Main Results: Seven Cochrane Reviews that included 103 studies (22,238 participants) were included. There is high confidence in the findings of five reviews, moderate confidence in one, and low confidence in the findings of another. The reviews reported data on six medicines or medicine classes: paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, benzodiazepines, opioids, and antidepressants. Three reviews included participants with acute or sub-acute LBP and five reviews included participants with chronic LBP. Acute LBP Paracetamol There was high-certainty evidence for no evidence of difference between paracetamol and placebo for reducing pain intensity (MD 0.49 on a 0 to 100 scale (higher scores indicate worse pain), 95% CI -1.99 to 2.97), reducing disability (MD 0.05 on a 0 to 24 scale (higher scores indicate worse disability), 95% CI -0.50 to 0.60), and increasing the risk of adverse events (RR 1.07, 95% CI 0.86 to 1.33). NSAIDs There was moderate-certainty evidence for a small between-group difference favouring NSAIDs compared to placebo at reducing pain intensity (MD -7.29 on a 0 to 100 scale (higher scores indicate worse pain), 95% CI -10.98 to -3.61), high-certainty evidence for a small between-group difference for reducing disability (MD -2.02 on a 0-24 scale (higher scores indicate worse disability), 95% CI -2.89 to -1.15), and very low-certainty evidence for no evidence of an increased risk of adverse events (RR 0.86, 95% CI 0. 63 to 1.18). Muscle relaxants and benzodiazepines There was moderate-certainty evidence for a small between-group difference favouring muscle relaxants compared to placebo for a higher chance of pain relief (RR 0.58, 95% CI 0.45 to 0.76), and higher chance of improving physical function (RR 0.55, 95% CI 0.40 to 0.77), and increased risk of adverse events (RR 1.50, 95% CI 1. 14 to 1.98). Opioids None of the included Cochrane Reviews aimed to identify evidence for acute LBP. Antidepressants No evidence was identified by the included reviews for acute LBP. Chronic LBP Paracetamol No evidence was identified by the included reviews for chronic LBP. NSAIDs There was low-certainty evidence for a small between-group difference favouring NSAIDs compared to placebo for reducing pain intensity (MD -6.97 on a 0 to 100 scale (higher scores indicate worse pain), 95% CI -10.74 to -3.19), reducing disability (MD -0.85 on a 0-24 scale (higher scores indicate worse disability), 95% CI -1.30 to -0.40), and no evidence of an increased risk of adverse events (RR 1.04, 95% CI -0.92 to 1.17), all at intermediate-term follow-up (> 3 months and ≤ 12 months postintervention). Muscle relaxants and benzodiazepines There was low-certainty evidence for a small between-group difference favouring benzodiazepines compared to placebo for a higher chance of pain relief (RR 0.71, 95% CI 0.54 to 0.93), and low-certainty evidence for no evidence of difference between muscle relaxants and placebo in the risk of adverse events (RR 1.02, 95% CI 0.67 to 1.57). Opioids There was high-certainty evidence for a small between-group difference favouring tapentadol compared to placebo at reducing pain intensity (MD -8.00 on a 0 to 100 scale (higher scores indicate worse pain), 95% CI -1.22 to -0.38), moderate-certainty evidence for a small between-group difference favouring strong opioids for reducing pain intensity (SMD -0.43, 95% CI -0.52 to -0.33), low-certainty evidence for a medium between-group difference favouring tramadol for reducing pain intensity (SMD -0.55, 95% CI -0.66 to -0.44) and very low-certainty evidence for a small between-group difference favouring buprenorphine for reducing pain intensity (SMD -0.41, 95% CI -0.57 to -0.26). There was moderate-certainty evidence for a small between-group difference favouring strong opioids compared to placebo for reducing disability (SMD -0.26, 95% CI -0.37 to -0.15), moderate-certainty evidence for a small between-group difference favouring tramadol for reducing disability (SMD -0.18, 95% CI -0.29 to -0.07), and low-certainty evidence for a small between-group difference favouring buprenorphine for reducing disability (SMD -0.14, 95% CI -0.53 to -0.25). There was low-certainty evidence for a small between-group difference for an increased risk of adverse events for opioids (all types) compared to placebo; nausea (RD 0.10, 95% CI 0.07 to 0.14), headaches (RD 0.03, 95% CI 0.01 to 0.05), constipation (RD 0.07, 95% CI 0.04 to 0.11), and dizziness (RD 0.08, 95% CI 0.05 to 0.11). Antidepressants There was low-certainty evidence for no evidence of difference for antidepressants (all types) compared to placebo for reducing pain intensity (SMD -0.04, 95% CI -0.25 to 0.17) and reducing disability (SMD -0.06, 95% CI -0.40 to 0.29)., Authors' Conclusions: We found no high- or moderate-certainty evidence that any investigated pharmacological intervention provided a large or medium effect on pain intensity for acute or chronic LBP compared to placebo. For acute LBP, we found moderate-certainty evidence that NSAIDs and muscle relaxants may provide a small effect on pain, and high-certainty evidence for no evidence of difference between paracetamol and placebo. For safety, we found very low- and high-certainty evidence for no evidence of difference with NSAIDs and paracetamol compared to placebo for the risk of adverse events, and moderate-certainty evidence that muscle relaxants may increase the risk of adverse events. For chronic LBP, we found low-certainty evidence that NSAIDs and very low- to high-certainty evidence that opioids may provide a small effect on pain. For safety, we found low-certainty evidence for no evidence of difference between NSAIDs and placebo for the risk of adverse events, and low-certainty evidence that opioids may increase the risk of adverse events., (Copyright © 2023 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.)

Background: People who use drugs with life-limiting illnesses experience substantial barriers to accessing palliative care. Demand for palliative care is expected to increase during communicable disease epidemics and pandemics. Understanding how epidemics and pandemics affect palliative care for people who use drugs is important from a service delivery perspective and for reducing population health inequities., Aim: To explore what is known about communicable disease epidemics and pandemics, palliative care, and people who use drugs., Design: Scoping review., Data Sources: We searched six bibliographic databases from inception to April 2021 as well as the grey literature. We included English and French records about palliative care access, programs, and policies and guidelines for people ⩾18 years old who use drugs during communicable disease epidemics and pandemics., Results: Forty-four articles were included in our analysis. We identified limited knowledge about palliative care for people who use drugs during epidemics and pandemics other than HIV/AIDS. Through our thematic synthesis of the records, we generated the following themes: enablers and barriers to access, organizational barriers, structural inequity, access to opioids and other psychoactive substances, and stigma., Conclusions: Our findings underscore the need for further research about how best to provide palliative care for people who use drugs during epidemics and pandemics. We suggest four ways that health systems can be better prepared to help alleviate the structural barriers that limit access as well as support the provision of high-quality palliative care during future epidemics and pandemics.

Primary care physicians are uniquely positioned to assist ill and injured workers to stay-at-work or to return-to-work. Purpose The purpose of this scoping review is to identify primary care physicians' learning needs in returning ill or injured workers to work and to identify gaps to guide future research. Methods We used established methodologies developed by Arksey and O'Malley, Cochrane and adapted by the Systematic Review Program at the Institute for Work & Health. We used Distiller SR©, an online systematic review software to screen for relevance and perform data extraction. We followed the PRISMA for Scoping Reviews checklist for reporting. Results We screened 2106 titles and abstracts, 375 full-text papers for relevance and included 44 studies for qualitative synthesis. The first learning need was related to administrative tasks. These included (1) appropriate record-keeping, (2) time management to review occupational information, (3) communication skills to provide clear, sufficient and relevant factual information, (4) coordination of services between different stakeholders, and (5) collaboration within teams and between different professions. The second learning need was related to attitudes and beliefs and included intrinsic biases, self-confidence, role clarity and culture of blaming the patient. The third learning need was related to specific knowledge and included work capacity assessments and needs for sick leave, environmental exposures, disclosure of information, prognosis of certain conditions and care to certain groups such as adolescents and pregnant workers. The fourth learning need was related to awareness of services and tools. Conclusions There are many opportunities to improve medical education for physicians in training or in continuing medical education to improve care for workers with an illness or injury that affect their work., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Abstract: Systematic reviews are reviews of the literature using a step-by-step approach in a systematic way. Meta-analyses are systematic reviews that use statistical methods to combine the included studies to generate an effect estimate. In this article, we summarize 10 steps for conducting systematic reviews and meta-analyses in the field of rehabilitation medicine: protocol, review team and funding, objectives and research question, literature search, study selection, risk of bias, data extraction, data analysis, reporting of results and conclusions, and publication and dissemination. There are currently 64,958 trials that contain the word "rehabilitation" in CENTRAL (the database of clinical trials in the Cochrane Library), only 1246 reviews, and 237 protocols. There is an urgent need for rehabilitation physicians to engage and conduct systematic reviews and meta-analysis of a variety of rehabilitation interventions. Systematic reviews have become the foundation of clinical practice guidelines, health technology assessments, formulary inclusion decisions and to guide funding additional research in that area., Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: Little data exist examining the impact of non-medical (recreational) cannabis legalisation among a working population. The objective was to compare cannabis use patterns and workplace risk perceptions, cannabis availability and workplace use policies before and almost 1 year after legalisation in Canadian workers., Methods: Two overlapping cross-sectional samples of Canadian workers were surveyed 4 months before legalisation (time 1 (T1), n=2011) and 9-11 months after legalisation (time 2 (T2), n=4032), gathering information on cannabis use (overall and workplace use), workers' perceptions regarding risks of workplace use, availability of cannabis at work and awareness of workplace substance use policies. The marginal distributions of these variables at T1 and T2 were compared, adjusting for sociodemographic, work and health and lifestyle factors., Results: Cannabis use status changed from prelegalisation to postlegalisation (p<0.0001), with fewer respondents reporting former use (ie, more than 1 year ago; 40.4% at T1, 33.0% at T2) and a greater proportion of workers reporting past-year use (30.4% at T1, 39.3% at T2). Never use remained stable (29.2% at T1, 27.6% at T2). Workplace cannabis use also remained stable (9.4% at T1, 9.1% at T2; p=0.4580). At T1, 62.7% of respondents reported being aware of their workplace having a substance use policy, increasing to 79.0% at T2 (p<0.0001). Small magnitude changes occurred in perceptions of risk and workplace availability., Conclusions: Results point to a lack of substantive changes in the short-term from prelegalisation to postlegalisation. Longer-term data among workers are needed given the evolving nature of this legislative policy., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To describe the design, development and pilot of a multicomponent intervention aimed at supporting withdrawal of opioids for people with chronic non-malignant pain for future evaluation in the Improving the Wellbeing of people with Opioid Treated CHronic pain (I-WOTCH) randomised controlled trial., Design: The I-WOTCH intervention draws on previous literature and collaboration with stakeholders (patient and public involvement). Intervention mapping and development activities of Behaviour Change Taxonomy are described., Setting: The intervention development was conducted by a multidisciplinary team with clinical, academic and service user perspectives. The team had expertise in the development and testing of complex health behaviour interventions, opioid tapering and pain management in primary and secondary care, I.T programming, and software development-to develop an opioid tapering App., Participants: The I-WOTCH trial participants are adults (18 years and over) with chronic non-malignant pain using strong opioids for at least 3 months and on most days in the preceding month., Outcomes: A multicomponent self-management support package to help people using opioids for chronic non-malignant pain reduce opioid use., Interventions and Results: Receiving information on the impact of long-term opioid use, and potential adverse effects were highlighted as important facilitators in making the decision to reduce opioids. Case studies of those who have successfully stopped taking opioids were also favoured as a facilitator to reduce opioid use. Barriers included the need for a 'trade-off to fill the deficit of the effect of the drug'. The final I-WOTCH intervention consists of an 8-10 week programme incorporating: education; problem-solving; motivation; group and one to one tailored planning; reflection and monitoring. A detailed facilitator manual was developed to promote consistent delivery of the intervention across the UK., Conclusions: We describe the development of an opioid reduction intervention package suitable for testing in the I-WOTCH randomised controlled trial., Trial Registration Number: ISRCTN49470934., Competing Interests: Competing interests: SE is the Chair of the specialised pain CRG at NHS England, he is Chief investigator and principal investigator of a number of NIHR and Industry funded trials, he has received personal fees from Medtronic Ltd, Mainstay Medical, Boston Scientific Corp for consultancy work. His department has received research funding from the National Institute of Health Research, Medtronic Ltd and Boston Scientific Corp. HS is director of Health Psychology Services Ltd, providing psychological services for a range of health related conditions. NKYT is chief investigator or coinvestigator of other chronic pain related projects funded by the NIHR, MRC, Warwick-Wellcome Translational Partnership. MU is chief investigator or coinvestigator on multiple previous and current research grants from the UK National Institute for Health Research, Arthritis Research UK and is a coinvestigator on grants funded by the Australian NHMRC. He was an NIHR Senior Investigator until March 2021. He has received travel expenses for speaking at conferences from the professional organisations hosting the conferences. He is a director and shareholder of Clinvivo Ltd that provides electronic data collection for health services research. He is part of an academic partnership with Serco Ltd, funded by the European Social Fund, related to return to work initiatives. He receives some salary support from University Hospitals Coventry and Warwickshire. He is a coinvestigator on three NIHR funded studies receiving additional support from Stryker Ltd. He has accepted honoraria for teaching/lecturing from consortium for advanced research training in Africa. Until March 2020, he was an editor of the NIHR journal series, and a member of the NIHR Journal Editors Group, for which he received a fee. ADF is author of the My Opioid Manager book and App distributed in iTunes and Google Play. Both book and app are free of charge. She is author of the Opioid Manager App, a paid app distributed only in iTunes for healthcare professionals. The app is owned by UHN, the hospital where ADF works. ADF does not get any financial benefit from the sales of the app. ADF has a monetized YouTube channel since January 2021 that contains some videos about opioids and opioid tapering. Since April 2021, ADF has an unrestricted educational grant to maintain an online self-assessment opioid course for healthcare professionals in Canada. The funding is provided by the Canadian Generics Pharmaceutical Association (CGPA). The funding organisation has no role in the preparation, approval, recruitment of participants, or data analysis of the course content. Responsibility for the course content is solely that of the authors. ST is chief investigator or coinvestigator on multiple previous and current research grants from the UK National Institute for Health Research., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Objectives: Despite the escalating public health emergency related to opioid-related deaths in Canada and the USA, opioids are essential for palliative care (PC) symptom management.Opioid safety is the prevention, identification and management of opioid-related harms. The Delphi technique was used to develop expert consensus recommendations about how to promote opioid safety in adults receiving PC in Canada and the USA., Methods: Through a Delphi process comprised of two rounds, USA and Canadian panellists in PC, addiction and pain medicine developed expert consensus recommendations. Elected Canadian Society of Palliative Care Physicians (CSPCP) board members then rated how important it is for PC physicians to be aware of each consensus recommendation.They also identified high-priority research areas from the topics that did not achieve consensus in Round 2., Results: The panellists (Round 1, n=23; Round 2, n=22) developed a total of 130 recommendations from the two rounds about the following six opioid-safety related domains: (1) General principles; (2) Measures for healthcare institution and PC training and clinical programmes; (3) Patient and caregiver assessments; (4) Prescribing practices; (5) Monitoring; and (6) Patients and caregiver education. Fifty-nine topics did not achieve consensus and were deemed potential areas of research. From these results, CSPCP identified 43 high-priority recommendations and 8 high-priority research areas., Conclusions: Urgent guidance about opioid safety is needed to address the opioid crisis. These consensus recommendations can promote safer opioid use, while recognising the importance of these medications for PC symptom management., Competing Interests: Competing interests: AF developed the Opioid Manager app that is available for sale on iTunes. This app is owned by University Health Network. AF does not receive any profits from the sales of this app., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Clinically focused interventions for people living with pain, such as health professional education, clinical decision support systems, prescription drug monitoring programs, and multidisciplinary care to support opioid tapering, have all been promoted as important solutions to the North American opioid crisis. Yet none have so far delivered substantive beneficial opioid-related population health outcomes. In fact, while total opioid prescribing has leveled off or reduced in many jurisdictions, population-level harms from opioids have continued to increase dramatically. We attribute this failure partly to a poor recognition of the epistemic and ethical complexities at the interface of clinical and population health. We draw on a framework of knowledge networks in wicked problems to identify 3 strategies to help navigate these complexities: (1) designing and evaluating clinically focused interventions as complex interventions, (2) reformulating evidence to make population health dynamics apparent, and (3) appealing to the inseparability of facts and values to support decision-making in uncertainty. We advocate that applying these strategies will better equip clinically focused interventions as complements to structural and public health interventions to achieve the desired beneficial population health effects. ( Am J Public Health . 2022;112(S1):S56-S65. https://doi.org/10.2105/AJPH.2021.306500).

Objectives: Neurogenic claudication due to lumbar spinal stenosis (LSS) is a growing health problem in older adults. We updated our previous Cochrane review (2013) to determine the effectiveness of non-operative treatment of LSS with neurogenic claudication., Design: A systematic review., Data Sources: CENTRAL, MEDLINE, EMBASE, CINAHL and Index to Chiropractic Literature databases were searched and updated up to 22 July 2020., Eligibility Criteria: We only included randomised controlled trials published in English where at least one arm provided data on non-operative treatment and included participants diagnosed with neurogenic claudication with imaging confirmed LSS., Data Extraction and Synthesis: Two independent reviewers extracted data and assessed risk of bias using the Cochrane Risk of Bias Tool 1. Grading of Recommendations Assessment, Development and Evaluation was used for evidence synthesis., Results: Of 15 200 citations screened, 156 were assessed and 23 new trials were identified. There is moderate-quality evidence from three trials that: Manual therapy and exercise provides superior and clinically important short-term improvement in symptoms and function compared with medical care or community-based group exercise; manual therapy, education and exercise delivered using a cognitive-behavioural approach demonstrates superior and clinically important improvements in walking distance in the immediate to long term compared with self-directed home exercises and glucocorticoid plus lidocaine injection is more effective than lidocaine alone in improving statistical, but not clinically important improvements in pain and function in the short term. The remaining 20 new trials demonstrated low-quality or very low-quality evidence for all comparisons and outcomes, like the findings of our original review., Conclusions: There is moderate-quality evidence that a multimodal approach which includes manual therapy and exercise, with or without education, is an effective treatment and that epidural steroids are not effective for the management of LSS with neurogenic claudication. All other non-operative interventions provided insufficient quality evidence to make conclusions on their effectiveness., Prospero Registration Number: CRD42020191860., Competing Interests: Competing interests: CA received research funding from the Canadian Chiropractic Research Foundation and the Arthritis Society. JY has received funding support from the Danish Foundation for Chiropractic Research and Postgraduate Education, the Ontario Chiropractic Association, the Canadian Memorial Chiropractic College, the National Chiropractic Mutual Insurance Company Foundation and the University of Southern Denmark. CC holds a Research Chair in Knowledge Translation in the Faculty of Health Sciences, Ontario Tech University, funded by the Canadian Chiropractic Research Foundation., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Communicable disease epidemics and pandemics magnify the health inequities experienced by marginalised populations. People who use substances suffer from high rates of morbidity and mortality and should be a priority to receive palliative care, yet they encounter many barriers to palliative care access. Given the pre-existing inequities to palliative care access for people with life-limiting illnesses who use substances, it is important to understand the impact of communicable disease epidemics and pandemics such as COVID-19 on this population., Methods and Analysis: We will conduct a scoping review and report according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews reporting guidelines. We conducted a comprehensive literature search in seven bibliographical databases from the inception of each database to August 2020. We also performed a grey literature search to identify the publications not indexed in the bibliographical databases. All the searches will be rerun in April 2021 to retrieve recently published information because the COVID-19 pandemic is ongoing at the time of this writing. We will extract the quantitative data using a standardised data extraction form and summarise it using descriptive statistics. Additionally, we will conduct thematic qualitative analyses and present our findings as narrative summaries., Ethics and Dissemination: Ethics approval is not required for a scoping review. We will disseminate our findings to healthcare providers and policymakers through professional networks, digital communications through social media platforms, conference presentations and publication in a scientific journal., Competing Interests: Competing interests: AF receives an unrestricted educational grant to maintain the online opioid self-assessment programme from the Canadian Generic Pharmaceutical Association (CGPA). AF is the inventor of the App Opioid Manager, which is sold in iTunes. The app is owned by UHN, the hospital where AF works and AF does not receive any profits from the app sales. AF has a YouTube monetised channel and receives payment for advertisements on the channel. There are some videos related to opioids in her channel. All other authors report no competing interests., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: In March 2020, we organized two tweet chats to discuss the COVID-19 pandemic and its impact on people affected by chronic pain. The objective of this study is to evaluate the #CovidPain tweet chat activities that took place at the early stages of the COVID-19 pandemic., Methods: We performed a quantitative analysis of the magnitude, range, engagement, and sentiment of each tweet chat. The data was extracted from Twitter and analyzed in Twitter Analytics and Symplur Signals using frequency and distributions. Then, we conducted a qualitative content analysis of the narrative tweets generated in response to the questions posted during the tweet chats., Results: The two tweet chats attracted 2305 participants, which generated 4351 tweets. The participants were healthcare providers, patient advocates, researchers/academics, and caregivers. COVID-19 had both negative and positive impacts. The negative consequences of COVID-19 included the reduction of physical activity, canceled appointments and treatments, more isolation, deterioration of preexisting mental health problems, and economic consequences. The positive consequences included efficient use of telemedicine, innovative methods for self-management, and at-home interventions., Conclusion: Twitter and tweet chats are useful in involving a diverse group of stakeholders for taking a deep dive into the topical issues relevant to a community that might be disproportionately affected by a public health crisis., Competing Interests: The authors have declared financial relationships, which are detailed in the next section., (Copyright © 2021, Furlan et al.)

Background: Screening for problematic opioid use is increasingly recommended in patients receiving palliative care., Aim: To identify tools used to assess for the presence or risk of problematic opioid use in palliative care., Design: Scoping review., Data Sources: Bibliographic databases (inception to January 31, 2020), reference lists, and grey literature were searched to find primary studies reporting on adults receiving palliative care and prescription opioids to manage symptoms from advanced cancer, neurodegenerative diseases, or end-stage organ diseases; and included tools to assess for problematic opioid use. There were no restrictions based on study design, location, or language., Results: We identified 42 observational studies (total 14,431 participants) published between 2009 and 2020 that used questionnaires ( n  = 32) and urine drug tests ( n  = 21) to assess for problematic opioid use in palliative care, primarily in US ( n  = 38) and outpatient palliative care settings ( n  = 36). The questionnaires were Cut down, Annoyed, Guilty, and Eye-opener (CAGE, n  = 8), CAGE-Adapted to Include Drugs (CAGE-AID, n  = 6), Opioid Risk Tool ( n  = 9), Screener and Opioid Assessment for Patients with Pain (SOAPP; n  = 3), SOAPP-Revised ( n  = 2), and SOAPP-Short Form ( n  = 5). Only two studies' primary objectives were to evaluate a questionnaire's psychometric properties in patients receiving palliative care. There was wide variation in how urine drug tests were incorporated into palliative care; frequency of abnormal urine drug test results ranged from 8.6% to 70%., Conclusion: Given the dearth of studies using tools developed or validated specifically for patients receiving palliative care, further research is needed to inform clinical practice and policy regarding problematic opioid use in palliative care.

Chronic pain is a complex multidimensional condition that requires management with multiple professions' expertise. Healthcare training programs tend to adhere to curricula within their own profession with very few interactions with other groups. Project ECHO (Extension for Community Healthcare Outcomes) Chronic Pain and Opioid Stewardship is a model for interprofessional education, using tele-mentoring, case-base discussions and clinically focused presentations. The goal is to improve competency and confidence in managing complex cases in primary care. This qualitative study engaged twenty healthcare practitioners from multiple professions who had participated in ECHO in focus group discussions about managing patients with chronic pain, about their reasons for and the effect of participating in Project ECHO Ontario Chronic Pain/Opioid Stewardship, and about their perspectives on interprofessional care. The results show that participating in ECHO resulted in personal and professional benefit, and increased understanding about their own roles and limitations, as well as other healthcare professionals' roles. The participants described changes in their attitudes toward patients with chronic pain, and their colleagues from other professions. Non-physician participants were more likely to approach physicians to discuss their assessment and diagnosis as well as prescriptions. The interprofessional nature of the program was seen as positive and contributed to perceived changes in practice collaboration. These results show that healthcare professionals from multiple professions expressed mainly positive views of ECHO's emphasis on interprofessional care, with different professions appreciating different aspects of that approach.

Background: Little information exists about cannabis use and its correlates among workers, particularly use before or at work, which may impact occupational safety. This study explores overall and workplace cannabis use patterns before legalization among Canadian workers and estimates the associations of personal and work-related characteristics with workplace and non-workplace cannabis use., Methods: Cross-sectional data were collected from 1651 Canadian workers in June 2018. The primary outcome was past-year cannabis use pattern: use, including before/at work (past-year workplace use); use, but not before/at work (past-year non-workplace use); no past-year use (non-past-year use). The associations of personal (sociodemographic, health) and work-related factors with workplace and non-workplace cannabis use were estimated using multinomial logistic regression., Results: A quarter of respondents reporting past-year cannabis use used cannabis before and/or at work. Respondents reporting workplace use were more likely to report more frequent cannabis use, use for medical or mixed purposes, and high THC cannabis use than workers reporting non-workplace use. Several personal factors were positively associated with workplace and non-workplace use (e.g., younger age, lower education). A safety-sensitive job, drug testing, supervisor role, less job visibility, lower perceived ability of supervisors to identify use/impairment, and less restrictive workplace smoking policies were positively associated with workplace use only., Conclusions: A non-trivial proportion of workers reported workplace use, but the nature of this use is complex. Work-related factors addressing the likelihood of detection and being in a safety-sensitive job were associated with workplace use. Worker education on lower risk use appears warranted., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: Chronic nonspecific low back pain (LBP) is very common; it is defined as pain without a recognizable etiology that lasts for more than three months. Some clinical practice guidelines suggest that acupuncture can offer an effective alternative therapy. This review is a split from an earlier Cochrane review and it focuses on chronic LBP., Objectives: To assess the effects of acupuncture compared to sham intervention, no treatment, or usual care for chronic nonspecific LBP., Search Methods: We searched CENTRAL, MEDLINE, Embase, CINAHL, two Chinese databases, and two trial registers to 29 August 2019 without restrictions on language or publication status. We also screened reference lists and LBP guidelines to identify potentially relevant studies., Selection Criteria: We included only randomized controlled trials (RCTs) of acupuncture for chronic nonspecific LBP in adults. We excluded RCTs that investigated LBP with a specific etiology. We included trials comparing acupuncture with sham intervention, no treatment, and usual care. The primary outcomes were pain, back-specific functional status, and quality of life; the secondary outcomes were pain-related disability, global assessment, or adverse events., Data Collection and Analysis: Two review authors independently screened the studies, assessed the risk of bias and extracted the data. We meta-analyzed data that were clinically homogeneous using a random-effects model in Review Manager 5.3. Otherwise, we reported the data qualitatively. We used the GRADE approach to assess the certainty of the evidence., Main Results: We included 33 studies (37 articles) with 8270 participants. The majority of studies were carried out in Europe, Asia, North and South America. Seven studies (5572 participants) conducted in Germany accounted for 67% of the participants. Sixteen trials compared acupuncture with sham intervention, usual care, or no treatment. Most studies had high risk of performance bias due to lack of blinding of the acupuncturist. A few studies were found to have high risk of detection, attrition, reporting or selection bias. We found low-certainty evidence (seven trials, 1403 participants) that acupuncture may relieve pain in the immediate term (up to seven days) compared to sham intervention (mean difference (MD) -9.22, 95% confidence interval (CI) -13.82 to -4.61, visual analogue scale (VAS) 0-100). The difference did not meet the clinically important threshold of 15 points or 30% relative change. Very low-certainty evidence from five trials (1481 participants) showed that acupuncture was not more effective than sham in improving back-specific function in the immediate term (standardized mean difference (SMD) -0.16, 95% CI -0.38 to 0.06; corresponding to the Hannover Function Ability Questionnaire (HFAQ, 0 to 100, higher values better) change (MD 3.33 points; 95% CI -1.25 to 7.90)). Three trials (1068 participants) yielded low-certainty evidence that acupuncture seemed not to be more effective clinically in the short term for quality of life (SMD 0.24, 95% CI 0.03 to 0.45; corresponding to the physical 12-item Short Form Health Survey (SF-12, 0-100, higher values better) change (MD 2.33 points; 95% CI 0.29 to 4.37)). The reasons for downgrading the certainty of the evidence to either low to very low were risk of bias, inconsistency, and imprecision. We found moderate-certainty evidence that acupuncture produced greater and clinically important pain relief (MD -20.32, 95% CI -24.50 to -16.14; four trials, 366 participants; (VAS, 0 to 100), and improved back function (SMD -0.53, 95% CI -0.73 to -0.34; five trials, 2960 participants; corresponding to the HFAQ change (MD 11.50 points; 95% CI 7.38 to 15.84)) in the immediate term compared to no treatment. The evidence was downgraded to moderate certainty due to risk of bias. No studies reported on quality of life in the short term or adverse events. Low-certainty evidence (five trials, 1054 participants) suggested that acupuncture may reduce pain (MD -10.26, 95% CI -17.11 to -3.40; not clinically important on 0 to 100 VAS), and improve back-specific function immediately after treatment (SMD: -0.47; 95% CI: -0.77 to -0.17; five trials, 1381 participants; corresponding to the HFAQ change (MD 9.78 points, 95% CI 3.54 to 16.02)) compared to usual care. Moderate-certainty evidence from one trial (731 participants) found that acupuncture was more effective in improving physical quality of life (MD 4.20, 95% CI 2.82 to 5.58) but not mental quality of life in the short term (MD 1.90, 95% CI 0.25 to 3.55). The certainty of evidence was downgraded to moderate to low because of risk of bias, inconsistency, and imprecision. Low-certainty evidence suggested a similar incidence of adverse events immediately after treatment in the acupuncture and sham intervention groups (four trials, 465 participants) (RR 0.68 95% CI 0.46 to 1.01), and the acupuncture and usual care groups (one trial, 74 participants) (RR 3.34, 95% CI 0.36 to 30.68). The certainty of the evidence was downgraded due to risk of bias and imprecision. No trial reported adverse events for acupuncture when compared to no treatment. The most commonly reported adverse events in the acupuncture groups were insertion point pain, bruising, hematoma, bleeding, worsening of LBP, and pain other than LBP (pain in leg and shoulder)., Authors' Conclusions: We found that acupuncture may not play a more clinically meaningful role than sham in relieving pain immediately after treatment or in improving quality of life in the short term, and acupuncture possibly did not improve back function compared to sham in the immediate term. However, acupuncture was more effective than no treatment in improving pain and function in the immediate term. Trials with usual care as the control showed acupuncture may not reduce pain clinically, but the therapy may improve function immediately after sessions as well as physical but not mental quality of life in the short term. The evidence was downgraded to moderate to very low-certainty considering most of studies had high risk of bias, inconsistency, and small sample size introducing imprecision. The decision to use acupuncture to treat chronic low back pain might depend on the availability, cost and patient's preferences., (Copyright © 2020 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.)

The proliferation of Advanced Vehicle Technologies (AVTs) has generated both excitement and concern among researchers, policymakers, and the general public. An increasing number of driver assistance systems are already available in today's automobiles; many of which are expected to become standard. Therefore, synthesizing the available evidence specific to the safety of AVTs is critical. The goal of this scoping review was to summarize this evidence with a focus on AVTs that require some driver oversight (i.e., Levels 0-3 as per the Society of Automotive Engineers (SAE) levels of automation taxonomy). A scoping review of research literature on AVTs was conducted for studies up to March 2018. Inclusion criteria consisted of: any study with empirical data of AVTs that included male and female drivers aged 16 years and older, healthy people (i.e., without impairments), passenger vehicles, driving simulators and/or large databases with road safety information that could be analyzed for the purpose of examining AVTs (SAE Levels 0-3), as well as measures of driving outcomes. A total of 324 peer-reviewed studies from 25 countries met the inclusion criteria for this review with over half published in the last 5 years. Data was extracted and summarized according to the following categories: measures used to evaluate the effect of AVTs on road safety (objective) and driver perceptions of the technology (subjective), testing environment, and study populations (i.e., driver age). The most commonly reported objective measures were longitudinal control (50 %), reaction time (40 %), and lateral position (23 %). The most common subjective measures were perceptions of trust (27 %), workload (20 %), and satisfaction (17 %). While most studies investigated singular AVTs (237 of 324 studies), the number of studies after 2013 that examined 2 or more AVTs concurrently increased. Studies involved drivers from different age groups (51 %) and were conducted in driving simulators (70 %). Overall, the evidence is generally in favour of AVTs having a positive effect on driving safety, although the nature and design of studies varied widely. Our examination of this evidence highlights the opportunities as well as the challenges involved with investigating AVTs. Ensuring such technologies are congruent with the needs of drivers, particularly younger and older driver age groups, who are known to have a higher crash risk, is critical. With automotive manufacturers keen to adopt the latest AVTs, this scoping review highlights how testing of this technology has been undertaken, with a focus on how new research can be conducted to improve road safety now and in the future., (Copyright © 2020. Published by Elsevier Ltd.)

Chronic pain affects one in five Canadians, and opioids continue to be prescribed to 12.3% of the Canadian population. A survey of family physicians was conducted in 2010 as a baseline prior to the release of the Canadian Opioid Guideline. We repeated the same survey with minor modifications to reflect the updated 2017 opioid prescribing guideline. The online survey was distributed in all provinces and territories in both English and French. There were 265 responses from May 2018 to October 2019, 55% of respondents were male, 16% had advanced training in pain management, 51% had more than 20 years in practice, 54% wrote five or fewer prescriptions of opioids per month, and 58% were confident in their skills in prescribing opioids. Of the 11 knowledge questions, only two were correctly selected by more than 80% of the respondents. Twenty-nine physicians (11%) do not prescribe opioids, and the main factor affecting their decisions were concerns about long-term adverse effects and lack of evidence for effectiveness of opioids in chronic noncancer pain. Of the 12 guideline-concordant practices, only two were performed regularly by 90% or more of the respondents: explain potential harms of long-term opioid therapy and beginning dose of less than 50 mg of morphine equivalent daily. This survey represents a small proportion of family physicians in Canada and its generalizability is limited. However, we identified a number of opioid-related and guideline-specific gaps, as well as barriers and enablers to prescribing opioids and adhering to the guideline.

Study Design: Retrospective review and literature review., Objective: The aim of this study was to provide an update on The Cochrane Back and Neck (CBN) activities., Summary of Background Data: Low back pain (LBP) affects 80% of people at some time in their lives. CBN Group has been housed in Toronto at the Institute for Work & Health since 1996 and has published 85 reviews and 32 protocols in the Cochrane Library., Methods: Narrative review of CBN publications, impact factor, usage data, and social media impact., Results: In the past 3 years, CBN conducted priority setting with organizations that develop clinical practice guidelines for LBP. CBN editors and associate editors published key methodological articles in the field of back and neck pain research. The methodological quality of CBN reviews has been assessed by external groups in a variety of areas, which found that CBN reviews had higher methodological quality than non-Cochrane reviews. CBN reviews have been included in 35 clinical practice guidelines for back and neck conditions. The 2018 journal impact factor of CBN is 11.154, which is higher than the 2018 impact factor for CDSR (7.755). CBN reviews ranked 4th among 53 Cochrane review groups in terms of Cochrane Library usage data. The most accessed CBN review was "Yoga treatment for chronic non-specific low-back pain" which had 9689 full-text downloads. CBN is active on Twitter with 3958 followers., Conclusion: CBN has published highly utilized systematic reviews and made important methodological contributions to the field of spine research over the past 22 years within Cochrane., Level of Evidence: 4.

Objectives: The objective of this historical cohort study was to determine the claimant and prescriber factors associated with receiving opioids at first postinjury dispense compared with non-steroidal anti-inflammatory drugs (NSAIDs) and skeletal muscle relaxants (SMRs) in a sample of workers' compensation claimants with low back pain (LBP) claims between 1998 and 2009 in British Columbia, Canada., Methods: Administrative workers' compensation, prescription and healthcare data were linked. The association between claimant factors (sociodemographics, occupation, diagnosis, comorbidities, pre-injury prescriptions and healthcare) and prescriber factors (sex, birth year, specialty) with drug class(es) at first dispense (opioids vs NSAIDs/SMRs) was examined with multilevel multinomial logistic regression., Results: Increasing days supplied with opioids in the previous year was associated with increased odds of receiving opioids only (1-14 days OR 1.62, 95% CI 1.51 to 1.75; ≥15 days OR 5.12, 95% CI 4.65 to 5.64) and opioids with NSAIDs/SMRs (1-14 days OR 1.49, 95% CI 1.39 to 1.60; ≥15 days OR 2.82, 95% CI 2.56 to 3.12). Other significant claimant factors included: pre-injury dispenses for NSAIDs, SMRs, antidepressants, anticonvulsants and sedative-hypnotics/anxiolytics; International Statistical Classification of Diseases and Related Health Problems, 9th Revision diagnosis; various pre-existing comorbidities; prior physician visits and hospitalisations; and year of injury, age, sex, health authority and occupation. Prescribers accounted for 25%-36% of the variability in the drug class(es) received, but prescriber sex, specialty and birth year did not explain observed between-prescriber variation., Conclusions: During this period in the opioid crisis, early postinjury dispensing was multifactorial, with several claimant factors associated with receiving opioids at first prescription. Prescriber variation in drug class choice appears particularly important, but was not explained by basic prescriber characteristics., Competing Interests: Competing interests: AF developed the Opioid Manager, a point-of-care tool that distils information from the Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain. This app, available on iTunes for US$9.99, is owned by the University Health Network and all revenues are used to invest in the continued maintenance of the app itself., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Chronic pain affects one in five Canadians. Frontline health care providers (HCPs) manage the majority of patients with chronic pain yet receive minimal training to do so. The Extension for Community Healthcare Outcomes (ECHO) model™ is an education intervention aimed at HCPs (not patients) to support and improve care in underserviced communities. ECHO Ontario Chronic Pain and Opioid Stewardship (ECHO PAIN) is an adaptation of the ECHO model where the program goals are to support and improve chronic pain and opioid management in the province of Ontario, Canada., Aims: This study aimed to investigate the perceptions of HCPs participating in ECHO PAIN., Methods: Thirteen HCPs attending ECHO PAIN participated in in-depth semistructured phone interviews. Resulting data were analyzed through a qualitative descriptive lens., Results: Analysis uncovered four themes: (1) HCPs' motivation for joining ECHO PAIN, (2) interprofessional collaboration through ECHO PAIN, (3) the use of opioids for pain management, and (4) barriers and facilitators to participation and satisfaction in ECHO PAIN. HCPs joined ECHO PAIN because of their struggles managing their complex patients with chronic pain. HCPs also recognized the importance of interprofessional collaboration in pain management and shared examples of integration of different professional approaches in their clinical teams. Opioids for pain management remained a controversial issue, and ECHO served as an opportunity to decrease this knowledge gap. Finally, HCPs described how time constraints, organizational support, and session structure acted as barriers to their participation and satisfaction in the ECHO PAIN program; technology mediated satisfaction., Conclusions: This study was the first in Canada to explore the motivations of HCPs in attending a chronic pain telementoring program as well as to examine the interprofessional effects of participation. HCPs increased their knowledge about management of chronic pain and increased their interprofessional approach., Competing Interests: All authors report that there are no conflicts of interest., (© 2020 The Author(s). Published with license by Taylor & Francis Group, LLC.)