Investigating uses of peer-operated Virtual Overdose Monitoring Services (VOMS) beyond overdose response: a qualitative study

ABSTRACT

Background: Virtual overdose monitoring services (VOMS) are novel technologies that allow remote monitoring of individuals while they use substances (especially those who use alone) electronically.

Objectives: The authors explored key partner perspectives regarding services offered by VOMS beyond overdose response with the aim of understanding the breadth and perception of the services amongst those that use these services and are impacted by them.

Methods: Forty-seven participants from six key partner groups [peers who had used VOMS (25%), peers who had not used VOMS (17%), family members of peers (11%), health professionals (21%), harm reduction sector employees (15%), and VOMS operators (15%)] underwent 20-to-60-minute semi-structured telephone interviews. Of peer and family groups, thirteen participants identified as female, eleven as male and one as non-binary, gender data was not recorded for other key partner groups. Interview guides were developed and interviews were conducted until saturation was reached across all participants. Themes and subthemes were identified and member checked with partner groups.

Results: Participants indicated that uses of VOMS beyond overdose monitoring included: (1) providing mental health support and community referral; (2) methamphetamine agitation de-escalation; (3) advice on self-care and harm reduction; and (4) a sense of community and peer support. Respondents were divided on how VOMS might affect emergency services (5).

Conclusions: VOMS are currently being used for purposes beyond drug poisoning prevention, including community methamphetamine psychosis de-escalation, mental health support, and community peer support. VOMS are capable of delivering a broad suite of harm reduction services and referring clients to recovery-oriented services.

KEYWORDS:

• Overdose
• drug poisoning
• virtual overdose monitoring services
• harm reduction
• supervised consumption
• safe consumption

Introduction

Opioid-related drug poisonings (overdoses) have resulted in the deaths of thousands of Canadians in recent years; 7,902 people died in 2021 alone (1). Supervised Consumption Sites/Safe Injection Facilities (SCS/SIFs) are effective in preventing drug poisoning deaths, encouraging safe injection practices, and improving access to community services without increasing justice involvement (2–5). Nonetheless, SCS present access barriers, including travel costs, travel time burden, long wait times for entry, time limits, client bans, lack of trust, worries about policing practices, limited hours of operation, political barriers, negative client interactions, and highly localized effectiveness for overdose prevention (6–10).

Virtual Overdose Monitoring Services (VOMS) may help expand the benefits of SCS to a broader audience. VOMS are novel eHealth harm reduction technologies developed to reduce fatal drug poisonings among people who do not use SCS (11). VOMS are diverse in nature, employing telephone lines, smart phone apps, body sensors, and other technologies (11–16) (VOMS utilize virtual technologies to initiate an emergency protocol, such as activating emergency medical services, if a client becomes unresponsive). VOMS in Canada include the National Overdose Response Service (NORS), the Brave App, the Lifeguard app and the Digital Overdose Response Service (DORS) app. One example from the United States is Never Use Alone. NORS and the Brave App are both peer-operated (operated by people with lived and living experience of substance use) person-to-person hotline type services which function by connecting clients with live operators who can monitor their status while they use substances, whereas Lifeguard and DORS are automated countdown apps which individuals using substances need to refresh every couple minutes while they use, and if they do not, it may indicated a potential overdose event.

With NORS and Brave, contact with peer-operators is initiated by the client, who dials a voice-only call (through cellular, landline, or internet connection) with the service and is subsequently connected to an operator. The operator and client develop a plan for how to manage the situation should the client become unresponsive. This includes taking information from the client that might assist emergency services or community members in locating the client if needed. Though NORS uses a national phone line and the Brave App uses a smartphone application, both services are similar in the sense that both are hotline based voice-only person-to-person services designed to prevent overdose response (12,15). At the time of data collection, the Brave App connected clients with operators at NORS, further increasing the similarity between the two services.

Service pathways for VOMS have yet to be documented in the literature. One study showed that overdose response buttons (another technology aimed at overdose prevention) have been used for originally unintended purposes, such as responding to gender-based violence (17). There is utility in better understanding the scope of VOMS to further policy, implementation, and service considerations. The objective of the current exploratory qualitative study was to detail informed key partner perspectives regarding the use of VOMS outside of overdose response and to document the nature of such uses. The study examined the perspectives of groups familiar with the NORS telephone line and the Brave App. Herein, we discuss emerging VOMS service pathways along with their implications.

Material and methods

A qualitative study was conducted, with thematic analysis informed by grounded theory. The data was originally collected as part of an implementation science and quality improvement project for NORS conducted on behalf of Healthcare Excellence Canada. This study used the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist. It was compliant with the Tri-Council Policy Statement for Ethical Conduct for Research Involving Humans (TCPS 2), and the Helsinki Declaration (18). The study was approved by the University of Calgary Conjoint Health Research Ethics Board (CHREB; REB21–1655).

Participants

Interviewees came from six categories identified as key partners (groups that have used substances, may use substances, support substance users, are impacted by substance use, and which may refer potential clients to VOMS) by the research team. These included peers who had used VOMS, peers who had not used VOMS, family members of peers, health professionals, harm reduction sector employees, and VOMS operators; (see Table 1 for details). Peers self-identified as currently using illicit substances such as non-prescribed opioids or methamphetamine. Health professionals were defined as current employees or contracted professionals of health delivery organizations (for example, nurses, health care managers, and physicians). Harm reduction sector employees were defined as employees of community-based harm reduction organizations. VOMS operators included management and line operators. Family members were of interest because NORS staff identified family members as a group that made up a small but significant number of callers in advance of the interview stage. Participants had to meet select inclusion criteria: (1) reside in Canada at the time of study; (2) be 18 years of age or older; (3) be able to communicate in English; (4) identify as an individual from one of the six key partner categories; and (5) be familiar with VOMS and their purpose. Participants were excluded a priori if they were deemed: (1) to be actively impaired by substances to an extent that would make their responses unreliable; or (2) unable to consent or adequately participate in the interview. No participants were excluded from this study based on impairment or inability to consent. Interviewees were recruited using a combination of purposive, convenience, and snowball sampling techniques. The first participants were contacts known to the authors who were knowledgeable about VOMS. The initial interviewees were invited to refer additional individuals who might meet the inclusion criteria to obtain a greater diversity of perspectives. An information package was provided to participants. Interviewees with lived experience of illicit substance use (peers) received a $50 Visa gift card for their participation.

Table 1. Interviewee numbers, response rate, and demographics by group.

Interviewee Group	Number of Interviewees	Number Invited	Response Rate (%)	Mean Age	Standard Deviation
People with lived/living experience who had used the National Overdose Response Service or the Brave App (Peers)	12	Not Collected	Not Collected	40	13.75
People with lived/living experience who had not used any virtual overdose monitoring services	8	Not Collected	Not Collected	41	10.65
Family members of people with lived and living experience of substance use	5	7	71	48	13.86
Health professionals (Including nurses and physicians)	10	22	45	Not Collected	Not Applicable
Harm reduction sector employees (those who work in supervised consumption services, needle exchanges or harm reductio outreach)	6	11	55	Not Collected	Not Applicable
Virtual overdose monitoring service operators from NORS/the Brave App	6	11	55	Not Collected	Not Applicable
Total	47	–	–	–	–

Interviews

Semi-structured interview guides were constructed in collaboration with VOMS operators (from NORS/the Brave App), two people with lived experience, and a consulting firm, which conducted the interviews. The guides were customized to be relevant to each participant group (e.g., questions about line operation were only relevant to VOMS operators). Interviews were conducted by telephone during February and March 2022 by two interviewers (SJ and LA). Verbal informed consent was obtained using a script, and participants were advised that responses would remain anonymous and be stored on a secure server. Although participants were familiar with VOMS, they were given a brief verbal overview of VOMS to ensure similar baseline knowledge (see Supplement 1). Interviewees were asked about the uses of VOMS beyond drug poisoning prevention and perceived or experiential system impacts using the interview guides. Interviews lasted 20–60 minutes each. Participants were free to withdraw or decline to answer questions at any time and mental health support was available (no participants accessed this).

Coding and analysis

Interviews were recorded and transcribed verbatim using a third-party transcription service. Thematic analysis informed by grounded theory (19) was used to inductively identify themes and subthemes (20,21). Dedoose qualitative software was used to code responses. Two evaluators (SJ and LA, both with master’s level training in qualitative methods) directly compared coding on the first three transcripts to ensure agreement of the thematic analysis; thereafter, evaluators coded the transcripts on their own, with each coding approximately half. Throughout the process, each evaluator reviewed transcripts coded by their counterpart through Dedoose to assure coding congruency. Codes were developed through joint evaluator agreement and kept in a codebook which was updated in real-time. Coding uncertainties were discussed between the two evaluators to achieve consensus. Once initial coding was complete, the two evaluators reviewed a representative sample of coded quotations for each theme with a consulting project manager (KM, with master’s level training in qualitative methods). Interviews were conducted until thematic saturation (i.e., lack of new themes) across all participants was reached based on the consensus of the two evaluators, a consulting project manager (KM), and the principal investigator (MG). Since the study aimed to understand current uses of VOMS outside of overdose prevention rather than to compare uses identified by the different key partner groups, thematic saturation was not sought within each key partner group. Member checking was conducted with VOMS operators, most of whom also identified as peers. These individuals included a line operator, a line supervisor, and two senior executives. Member checking was also performed through clinician contacts and discussion with harm reduction groups at the Saskatoon Canadian Society of Addiction Medicine (CSAM) conference (November, 2022).

Results

Of the 47 participants, twelve identified as peers who had used a VOMS, eight were peers who had not used a VOMS, five were family members of peers, ten were health professionals, six were harm reduction sector employees, and six were VOMS operators from NORS or the Brave App (Table 1). Due to the small pool of peers invited, the total number of invitations was not recorded for privacy reasons. The response rate amongst the non-peer groups was 53%. Demographic information was collected from peers and the family of peers. Age ranged from 20 to 66 with a mean of 42 ± 12.7. Of these, the minimum age was 20, and the maximum was 66, with a mean age of 42. Thirteen identified as female, eleven as male, and one as non-binary. Six identified as BIPOC, four of whom also identified as Indigenous People. Twenty-three participants were from Alberta, fifteen from Ontario, three from Nova Scotia, and one from each of British Columbia, Newfoundland and Labrador, Nunavut, Quebec, Saskatchewan, and the Yukon Territory. Seven participants self-identified as from a rural area. There was no attrition after the interview stage. Five key themes were found. Four themes were related to service pathways (Themes 1–4), while one was related to perceived healthcare system impacts (Theme 5). Additional supporting quotes can be found in Appendix 1. The limited participant pool prevented the achievement of thematic saturation within each key partner group, which was not necessary to fulfill the study objective. The results presented here are a synthesis of perspectives from all key partner groups and should not be interpreted as a comparison of perspectives between different key partner groups.

Theme 1: VOMS can offer mental health support and referral to community services

VOMS operators and individuals with lived experience believed that VOMS helped provide mental health support during periods of isolation. Specifically, supporting clients with agoraphobia, isolation, and loneliness related to the COVID-19 pandemic was identified as an area where VOMS were perceived to have utility. Some clients who contacted VOMS were family or friends of peers who were searching for resources for their loved ones. Some calls were from individuals suffering from substance-associated suicidal ideation.

So a lot of mental health calls … where they’re lonely. And we can just talk to them for as much as we can. We’ve had people call us who are suicidal. We’ve had inquiries from parents … or other close members of their family or friends – who are worried about a certain individual and needed help on where to find it [assistance/local community services]. (VOMS Operator)

Respondents believed that using VOMS for peer-to-peer mental and emotional health supports and resource provision was appropriate and might be a preferred alternative to more traditional mental health supports (e.g., hospitals/crisis lines) for some individuals, given the higher relatability of peer operators. Respondents also indicated that VOMS could connect clients to more traditional mental health supports (e.g., crisis lines or counselors) or recovery-oriented addiction services if requested. VOMS operators and clients discussed how the services help with resource navigation. Additionally, some providers mentioned “reference plans,” which involved vetted resources identified by VOMS operators before referring clients. Others discussed using national resource repositories provided to clients when required.

So I have called for resources a few times, yes. They’re really great with connecting – they have a huge resource list across Canada and there’s been a few times in different cities where my in-laws live where we asked for help and resources out there and they can always point us in the right direction. (Peer, Used VOMS)

Several participants emphasized the importance of appropriate training and qualifications to provide mental health support. Some respondents, especially health professionals, speculated that VOMS would be unable to provide substantive mental health support due to the high volume of service use from specific callers and limited resources. Another consideration that emerged was the need to avoid redundancy of services. Participants indicated that a balance is needed between enhancing service navigability, avoiding duplication, and offering a single service entry point consistent with a low threshold intervention approach.

I mean, I feel like I need to call the app myself now and just see what it’s actually like because if you’re thinking about integrating mental health stuff and other resources, I feel like there has to be a process to go through and a lot of training for that. (Health Professional)

Theme 2: VOMS may be useful for methamphetamine agitation/psychosis de-escalation

Operators and health professionals found VOMS useful for de-escalation of agitation and psychotic symptoms associated with methamphetamine use. Line operators would only call emergency medical services if needed and instead attempt client-centered compassionate de-escalation strategies such as having calming conversations, offering grounding techniques, advising clients to decrease stimuli, or suggesting rest when presented with methamphetamine-induced agitation or psychotic symptoms. Operators indicated that they believed this approach helped ensure individuals would not wander into cold weather or other potentially dangerous situations, such as oncoming traffic, while in their altered state.

Yes, I think that sometimes with methamphetamine we are talking … [and the caller has]…aggression and psychotic symptoms and maybe if this individual is now in a severely altered state of mind we can ensure that they are at least safe and aren’t wandering off into the winter and freezing limbs and that there’s some support for them. (Health Professional)

Some interviewees indicated that they incorporated other harm reduction approaches to methamphetamine-induced agitation or psychotic symptoms, such as providing recommendations to switch to using a different substance, with one operator stating, “And we’re like, ‘Maybe you should switch drugs … maybe coke would be a better drug for you.” (VOMS Operator). VOMS operators emphasized the importance of appropriate time and training to address methamphetamine agitation de-escalation through voice calls: “NORS provides de-escalation training that is inclusive of psychosis … [we] will need refresher courses throughout the year” (VOMS Operator). Line operators reported feeling able to manage client stress and anxiety while providing reassurance and reorienting to their environment (ie: to help individuals manage acute psychosis by orienting them back to their current time and place/reality when acutely confused).

Theme 3: VOMS can provide self-care and harm reduction education

VOMS operators indicated that some client questions pertained to general health and social issues, harm reduction education (e.g., safe injection practices), and substance-related guidance (e.g., avoiding overdose). This included discussions on opioid agonist medications, wound care, where to get food, social service support, and education on safe sex. Operators also recommended when to seek further care, such as going to the hospital or recommending local services (e.g., food banks). Some participants noted that clients requested information on how to use substances more safely (e.g., going slow and test-dosing drugs or using sterile equipment). Service clients would also share information with VOMS staff (for example, detailing observations about the local drug supply that might be useful for other clients).

[I appreciate] how much they offer and resources and, like, where to get clean supplies in your city and doctors’ offices. It’s really good for information. (Peer, Used VOMS)

We provide care in a number of contexts, man. We do. We do so it’s not just drug use. So like – or opiate specific. Meth use is a big one, all right? People coming to us for wound care. Questions around how to prep different products. Is this product safe? Is that a new product? Do you want to test it first before you do a full hit? (VOMS Operator)

Theme 4: VOMS can provide a sense of community and peer support

Operators and clients believed that VOMS can create and act as an interconnected virtual community where people feel understood due to peer support aspects of the services, creating a safe environment. Operators further described the virtual chat room for NORS staff as a space to form a sense of connection with each other. Some participants voiced concerns about the appropriateness of VOMS for casual conversations outside of substance use sessions, with one operator stating, “there’s callers that call just to talk. And that’s not what it was about … I’m not there to answer the call and have a conversation with people” (VOMS Operator).

Well honestly, I was scared to call the line, because I know there’s a lot of judgement in the addiction community and stuff but I ended up calling anyway. And it was honestly – it surprised me how great they were – I’m not just saying that. They actually were fucking great. Almost every person I talked to there, were so understanding and so nice. And I thought that when I called the line that they would just be, ‘OK. What are you using?’ Whatever. I use and then we’re done. And honestly, and some of the people that were on the line I got pretty close to, because I – there’s lots of regular people that are always on there that I would connect with more than once. And it wasn’t even just about using. I’d just talk to them about shit too. Obviously it was about using, but I got to build actually some relationships with a few of them, which was great. (Peer, Used VOMS)

Theme 5: Cautious optimism about health system impacts

Most respondents felt that VOMS would positively affect the health system by reducing the number of unnecessary emergency department visits for stimulant psychosis, mental health concerns, and suicidal ideation while minimizing the number of drug poisoning callouts. For example, one operator mentioned assessing the need for clients to go to the emergency department by examining photos that the client provided. Peer operators believed that offering these services was appropriate in the context of peer support.

I think [the service would] reduce the number of emergency department impact[s], you know, like people don’t want to go to Emergency [laughs] and if they end up there it’s because somebody took them there or because they’re so psychotic they don’t know what else to do. And I think that that in itself is terrifying and, you know, if people were able to access sort of crisis intervention in the community I think they would do it. (Health Professional)

Some health professionals also expressed concerns that VOMS might lead to false alarms or that they might fail to appropriately support the client as intended, leading to unnecessary health system resource use and potentially worsening outcomes.

I guess it depends on the quality of the service and the quality of the app, because it could go, you know, in two ways. Like, in terms of like if it’s – so if it’s not a well working service, and it’s causing a lot of false calls or false appointments if it is tied in to, say, EMS response. But it can be helpful for keeping people from needing, like, hospital care, if they are supervised and supported in the community. So I think it can go either way. It can either be a nice support to the services that are already available, and lessen the burden on, but it could also tax it even more if it’s not well thought out and run. (Health Professional)

Discussion

To our knowledge, this exploratory study represents the first qualitative study examining key partner perspectives about service pathways for VOMS outside of overdose prevention. The interviews yielded four novel service pathway themes, indicating that VOMS may fill gaps in existing systems related to harm reduction, community wellness, and health while reaching populations with limited access to health services and resources. Despite a limited literature base, these findings are consistent with one other study involving an overdose prevention technology which found that overdose buttons were being used for purposes other than those originally intended (17). Differing perspectives on potential health system impacts was also a theme. Though participants expressed worries about false alarms or unnecessary emergency callouts, published pilot data from NORS revealed a false alarm rate of only 3.8% (11).

While the services identified by participants may be considered beyond the scope of the core purpose of VOMS (preventing overdoses) or be seen as a duplication of other services, a key principle of supporting vulnerable populations and harm reduction is responding to the needs among these groups with a broad approach (22). Furthermore, integrating peer support services into mental health and addiction services is generally supported in the literature (23). The results of our study show that, much like non-technology-based peer services, peer operators feel able to support client needs around mental health support, resource referral, methamphetamine agitation de-escalation, self-care/harm reduction education, and providing a sense of community. We believe that these perspectives reflect the ongoing adaptation of VOMS to funding, resourcing, and client needs. Indeed, just as many physical SCS offer connection to harm reduction supports, peer support, mental health resources, and recovery pathways (24), VOMS perform similar activities for their client base, providing low threshold access and support. We postulate that, if properly implemented, offering additional services (or relevant referrals to vetted service providers) might help to reduce system strain and improve system navigation.

As emphasized by study participants, proper training for VOMS staff is critical to ensure appropriate support, referral, and escalation of client care needs (for example, service operators should identify when to recommend medical care). Without proper training, VOMS operators could provide suggestions or advice that could potentially cause harm or be misconstrued to be medical advice. For example, one operator stated that they suggest switching from methamphetamine, which may induce psychosis, to other stimulants, such as cocaine which do not cause psychotic symptoms. While there are benefits to this from a harm reduction perspective, the medicolegal implications of offering such advice outside a clinical setting are less clear. Consequently, clear training for operators and ensuring clients understand that VOMS do not provide medical advice are important considerations.

Use of VOMS for methamphetamine agitation de-escalation is somewhat surprising and presents potential opportunities and risks. Methamphetamine psychosis affects > 40% of methamphetamine users (25,26) and produces symptoms of hallucinations and paranoid delusions, which can be debilitating and potentially lead to violence (27–29). De-escalation techniques are fundamental for working with stimulant-induced crisis (30) and are recommended for use in a wide range of settings (31,32). We believe there is a need for better community resources to help manage these symptoms, especially for people who use by themselves. By providing non-pharmacological behavioral management advice, VOMS may prevent potential injury or harm. Incorporating evidence-based, medicolegally vetted, procedural algorithms for methamphetamine-related symptom management is an important operational consideration. No other service that we are aware of provides virtual de-escalation, demonstrating a novel approach to managing community-based substance-induced agitation and psychosis which could also decrease the management burden on both justice and health systems. .

Interviewees stated that having operators with lived experience allowed clients to feel comfortable using the service by providing a sense of familiarity, understanding, trust, and safety while encouraging the development of a sense of community amongst line operators and clients. Previous research has shown that peer-implemented overdose response programs are promising for reducing barriers to naloxone access (33). The employment of peer line operators ensures a level of understanding and trust which may not be felt to the same extent when clients use a service operated by professionals (e.g., a crisis line) who may not have lived experience. We hypothesize that the use of peer operators might lead to more frequent calls not only for overdose prevention but also for mental health supports, feelings of loneliness, assistance connecting to resources, and social connection. We believe that support for the peers engaged with this work is crucial as it can be triggering and impact their own health and well-being, particularly if they use VOMS themselves. Line operator training (e.g., around boundary setting) is crucial in managing calls that blur the lines between casual conversation, friendship, and peer support. Despite potential boundary issues, VOMS operators generally described working for VOMS to be a source of personal support and wellness. High levels of trust between clients and operators might also enhance information sharing regarding current local contexts (for example, about the local drug supply) and might present an opportunity to correlate such data with other existing warning or surveillance systems.

Strengths and limitations

Strengths of the study include a relatively large sample size with data collected to saturation across all interviewee groups (though not within interviewee groups), national representation across Canada, the richness of transcripts, and novel findings. Limitations of the study include the convenience and snowball nature of sampling, the use of a probing question set geared toward certain items of interest for quality improvement (e.g., methamphetamine de-escalation), a relatively urban sample, and the need for participants to have access to a phone. In addition, participants were mostly concentrated within the provinces of Alberta and Ontario, Canada due to current use patterns and familiarity of these services in those areas. The results of this study may not be directly applicable to all types of VOMS since respondents were familiar with person-to-person services but not necessarily other types of VOMS (e.g., app-only, sensors). Lastly, intersectional comparisons were unable to be assessed due to the design of our study.

Conclusions

The findings of this preliminary study have important implications for peer-operated VOMS service delivery, planning, operations, and liability. VOMS are already being used for purposes beyond drug poisoning prevention and might help fill gaps in mental health and self-care services while connecting clients with a wide range of community resources and providing a safe space for people to come together. Additionally, VOMS may be able to assist with methamphetamine de-escalation. Appropriate implementation, training, policy, and medicolegal oversight are critical for the operation of VOMS in these new areas.

Future directions

Future work should compare different types of VOMS and their ability to meet various client needs. Additionally, an examination of various VOMS governance, organizational, and procedural structures would be informative. Legal implications of advice provided to callers is another avenue for future work. Despite optimism among participants about health system impacts, measuring the impact of VOMS on the health and social systems is another avenue for inquiry.

Acknowledgments

The authors would like to acknowledge the contributions of Health Canada’s Substance Use and Addictions Program (SUAP) and the Canadian Institutes of Health Research (CIHR) for helping fund this project. The study design, data collection and analysis, interpretation of results, or the decision to submit for publication was done independently of SUAP and CIHR. Health Canada’s views are not necessarily represented by the views expressed in this article. We would also like to thank the National Overdose Response Service (NORS), Grenfell Ministries, and the Substance User Network of the Atlantic Region (SUNAR) for helping recruit participants. We also appreciate the work of Three Hive Consulting in conducting interviews and aiding with analysis.

Disclosure statement

MG is a co-founder of the National Overdose Response Service (NORS) and a board member of the Canadian Society of Addiction Medicine; he has no personal financial conflicts of interest to disclose. The results of this work may be used to make operational changes at NORS or to apply for additional funding for NORS. PT is a phone line supervisor with NORS and has no personal financial interest in this work. The remaining authors are not affiliated with NORS or any other VOMS and certify they have no competing interests.

Additional information

Funding

This work was supported by Health Canada’s Substance Use and Addictions Program (SUAP) Grant [Agreement Number 2122-HQ-000021] and the Canadian Institutes of Health Research (CIHR) Grant [Funding Reference Number (FRN) 181006]. SUAP and CIHR did not play any role in study design, data collection and analysis, interpretation of results, or the decision to submit for publication. The views expressed herein do not necessarily represent the views of Health Canada or the CIHR.