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The Evidence Speaks

The Evidence Speaks (March 2019)

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The Evidence Speaks Series is a recurring feature highlighting the latest in CHÉOS research. This series features summaries of select publications as well as in-depth features on the latest work from our investigators. In the early days of CHÉOS, the Centre had a series known as “The Evidence Speaks,” a monograph series to keep media and the research community up-to-date with CHÉOS’ current research results in the health outcomes field.

Walsh C, Hubley AM, To MJ, Norena M, Gadermann A, Farrell S, Hwang SW, Palepu A. The effect of forensic events on health status and housing stability among homeless and vulnerably housed individuals: A cohort study. PLoS ONE. 2019 Feb 7;14(2):e0211704.

CHÉOS Scientists Drs. Anita Palepu and Anne Gadermann recently published an analysis of the effect of arrest or incarceration (“forensic events”) on the physical and mental health status and housing vulnerability of homeless people in Vancouver, Ottawa, and Toronto. People released from incarceration have an extremely inflated risk of poor health outcomes and mortality compared to the general population and, in Canada, about 30 per cent of incarcerated people are released without secure housing. In the six months following release, people with mental health problems are up to four times more likely to die of suicide or drug overdose than people without mental health complications. To characterize the impact of incarceration on health status and housing, the research group analyzed data from the Health and Housing in Transition (HHiT) Study, a prospective cohort study beginning in 2009 that investigated the health and housing status of homeless people in Canada. In HHiT, follow-up interviews were conducted annually for four years and participants completed a 60- to 90-minute survey. In the current study, the follow-up data were analyzed with arrest and incarceration as the explanatory variable of interest. Housing stability was assessed using the proxy measure of number of residential moves in the preceding year and physical and mental health status was assessed using the Short Form 12-item health survey. Of the 1173 participants included in the follow-up, 446 (38%) reported a history of arrest or incarceration in the previous 12 months; participants with this history had significantly more residential moves during the follow-up period (lower housing stability). Arrest and incarceration were not significantly associated with health status over time though the entire participant pool had lower physical and mental health than the general population. Participants from Vancouver were more likely to have lower housing stability than those from Toronto. Female sex and problematic substance use were associated with decreased housing stability and mental and physical health. This research highlights the need for provision of long-term social support and post-release planning for arrested or incarcerated people.

Oviedo-Joekes E, Palis H, Guh D, Marsh DC, MacDonald S, Harrison S, Brissette S, Anis AH, Schechter MT. Adverse events during treatment induction with injectable diacetylmorphine and hydromorphone for opioid use disorder. J Addict Med. 2019 Feb 7 epub ahead of print.

CHÉOS Scientists Eugenia Oviedo-JoekesAslam Anis, and Martin Schechter recently published a combined analysis of NAOMI, SALOME, and RUTH that describes the rates of adverse events during the induction period of injectable opioid agonist therapy (OAT) in people with opioid use disorder during the three trials. NAOMI was a trial comparing injectable diacetylmorphine (DAM; pharmaceutical-grade heroin) to oral methadone, SALOME compared injectable hydromorphone (HDM; Dilaudid) to DAM, and RUTH was an observational cohort of individuals receiving DAM or HDM after the trials ended. The induction period refers to the three-day period in which doses are safely increased under observation from the study nurses who record dose tolerance and adjust accordingly, with input from the attending physician and study participant. After combining the three studies, data for a total of 1175 induction injection days were available (700 for DAM and 475 for HDM). A total of 40 cases of somnolence (drowsiness, sleepiness, grogginess) or opioid overdose were recorded (34 for DAM, 4.9 per 100 injection days; 6 for HDM, 1.5 per 100 injection days). Five opioid overdoses requiring naloxone occurred during the three trials (4 for DAM, 0.6 per 100 injection days; 1 for HDM, 0.2 per 100 injection days) — all 5 were successfully reversed on-site. The rate of adverse events per injection day was higher during the induction period compared to post-induction, for both HDM and DAM. This analysis demonstrates that the three-day induction period allowed patients to safely reach high doses in a short period of time and provides valuable data for clinical implementation of injectable OAT. The study re-confirms the safety of these treatments for people with opioid use disorder.

Rizzardo S, Bansback N, Dragojlovic N, Douglas C, Li KH, Mitton C, Marra C, Blanis L, Lynd LD. Evaluating Canadians’ values for drug coverage decision making. Value Health. 2019 Mar;22(3):362-9.

In their newest publication, Drs. Nick Bansback and Larry Lynd evaluate the Canadian public’s values and preferences related to drug funding decisions. Health care decision-makers choose to fund new drugs based on value to society. Though there has been research into the values held by citizens, patients, and physicians that should be considered in making these decisions, how these groups rank or weight these values is currently unknown. To measure the relative value of factors relating to drug reimbursement decisions, Bansback and Lynd collected online survey data from a representative sample of over 2,500 Canadians. Respondents were asked to rank 13 factors pertaining to values relevant to drug funding, including drug-, disease-, and patient-related factors. Study participants most frequently ranked safety as their top value (18% of respondents). Other values commonly ranked in the top five were potential effect on quality of life, severity of the disease treated, ability of the drug to work, and potential to extend life. On the other hand, Canadians ranked rarity of disease as the lowest value (0.10% of subjects ranked it first) — the other values in the bottom five were adherence of person taking the drug, previously unmet need, age of those treated, and lifestyle of the population affected by the disease. The values ranked in the top five were five to seven times more important to respondents than those that were ranked in the bottom five. These findings are a valuable step in understanding societal values in Canada specific to decision making, priority setting, and drug funding. In particular, this research can inform decision making around funding for rare diseases and suggests that the public values a drug’s effectiveness and safety, equal access to treatment, and disease severity over the rarity of the disease for which a drug would be funded.