Category: Harm reduction

Can GPs help problem drinkers who also use other drugs? Article in the Forum magazine

The Forum magazine is the official journal of the Irish College of General Practitioners ICGP. Published monthly by MedMedia since 1991, it is Ireland’s premier journal of medical education.

In January, the journal published a clinical review by McGowan et al (2014)1 which provides a reader-friendly summary of the evidence on the brief interventions in primary care. We commend the authors for that but also wish to highlight the additional challenges involved in implementing brief interventions for at-risk groups including people who also use other drugs, in economically challenging times.

In Ireland, we rank first in the use of heroin in Europe2. With more than 3000 patients attending general practice for methadone treatment, Ireland has a well-established and internationally recognised good example of primary-care based opioid substitution programme 3. Internationally, excessive drinking by patients recovering from drug dependence, is often overlooked and underestimated4. In Ireland, a national survey of primary-care based methadone treatment found 35% prevalence of ‘problem drinking’5. Although effective brief interventions for the general population are available, when it comes to other drugs – we’re still guessing.

To explore the scientific evidence on brief interventions for people who also use other drugs, we conducted a Cochrane systematic review6. Drinking in methadone treatment is probably as old as the methadone treatment itself, but only four clinical trials evaluated effectiveness of interventions to tackle it. Those trials were so different, that we couldn’t pool their results together and come up with a definitive answer. Since the literature couldn’t give us a conclusive answer, we asked patients and their GPs what they think of alcohol interventions in methadone treatment. Surprisingly, the patients didn’t oppose being asked about drinking and welcomed it as a sign of GP caring about them as whole persons7. GPs reported issues that were similar to other countries – time, lack of specialist staff and training8. With increasing workload demands, time is certainly a big issue for GPs, although clear guidance and training on delivering effective ‘brief’ interventions for problem alcohol use can help GPs address this issue within the constraints of a ten-minute consultation.
The information from the Cochrane review and qualitative interviews helped us to formulate clinical guidelines for primary care 9. The guideline development group recommended that all patients in methadone treatment are screened for alcohol annually, that thresholds for screening and referral are lowered for this patient group and that the screening process is more proactive. No matter how good such guidelines are, they never implement themselves10. Structural, organisational and individual barriers hinder the process of implementing innovation in general practice – similar to other clinical areas 11.
Given these barriers, our group developed a ‘complex intervention’ to support care of problem alcohol and drug users 12, consisting of a brief alcohol intervention for people who also use other drugs, coupled with additional practice support with care and referral. The next step in developing the complex intervention is its testing in a controlled feasibility study 13. The study, ‘Are Psychosocial INTerventions Effective for Problem Alcohol Use among Problem Drug Users’ (the PINTA study) involves 16 practices in Ireland’s Midwest and Eastern regions14. The focus of this study is to evaluate the impact of psychology based treatments as opposed to the approach of medicating patients dealing with drug and alcohol addiction. There is a significant knowledge gap in this area internationally and we hope this study will help practitioners in Ireland assist their patients to deal with this issue 15… Read more at www.icgp.ie
Bibliography

Evidence-based solutions for #alcoholharm: Campaigning for change seminar

The wide acceptance of alcohol harms in the Irish society is worrying. Is the proposed public health alcohol bill a step change opportunity for Irish people? Alcohol Action Ireland, an advocacy charity which has been around for more than 10 years, hosted a public seminarwith experts and politicians in the Royal Irish Academy on March 3rd.
Campaigning for Change seminar in Dublin, March 3, 2014 
Minister White opened the night by pledging the government’s goal to reduce the national consumption of alcohol below the OECD average by 2020. The new public health alcohol bill proposes radical measures, such as minimum unit pricing and alcohol advertising ban, which will cause discomfort. Therefore, the government should proceed with evidence-based consensus. A new North-South minimum unit pricing study will bring concrete evidence for the regulations that the bill proposes.
Dil Wickremasinghe, the second-to-speak activist, broadcaster and Director of Insight Matters, shared her story of coming out as a teenage lesbian. Alcohol companies are behind the sponsoring for many LGBT events. The sponsors and culture create an enormous pressure on immigrants to keep up drinking with the local community. Alcohol and socializing go hand in hand in Ireland – We’re Irish, we need a pint to have a good time.
A public health specialist, Dr Bedford talked about his life-long experience of campaigning for alcohol regulations, such as random breathalyzing, which brought immediate drop in the alcohol harms. Because of the success with previous campaigns, he recommended the public health advocacy tool.  If we organize ourselves well, we can get results, but we need to keep the campaign message simple. Celebrities can draw audience to our campaigns, such as Gay Byrne did for the RSA random breath testing. If you’re not in the media in this business, you don’t exist. Repeat the message; repeat the message – same simple message all the time. The public health campaigning is for marathon runners, not sprinters.

Alastair Campbell, a writer, campaigner and a former Director of Communications and Strategy for Tony Blair, pondered when the change comes and how the countries are similar to individuals in their alcohol denial. The leadership comes from people who decide to make change happen; the countries have to admit that they have a problem. Countries’ leaders hesitate with changes, as Mr Campbell recalled a Tony Blair anecdote about the introduction of smoking ban law in UK “let’s see how it works in Ireland”. UK failed with introducing the prepared minimum pricing policy because of the alcohol industry pressure. Ireland can learn from that failure. Unless we understand that we are all paying for fixing of harms caused by alcohol, we won’t understand the minimum pricing. Low-risk drinkers – don’t be afraid of minimum pricing.

Retention versus continuity of care?

Retention in treatment has been traditionally regarded as a key outcome measure of addiction treatment. Thinking about this indicator brings us to fundamental questions of what a success in treatment is and how it can be measured.
The longer drug users stay in treatment, the higher their chances of success. Their health improves; they commit less crime and have more stable daily routine. Early identification and treatment of drug problems is also associated with better outcomes. NIATx, for instance, is an easy to use model of process improvement designed specifically for behavioral health. It helps substance abuse and mental health treatment organizations improve user access to and retention in treatment, defined as “attendance at the second, third, or fourth outpatient treatment sessions”. Others regard 12-month retention in care as success.
Rowdy Yates said, at the INEF conference in Dublin, 2011 that drug users seeking treatment want to give up drugs and what they get from us? Methadone [a replacement opioid]. This statement reflects the inability of many treatment systems to offer a menu of options and tailor them to individual needs of drug users. Medicating drug problem is one of the solutions that work for a large population of treatment seekers. Other options should be offered too.
Dr Okruhlica, in Slovakia, agrees with the diagnosis of addiction by the International Classification of Disorders (ICD) or Diagnostic and Statistical Manual DSM. This definition lists several symptoms of addiction. If somebody has certain number of these symptoms, they receive the diagnosis. If the person doesn’t have symptoms for a year, they cannot be regarded as ill any longer. Harm reduction experts believe that while the medical diagnosis of addiction could be helpful in understanding the problem, even the most dependent users have control over their drug use and choice plays an important role in their life. Dr Zinbergwas a pioneer of this approach with his monograph The Basis for Controlled Intoxicant Use. Studies on uncontrolled drug use followed. These views are regarded as extreme by many. Their believability is further undermined by the fact that non-problem drug users live in anonymity. For example, very few scientific studies manage to engage with non-problematic heroin users.
On the other hand, the recovery-oriented movements, especially AA, maintain that once a person “gets” addiction, they will become ill forever. This opinion can be very helpful for people in treatment, but can actually harm people out of treatment. Ex-users seeking re-integration into job markets are viewed as irresponsible and incapable of holding jobs for long time – result of a society stigmatization.
Because retention in treatment, as a robust outcome indicator, is highly esteemed in the drug addiction field, most professionals working in the addiction are able to place them somewhere on the continuum delineated by the two extremes – illness for life vs. uncontrolled drug use. See figure 1 below.
Figure 1 Continuum of opinions
Alongside the controversy around medicalization of drug use runs another debate about language. For many, language doesn’t matter too much and is a matter of political correctness. Opposite to them, I would like to hope, stand the language-believers. For them, the words we use shape and influence the world we live in. If we call drug users “junkies” they will become “junkies” – whatever that word represents to those who use it. Similarly, the term retention could be too close to detention; people are not kept in treatment to help them regain life, but to help sustain the treatment centre. Just like in the prison, where the inmates have little control over their length of stay, the people detained or retained in treatment have little control over length of their treatment. Opponents of the word retention propose continuity of care as an alternative, more humane, term to describe this golden-standard treatment outcome indicator. For them, it incorporates also the individual willingness to receivecare. But, are patients aware of it? I ask.

Language shapes and influences the drug treatment systems that we study or work for. It is important to recognize that even though retention and continuity of care could be the same thing – looked at from different angles – we have to choose the words we use in treatment carefully and make sure people who use our services are aware of it.

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”.

A decade in the addictions field

book, envelope, window

Edited March 4, 2020 by janklimas

… or women, men and non-binary folk who mentored me.

Career in addiction health services research can be daunting. There are moments when people in this career path struggle at work. Have you ever been in that situation yourself? Here’s my story.

Needle exchange movie at 16

The internet was still a toddler and I watched the TV rarely. But when I turned on the box on one of such occasions, a summer afternoon, I was brought into the streets of the Slovakian capital, Bratislava, which was a world far far away for me. Young social work students backpacked those streets with bags full with clean needles and distributed them to drug users and sex workers; they talked about what this exciting and controversial pastime meant for them. They worked for a needle exchange project – Odyseus – and I wanted to do it too. I was excited to help drug users in the same way these women did, but I had to wait a couple of years until I grew up.

At that time, they still called it ‘Street work’ which later became ‘Terrain Social Work’. In the following years, I learned from my future boss that the Slovakian public TV screened the film quite often, but mainly as a filler in the downtime hours.

Unanswered phone call at 20

After acceptance at the psychology degree, my world changed and the range of my interests expanded. Nevertheless, I never forgot about that documentary. It was in the second year when I saw a poster at our university board, at advertised Needle Exchange as a part time job for students. I picked up a public phone and dialled a number from the poster – following my teenage dream. Nobody picked it up, so I left a message which too remained unanswered, forever. The number on the advert wasn’t for the Needle Exchange which the documentary talked about, but I didn’t know it at that time. By chance, I ended up working for the agency from the documentary movie because they had an email address posted on the internet and were more responsive than the project which advertised on our student board.

Student project at 21

Part of my comprehensive exam in the 3rd year of my undergrad was a research project. As most of my friends, I struggled with access to patients. Because of that, almost everyone did a literature review – without having a clue what we were doing. I chose the role of family and drugs as my topic, but it wasn’t an easy choice. At that time, my interest in drugs was drifting away and I felt like researching something else, for example depression or disabilities. I don’t remember how I ended up with drugs again, but my review led to working with Dr Timulak, and eventually, to my MSc and PhD projects.

Dr Peter Halama, PhD and Hungarian trams at 25

Dr Halama, PhD was this new face at the Trnava University, when I wrapped up my comprehensive exam. They were good friends with Dr Timulak and when I asked him about ideas for my MSc research, he said that Dr Halama was doing some interviews with drug users. Two years later, I found myself co-presenting our findings with Peter at a psychotherapeutic conference in Slovakia. Read more about that research here. From there, it was easy to continue in my research with Peter at a doctoral level. I enrolled as a part time student in Social Psychology, which did not convince him that I would finish it. When I announced – after two years of studies – that I’m moving to Hungary for a year, I think Peter had a hard time suppressing his doubts that I would finish my PhD from Hungary. My Hungarian adventure was, however, a real turning point. I had to commute between offices and spent long hours in trams. Being too bored of watching cars and people pass by, I started to read open access articles which I downloaded from internet the previous day. Some were more interesting, others less, but when I found something really relevant to my work, I felt like a gold miner who just dug his jewel out of piles of dirt. My passion grew stronger with every new paper.

Irish job hunt at 28

When we arrived to Ireland in early Autumn 2008, all I had was a small EU grant with a budget of 3000 euros and an unclear host organization. We managed to survive for almost a year with a great help of my wife’s EVS stipend and occasional p/t jobs. The work on my PhD and the EU grant took most of my time, leaving only a couple of hours for finding a more stable position. When I eventually ran out of money, it was late winter and the job market had dried up. I submitted my resume to many advertisements, including a research job on men’s sexual health. I must say that research was not on my list of Top 5 jobs, but when this position came up after 8 hopeless months of job hunt it was a true God-send. The pictured ad initially offered a PhD post in drugs research, but at the interview, my current boss – Prof Walter Cullen – told me about a p/t place on the same project. That’s how I came to research drinking among methadone patients in primary care at UCD.

Dr Dennis McCarty, PhD at 31

OK, I know I said that there were 5 key decisions earlier, but there has been a lot going on recently. In July 2011, I have been to a summer school on drugs in Amsterdam, Netherlands – no one could imagine a better place for this adventure. Dr McCarty, lectured for several days on different policy models and evidence based treatments. Two years later, I’m sitting in an office down the hall from Dr McCarty’s office, writing my final report about the INVEST fellowship. 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. I hope this ‘fire’ will keep on burning for at least another 10 years.

Engage in not for profit organizations.

Two organizations jump started my work in non-profits, the University Pastoral Centre and a youth club. I learned the power of community building through youth activism with John Lesondak and taught team building for non-profits with Ivan Humenik. With Ivan and friends, we also had a musical band, JK& band. These activities inspired me to get involved in the community projects for people who use drugs.

Access mentors in voluntary service programs.

Petra a Ivan Sedliacik connected us to the world through the European Voluntary Service, which is a training program of the European Union. My youth exchange training took part in Budapest, Hungary, and a small suburban town called Goddollo with Zsuzsa Szabo. I was trained as European volunteer, improving soft skills and contributing to the common good. Petra and Ivan continued to support me throughout my training and shared their own experiences from living abroad and being European volunteers.

Be a life-long learner.

A Leonardo Da Vinci Scholarship, which was European Union’s Lifelong Learning Program, took me to Cork city on the south of Ireland. Geoff Dickson mentored me in the city’s YMCA. A few miles away, in Ballincolig, Ivan McMahon overlooked my evaluation of youth programs for early school leavers and single moms. It was great to see the practical application of science in Ireland while doing my part time doctoral degree. I got to evaluate training programs, develop program databases and identify best practice approaches for real life problems by searching the literature.

Write outside your comfort zone.

While writing scholarly articles is difficult itself, one can easily fall asleep their comfort zone. I stepped out of this zone in 2013 when I enrolled in a prompt-based creative writing workshop in Portland, OR, housed by the state’s largest bookstore, the Powell’s books on Burnside street (https://writearound.org/). This is when I began to take my writing interests seriously thanks to our volunteer instructor, Matt Blair. His workshop re-invigorated my passion for writing and taught me the value of daily writing practice.