Key Message

What Is the Issue?

Opioids such as morphine and hydromorphone are commonly used to treat postoperative pain; however, they are associated with serious risks such as respiratory depression.

Methadone (a synthetic opioid) has been proposed as a potential option for preoperative or postoperative analgesia that may improve pain relief and reduce overall opioid requirements. 

What Did We Do?

We sought to identify and summarize studies of the clinical effectiveness and safety of oral methadone for preoperative or postoperative analgesia in adults as well as recommendations from evidence-based guidelines.

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 publications, and narratively summarized the findings. 

What Did We Find?

We identified 1 randomized controlled trial (RCT) that evaluated the use of preoperative oral methadone versus placebo in adults undergoing sternotomy for isolated coronary artery bypass graft surgery. We did not identify any studies that compared oral methadone to other analgesics that met our criteria. We did not identify any evidence-based guidelines that included recommendations on the use of oral methadone for preoperative and postoperative analgesia.

There were no differences in pain scores 24, 48, and 72 hours postoperatively in patients who received oral methadone versus placebo. Postoperative morphine requirements were lower in the methadone group than the placebo group at 24 hours; however, there were no differences between groups at 48 or 72 hours.

There were no differences in common side effects related to opioid use (nausea, vomiting, pruritus, constipation, urinary retention, hypoventilation, or hypoxia) between patients undergoing surgery treated with oral methadone versus placebo at 24, 48, or 72 hours. 

What Does It Mean?

We identified very limited evidence on the use of oral methadone for preoperative or postoperative analgesia in patients undergoing surgery. There were no differences between patients undergoing surgery treated preoperatively with oral methadone versus placebo in most of the pain outcomes measured in the included RCT.

Additional evidence may be necessary to aid decision-making around the use of oral methadone as preoperative or postoperative analgesia for adult patients undergoing surgery.

Key Message

What Is the Issue?

• Colorectal cancer is 1 of the most common cancers globally. In Canada, it is estimated that more than 25,000 people will be diagnosed with colorectal cancer in 2024 and that more than 9,000 people will die of it.
• To reduce the incidence and mortality of colorectal cancer, screening programs across various jurisdictions in Canada have implemented screening strategies involving routine fecal testing and colonoscopy. While colonoscopy is often considered the gold standard for colorectal cancer screening, missed polyps remain a challenge with this modality.
• In recent years, many artificial intelligence (AI)–enabled polyp detection systems have been developed for use during colonoscopy. A review of the clinical and cost-effectiveness of these systems could help clarify their potential role in clinical practice.

What Did We Do?

• To inform decisions regarding the use of AI-assisted colonoscopy, we conducted a rapid review to identify and summarize evidence that compared the clinical and cost-effectiveness of AI-assisted colonoscopy to conventional colonoscopy and among different AI-assisted colonoscopy systems.
• 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 1 health technology assessment (HTA), 3 systematic reviews (SRs), and 1 randomized controlled trial (RCT) that evaluated the clinical and cost-effectiveness of AI-assisted colonoscopy for detecting polyps, adenomas, precancerous lesions, and colorectal cancer.
• AI-assisted colonoscopy may improve clinical outcomes compared to conventional colonoscopy, including adenoma detection rates, the number of adenomas detected per procedure, and adenoma miss rates, although it may also lead to longer withdrawal times. However, not all studies included in this report demonstrated statistically significant differences between the groups for each of these outcomes.
• The included RCT allocated participants to receive AI-assisted colonoscopy with either Deep-GI or CAD EYE, but the authors did not perform statistical testing to compare the outcomes between these 2 treatment groups.
• Findings from 6 economic evaluations summarized in the HTA suggest that AI-assisted colonoscopy is likely to be cost-effective or dominant — meaning it is less costly and more effective — compared to conventional colonoscopy.
• We did not find any studies on the relative cost-effectiveness of different AI-assisted colonoscopy systems that met our selection criteria for this review.
• None of the included studies reported long-term outcomes, such as colorectal cancer incidence and mortality; therefore, the impact of AI-assisted colonoscopy on these outcomes is unknown.

What Does This Mean?

• AI-assisted colonoscopy may improve clinical outcomes and be more cost-effective than conventional colonoscopy for detecting polyps, adenomas, precancerous lesions, and colorectal cancer.
• The clinical and cost-effectiveness of different types of AI-assisted colonoscopy systems compared to each other is unknown.
• Clinicians and decision-makers can use the evidence summarized in this review to inform decisions regarding the implementation of AI-assisted colonoscopy.

Key Message

What Is the Issue?

• Pharmacological treatment for attention-deficit/hyperactivity disorder (ADHD) focuses on medications that elevate the levels of certain neurotransmitters in the brain such dopamine and norepinephrine to target ADHD symptoms of impulsivity, inattention, and hyperactivity.
• The medications are classified as stimulants and nonstimulants. Stimulants are drugs with a rapid effect, but they also have the potential for dependence, misuse, and diversion; nonstimulants may take longer to have an effect, but they do not have the same potential for drug misuse.
• Decision-makers are interested in understanding how medications are chosen to treat ADHD in the general adult population as well as in the correctional setting.

What Did We Do?

• We identified and summarized the literature on the evidence of the clinical effectiveness, safety, and cost-effectiveness of stimulants and nonstimulants for the treatment of ADHD in adults. We also searched for evidence-based guidelines that provide recommendations on the use of stimulants and nonstimulants for the management of ADHD in adults.
• We searched key resources, including journal citation databases, and conducted a focused internet search for relevant evidence published since 2019. One reviewer screened citations for inclusion based on predefined criteria, critically appraised the included studies, and narratively summarized the findings.

What Did We Find?

• We identified an Australian evidence-based guideline for ADHD. The aim of the guideline is to promote the timely identification, diagnosis, and treatment of ADHD across the lifespan of patients.
• With respect to medication choice for the treatment of ADHD in adults (aged 18 years and older), the guideline recommends that stimulants — such as methylphenidate, dexamfetamine, or lisdexamfetamine — be offered as first-line treatment for people living with ADHD whose symptoms cause significant impairment.
• The guideline recommends that nonstimulants, such as atomoxetine or guanfacine, be offered as second-line treatment if stimulants are contraindicated, not tolerated, or ineffective. Concurrent treatment with both stimulants and nonstimulants is also recommended to increase the benefit of treatment. Other drugs such as bupropion, clonidine, modafinil, reboxetine, and venlafaxine may be offered as third-line treatments. Regarding fourth-line treatments for adults with ADHD, based on expert opinion and clinical experience of the guideline development group members, a clinical practice point was made to include lamotrigine, aripiprazole, agomelatine, armodafinil, and desvenlafaxine.
• Although we found no evidence on the optimal medication choice for specific populations, such as people in the correctional system or people with co-occurring substance use disorder, the guideline recommends exercising caution when prescribing stimulants as first-line therapy to people who have a risk of misuse or diversion.
• We did not find any studies on the clinical effectiveness, safety, and cost-effectiveness of stimulants compared to nonstimulants for the management of adult ADHD.

What Does This Mean?

• Recommendations from the identified guideline suggest that stimulants are commonly prescribed as first-line treatment for adult ADHD because of their rapid effect.
• However, for people living with ADHD who have a risk of misuse or diversion, prescribing nonstimulants as first-line therapy may be a better option.

Key Message

What Is the Issue?

• The emergency treatment of prolonged seizures or status epilepticus is required to be rapid and efficient to prevent permanent brain damage or death.
• Benzodiazepines, such as midazolam, lorazepam, diazepam, and clonazepam, are established as first-line treatment medications for acute treatments of seizures.
• Various administration routes of delivery for these drugs have become available, but the comparative clinical effectiveness and safety among administration routes are still unclear.
• Decision-makers are interested in whether the current use of intramuscular (IM) midazolam for treatment of seizures by paramedics in a prehospital environment can be switched to IV lorazepam as normally used by nurses and physicians in clinic settings.

What Did We Do?

• We identified and summarized the literature on the evidence of the clinical effectiveness and safety of midazolam compared to lorazepam in adults to control seizures.
• We searched key resources, including journal citation databases, and conducted a focused internet search for relevant evidence published since 2019. One reviewer screened citations for inclusion based on predefined criteria, critically appraised the included studies, and narratively summarized the findings.

What Did We Find?

• We identified 1 systematic review (SR) that included 4 randomized controlled trials (RCTs), only 1 was relevant to this review. This double-blind RCT determined the efficacy of IM midazolam as noninferior to IV lorazepam for treatment of seizures by paramedics in a mixed population of adults (89%) and children (11%).
• The authors of the SR conducted a subanalysis of a dataset of participant-level data and showed that IM midazolam was as effective and safe as IV lorazepam in adult patients for prehospital seizure cessation. The findings of the adult population were similar to those of the whole randomized population of both adults and children.

What Does This Mean?

• With the shorter time required to administration of midazolam by the IM route compared to administration of lorazepam by the IV route, and the comparable efficacy and safety between the 2 active treatments, the use of IM midazolam may be a better option in the prehospital environment when IV access in patients with seizures is not readily established.
• Switching of IM midazolam to IV lorazepam for treatment of seizures by paramedics may not be practical.