Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, Canada, M5S 2S1; Ontario Node, Canadian Research Initiative in Substance Misuse (CRISM), Centre for Addiction and Mental Health (CAMH), Toronto, Canada, M5S 2S1; Institute of Medical Science, Faculty of Medicine, University of Toronto, Medical Sciences Building, 1 King's College Circle, Room 2374, Toronto, Ontario, Canada, M5S 1A8.
Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, Canada, M5S 2S1.
Int J Drug Policy. 2024 May;127:104343. doi: 10.1016/j.drugpo.2024.104343. Epub 2024 Mar 29.
Daily supervised Opioid Agonist Treatment (OAT) medication has been identified as a barrier to treatment retention. Canadian OAT guidelines outline take-home dose (THD) criteria, yet, OAT prescribers use their clinical judgement to decide whether an individual is 'clinically stable' to receive THD. There is limited information regarding whether these decisions may result in inequitable access to THD, including in the context of updated COVID-19 guidance. The current Canadian OAT THD guideline synthesis and systematic review aimed to address this knowledge gap.
This systematic review included a two-pronged approach. First, we searched available academic literature in Embase, Medline, and PsychINFO up until October 12th, 2022, to identify studies that compared characteristics of individuals on OAT who had and had not been granted access to THD to explore potential inequities in access. Next, we identified all Canadian national and provincial OAT guidelines through a semi-structured grey literature search (conducted between September-October 2022) and extracted all THD 'stability' and allowances/timeline criteria to compare against characteristics identified in the literature search. Data from both review arms were synthesized and narratively presented.
A total of n = 56 guidelines and n = 7 academic studies were included. The systematic review identified a number of patient characteristics such as age, sex, race/ethnicity, marital status, housing, employment, neighborhood income, drug use, mental health, health service utilization, as well as treatment duration that were associated with differential access to THD. The Canadian OAT THD guideline synthesis identified many of these same characteristics as 'stability' criteria, underscoring the potential for Canadian OAT guidelines to result in inequitable access to THD.
This two-pronged literature review demonstrated that current guidelines likely contribute to inequitable OAT THD access due primarily to inconsistent 'stability' criteria across guidelines. More research is needed to understand differential OAT THD access with a focus on prescriber decision-making and evaluating associated treatment and safety outcomes. The development of a client-centered, equity-focused, and evidence-informed decision making framework that incorporates more clear definitions of 'stability' criteria and indications for prescriber discretion is warranted.
每日监督阿片类激动剂治疗（OAT）药物已被确定为治疗保留的障碍。加拿大 OAT 指南概述了外出服药（THD）标准，但 OAT 开处方者使用其临床判断来决定个体是否“临床稳定”以接受 THD。关于这些决策是否可能导致 THD 获得不公平，包括在更新的 COVID-19 指南的背景下，相关信息有限。目前的加拿大 OAT THD 指南综合和系统评价旨在解决这一知识空白。
本系统评价采用双管齐下的方法。首先，我们在 Embase、Medline 和 PsychINFO 中搜索了截至 2022 年 10 月 12 日的现有学术文献，以确定比较接受和未接受 THD 的 OAT 个体特征的研究，以探索获得途径的潜在不公平。接下来，我们通过半结构化灰色文献搜索（2022 年 9 月至 10 月进行）确定了所有加拿大国家和省级 OAT 指南，并提取了所有 THD“稳定性”和允许/时间表标准，以与文献搜索中确定的特征进行比较。对来自两个审查臂的数据进行了综合和叙述性呈现。
共纳入 n = 56 项指南和 n = 7 项学术研究。系统评价确定了许多患者特征，如年龄、性别、种族/族裔、婚姻状况、住房、就业、邻里收入、药物使用、心理健康、卫生服务利用以及治疗持续时间，这些特征与 THD 的获得途径不同有关。加拿大 OAT THD 指南综合确定了许多相同的特征作为“稳定性”标准，强调了加拿大 OAT 指南可能导致 THD 获得不公平的潜力。
这两方面的文献综述表明，由于指南之间的“稳定性”标准不一致，当前指南可能导致 OAT THD 获得不公平。需要进一步研究以了解 OAT THD 获得途径的差异，重点关注处方者决策，并评估相关的治疗和安全结果。需要制定一个以客户为中心、注重公平、以证据为基础的决策制定框架，其中纳入更明确的“稳定性”标准定义和处方者酌处权的指示。
