Category: Drugs

76th Annual Conference of College on Problems of Drug Dependence: Decide to be fearless& fabulous

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 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 Cochranesystematic review of literature found small-to-medium variable effects. The preliminary results of the project show that the nurse manager programme 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 programme 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.

Check out the http://www.cpddblog.com/

Dennis McCarty won the 2014 NIDA International Program Award of Excellence

 June 14, 2014 ― Professor Dennis McCarty, Ph.D., professor in the Department of Public Health and Preventive Medicine at Oregon Health & Sciences University (OHSU), and director of the Substance Abuse Policy Center in the Center for Health Systems Effectiveness, has been awarded by the 2014 National Institute on Drug Abuse (NIDA) International Program.

The award is for Excellent Mentoring. Dr. McCarty mentors clinicians and researchers who test emerging drug abuse treatments in community settings through the Western States Node of the NIDA Clinical Trials Network, which he codirects. He extends his mentoring to state and local policymakers through his role as director of the Substance Abuse Policy Center in the Center for Health Systems Effectiveness, which works to link policy, practice, and research on substance abuse treatment.

Dr. McCarty also is scientific director of the University of Amsterdam Summer Institute on Alcohol, Drugs and Addiction. I met Dennis in Amsterdam in 2011. He lectured for several days on different policy models and evidence based treatments. Two years later, on March 1, 2013, I joined Dennis as a NIDA CTN INVEST Fellow. INVEST is International Visiting Scientists & Technical Exchange Program for drug abuse research. Oregon Health & Sciences University hosted my six months fellowship during which I assessed the use of Screening and Brief Intervention (SBIRT) for alcohol use disorders among patients receiving agonist medication for opioid use disorders. Visit this post to read more about how I got here. I did not think that the summer school would lead to a fellowship in Portland, OR and I’m most grateful that it did.

With Dennis, I have learned about things I thought did not exist. For example, about researchers who enjoy writing. Writing up research projects is a task that many new researchers fear the most. Dennis is a master writer and his craft is contagious; I’ve discovered a need in me, a strong urge to write a lot and in many different formats. Dennis received the award today, at the 19th annual NIDA International Forum in San Juan, Puerto Rico. The 2014 Forum focused on “Building International Collaborative Research on Drug Abuse.”

Four other experts were awarded 2014 NIDA International Awards of Excellence. Mr. O’Keeffe, a professor at Virginia Commonwealth University, was honored for Excellence in International Leadership. The award for Excellence in Collaborative Research went to Dr. Chawarski, Ph.D., Yale School of Medicine, and Dr. Kasinather, Ph.D., Universiti Sains Malaysia. A special award was presented to Dr. Dewey, Ph.D., Virginia Commonwealth University, in recognition of his service to the addiction research community as founder of the Friends of NIDA, and his research on how opioids and marijuana change brain and contribute to tolerance and addiction.

NIDA International Awards of Excellence winners are selected based on contributions to areas essential to the mission of the NIDA International Program: mentoring, international leadership, and collaborative research. Anybody can suggest a nomination to NIDA. Read more at www.drugabuse.gov/international/awards-excellence.

The NIDA International Program connects people across continents to find evidence-based solutions for addiction, and drug-related HIV/AIDS. NIDA is part of the National Institutes of Health – the principal research agency of the U.S. Government and a component of the U.S. Department of Health and Human Services.

Story first released by OHSU Newsroom: http://www.ohsu.edu/xd/about/news_events/news/index.cfm

AUDGPI 2014: Addiction research at the 17th Annual Scientific Meeting of the Association of Departments of General Practice in Ireland

What is the role of primary care in addiction treatment? How can be addiction treatment better integrated in the general medical settings? These and other puzzles were discussed during the addiction talks at the meeting of the primary care academics in Ireland. University College Cork hosted this year’s meeting attended by approximately 80 delegates.


The drug-related research was scattered in the 12 parallel sessions from 10.30-16.30, one of which was specifically focused on drugs in primary care. North Dublin City general practices (GP) training presented two decades of experiences with GP placements in Dublin low-threshold services for people without home or with addiction (see www.primarycaresafetynet.ie). Students in the final year of 4-year GP training benefited from the experiences greatly; it was different though. They provided mainly social medicine and had to adjust to a different culture of people living on the brink of our society. To prevent burnout and emotional detachment, the administrators introduced Mindfulness for trainees.

From the same environment, a survey followed-up physical and mental health of people without home in 1997, 2005 and again in 2013. The situation of mental disorders hasn’t changed – it remains bleak, but the baseline data is important for service organisation and delivery. The study now compares Dublin and Limerick.

Among the 39 conference posters, addiction was represented by my poster was (no 15) shown in Figure 2.

Figure 2 Poster by Klimas et al (Cork, March 7, 2014)
Research priorities of general practitioners were explored by the PRIMary healthcarE research group at University of Limerick. They organised a novel World café – a self-facilitated focus group with coffee for participants – 4 key questions prepared by organizers (www.theworldcafe.com). Music & flowers on the tables helped to break ice. Tablecloths served as writing paper. The researchers took the tablecloths with them and put participants’ notes in the computer; Visio programme facilitated mind maps. The doctors and community members prioritized the bigger picture: they wanted more accessible and responsive primary care.

The drugs-focused parallel session brought 3 presentations from Galway, Limerick and Dublin. Field et al., studied the management of problem alcohol use among problem drug users in primary care; Henderson et al., analysed key performance indicators for mental health and substance use disorders, and Whiston et al., pilot-tested brief interventions for illicit drug and alcohol use in methadone-maintained patients in 4 methadone maintenance treatment clinics in Dublin.

Alcohol: poets’ love affair

Spoken word events often take place in bars. Poets who perform at and attend these events are over the legal limit for drinking. But what if an underage poet wants to join them? Their chances to avoid the alcohol culture are grim.

Poetry slam at Accent’s drink-free venue


Young talented poets are forced to perform in alcohol temples. There, they listen to the established artists talking about their drinking. They watch older poets drink one beer after another, which is nothing new in the poetry art. Poetry has a long-established love affair with alcohol, not only in Ireland. For example, W. B. Yeats, an Irish poet and playwright, would have had experiences with the drinking culture. Perhaps they contributed to his Drinking Song:

“Wine comes in at the mouth
And love comes in at the eye;
That’s all we shall know for truth
Before we grow old and die.
I lift the glass to my mouth,
I look at you, and I sigh.”
Being open about alcohol is good – we live in an alcohol-soaked society after all. Denial and silence doesn’t work. Harm reduction approaches to drug use works. Adolescence is a period of experimentation which includes drugs and other risky behaviors. Parents of teen poets could use, for example, Marsha Rosenbaum’s Safety First reality based approach. This approach helps teenagers to make responsible decisions by honest, science-based information, encouraging moderation, understanding consequences and putting safety first.
In addition to education, drink-free venues for arts and poetry events should be promoted. For example, Accents Coffee & Tea Lounge is an alcohol-free place in Dublin City centre. It was created by Anna Young as a cozy environment for people to meet and as an alternative to a pub. Before they opened, there weren’t many places where you could buy coffee late at night in Dublin. It is the only café in Dublin opened till 11 pm. Accents is the home to two poetry events, a poetry slam competition on the first Sunday of the month (See picture), and A-Musing gig, Stand-up comedy and poetry night on the last Sunday of every month.
I hope that there will be more venues like this for aspiring poets. In the meantime, support a poet by “buying him or her beer”.

The truth about drugs found in a cornershop

Our local corner shop sells alcohol. They also sell groceries, such as garlic, which I went to buy last week. I noticed a booklet by the cash register just as I was paying: The truth about drugs. It looked unattractive – dark colors, scary statements – but I took it to learn more about the drug free world as promised on the cover.
The brochure was full of mistakes, contradictions and misrepresentations of drugs. Most of them were myths which are not supported by the evidence and have been perpetuated for decades:
1) MYTH: Drugs have been part of our culture since the middle of the last century.
                FACT: Drugs have been here since ever. They are at least as old as the humankind.
2) MYTH: Young people today are exposed earlier than ever to drugs.
                FACT: This is a favorite headline of most prevention programs. Finding increased rates of drug use among the youths is not difficult. Finding reasons for this increase is difficult and requires knowledge of drug markets. Young people may be using drugs as much as before. They may be using different drugs than in the past, but that’s a matter of drug availability and supply.
3) MYTH: People take drugs because they want to change something about their lives. [] They think drugs are a solution.
                FACT: People take drugs for all sorts of reasons. For alcohol, these reasons can be broadly divided into: social, coping, enhancement conformity and motives. Coping with problems and solution-seeking is just one of the reasons.
4) MYTH: A small amount acts as a stimulant (speeds you up). [] This is true of any drug.
                This is UNTRUE for depressants (downers) and some other drugs. Although, the brochure lists sedative effects of depressants later, I don’t understand why it misleads the readers.
5) MYTH: Drugs make a person feel slow and stupid…
                FACT: Same as above. Cocaine hardly makes people feel slow. It is hard to discern why false statements, such as this one, made it into the brochure. There’s almost no wheat among the weeds.
6) MYTH: Marijuana [] can also be brewed as a tea.
                FALSE: The active compounds are not water soluble. THC is fat soluble though.
7) MYTH: people take drugs to get rid of unwanted situations or feelings (p.13)
                FACT: People take drugs for all sorts of reasons. See point 3 above.
8) UNDERSTATEMENT: the long-term effects of alcohol are understated on p.15 – Alcohol is a hard drug.
9) MISTAKE: Cocaine and crack cocaine can be taken orally…
                Yes, BUT it takes ages to start acting and it’s harder to estimate the right dose – the risk of overdose is higher. That’s why people don’t eat cocaine. Coca leaves are chewed not ingested.
10) DEPRESSION can drive anybody to suicide, not just people who use cocaine. Suicidal thoughts (p.19) are one of depression’s symptoms.
11) TOBACCO: no information in the booklet, although my local store sells cigarettes. They are stored very close to the booklets. Most people tried smoking.

Violence

The brochure’s information about the effects of drugs on violence is inconsistent. Moreover, most people use multiple drugs whose effects on relationships synergize. It’s difficult to separate effects of individual drugs. The brochure states:
  • Heroin – violence and crime are linked to its use
  • Inhalants – users may also suddenly react with extreme violence
  • Crystal meth – causes aggression and violent or psychotic behavior
  • Alcohol – can lead to violence and conflicts in personal relationships
  • Alcohol is ‘more harmful than heroin’ say Prof Nutt, King and Williams in the Lancet journal. Watch BBC News interview.

Target group and choice

The brochure’s target group is unclear. Technical terms are used widely alongside academic references. In two places, it mentions development of “Teenage bodies”, and “teens” surveyed about drugs. It misleads the reader to believe that they can make a decision about drugs. The truth is that the only option provided in this booklet is to live drug-free.
The wide availability of this pamphlet worries me most. Despite wrong information, it’s available at the most exposed spot in 24/7 stores – at the cash register. How come those government health promotion brochures are not there (http://healthpromotion.ie/)? Or the excellent Safety First brochure: reality-based approach to teens, drugs and drug education (www.drugpolicy.org/docUploads/safetyfirst.pdf‎)?

The safest life-choice is to not to use any drugs. Drug-free is a world for some, but not for all. Most of us will use some drugs, legal or illegal, at some point in our lives.