Category: Drugs

Pedicabs, Cochrane & Drugs Conference in San Diego

I was in San Diego (CA) 9 years ago. We went there with my wife, then a girlfriend, on a J1 Student work & travel programme. We worked as pedicab drivers – did not make much money but got the best tan (and time) in our lives. This year, we returned to Sand Diego for my presentation at the conference of the College on Problems of Drugs Dependence.

The drugs conference

This was probably the biggest conference I’ve ever attended. I underestimated the power that such enormous scientific stimulation can have on my thinking and experiencing of the world of addictions. My notebook is again full of ideas for research and life. To share just one of them, Wyoming is the only state in which has free access to Cochrane reviews in US. Cochrane collaboration is committed to produce high quality reviews of scientific evidence which aim to change the clinical practice and policy. USA produces the biggest number of studies that get included in Cochrane reviews. Are they not interested in reading what Cochrane reviews make of their clinical trials?

As I was coming back from the conference hotel to my hostel in the down town, I passed by an older man in red jacket entering the historical Simmons hotel with a bag of groceries. ‘I used to live here, 9 months ago’ said I when I saw him. ‘Nine years ago, I used to be a general manager of this hotel’ was his response. Back then, it was very difficult to convince this stern man that we would be able to pay our rent from our pedicab money. His face glowed when he finished our small talk ‘It’s a nice place to live’.

The pedicabs

To my big surprise, we haven’t seen many pedicabs on the streets of San Diego. But it didn’t discourage us from taking a memorial ride from the US Midway to down town. We stopped a driver from Canada wearing a US flag as his head band. He explained what has caused the decline of pedicabs in SD:

  • no J1 student drivers allowed (since 2009)
  • the upper limit of new licenses – drop from 600 to 200
  • Californian driving license required (since 2011)
  • insurance for all

… we still didn’t manage to get on the Midway, maybe next time.
My new friend Portland, John Fitzgerald, PhD, wrote about this conference too, in his June blog.

Square peg in a round hole: You can’t always do a meta-analysis.

“As they say in the West of Ireland, you can’t fit a square peg in a round hole*. If some trials in your systematic review are like that round hole and other are that square peg, you aren’t going to be able to do a meta-analysis unless you re-shape ‘the edges’ of your systematic literature review.”

Which talking therapies (counselling) work for drug users with alcohol problems?

 The following text is based on a lay summary of a my recent Cochrane systematic review: Klimas J, Field C-A, Cullen W, O’Gorman CSM, Glynn LG, Keenan E, Saunders J, Bury G, Dunne C. Psychosocial interventions for problem alcohol use in illicit drug users. Cochrane Database of Systematic Reviews 2011, Issue 8. Art. No.: CD009269. DOI: 10.1002/14651858.CD009269.pub2

Check my presentation from the Annual Symposium of the Society for the study of Addiction on November 8th, 2012 in York, UK here:

What is problem alcohol use and what are psychosocial interventions?

Problematic use of alcohol means drinking above the recommended safe drinking limits. It can lead to serious alcohol problems or dependence. Excessive drinking in people who have problems with other drugs is common and often makes their problems worse as well as having serious health consequences for the person involved.

Psychosocial interventions are talking therapies that aim to identify an alcohol problem and motivate an individual to do something about it. They can be performed by staff with training in these approaches, for example doctor, nurse, counsellor, psychologist etc. Talking therapies may help people cut down their drinking but the impact is not known in people who have problems with other drugs.

We wanted to do a review to see whether talking therapies have an impact on alcohol problems in drug users. In this review, we wanted to evaluate information from randomised trials in relation to impact of talking therapies on alcohol drinking in adult (over the age of 18 years) users of illicit drugs (mainly opiates and stimulants).

This review found the following studies, and came to the following conclusions:

We found four studies which examined 594 people with drug problems. One study looked at Cognitive-behavioural coping skills training vs. Twelve-step facilitation. One study looked at Brief intervention vs. Treatment as usual. One study looked at Motivational interviewing (group and individual format) vs. Hepatitis health promotion. The last study looked at Brief motivational intervention vs. Assessment only.

– The studies were so different that we could not combine their results to answer our question.

– It remains uncertain whether talking therapies affect drinking in people who have problems with other drugs because of the low quality of the evidence.

– It remains uncertain whether talking therapies for drinking affect illicit drug use in people who have problems with other drugs. There was not enough information to compare different types of talking therapies.

– Many of the studies did not account for possible sources of bias.

– More high-quality studies, such as randomised controlled trials, are needed to answer our question.

The review was funded by a Cochrane Training Fellowship awarded to me by the Health Research Board of Ireland. Praise from the Cochrane quality advisor:

… compliments and congratulations for the high methodological quality of your systenatic review. It is really well done and I think I’ll use it in the future as an example for other review authors on how to do a good and clear work. (Minozzi, September 7, 2012)

*Note: A square peg in a round hole is an idiomatic expression which describes the unusual individualist who could not fit into a niche of his society.[1] (http://en.wikipedia.org/wiki/Square_peg_in_a_round_hole)

Symposium of the Society for the Study of Addiction: A cultural shift? (#ssa)

Among the Top 5 conferences in the Addiction field worldwide, the SSA symposium (http://www.addiction-ssa.org/) came to pass last week in York (UK). For obvious reasons, the conference organisers are loyal to the same venue for a number of years. Not only it is a spectacular historical town, but it’s accessible from most of the UK research centres of excellence by a couple of hours drive.

Our group brought to the conference a set of related presentations honouring the results of our hard work in the past years. They were all linked by a genuine need to come up with realistic solutions to drinking among methadone users (or other problem drug users):

Problem alcohol use among DUs in primary care: evidence, barriers, research agenda

 The following are titles of three related papers presented together at the conference:

  1.  Problem alcohol use among problem drug users: Development of clinical guidelines for general practice
  2.  The management of problem alcohol use among drug users in primary care: Exploring patients’ experience of screening and treatment
  3.  Psychosocial interventions to reduce alcohol consumption in concurrent problem alcohol and illicit drug users: Cochrane review

To our greatest surprise, we found ourselves amidst a long thought-provoking discussion with the interested audience following our  presentations. This had to be cut off by a chair who was mindful of a long line-up of subsequent talks. I hope this wasn’t only a mere reflection of a hight need or interest in the proffesional community but also an acknowledgement of our expertise in conducting and presentig this research programme.

Following this positive reception of our research we resolved to focus more on quality, than quantity for our research endeavours in 2013; so that we can make for better candidates for the next year’s poster prizes and/or for publishers of the top drugs journal – The Addiction.

Visiting this event for the first time 2 years ago, I couldn’t pass without notice a heavy focus on medical aspects of addiction, e.g. medicines and treatment. That changed. This year, there were many presentations from the community/ practitioner crowd on topics unheard of at this meeting before (e.g. John Roche’s New drugs, new problems? Responding to club drugs in Leeds or Duncan Raistrick’s Payment by Results) – all attended by a number of attendees. The same – non-medicinalising – trend apperead in the conference tweets:

Excellent final talk at #SSA by Tim Leighton. Recovery is not new. Recovery movement = contemporary Temperance movement.
— Dr Vanessa Crawford (@addictionpsych) November 9, 2012

My second observation is about the symposium audience. Many new (young) faces appeared among the seasoned veterans of this conference. This influenced conference’s social programme too, as the conferring crowd quickly dispersed into their rooms following some modest dinner celebrations. Is the crushing hand of recession strengthening its grip and forcing addiction experts to work more – celebrate less? Or are we witnessing a cultural shift in the UK’s most established addiction meeting?

Submitting ethics for new research: killing so many trees

Ethical principles, ethics committees and research

This has been a busy week from an ethics perspective. All research should be ethical and adhere to the ethical guidelines. The gatekeepers for the ethical principles are usually ethical committees, institutional review boards or panels. Researchers submit their proposals for approval to the committees and they decide whether the proposed research is in line with the universally accepted principles of ethical research. For example: Research carried out on humans should be in compliance with the Helsinki Declaration (http://www.wma.net/en/30publications/10policies/b3/index.html).

In Ireland, we have 25 committees/ boards who can provide ethical approval and we submitted two applications for ethical approval to two different committees this week:
1. Are psychosocial interventions for problem alcohol use effective among problem drug users in primary care (PINTA): A Controlled before-and-after feasibility study
2. Prospective audit of characteristics of opioid overdoses in an emergency ambulance service
…so many trees going to the ethics.

As usual, we submitted the ethics application on the last day of the deadline.
I wasn’t even sure if the cyclist courier would take it on a bike to the addressee, because the package had surely over 2 kilos. Fingers crossed.

Trust: the usual suspect in the addiction story

Believe me, or not, trust is something that has been emphasized in addiction treatment for many years. One can hardly argue that it has become one of the usual suspects in the life stories of most recovering drug users.

In this post, I write about two main findings of my latest research published in the current issue of the Czech academic journal Adiktologie (Addictiology). Although they may not be the key findings, which I discovered, this blog gives me an opportunity to illuminate what I feel people should take away from this paper.

 

 


This comes with no surprise – trust is key for building or restoring relationships of all people. No matter if they have drug problems, or not. In this way, my research confirmed what common sense tells us without any special knowledge of research. Re-prioritisation of relationships during treatment was facilitated by the experience of help, support and restoration of trust in relationships.

Because I was able to look at the pre-recovery years of drug users lives, when they actively used drugs, I could go with the trust issue a little further. Changes in relationship priority during active drug use occurred on the basis of barriers (e.g. the need to obtain drugs, stigma), which restrained active drug users from engaging in and maintaining the social relationships.

 

This research has further deepened my understanding of how problem drug users function and indeed how similar they are to people who don’t have drug problems. Some readers may not like this, but they may be less different to ‘us’ than we thought. The key factors that keep them function in a way that is hardly acceptable  by the main-stream population are drug-related barriers. These barriers prevent them from engaging in the usual social life pleasures, such as keeping in touch with non-drug-using friends, visiting parents etc. My research highlighted that they don’t do these things because they have different priorities, which are not compatible with them (See Figure 1 below).

Saying that they are not bothered with relationships or that they’ve no interest in them is too simplistic, and as suggested by this research, not true. Other research showed that people with drug problems do engage in social relationships, pro-social activities, social relationships, raising children – they just don’t do it in a way that ‘we’ are willing to accept. The question that remains to be answered by future research is what would happen if the barriers of engaging in culturally-acceptable social activities were removed? Would ‘they’ be more like ‘us’? The first signals supporting this question come from the opioid agonist treatment. People maintained on pharmaceutical opioids, substituting their illicit drug use, lead more stable lives, commit less crime and have better chances of being employed than people without these substitutes.


Original abstract:
Background: interpersonal problems among drug users (DU) are frequent, are related to other problems, and improve during the addiction treatment.
Aims: to better understand changes in relationships which occur in the course of drug use and drug treatment, as well as their subjective appraisal by ex-drug users, using retrospective methodology.
Method: semi-structured interviews with DUs in a therapeutic community (TC) were analysed with descriptive-interpretive method. The coding of interview transcripts into categories was performed in two phases using qualitative software NVivo 7. Five interviews were coded in the pilot phase, followed by an audit by an external psychologist and progressive coding of the rest of the transcripts, with data saturation being reached in the second phase.
Participants: nine male and one female client, aged 18-36 years (mean: 25.9), participated in the study and the length of their stay in the TC was 2-35 months (mean: 9.9). The approximate mean age of drug use onset was 15.6 years (12-28).
Results: the analysis provided 21 categories which were divided into three domains based on chronological order. Changes in relationship priority during active drug use occurred on the basis of barriers (such as the need to obtain drugs and stigma), which restrained active DUs from engaging in and maintaining their social relationships. Re-prioritisation of relationships during treatment was facilitated by the experience of help, support and the restoration of trust in relationships.
Conclusions: this study builds on the previous work exploring the broad issue of social consequences of drug use and offers clients’ perspective on this topic.
Cite as: Klimas, J. (2012) Interpersonal relationships during drug use and treatment from the perspective of clients in a therapeutic community. [Interpersonálne vzťahy v priebehu užívania drog a liečby závislosti z pohľadu klientov/iek v terapeutickej komunite.]. Adiktologie (12)1, 36-45
More at: www.adiktologie.cz

Figure 1. Evolution of relationships during drug use, addiction and treatment