Not one, but two conferences in Puerto Rico made my trip fantastic. As usual, the NIDA International forum happened for the 15th time on the weekend before the 76th Annual Conference of the College on Problems of Drug Dependence. The lines below offer some insights from these meetings.
Integration of addiction treatment into primary care: the portals of entry
Is abstinence related with good health? Is decreased drug use related with good health?
Tae Woo Park and Richard Saitz asked these questions in a secondary analysis of data from a clinical trial of 589 patients using cocaine or cannabis with very low dependence proportion among the sample (ASSIST score >27). To answer their questions, they used clinical measures of good health, such as, SIP-D, PHQ-9, and EUROQoL. Health outcomes were associated with decreases in illicit drug use in primary. However, abstinence and decreased use may represent very different magnitudes. Self-reports related dysphoria could also play a role in the differences. It takes a long time to make improvement in those consequences? 6 months of follow up observations may not be enough. Patient-preferred outcomes are paramount: do they want to have a score lower than XY on PHQ-9? What outcomes are important for them?
The TOPCARE (www.mytopcare.org) project implemented guidelines for potential opioid misuse (Jan Liebschutz). Her slides blew up half-way through the presentation but she delivered the talk excellently. Nurse care management was a component of the guideline implementation trial. Academic detailing (45min, with opioid prescribing expert) included principles of prescribing brochure and difficult case discussion. Is academic detailing effective? The Cochrane systematic review of literature found small-to-medium variable effects. The preliminary results of the project show that the nurse manager program is a no brainer.
Rich Saitz commented on the sad state of affairs in the addiction treatment, where only 10% of people with addiction are in treatment. Integrated care is the best thing since the sliced bread, but where’s the evidence? His research showed no added benefit of integrated versus care as usual. Why? Maybe, addiction is not a one thing, but we treat it like one thing. Dr Tai provoked the audience with a question: “Do our patients with addiction have the capability to participate in the treatment planning and referral?” If they seek medical care for their broken leg and we refer them to an addiction specialist, will they go? most likely not.
But it is the same with hypertension. Referral is a process and not a once-off thing. Although they may not follow our advice at the first visit, a rapport built by a skilled professional over a series of discussions can help them get the most appropriate care.
Does the efficacy of medications for addiction decrease over time?
An old saying among doctors states “One should prescribe a new medication quickly before it loses its efficacy”. Elias Klemperer pooled the data from several Cochrane systematic reviews on addiction medicines, such as, NIRT gum, Acamprosate, or Buproprion. Their effectiveness decreased over time. The changes in methodologies might have caused the decline; also the sponsorship of trials, target populations or publication bias.
Write, wrote, written
Primary author is in the driver’s seat, others are passengers. Primary author pulls the train. Dr Adam Carrico (UCSF) asked us “What are you really passionate about?” Find it and use your passion for those themes to drive your writing habit. Decide to be fearless& fabulous. Develop a writing routine. Put together a queue of writing projects and don’t churn out 2 products at the same time, one of them will suffer. Schedule writing retreats with colleagues. Set Timelines for writing grant and program time for reviews by trusted people, give people a warning that this is what you’re planning to do. The JAMA June 2014 issue offers useful tips on how to write an editorial.
Dr Knudsen reported on the editorial internship of the Journal of Substance Abuse Treatment – JSAT, which started in 2006, with Dr McGovern (current editor) and Knudsen as the 1stfellows. Success rate of the fellowship applications is 2/30-45, prior involvement is appreciated (peer reviewer, submission). The new 2014 fellows are: Drs Madson and Rash. In the one year of the fellowship, the fellows typically review 12-15 manuscripts, some years, as a managing editor of a special issue. The Drug and Alcohol Dependence journal has a similar scheme.