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Mental and substance use disorders are the leading cause of disability and overall burden of disease in children and youth worldwide. Further, overdose and suicide are the leading contributors to mortality among youth in North America. The need for effective healthcare systems for youth will only become more substantial, especially in the context of the opioid overdose crisis and the COVID-19 pandemic. This research investigated the current paradigm surrounding substance use disorder treatment among youth and aimed to contribute a more innovative and effective response to high-risk substance use and overdose among youth. Firstly, a narrative review assessed the current reality of treatment approaches for high-risk opioid use among youth by means of narrative review. Findings revealed a dearth of academic effort and clinical research on interventions for youth with high-risk substance use, which demonstrates the many gaps within the field of addiction psychiatry and adolescent medicine. Secondly, a rapid review evaluated the clinical guidance in place for youth with high-risk opioid use. The clinical practice guidelines available, or lack thereof, reaffirms the systematic failure in addressing the mental health and substance use needs of youth. Lastly, to inform service development and ameliorate the standard of care for youth, a multidisciplinary panel of clinicians and researchers in the field of youth substance use disorder developed 60 recognized statements through Delphi process. This international collaborative project provides a basis for education and establishes an infrastructure for research by outlining clinical risks, determining target populations, defining intervention goals, recognizing evidence-based strategies, and identifying appropriate treatment settings and expertise. Comprehensively, this research identifies critical problems in the current systems of care for adolescents and young adults internationally and provides a framework for the improved prevention, treatment, and management of high-risk substance use and overdose among this vulnerable group. Healthcare systems must strive to support youth through their development with tailored and stigma-free evidence-based approaches. High-quality studies are needed to further determine the safety and effectiveness of treatment options for youth.
North America is in the midst of an opioid overdose epidemic. British Columbia has been particularly impacted by the epidemic, as over 7,000 have died from illicit drug overdoses since the crisis was declared a public health emergency in 2016. These deaths have largely been fueled by the widespread prevalence of illicitly manufactured fentanyl. Moreover, the crisis has now been exacerbated by the COVID-19 pandemic, as several jurisdictions have experienced record numbers of overdose deaths in 2020. We undertook a narrative review to describe the risk and protective factors for opioid overdose examined in the current literature. While a range of factors have been studied, it remains unclear how factors previously identified in those using heroin, and how novel fentanyl-related factors are influencing the risk of overdose in those using fentanyl. We thereby conducted a cross-sectional pilot study to investigate the risk and protective factors for non-fatal opioid overdose among 36 participants using street fentanyl during the COVID-19 pandemic. We found that 86.1% reported the intentional use of fentanyl, and 47.2% reported having overdosed in the past six months. These findings add to the growing evidence base that more individuals are intentionally using fentanyl, rather than unintentionally using it. Gender, history of opioid overdose, and suicidal ideation were identified as risk factors for recent overdose. Route of administration, receiving opioid agonist treatment, and receiving safe supply were not significantly associated with overdose. This suggests that risk and protective factors previously identified in individuals who use heroin should be re-examined as their contributions to overdose risk may be different in individuals who use fentanyl. Novel factors related to fentanyl and the pandemic should be further investigated to examine their roles in overdose risk. Future studies in this urgently needed area of research will improve the identification of individuals at risk of overdose, and inform the development of tailored interventions and policies to improve health outcomes in this vulnerable population.
Background: Concurrent mental health problems is a major issue in opioid use disorder. As the first step in developing effective interventions, a clear understanding of factors that potentially contribute to the improvement of mental health in this population, most prominently the role of opioid medications, is required. Previous reviews did not isolate the impact of opioid agonists on mental health from those of psychosocial interventions in substitution treatment of opioid use disorder. We compared mental health outcomes between opioid medications and control conditions, i.e. placebo or waitlist, to isolate these effects.Methods: Embase, MEDLINE, PsychInfo, CINAHL Complete, Web of Science Core Collection and RCT registries were among the systematically searched databases. RCTs were included if they com- pared any opioids with each other or with a placebo/waitlist in substitution treatment of patients with opioid use disorder and reported mental health outcomes using a validated measure. Individual study-level data were extracted from all available sources. Primary outcomes included difference in standardized mean score changes (SMD) for depressive symptoms and overall mental health symptomatol- ogy between opioid agonists and placebo/waitlist. Random effects model was used for both the direct pairwise meta-analysis and network meta-analysis. (Registered at https://www.crd.york.ac.uk/pros- pero/, CRD42018109375)Results: Out of 6034 citations, 19 studies were included in the qualitative synthesis and 16 in the quantitative synthesis. Out of 19 studies, 18 had high overall risk of bias. Direct pairwise meta-analysis indicated that diacetylmorphine (DAM) outperformed methadone on overall mental health (SMD (CI95%)= -0.23 (-0.34, -0.13)). Buprenorphine outperformed waitlist or placebo on improvement of depressive symptoms (SMD (CI95%)= -0.95 (-1.53, -0.36)) and overall mental health (SMD (CI95%)= -0.68 (-1.33, -0.03)). Based on network meta-analysis for primary outcomes, buprenorphine (SMD (CI95%)= -0.61 (-1.20, -0.11)), DAM (SMD (CI95%)= -1.40 (-2.70, -0.23)), and methadone (SMD (CI95%)= -1.20 (-2.30, -0.11)) were superior to waitlist/placebo on overall mental health symp- tomatology, but none of the medications were superior to waitlist in improving depressive symptoms.Conclusions: Opioid agonists used in substitution treatment improve overall mental health, and DAM outperforms methadone in this regard which has implications for treatment guidelines. Future trials will benefit from stricter control for sources of bias.