Abhimanyu Sud

Patient engagement in the health technology and pharmaceutical regulation space can be instituted both in the feedback process regarding particular health technologies, as well as in broader decision making, such as those related to institutional features. In this commentary, we offer an analytical reflection on the ethics and political economy of patient engagement in Canadian institutional decisions among Canada’s five primary pharmaceutical and health technology regulatory and advisory agencies. The article begins by addressing motivations behind including patients and members of the public in institutional decision making. We introduce a framework for understanding the ethical reasons why institutions choose to engage the public and patients, and the challenges they face when doing so. The commentary gives an overview based on publicly available data of patient and public engagement practices at Canada’s five primary health technology regulatory and advisory agencies: Health Canada; the Canadian Agency for Drugs and Technologies in Health, now known as Canada’s Drug Agency; Institut national d’excellence en santé et en services sociaux ; the Patented Medicine Prices Review Board; and the pan-Canadian Pharmaceutical Alliance. Key trends across the five institutions are addressed, including an overall preference for the inclusion of patients in institutional decisions over technology-specific decisions. We suggest the development of a more coordinated approach to patient and public engagement in Canadian pharmaceutical and health technology decision making, guided by an understanding of the political economy of ethical priorities we have described.

Chronic non-cancer pain (CNCP) is widespread in Canada, with Family Physicians (FPs) playing a crucial role in patient care and opioid stewardship amidst high prescribing rates. Two national surveys conducted in 2010 and 2018 revealed notable knowledge gaps and poor adherence to safe opioid prescribing practices among Canadian FPs. To provide an update on Canadian FPs' knowledge, attitudes, and behavior regarding opioid prescribing for CNCP. This study is the third national cross-sectional online survey of Canadian FPs. The results are presented narratively, and only descriptive statistics are offered. A total of 529 responses were collected from July 2023 to June 2024, primarily from female participants (52%) and Ontario (50%). Eighteen percent of respondents did not prescribe opioids for CNCP, and 17% prescribed only weak opioids. Wait time for a pain specialist and for a non-urgent referral to an addiction specialist were less than one month among 23% and 25% of respondents, respectively. Only 27% of respondents were able to correctly identify the minimum daily dose of morphine equivalents to start prescribing a transdermal fentanyl patch. Respondents' adherence to recommended practices before starting opioids varied from 16% for "providing written information about opioid therapy" to 93% for "explaining potential harms of long-term opioid therapy." Several knowledge gaps and a lack of adherence to certain guideline-recommended practices were observed among respondents, along with reduced wait times for consultations with pain specialists.

The COVID-19 pandemic was a time of significant crisis for most Canadians. For those living with chronic pain, it was a disproportionately challenging time. There have been calls for researchers to address the experiences of chronic pain during the time of pandemic, including for those who also struggle with systemic and structural marginalization. The purpose of this study was to highlight the experiences of people living with chronic pain and poverty during the pandemic. Guided by tenets of institutional ethnography, we highlight how the pandemic was often experienced as a source of temporary relief from pre-existing struggles and constituted an additional and unexceptional struggle. We also highlight how people drew on learned resourcefulness during this time, which can be understood as perseverance. Our findings indicate that the knowledge and experience gained from living with pre-existing, ongoing struggles contradicted pandemic narratives of crisis, adding nuance to the variability of experience. This calls attention to how the constructed nature of crisis may not align with the daily realities of those facing social inequities. We conclude that greater attention is needed on the social aspects that define people’s lives, necessitating a role for critical social science within the chronic pain field.

Opioids are commonly prescribed for spine-related pain; however, emerging evidence suggests that access to chiropractic care may reduce reliance on opioids. We conducted a systematic review and meta-analysis to assess the impact of chiropractic care on new or continued prescription opioid use among adults with noncancer spine pain. We searched for eligible randomized controlled trials (RCTs) and observational studies in MEDLINE, Embase, AMED, CINAHL, Web of Science, and the Index to Chiropractic Literature up to March 20, 2025. Paired reviewers independently assessed risk-of-bias and extracted data. We performed random- and fixed-effects meta-analyses and used GRADE to assess the certainty of evidence. In total, 2 RCTs (838 participants) and 18 cohort studies (6,035,220 participants) were included in our analyses. We found very low certainty evidence that, compared with standard medical care alone, receipt of chiropractic care may reduce the odds of receiving prescription opioids by 64% (odds ratio [OR] = 0.36; 95% confidence interval [CI], 0.25–0.52; absolute risk reduction [ARR] 15%). However, we found a credible subgroup effect that earlier receipt of chiropractic services (within the first 30 days of presenting with spine-related pain) is associated with a greater decrease in the odds of receiving prescription opioids (OR = 0.33; 95% CI = 0.22–0.51; ARR = 15%) than later (≥30 days after presentation: OR = 0.73; 95% CI = 0.53–0.99; ARR = 8%; test of interaction, P < 0.001), but both with very low certainty evidence. Rigorously designed RCTs are needed to confirm these results.

Introduction: SARS-CoV-2 is now endemic and expected to remain a health threat, with new variants continuing to emerge and the potential for vaccines to become less effective. While effective vaccines and natural immunity have significantly reduced hospitalisations and the need for critical care, outpatient treatment options remain limited, and real-world evidence on their clinical and cost-effectiveness is lacking. In this paper, we present the design of the Canadian Adaptive Platform Trial of Treatments for COVID in Community Settings (CanTreatCOVID). By evaluating multiple treatment options in a pragmatic adaptive platform trial, this study will generate high-quality, generalisable evidence to inform clinical guidelines and healthcare decision-making. Methods and analysis: CanTreatCOVID is an open-label, individually randomised, multicentre, national adaptive platform trial designed to evaluate the clinical and cost-effectiveness of therapeutics for non-hospitalised SARS-CoV-2 patients across Canada. Eligible participants must present with symptomatic SARS-CoV-2 infection, confirmed by PCR or rapid antigen testing (RAT), within 5 days of symptom onset. The trial targets two groups that are expected to be at higher risk of more severe disease: (1) individuals aged 50 years and older and (2) those aged 18–49 years with one or more comorbidities. CanTreatCOVID uses numerous approaches to recruit participants to the study, including a multifaceted public communication strategy and outreach through primary care, outpatient clinics and emergency departments. Participants are randomised to receive either usual care, including supportive and symptom-based management, or an investigational therapeutic selected by the Canadian COVID-19 Outpatient Therapeutics Committee. The first therapeutic arm evaluates nirmatrelvir/ritonavir (Paxlovid), administered two times per day for 5 days. The second therapeutic arm investigates a combination antioxidant therapy (selenium 300 µg, zinc 40 mg, lycopene 45 mg and vitamin C 1.5 g), administered for 10 days. The primary outcome is all-cause hospitalisation or death within 28 days of randomisation. Ethics and dissemination: The CanTreatCOVID master protocol and subprotocols have been approved by Health Canada and local research ethics boards in the participating provinces across Canada. The results of the study will be disseminated to policy-makers, presented at conferences and published in peer-reviewed journals to ensure that findings are accessible to the broader scientific and medical communities. This study was approved by the Unity Health Toronto Research Ethics Board (#22-179) and Clinical Trials Ontario (Project ID 4133). Trial registration number: NCT05614349

Opioid use disorder (OUD) is a growing public health concern in North America, often coexisting with chronic noncancer pain (CNCP). Managing both conditions presents unique challenges, highlighting the need for evidence to guide decision making. The study aimed to conduct a systematic review that summarizes evidence on the efficacy, effectiveness, and safety of opioid analgesics alone or in combination with opioid agonist therapy (OAT) to manage CNCP in people with OUD or with a history of OUD. We searched MEDLINE, Embase, PsycINFO, CINAHL and AMED from inception to July 2023 for randomized studies and up to January 2025 for non-randomized studies that explored the efficacy, effectiveness, and safety of opioids for people living with chronic pain and current or prior OUD. We assessed the risk of bias in included studies, evaluated the quality of evidence using the GRADE approach, and provided a narrative summary of treatment effects. Our search identified 15,988 unique citations, of which six observational studies were deemed eligible to inform safety outcomes for review, while no observational studies or RCTs met the eligibility criteria for efficacy or effectiveness outcomes. The likelihood of suicidality was twice as high in CNCP patients with OUD receiving long-term opioid analgesics compared to those without OUD (absolute risk increase: 127; 95% CI: 36 to 249 more participants with suicidality in 1,000 participants; moderate certainty evidence). Compared to opioid analgesics alone, the risk of fatal opioid-related overdose may decrease in patients with CNCP and OUD who receive both opioid analgesics and OAT (absolute risk reduction: 60; 95%CI: 18 to 94 fewer deaths in 1,000 participants; low certainty evidence). There is a paucity of evidence to inform practice and policy regarding opioid analgesic prescribing amongst people with OUD. Existing evidence suggests that such prescribing is associated with a higher risk of suicidality, while the use of OAT together with opioid analgesics in this population may be protective against fatal overdose. Further observational and trial research is needed to clarify the benefits and harms of opioid analgesics for CNCP patients with OUD.

The French Model of opioid use disorder care is frequently cited to advocate for policy responses to the opioid crisis. Prior research reveals a disproportionate emphasis in such citations on federal regulatory changes, raising concerns about overly narrow interpretations and potential missed opportunities for evidence-informed policymaking. We aimed to analyze how the French Model has been used to construct policy responses to the opioid crisis internationally, exploring how unique contexts may shape them. We conducted a qualitative content analysis of scientific references to the French Model, informed by Bacchi's “What is the problem represented to be?” policy analysis approach. We analyzed 120 documents authored by scholars in 21 countries. Two concepts were identified to explain problem–solution constructions within their context: (1) cultural enthusiasm versus cultural concern for pharmaceuticals and (2) top-down, bottom-up, and mixed approaches to change. We mapped the problem solution constructions on a schema developed by intersecting these concepts. The schema had six configurations. Four of the six configurations were represented in the analyzed documents. Solutions were shaped by the various contexts in which they were constructed. They varied from deregulation of opioid agonists as a rapid response in the context of overdose crises to prescription drug monitoring programs as a response to diversion and misuse of buprenorphine. The schema we developed based on two cross-cutting concepts may be used to foster alternative, context-sensitive policy solutions.

Background: Chronic pain (CP) often co-occurs with depression, but promising scalable interventions have been under-investigated. We assessed the effectiveness of the virtually-delivered Sahaj Samadhi Meditation (SSM) program in reducing depressive symptoms in people with CP and moderate depressive symptoms. Methods: We conducted a randomized controlled trial comparing SSM to the Health Enhancement Program (HEP), an active control. Participants were recruited from multiple sites in the Greater Toronto Area and virtually. Both 12-week programs were delivered virtually in groups by appropriately trained facilitators. Depressive symptoms were assessed using the Patient Health Questionnaire (PHQ-9) at baseline, 12 weeks, and 24 weeks. ClinicalTrials.gov registration number: NCT04039568. Results: Of 108 participants enrolled, 89 were randomized to SSM (n=43) or HEP (n=46). Between-group differences for the PHQ-9 were not significant. Within-group mean differences for SSM were significant and greater than the minimal clinically important difference at both 12 weeks and 24 weeks (− 3.97 (95% CI − 6.69 to − 1.24) and − 4.96 (− 8.36 to − 1.56), respectively), while within-group mean differences were not significant for HEP. Conclusion: This study suggests potential benefits of SSM for individuals with comorbid CP and depression. Future trials should include larger sample sizes in non-pandemic conditions to better evaluate the effectiveness of SSM. Further research should also explore pragmatic trial designs and the integration of mind-body interventions in clinical settings.

Introduction: Delayed hospital discharge is a persistent care quality issue experienced across health systems worldwide and remains a priority area to be addressed in Canada. Often associated with a decrease in services while waiting to leave the hospital, delayed discharge from hospital can lead to increased frailty, physical and cognitive decline, and caregiver burnout. Optimizing availability of and timely access to community-based health and social care are avenues that could reduce initial admissions to the hospital and length of hospital stay, and facilitate hospital discharges. Methods: This research will explore the ways in which community resources could be leveraged to potentially avoid hospitalization and delayed hospital discharge for older adults using sequential mixed-methods including co-design. To better understand the characteristics and needs of older adults, the research team will first identify sub-populations of older adults (65 years old or older) at risk of hospitalization and delayed discharge using comprehensive, longitudinal administrative health data. From these health data, risk profiles and personas will be created and then shared with key partners (e.g., older adults, caregivers, healthcare providers, healthcare decision-makers), who will be engaged to identify, leverage, and create targeted care solutions. The barriers and facilitators to the implementation of these care solutions will then be explored. Discussion: Delayed hospital discharge has been a critical care quality issue across Canada for decades. The current research will provide health system leaders with an approach to better allocate services to older adults in order to avoid delayed hospital discharge and identify gaps in health and social care resources based on the characteristics, needs, and preferences of older adults, their caregivers, and providers.

Introduction: While effective vaccines and natural immunity have significantly reduced hospitalizations and the need for critical care, SARS-CoV-2 is now endemic and is expected to continue to pose a threat to health. New variants are expected to continue to emerge, and vaccines may become less effective. Effective and affordable therapeutics for SARS-CoV-2 that can be easily used in community settings are needed to accelerate recovery, reduce hospitalizations and mortality, and mitigate the development of post-acute sequelae of SARS-CoV-2, also known as “long COVID.” In this paper we present the design of the Canadian Adaptive Platform Trial of Treatments for COVID in Community Settings (CanTreatCOVID). Methods and analysis: CanTreatCOVID is an open-label, individually randomized, multi-centre, national adaptive platform trial designed to evaluate the clinical and cost-effectiveness of therapeutics for non-hospitalized SARS-CoV-2 patients across Canada. Eligible participants must present with symptomatic SARS-CoV-2 infection, confirmed by PCR or rapid antigen testing (RAT), within 5 days of symptom onset. The trial targets two groups that are expected to be at higher risk of more severe disease: (1) individuals aged 50 years and older, and (2) those aged 18-49 years with one or more comorbidities. CanTreatCOVID uses numerous approaches to recruit participants to the study, including a multi-faceted public communication strategy and outreach through primary care, out-patient clinics, and emergency departments. Participants are randomized to receive either usual care, including supportive and symptom-based management, or an investigational therapeutic selected by the Canadian COVID-19 Outpatient Therapeutics Committee. The first therapeutic arm evaluates nirmatrelvir/ritonavir (Paxlovid™), administered twice daily for 5 days. The second therapeutic arm investigates a combination antioxidant therapy (selenium 300 µg, zinc 40 mg, lycopene 45 mg, and vitamin C 1.5 g), administered for 10 days. The primary outcome is all-cause hospitalization or death within 28 days of randomization. Ethics and dissemination: The CanTreatCOVID master protocol and sub-protocols have been approved by Health Canada and local research ethics boards in the participating provinces across Canada. The results of the study will be disseminated to policymakers, presented at conferences, and published in peer-reviewed journals to ensure that findings are accessible to the broader scientific and medical communities. Trial registration number: NCT05614349 Strengths and Limitations Box: The CanTreatCOVID community-focused design allows enrollment without in-person visits. The adaptive platform trial structure provides flexibility to add promising therapies and remove ineffective ones, which is critical in a rapidly changing pandemic environment CanTreatCOVID gathers real-world data on outpatient COVID-19 care The open-label design avoids logistical challenges associated with placebo controls in large-scale trials, though it may introduce bias related to subjective outcomes The reliance on self-reported adherence to study medications could lead to variability