Purpose of review: To assess the current state of the opioid overdose crisis along three major axes: drug markets and patterns of use, the effectiveness of systems of care, and international developments. Recent findings: Overdose is a major contributor to mortality and disability among people who use drugs. The increasing number of opioid overdoses in North America especially is an indication of changing drug markets and failing regional systems of care. Globally, we see three clusters of overdose prevalence: (1) a group of countries led by the United States with historically high rates of opioid overdose, (2) a group of countries with increasing rates within a concerning range, (3) a group with very low rates. The contamination of street drugs, the quality and accessibility of treatment, and the overall system of care all contribute to the prevalence of overdose. Summary: Drug markets and pattern of consumption in parts of the world are shifting towards contamination and opioids like fentanyl as the drug of choice, which dismantles insufficient and largely ineffective systems of care. Furthermore, outside of North America, more countries like Estonia, Lithuania, Sweden, Finland, and Norway show very concerning numbers. Without a consistent system response, effects will be devastating.

Background: Public health emergencies like epidemics put enormous pressure on health care systems while revealing deep structural and functional problems in the organization of care. The current coronavirus disease (COVID-19) pandemic illustrates this at a global level. The sudden increased demand on delivery systems puts unique pressures on pre-established care pathways. These extraordinary times require efficient tools for smart governance and resource allocation. Objective: The aim of this study is to develop an innovative web-based solution addressing the seemingly insurmountable challenges of triaging, monitoring, and delivering nonhospital services unleashed by the COVID-19 pandemic. Methods: An adaptable crisis management digital platform was envisioned and designed with the goal of improving the system’s response on the basis of the literature; an existing shared health record platform; and discussions between health care providers, decision makers, academia, and the private sector in response to the COVID 19 epidemic. Results: The Crisis Management Platform was developed and offered to health authorities in Ontario on a nonprofit basis. It has the capability to dramatically streamline patient intake, triage, monitoring, referral, and delivery of nonhospital services. It decentralizes the provision of services (by moving them online) and centralizes data gathering and analysis, maximizing the use of existing human resources, facilitating evidence-based decision making, and minimizing the risk to both users and providers. It has unlimited scale-up possibilities (only constrained by human health risk resource availability) with minimal marginal cost. Similar web-based solutions have the potential to fill an urgent gap in resource allocation, becoming a unique asset for health systems governance and management during critical times. They highlight the potential effectiveness of web-based solutions if built on an outcome-driven architecture. Conclusions: Data and web-based approaches in response to a public health crisis are key to evidence-driven oversight and management of public health emergencies.

Drug markets are dynamic systems which change based on demand, competition, legislation and revenue. Shifts that are not met with immediate and appropriate responses from the healthcare system can lead to public health crises with tragic levels of morbidity and mortality, as experienced Europe in the early 1990s and as is the case in North America currently. The major feature of the current drug market shift in North America is towards highly potent synthetic opioids such as fentanyl and fentanyl analogues. An additional spike in stimulant use further complicates this issue. Without understanding the ever-changing dynamics of drug markets and consequent patterns of drug use, the healthcare system will continue to be ineffective in its response, and morbidity and mortality will continue to increase. Economic perspectives are largely neglected in research and clinical contexts, but better treatment alternatives need to consider the large-scale macroeconomic conditions of drug markets as well as the behavioural economics of individual substance use. It is important for policy makers, health authorities, first responders and medical providers to be aware of the clinical implications of drug market changes in order to best serve people who use drugs. Only with significant clinical research, a comprehensive reorganization of the system of care across all sectors, and an evidence-driven governance, will we be successful in addressing the challenges brought on by the recent shifts in drug markets.

Background: Egypt is a country of nearly 100 million citizens, and there are less than 1000 registered psychiatrists. The mental health care system is under resourced and nearly inaccessible for the majority of the population. In addition, youth under the age of 25 years represent 50% of Egyptian citizens; however, there are no specific services addressing their unique needs. How can the needs of the largest population in the Middle East be effectively addressed? Is a web-based framework an option for Egyptian psychiatrists to serve the population? Objective: The aims of this study were to better understand the opinions of psychiatrists on the current state of mental health care services in Egypt and their current knowledge on electronic mental health (EMH); assess the attitudes of Egyptian psychiatrists toward web-based interventions and telemedicine for mental health; and identify perceived advantages and barriers of EMH development in Egypt. Methods: A cross-sectional survey was conducted online among 640 Egyptian psychiatrists. It included a total of 36 items within a set of 16 questions asking about EMH literacy, integrating EMH into the mental health care system, and the perceived priorities and barriers of EMH. The sampling was supported by Tanta University, a large academic institution close to Cairo. Statistical analysis was performed using SPSS 25 (IBM Corp). Descriptive statistics, the chi-square test, the independent sample t test, and analysis of variance were applied. Results: A total of 188 participants responded (response rate of 29.4%), of which 54.2% (102/188) were female and 54.3% (102/188) were between 30 and 45 years old. Less than half of the participants thought that the current health care system was efficient for adults (69/155, 44.4%), and even less thought it was efficient for youth (44/155, 28.3%). Almost all participants agreed that EMH would be beneficial for patient care (147/155, 94.8%) and that integrating EMH into the current health care system would be a good idea (118/155, 76.2%). The highest rated utility of web-based solutions was documentation, followed by psychoeducation and communication with professionals. The main advantages were to improve access to care in rural areas of the country and its convenience. Conclusions: There is scarcity of mental health resources in Egypt. Egyptian psychiatrists are interested in EMH and believe web-based platforms can become part of the solution for the Egyptian mental health care system.

Background: In Egypt, the shortage of mental health services, particularly for adolescents and young adults, is apparent. Electronic mental health (EMH) has been proposed as a solution to bridge the gap and better address the needs of young people. However, EMH is new to Egypt and its acceptability among target populations is crucial to its implementation and success. Objective: The objective of this study is to explore the interest of Egyptian youth in EMH, identify perceived barriers to EMH, and inform the design of EMH tools to best address the needs of youth. Methods: A web-based cross-sectional survey was distributed among medical students at Tanta University in Egypt. Chi-square and one-way analysis of variance tests were performed for inferential analyses using a significance level of .05. Results: Of the 707 individuals who completed the survey (90.9% response rate), 60.5% (428) were female, 62% (438) lived in urban and suburban areas, and the mean age of the sample was 20.5 (SD 1.8) years. The vast majority of participants (522/707, 73.8%) had already used the internet to find information about mental health problems, but the information was unsatisfactory for about half of them (386/707, 54.6%). Almost all students reported that they would prefer web-based therapy if EMH were available through a trustworthy national web-based platform for youth mental health (601/707, 85%). Students believed that emotional difficulties, social support, and coping strategies were the main topics that EMH should help with. The most common perceived barriers for EMH use in Egypt were concerns about privacy (382/707, 54%) and a lack of technology literacy and unfamiliarity with EMH (352/707, 50%). Conclusions: EMH is a promising strategy for addressing gaps in the mental health care for young people. To construct and implement a digital system of care that addresses the unique needs and preferences of youth, adolescents and young adults should be involved in the co-development and design.

Chronic pain and substance use disorders are serious conditions that are prevalent among homeless populations. The aim of this study was to examine the association between chronic pain and substance use among individuals experiencing homelessness and mental illness. We analyzed cross-sectional data from two sites of the At Home/Chez Soi study (Vancouver and Toronto) using bivariate statistics and multivariate logistic regression. Substance use and chronic pain parameters were assessed with the Maudsley Addiction Profile and purpose-designed short instruments. The sample comprised 828 participants. Mean age was 42.4 years and 54% reported chronic pain. In bivariate analysis, chronic pain was significantly associated with use of opioids and stimulants, daily substance use, polysubstance use and injecting as route of administration. In multivariate analysis, only daily substance use (OR: 1.46, 95% CI: 1.02–2.09) and injecting (OR: 1.81, 95% CI: 1.08–3.05) remained as significant associated factors, whereas neither use of opioids nor use of stimulants specifically were significantly associated with chronic pain. Among participants with chronic pain, daily substance users (50% vs. 22%, p < 0.001) and injectors (66% vs. 24%, p < 0.001) were more likely to use non-prescribed medication for pain. Participants with daily substance use were less likely to receive professional treatment (52% vs. 64%, p = 0.017) and prescribed pain medication (42% vs. 54%, p = 0.023). Our findings suggest an association of chronic pain with patterns related to severity of substance use rather than to specific substance use in homeless persons with mental illness. Interventions aiming at prevention and treatment of chronic pain in this population should consider severity of substance use and associated risk behavior over use of specific substances.