Category: Drugs

Doing research with busy doctors – an open space world

Family doctors are notoriously busy. Lack of their time is the number #1 barrier of doing anything outside their patient workload, including research. And yet, some enthusiasts get involved in the research endeavour, believing it can enhance primary care.

Knowing this, I looked for ways to do research with busy family physicians for my INVEST fellowship in Portland, OR. I needed to get them in one room and ask the group a couple of questions about their recent resident training initiative, SBIRT Oregon. The only time when my doctors were all in the clinic was right after another meeting. One of them suggested doing an open meeting technology. The phrase vaguely rang a bell with me.

‘Open space’ describes the process by which a wide range of individuals, in any organisation, can facilitate creative meetings around a complex theme of importance to all stakeholders 1. While a theme may be important to all stakeholders, they may have differing perspectives and responses, so this approach permits all voices to be heard and facilitates a process where stakeholders move from conflicting views to consensus. The approach has been widely used in commerce, religious communities, (non-)governmental agencies and war zones 2.

How did this work for us?

Our field ‘experiment’ lasted for about 90 minutes with two meetings in one room, right after each other. The meetings were unrelated, but 3/4 of the participants from the first meeting were scheduled for the second meeting too. I and my co-facilitator arrived well ahead of the first meeting. As doctors started to show up for the 2nd meeting – the 1st meeting was still in progress – some people were confused; others patiently listened to people talking at the 1st meeting. I found it very useful to sit on the 1st meeting and the transition to the 2nd meeting was much easier – all were in their seats already.

All in all, this set up had many advantages for multiple meetings with extra busy attendees. It can help solve problems and it works best with many people attending your meeting, but maybe it’s not ideal for research focus groups. A tip for a freshman facilitator: it’s amazing how much powerful an incentive for research can food be, especially pizza.

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1http://www.michaelherman.com/cgi/wiki.cgi
2http://www.openspaceworld.com/papers.htm

Relationships of drug users change, but slowly

relationships change

Are social relationships sensitive to therapeutic change?

The ‘‘Phase Model of Change’’ –  a famous model in psychotherapy – says that change in overall functioning in life, including interpersonal problems, occurs during later phases of therapy. Well-being and symptoms take precedence. Social problems may last long, but this cross-sectional Slovakian study showed it’s worth asking drug users about their relationships. Intrusiveness and affectionate support seem to be the key players.

Read More: http://informahealthcare.com/doi/abs/10.3109/14659891.2013.790496

Helping agonist patients with alcohol problems: A NEW guide for primary care staff

What should doctors do differently when screening for alcohol use and delivering brief interventions for agonist patients in primary care? General principles remain the same like for other people, but:
  1. the screening and treatment processes should be more systematic and proactive in all problem drug users, especially in those with concurrent chronic illnesses or psychiatric co-morbidity,
  2. lower thresholds should be applied for both identification and intervention of problem alcohol use and referral to specialist services,
  3. special skills and specialist supervision is required if managing persistent/dependent alcohol use in primary care.

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)