Category: Drugs

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.

The mystery of change (-ing others): article in the Irish Psychologist

How may I help you– change you?* 

“Change is the Law of Life. And those who look only to the past or present are certain to miss the future.” – John F. Kennedy


Trying to help somebody to change their bad habits is an admirable act of kindness. It shows our compassion and care for the less fortunate. The best is when it comes from the person’s own initiative. Motivated helpers are assumed to be good helpers. Some of us help others pro bono, while others do it as part of their job description. But what if the professional helper doesn’t want to help? How do you help the helper with change in others?

Encouraging professional helpers to address excessive drinking is a complex problem. It’s so complex and resistant to change, that their unwillingness to adopt these new practices can be viewed as a bad habit. Many experts called for complex strategies to persuade their clinician colleagues to address alcohol. But complex strategies did not help.
Professors Anderson, Laurant, Kaner, Wensing and Grol reviewed available scientific evidence and claimed it was possible to increase the engagement of doctors in screening and advice-giving for excessive drinking. They saw a potential in programs which were specifically focussed on alcohol and that were multi-component. Later, some of the original team tested this theory by doing a clinical trial, which is a type of study considered as a golden-standard by many experts. Their Swedish experiment “failed to show an effect and proved difficult to implement”. Are the Swedish too stubborn to embrace change? Let’s not be harsh by accepting this cultural stereotype as a plausible explanation for their negative findings, before we look at more perplexing findings from other countries.
When scientists ask doctors and other professional helpers about what’s so difficult in talking alcohol with their patients, they give the same reasons all over the world. The World Health Organisation (WHO) commissioned a multi-state study, at the beginning of the millennium, which documented all of these reasons – the myths about alcohol care. The myths were lack of time, inadequate training, a view that alcohol is not a matter that needs to be addressed by medical doctors, conviction that doctors’ advice won’t work and fear of talking about such sensitive issue. It seems that the next twist in the story of change brings us to helpers’ beliefs.
Recent research at the University of Michigan, cardiovascular centre demonstrated how doctors’ confidence in their ability to advise patients on diet and exercise correspond with their own personal health and fitness levels. Could this apply to alcohol too? Would it help if we use some evidence-based strategy to boost their confidence or ambivalence about drinking behaviours?
Motivational enhancement therapy (MET) is an evidence-based treatment which targets person’s ambivalence about unwanted behaviours including their attitudes and beliefs. A team supervised by Professors Hettema and Sorensen used this Swiss-army knife of addiction counselling to help doctors-to-be to resolve their ambivalence around managing alcohol and drug problems. They’ve put a group of nine medical residents through a brief MET therapy before they learned more about alcohol consulting and advice-giving. Five weeks later, their consulting and advice-giving went up, but due to the small numbers, the researchers called for caution with interpretation of their results.
Resident education was combined with a team-based approach to systems change in the Richmond clinic – a busy family practice in the south-east Portland, Oregon. Dr Muench led his team to change the way they deal with drinking issues – from receptionists, through medical assistants to physicians.
Dr Muench is a slim, middle-aged physician with a passion for teaching young doctors and helping patients from difficult backgrounds. Explaining their approach to practice change, he points out, ‘we’ve strengthened our practice systems, but the system leaks at three points. They are at the front desk, in the consultation room and in the teaching modules.’ In making these comments, Dr Muench argues that while their project led to many improvements, there are things that can be improved. Ultimately, Muench conveys a positive message about systems change being possible, although not without some obstacles. In the Richmond team-based approach, the receptionists should give patients alcohol check-ups while they wait for the consultation, but they often forget because the PC fails to remind them of this. When the receptionist doesn’t forget to hand out the form, and the patient brings it to a medical assistant, she frequently forgets to complete the full assessment. It is no surprise then that the next ‘cog in the machine’ – the doctors – ‘forget’ to discuss alcohol with patients.
What science tells us about implementing change is reassuringly similar to the traditional knowledge of common folk. If you can’t change others, change yourself. “We must become the change we want to see”, said Gandhi. Richmond truly became the change they wanted to see in others. And yet, the project’s 75% yardstick of engaging patients into alcohol discussions wasn’t met. Why was Richmond below targets? Embracing change in healthcare requires system changes and education on several levels – multi-level changes.

*This is a shortened version of my article published in the Irish Psychologist, Volume 40, Issue 2/3. Dennis McCarty, PhD gave me feedback on drafts of this blog post.

Citation for the full version of this article:

Klimas, J. (2013). The mystery of change(ing) others. Irish Psychologist, 40(2-3), 78-79. http://www.psihq.ie/irish-psychologist-journal-of-psychology

Recruitment shock

3.6% response rate? Shocking! For our new feasibility study, we sent over 200 invitations to primary care doctors in Ireland and the invitees sent us back a very strong signal. “We are not interested”, or “we are too busy”, or “we don’t have enough eligible patients”? Whatever the reason, the message remained the same: No, thanks.

The primary objective of our study, as for most feasibility studies, is to estimate numbers needed for a definitive trial. We want to know how many people should be invited into the study; of those, how many should be randomized; of those, how many will stay until the end. Right from the beginning, we were faced with a question whether we can recruit enough people for a fully-powered experiment.

Statistical power

Power in research experiments is about finding the truth. Experimenters want to know whether their drugs or treatments work. If the drug or treatment works and they give it to a group of people, some of them will improve, some won’t. There’s a lot of chance and uncertainty in any drug or treatment administration. If we want to know the truth beyond the effects of chance, we need to give the drug or treatment to the right number of people. There’s a formula for it, known to most statisticians. It depends on many things, like the size of the improvement that you want to observe in the treated group, or other confounding factors. The higher power in a study, the more likely it says true (see, e.g., Dr Paul D Ellis’, PhD site here).
A rule of thumb says that the more people are in the study, the higher the chances of finding a meaningful impact of the intervention. Common sense also tells us that the more people in the trial, the more representative they are of the whole population – the more confidence you can be that your results apply to all; except for Martians – unless you really want to study Martian citizenship.

Solution

The easiest would be to call some friends, doctors, and ask for a favor. This should work, but it’s not really scientific. Or you can shut down the study and conclude that it’s not feasible. Or you can do the study with the small number of interested participants. Or you can send another mailshot, a reminder, to all – sometimes that can help.

Fidelity questions

Clinical trials use elaborate methods to make sure that everybody does the exact thing as they planned. Measuring treatment fidelity is checking the agreement between study plan and practice. Some health problems require complex changes. How to measure fidelity in trials of complex interventions? Here are some ideas for fidelity checking.

The National Institutes of Health established a workgroup for treatment fidelity, as part of their behaviour change consortium (1999). They surveyed each centre in the consortium to find out which fidelity measures they use in trials. The workgroup recommendations span five areas: study design, training providers, delivery of treatment, receipt of treatment and enactment of treatment skills. They are useful for investigators who want to measure and improve their treatment fidelity. The key areas for our study are design, training, delivery and receipt.

Fidelity in our PINTA study

Our feasibility study has several aims. The first is to estimate parameters for a fully powered clinical trial. Secondly, we also want to know whether our intervention works. As a complex intervention, it targets multiple levels – doctor and patient level. We hope to improve doctors’ practices and patients’ health behaviour. Intervention fidelity in a multi-level study means adhering to different guidelines and processes. Our trainers must deliver uniform training to all learners groups. The doctors must provide consistent interventions to all patients in the intervention group.

Availability of personal portable audio recorders, e.g. smartphones, provides new and exciting opportunities for fidelity checking, but it raises some ethical issues. Doctors and other interventionists can easily record their consultations with patients and email them to researchers for fidelity checking, but email is not safe.

To avoid the potential confidentiality breach, the researchers can ring the doctors, give them a one-sentence brief and ask them what would they respond should this patient appear in their next appointment. Recording such phone calls is not a technical or ethical problem; it is not without limitations, though. Telephonic consultation with researcher in the role of patient does not reflect real life consultations and, as such, cannot be an accurate skills check. Doctors may not want to be called and recorded for quality assurance purposes, even if it’s anonymous and does not affect their income or professional standing.

When designing measures to improve treatment fidelity in our study, we have to consider how they will be perceived by our participants and providers. These are the strategies for monitoring and improving treatment fidelity that we plan to use:

Design:

  • Guidelines for primary care providers to manage problem alcohol use among problem drug users
  • Scripted curriculum for the group training of providers

Training:

  • Booster session (practice visits) to prevent drift in provider skills
  • Access of providers to research staff for questions about the intervention
Delivery:

  • Instructional video of patient–doctor interaction to standardize the delivery
  • Cards with examples of standard drinks and scripted responses – to standardize the delivery
  • Question about patient scenario in follow-up questionnaires (telephone contact)
Receipt:

  • SBIRT checklist for providers (process measure)
  • Pre- and post training test (knowledge measure)
  • Patient follow-up questionnaire will check whether each component of the intervention was delivered

Measuring fidelity in trials of complex interventions is important. It is not technically demanding. Ultimately this becomes a question of personal development and credibility – willingness to have one’s skills analysed and improved is the basis of reflective practice.