Category: Harm reduction

What do persons on methadone in primary care think about alcohol screening?

Enhancing alcohol screening and brief intervention among people receiving opioid agonist treatment: Qualitative study in primary care

New Paper Out Now

Although very common, excessive drinking by people who also use other drugs is rarely studied by scientists. The purpose of this study was to find out patient’s and clinicians’ opinions about addressing this issue. All of them took part in a study called PINTA – Psychosocial interventions for problem alcohol use among problem drug users.

photocredit: emerald

Doctors reported obstacles to addressing heavy drinking and overlooking and underestimating this problem in this population.

Patients revealed that their drinking was rarely spoken about and feared that their methadone would be withheld.

Read the full article in the latest issue of the Drugs and Alcohol Today: http://www.emeraldinsight.com/loi/dat

See also my previous posts about the PINTA study:

New paper out now: Psychosocial Interventions for Alcohol use among problem drug users

2014

Beg, steel or borrow: getting physicians to recruit patients in clinical trials

Addiction Medicine Education for Healthcare Improvement Initiatives: New Paper out Now

2013

Honor pot: testing doctors’ drug counselling skills in a new pilot study in Ireland

Fidelity questions

Why Empirically Supported Psychosocial Treatments Are Important for Drug Users? New research project

New article out now: Time to confront the iatrogenic opioid addiction

The Medical Post
May 2, 2016
CanadianHealthcareNetwork.ca
OPINION: JAN KLIMAS
 Time to confront iatrogenic opioid addiction
Canada has been grappling for decades in a largely ineffective attempt to keep heroin out of our borders. Now the unsafe prescribing of opioids has organized crime groups turning their attention to ‘customers’ whose addiction started in the doctor’s office. Physicians are going to have to face the tough conversations that involve two of the hardest words in a doctor’s vocabulary: ‘enough’ and ‘no.
The full article is now online, and has appeared in the Doctor Daily e-newsletter on Monday May 2m 2016

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New paper out now: Primary care distributes life-saving medication for 17 years

The year was 1996 and Ireland was recovering from a recent heroin epidemic. Methadone, a medical replacement drug for heroin, was jut making its way into specialised clinics in Dublin.

Professor Gerard Bury and colleagues had a revolutionary idea that people who use drugs can receive agonist drugs, like methadone, from their family doctors.

photocredit: tandfonline.com/loi/igen20#.VlO9bHarTrc

The opioid agonist treatment has substantially changed the course of the drug use epidemic. Yet, many continue to die and suffer from chronic diseases. In Ireland, everybody who’s prescribed this medication has to be registered with the Central Treatment List.

In this new study, we wanted to revisit a group of people who were the first to receive their agonist medication, i.e., methadone in the primary care in Ireland.
At follow-up in 2013, 27 (27.6%) of the 98 people had died in Ireland and had relevant entries in the Register of Deaths, 19 (19.4%) were currently in OAT and the status of the remaining 52 (53%) was ‘alive,’ as per the Irish death registry.
The 52 patients ‘alive’ had left the Central Treatment List, but no further information was available on their status.

“Our inability to establish the interval data for the retention in treatment is a significant study limitation, but the overall retention of 19 out of the surviving 71 patients is comparable to previous research.”


The deceased died of multiple causes; only six had a single cause. Drug toxicity, overdose, or both, were the most common causes of death.

Cited study:
Jan Klimas, Anna Keane, Walter Cullen, Fergus O’Kelly, and Gerard Bury (2015) Seventeen year mortality in a cohort of patients attending opioid agonist treatment in Ireland. European Journal of General Practice (http://dx.doi.org/10.3109/13814788.2015.1109076)

Irish doctors trained to save by the nose

Can junior doctors learn to spray a life-saving medication into noses of people who overdosed on opioids? A new study from Ireland attempted to answer the question.

Overdose is the most common cause of fatalities among opioid users. Naloxone is a life-saving medication for reversing opioid overdose. In Ireland, it is currently available to ambulance and emergency care services, but General Practitioners (GP) are in regular contact with opioid users and their families. This positions them to provide naloxone themselves or to instruct patients how to use it. The new Clinical Practice Guidelines of the Pre-hospital Emergency Care Council of Ireland allows trained bystanders to administer intranasal naloxone.

We describe the development and process evaluation of an educational intervention, designed to help GP trainees identify and manage opioid overdose with intranasal naloxone.

Participants (N = 23) from one postgraduate training scheme in Ireland participated in a one-hour training session. The repeated-measures design, using the validated Opioid Overdose Knowledge (OOKS) and Attitudes (OOAS) Scales, examined changes immediately after training. Acceptability and satisfaction with training were measured with a self-administered questionnaire.
Knowledge of the risks of overdose and appropriate actions to be taken increased significantly post-training [OOKS mean difference, 3.52 (standard deviation 4.45); P < 0.001]; attitudes improved too [OOAS mean difference, 11.13 (SD 6.38); P < 0.001]. The most and least useful delivery methods were simulation and video, respectively.

Appropriate training is a key requirement for the distribution of naloxone through general practice. In future studies, the knowledge from this pilot will be used to inform a train-the-trainer model, whereby healthcare professionals and other front-line service providers will be trained to instruct opioid users and their families in overdose prevention and naloxone use.
BMC Medical Education 2015, 15:206  doi:10.1186/s12909-015-0487-y
The electronic version of this article is the complete one and can be found online at:http://www.biomedcentral.com/1472-6920/15/206

International AIDS conference and the role of Drug Policy #‎IAS2015

Dr. Evan Wood speaks at ‪#‎IAS2015 conference in Vancouver, on How Drug Policy should respond to the HIV Epidemic. International AIDS conference 2015’s daily plenary sessions feature some of the world’s most distinguished HIV scientists, policy specialists and community leaders.

Tuesday July 21, 2015:

When Dr Wood led the writers of the Vienna declaration at the AIDS conference in 2010, I was a fresh research assistant in Dublin, Ireland. As a Slovakian, I followed preparations of the conference with great excitement. Bratislava, our capital, was only 30-mins drive from the conference. All my former colleagues went the www.ODYSEUS.org needle exchange attended the conference in Vienna.

 
Dr Evan Wood (photo credit:http://bc-cfe.tumblr.com/)

It has never crossed my mind that five years later, I’d be working alongside this giant brain and great leader, Dr Wood. This time, I got to see his talk at the conference in Vancouver, Canada.

 

What is the problem?

Drugs are not the problem, addiction is. A neuroscientist, Dr Carl Hart, thinks that more dangerous than drugs is ignorance about drugs. Most people who use drugs do so relatively without problems or addictions. Our understanding and definition of addiction evolved over time. Experts now think it’s a disease; some say a disease of the brain. In the past, addiction went from being considered as a moral failing, to medical condition, to psychosocial, bio-psycho-social, and to bio-psycho-social-spiritual disease. Reducing it back to the brain component seems to go against the flow of time and our evolution of knowledge.
“Addiction is a disease — a treatable disease — and it needs to be understood.”
– Dr. Nora Volkow
Dr Wood told us a story of the epidemic of HIV among people using drugs in Vancouver, BC. If you’ve lived in British Columbia, you’d seen a miraculous 90% reduction in new HIV cases over the years. It was well over a decade before HIV has emerged among people who used drugs. Historically, single room occupancy hotels served fishermen and loggers – seasonal workers. Poverty took over these hotels a century later. People went up into these buildings where the likelihood of interacting with police is less, but provision of clean needles or HIV tests is very problematic. In 2002, the only needle programme closed at 6PM each night.  The illegal Marijuana-growing industry in BC is closely linked to the Cocaine industry.  People who inject cocaine need to do so many times a day. Without an access to clean needles, this led to huge health problems. Almost 1 Fatal overdose per day happened during the HIV epidemic.

What is the solution?

 
Treat everyone. Access to care is a human right. Is it feasible? Treatment rates are low, but does everyone need the treatment? In U.S. only about 10 percent of people with addictions get treatment, out of an estimated 23.2 mi people affected.  Although treatment may not have the solution or capacity to help those millions of people, the progress in addiction science has led to new, effective medications. They can mean the difference between life and death for some people, especially those living with HIV.
The empowerment of the community in Vancouver, BC, really turned the tide of the HIV epidemic. They urged the city government to take action that came up with a 4-pillar approach to drug problem in Vancouver: 1. Peer-to-peer syringe provision – in 2010, there were over 30 places where you could get clean needles; people are moving away from injecting despite the availability of clean needles; 2. Safe-injecting rooms preclude the opportunity for needle-sharing. Dirty needles don’t end up on the society. None of the 2mi injections of drugs in the safe rooms has led to a fatal overdose; 3. Expansion of methadone treatment; it’s not just that methadone protects against HIV but there’s advantages in terms of antiretroviral therapy; 4. Treatment as prevention impact of the viral load in the community is the strongest drive for people becoming HIV positive. In the population of people who have been considered hard to treat, only about 3% are not on antiretrovirals.

What does it mean for early-career addiction scientists?

 
The mandate of addiction science is to find evidence to help people with addiction. We’ve studied drugs for decades and learned that their effects are predictable, mainly: the higher the dose, the higher the likelihood of toxic effects.  Moving on from studying the effects of drugs, we should study the effect of contexts where drugs are being used. How do these contexts change the effect of drugs on people? What’s the role of milieu in addiction?
“What is far more important – studying the brain or studying behavior?”
– Dr. Carl Hart

When the HIV epidemics happen, they do not occur by accident. They are the consequence of an un-orchestrated happenstance. They have their origins in harmful policies and circumstances, limitations and harms of criminal justice approaches. In this context, the importance of community empowerment and the value of integrating harm reduction, addiction- and HIV- treatment cannot be underestimated.