Key Message

What Is the Issue?

• Opioid agonist therapy (OAT), including methadone and buprenorphine-naloxone, is the primary approach for managing opioid use disorder (OUD) in Canada and has been shown to reduce withdrawal symptoms and opioid use. Recent Canadian clinical guidelines prioritize buprenorphine-naloxone as the first-line treatment for OUD.
• Buprenorphine-naloxone formulations, available as transmucosal tablets or films, are effective for OUD treatment. However, there is a risk of diversion of the tablet formulation; that is, it can be distributed and used by individuals other than those for whom the drugs were prescribed. Crushing buprenorphine-naloxone tablets before administration has been proposed as a potential strategy to mitigate diversion.

What Did We Do?

• We sought to identify, summarize, and critically appraise available studies, as well as review evidence-based guideline recommendations on the administration of sublingual crushed buprenorphine-naloxone tablets for the treatment of opioid dependency.
• We searched key resources, including journal citation databases, and conducted a focused internet search for relevant evidence published since 2016.
• One reviewer screened articles for inclusion based on predefined criteria.

What Did We Find?

• We did not find any evidence regarding the clinical effectiveness and safety of sublingual crushed buprenorphine-naloxone tablets for treating opioid dependency.
• We did not find any evidence-based guidelines regarding sublingual crushed buprenorphine-naloxone tablets for treating opioid dependency.

What Does It Mean?

• We identified no relevant literature on whether crushing buprenorphine-naloxone tablets effectively prevents misuse and diversion in adults with opioid dependence. As a result, no conclusions could be drawn regarding its effectiveness and safety, and no recommendations could be made.
• Additional research is needed to assess the impact of crushing buprenorphine-naloxone tablets on efficacy, bioavailability, and adverse effects to determine the clinical implications of this practice.

Key Message

What Is the Issue?

• The subtalar joint enables the inversion and eversion of the feet. Excessive movement of the subtalar joint can lead to painful foot conditions that may require surgical treatment in severe cases.
• Subtalar joint arthroereisis involves the insertion of an implant that limits excessive movement of the subtalar joint. It is considered a minimally invasive surgical procedure with a relatively fast healing period compared to alternative surgical procedures.
• While this procedure is commonly used for children with pes planus, it is becoming a more common treatment for adults with foot conditions. There is uncertainty as to whether subtalar joint arthroereisis can be effective for adults.

What Did We Do?

• We conducted a rapid review to identify, summarize, and critically appraise evidence regarding the clinical effectiveness and cost-effectiveness of subtalar joint arthroereisis for adults with pes planus (i.e., flatfoot), plantar fasciitis, and other foot conditions. Additionally, we aimed to identify, summarize, and critically appraise evidence-based guidelines regarding the use of subtalar joint arthroereisis for adults.
• An information specialist conducted a customized literature search, balancing comprehensiveness with relevancy, of multiple sources and grey literature on November 20, 2024.

What Did We Find?

• We identified 8 relevant studies (1 systematic review and 7 nonrandomized studies) that evaluated the clinical effectiveness of subtalar joint arthroereisis for adults with pes planus. Compared to baseline, the literature suggests that subtalar joint arthroereisis improves key clinical outcomes, such as overall foot and ankle condition, health-related quality of life, and pain relief (1 systematic review and 4 nonrandomized studies). One nonrandomized study found mixed results when comparing subtalar joint arthroereisis to lateral column lengthening for adults living with stage IIb adult-acquired flatfoot deformity.
• We also found 2 relevant nonrandomized studies regarding the clinical effectiveness of subtalar joint arthroereisis for adults with other foot conditions (i.e., reducible talotarsal joint dislocation and partial talotarsal joint instability). Compared to baseline, the literature suggests that subtalar joint arthroereisis improves the function of the foot and ankle, pain relief, and ability to perform activities of daily living in the long term for adults with partial talotarsal joint issues (1 nonrandomized study).
• For the studies in this report, sinus tarsi pain was the most reported adverse event and the cause of implant removal. Other adverse events included implant revision, surgical infection, stress fractures, insufficient deformity correction, reoccurrence of foot deformity, wound healing issues, and muscle and tendon complications (10 studies).
• Overall, there is uncertainty in the identified evidence due to risk of bias and methodological limitations.
• We did not identify relevant studies regarding the clinical effectiveness of subtalar joint arthroereisis for adults with plantar fasciitis. We also did not find any relevant cost-effectiveness studies or evidence-based guidelines regarding the use of subtalar joint arthroereisis for adults.

What Does This Mean?

• These results should be interpreted with caution. Most studies included in this report were of low-quality and limited to comparing before-after outcomes. Additionally, most studies did not account for the impact of confounding variables (e.g., obesity) and heterogeneity within and between treatment arms (e.g., implant sizes, adjunct procedures, and implant type). Comparative evidence from robust studies is needed before definitive conclusions regarding the clinical effectiveness of subtalar joint arthroereisis can be made.
• Future studies could consider evaluating the cost-effectiveness of subtalar joint arthroereisis with considerations of the implications of implant removals, as well as the clinical effectiveness of subtalar joint arthroereisis for individuals with plantar fasciitis. Given that subtalar joint arthroereisis is commonly provided in combination with other procedures, future research may also consider evaluating best practices with adjunctive treatments for adults with foot conditions.

Key Message

What Is the Issue?

• Sexual dysfunction, including erectile dysfunction (ED) is a common problem for males starting in their early 40s and increases with age.
• ED may be caused by 1 or more reasons, including organic (e.g., vasculogenic, hormonal), psychogenic, or mixed psychogenic and organic reasons. ED is also common after pelvic trauma and penile fracture, surgery (e.g., prostatectomy), and radiation therapy (e.g., prostate cancer).
• There are many nonsurgical treatment options for ED, including oral phosphodiesterase type 5 (PDE5) inhibitors, penile self-injections with vasoactive drugs, and extracorporeal shockwave therapy (ESWT). A review of the clinical effectiveness of ESWT could help clarify the potential role in clinical practice, in which populations and with which treatment protocols.

What Did We Do?

• To inform decisions regarding the use of ESWT, we conducted a rapid review to identify and summarize evidence that compared the clinical effectiveness of ESWT to any comparators (e.g., sham or no treatment, pharmacological therapy, or platelet-rich plasma). We identified evidence-based guidelines that provided recommendations related to ESWT in males with ED.
• We searched key resources, including journal citation databases, and conducted a focused internet search for relevant evidence published since 2014. One reviewer screened articles for inclusion based on predefined criteria, critically appraised the included studies, and narratively summarized the findings.

What Did We Find?

• We found 1 health technology assessment (HTA), 1 overview of systematic reviews (SRs), and 7 SRs that evaluated the clinical effectiveness of ESWT for ED. We found 4 evidence-based guidelines that provided recommendations on the use of ESWT for ED.
• Comparing ESWT to sham or no treatment, shockwave therapy (SWT) increases the mean International Index of Erectile Function – Erectile Function subscale (IIEF-EF) score and the proportion of males achieving a minimal clinically important difference (MCID) when compared to sham or no treatment. This differed when looking at subpopulations. Similarly, ESWT increases the mean Erectile Hardness Scale (EHS) score and the proportion of males with an improvement of 3 or more when compared to sham or no treatment. This differed when looking at subpopulations.
• Comparing ESWT to pharmacological therapy, there was no statistical difference between groups for the IIEF-EF subscale (when reported) and the EHS. One observational study in an SR reported a statistically significant difference in the number of males who had an improved EHS score of 3 or more after treatment.
• Comparing ESWT to platelet-rich plasma, there was no difference in any outcomes; however, this was poorly reported.
  Comparing ESWT protocols, there was no difference in any outcomes; however, this was poorly reported.
• One SR reported on treatment-related adverse effects, with few adverse effects reported. Two SRs reported on discontinuation from treatment, with no discontinuations.
• International guidelines varied on recommending ESWT for ED, with 2 recommending it in specific populations, 1 not recommending it, and 1 guideline (published in 2019) stating there was insufficient evidence to make a recommendation.

What Does This Mean?

• ESWT may improve clinical outcomes for males with ED when compared to sham or no treatment.
• There may be differences in the effectiveness of ESWT treatment for subpopulations.
• Data on the clinical effectiveness of different protocols of ESWT were limited.
• ESWT is safe, with few treatment-related adverse events.
   

Key Message

What Is the Issue?

Bupropion is a drug used in the treatment of depression. Bupropion is 1 of many treatment options available for depression and is associated with several side effects as well as the potential for misuse. The risk of side effects may be increased with higher daily doses of bupropion; therefore, it is important to determine the appropriate dosing for bupropion for the treatment of depression. 

What Did We Do?

To help determine the appropriate dosing of bupropion for the treatment of major depressive disorder and treatment-resistant depression in adults, we sought to identify and summarize studies of the clinical efficacy and safety of high-dose (301 mg per day to 450 mg per day) versus standard-dose ( 300 mg per day) bupropion. We also sought to identify and summarize recommendations on the use of high-dose bupropion for the treatment of depression in evidence-based guidelines. · We searched key resources, including journal citation databases, and conducted a focused internet search for relevant evidence, published since 2014. One reviewer screened articles for inclusion, based on predefined criteria.

What Did We Find?

We did not identify any studies that evaluated the clinical efficacy and safety of high-dose versus standard-dose bupropion for the treatment of depression, which met our criteria for this review. · We did not identify any evidence-based guidelines that included recommendations on the use of high-dose bupropion in adults with depression that met our criteria for this review. 

What Does it Mean?

We cannot draw conclusions on the use of high-dose bupropion for the treatment of major depressive disorder or treatment-resistant depression in adults due to the lack of identified studies or evidence-based guidelines that met our criteria for this review. Future studies that compare high-dose and standard-dose bupropion for the treatment of depression could aid decision-making around the subject area of appropriate bupropion dosing.

Key Message

What Is the Issue?

The rate of mental illnesses, such as major depressive disorder and generalized anxiety disorder, has significantly increased among people aged 15 and older living in Canada.

In Canada, more than 1 in 3 of those with mental illnesses do not receive adequate mental health (MH) services, with notable geographic disparities in the availability and quality of services. Specialized MH services remain particularly scarce in remote and rural areas.

Providing MH counselling through virtual platforms has the potential to enhance the accessibility of MH services and reduce the stigma associated with in-person services.

A review of the clinical effectiveness and evidence-based guidelines is required to help understand the potential role of virtual MH counselling in clinical practice.

What Did We Do?

To inform decisions regarding the use of virtual MH counselling for people with depression, anxiety, obsessive-compulsive disorder (OCD) or posttraumatic stress disorder (PTSD), we conducted a rapid review and summarized evidence that compared the clinical effectiveness of MH counselling provided in a virtual setting versus in person. We also sought to identify evidence-based guidelines regarding the use of virtual MH counselling for these populations.

We searched key resources, including journal citation databases, and conducted a focused internet search for relevant evidence published since 2019. One reviewer screened articles for inclusion based on predefined criteria, critically appraised the included studies, and narratively summarized the findings.

What Did We Find?

We found 6 systematic reviews (SRs) relevant to the present review that evaluated the clinical effectiveness of MH counselling provided through virtual versus in-person settings. Most SRs and their included randomized controlled trials (RCTs) reported results on the reduction of depression and anxiety, followed by PTSD and OCD.

For depression, PTSD and specific anxiety outcomes (generalized anxiety disorder, social anxiety disorder, and panic disorder), the effectiveness of virtual MH counselling in improving these outcomes was comparable to in-person settings. For OCD, results were inconsistent, suggesting virtual MH counselling can be an alternative treatment where in-person MH counselling is not readily available.

We found 5 evidence-based guidelines that provide recommendations on the use of virtual MH counselling for adults with depression, anxiety, and PTSD, based mostly on low-quality evidence or expert opinion. We did not find any evidence-based guidelines or relevant recommendations regarding the use of virtual MH counselling for people of any age with OCD nor children and youth with depression, anxiety, and PTSD.

Virtual MH counselling is recommended as a first-line intervention for adults with mild depression and for reducing symptoms of anxiety in older adults.

Virtual MH counselling is recommended as second-line adjunctive or alternative intervention for adults with moderate-severe depression, certain anxiety disorders, and PTSD.

What Does This Mean?

Virtual MH counselling may improve clinical outcomes for people with depression, anxiety, OCD, or PTSD and can be used as a comparable or alternative treatment to in-person MH counselling.

Virtual MH counselling may address equity issues regarding access to evidence-based MH services where in-person MH counselling is not readily available.

Clinicians and health care decision-makers can use the evidence summarized in this review to inform decisions regarding the implementation of virtual MH counselling for adults with depression, anxiety, OCD, or PTSD.