76th Annual Conference of College on Problems of Drug Dependence: Decide to be fearless& fabulous
Not one, but two conferences in Puerto Rico made my trip fantastic. As usual, the NIDA International forum happened for the 15th time on the weekend before the Conference of the College on Problems of Drug Dependence. The lines below offer some insights from these meetings.
Integration of addiction treatment into primary care: the portals of entry
Is abstinence related with good health? Is decreased drug use related with good health?
Tae Woo Park and Richard Saitz asked these questions in a secondary analysis of data from a clinical trial of 589 patients using cocaine or cannabis with very low dependence proportion among the sample (ASSIST score >27). To answer their questions, they used clinical measures of good health, such as, SIP-D, PHQ-9, and EUROQoL. Health outcomes were associated with decreases in illicit drug use in primary. However, abstinence and decreased use may represent very different magnitudes. Self-reports related dysphoria could also play a role in the differences. It takes a long time to make improvement in those consequences? 6 months of follow up observations may not be enough. Patient-preferred outcomes are paramount: do they want to have a score lower than XY on PHQ-9? What outcomes are important for them?
The TOPCARE (www.mytopcare.org) project implemented guidelines for potential opioid misuse (Jan Liebschutz). Her slides blew up half-way through the presentation but she delivered the talk excellently. Nurse care management was a component of the guideline implementation trial. Academic detailing (45min, with opioid prescribing expert) included principles of prescribing brochure and difficult case discussion. Is academic detailing effective? The Cochranesystematic review of literature found small-to-medium variable effects. The preliminary results of the project show that the nurse manager programme is a no brainer.
Rich Saitz commented on the sad state of affairs in the addiction treatment, where only 10% of people with addiction are in treatment. Integrated care is the best thing since the sliced bread, but where’s the evidence? His research showed no added benefit of integrated versus care as usual. Why? Maybe, addiction is not a one thing, but we treat it like one thing. Dr Tai provoked the audience with a question: “Do our patients with addiction have the capability to participate in the treatment planning and referral?” If they seek medical care for their broken leg and we refer them to an addiction specialist, will they go? most likely not.
But it is the same with hypertension. Referral is a process and not a once-off thing. Although they may not follow our advice at the first visit, a rapport built by a skilled professional over a series of discussions can help them get the most appropriate care.
Does the efficacy of medications for addiction decrease over time?
An old saying among doctors states “One should prescribe a new medication quickly before it loses its efficacy”. Elias Klemperer pooled the data from several Cochrane systematic reviews on addiction medicines, such as, NIRT gum, Acamprosate, or Buproprion. Their effectiveness decreased over time. The changes in methodologies might have caused the decline; also the sponsorship of trials, target populations or publication bias.
Write, wrote, written
Primary author is in the driver’s seat, others are passengers. Primary author pulls the train. Dr Adam Carrico(UCSF) asked us “What are you really passionate about?” Find it and use your passion for those themes to drive your writing habit. Decide to be fearless& fabulous. Develop a writing routine. Put together a queue of writing projects and don’t churn out 2 products at the same time, one of them will suffer. Schedule writing retreats with colleagues. Set Timelines for writing grant and programme time for reviews by trusted people, give people a warning that this is what you’re planning to do. The JAMA June 2014 issue offers useful tips on how to write an editorial.
Dr Knudsen reported on the editorial internship of the Journal of Substance Abuse Treatment – JSAT, which started in 2006, with Dr McGovern (current editor) and Knudsen as the 1stfellows. Success rate of the fellowship applications is 2/30-45, prior involvement is appreciated (peer reviewer, submission). The new 2014 fellows are: Drs Madson and Rash. In the one year of the fellowship, the fellows typically review 12-15 manuscripts, some years, as a managing editor of a special issue. The Drug and Alcohol Dependence journal has a similar scheme.
Check out the http://www.cpddblog.com/
Dennis McCarty won the 2014 NIDA International Program Award of Excellence
June 14, 2014 ― Professor Dennis McCarty, Ph.D., professor in the Department of Public Health and Preventive Medicine at Oregon Health & Sciences University (OHSU), and director of the Substance Abuse Policy Center in the Center for Health Systems Effectiveness, has been awarded by the 2014 National Institute on Drug Abuse (NIDA) International Program.
The award is for Excellent Mentoring. Dr. McCarty mentors clinicians and researchers who test emerging drug abuse treatments in community settings through the Western States Node of the NIDA Clinical Trials Network, which he codirects. He extends his mentoring to state and local policymakers through his role as director of the Substance Abuse Policy Center in the Center for Health Systems Effectiveness, which works to link policy, practice, and research on substance abuse treatment.
Dr. McCarty also is scientific director of the University of Amsterdam Summer Institute on Alcohol, Drugs and Addiction. I met Dennis in Amsterdam in 2011. He lectured for several days on different policy models and evidence based treatments. Two years later, on March 1, 2013, I joined Dennis as a NIDA CTN INVEST Fellow. INVEST is International Visiting Scientists & Technical Exchange Program for drug abuse research. Oregon Health & Sciences University hosted my six months fellowship during which I assessed the use of Screening and Brief Intervention (SBIRT) for alcohol use disorders among patients receiving agonist medication for opioid use disorders. 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. Dennis received the award today, at the 19th annual NIDA International Forum in San Juan, Puerto Rico. The 2014 Forum focused on “Building International Collaborative Research on Drug Abuse.”
Four other experts were awarded 2014 NIDA International Awards of Excellence. Mr. O’Keeffe, a professor at Virginia Commonwealth University, was honored for Excellence in International Leadership. The award for Excellence in Collaborative Research went to Dr. Chawarski, Ph.D., Yale School of Medicine, and Dr. Kasinather, Ph.D., Universiti Sains Malaysia. A special award was presented to Dr. Dewey, Ph.D., Virginia Commonwealth University, in recognition of his service to the addiction research community as founder of the Friends of NIDA, and his research on how opioids and marijuana change brain and contribute to tolerance and addiction.
NIDA International Awards of Excellence winners are selected based on contributions to areas essential to the mission of the NIDA International Program: mentoring, international leadership, and collaborative research. Anybody can suggest a nomination to NIDA. Read more at www.drugabuse.gov/international/awards-excellence.
The NIDA International Program connects people across continents to find evidence-based solutions for addiction, and drug-related HIV/AIDS. NIDA is part of the National Institutes of Health – the principal research agency of the U.S. Government and a component of the U.S. Department of Health and Human Services.
Story first released by OHSU Newsroom: http://www.ohsu.edu/xd/about/news_events/news/index.cfm
Three years post doctorate
27 April 2014
Transitions are life changes that allow us to pause, reflect and plan. Here’s a short history of my transition from the pre-doctoral to the post-doctoral stage. Read the full story here.
Hungary 2007. My Hungarian adventurewas a real turning point in my career. I had to commute to work and spent long hours in trams. Bored of watching cars and people, I started to read open-access articles about addiction. When I found something really relevant to my PhD, I felt like a gold miner who just dug his jewel out of piles of dirt. My passion grew stronger with every new paper.
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| Figure 1. Jano in transition |
Ireland 2008. When we arrived to Ireland in late 2008, I had a small EU grant, with a budget of 3000 euros, and an unclear host organization. We survived for almost a year living from my wife’s EVSstipend and seasonal part-time jobs. My PhD and the EU grant took most of my time, leaving only a couple of hours for job-hunting. When I eventually ran out of money, it was late winter and the job market had dried up. Finally, I found an academic job, initially advertised as a PhD in Translational Medicine but my potential boss – Prof Walter Cullen – told me at the interview that I should apply for a p/t job on the same project. That’s how I came to research drinking among methadone patients in primary care at UCD.
Oregon 2013. In July 2011, only two months after receiving PhD, I have attended a summer school on addiction in Amsterdam, Netherlands. Dr McCarty, the school director, lectured about various policy models and evidence-based treatments for several days. Two years later, I did a NIDA fellowship with Dr McCarty at Oregon Health& Sciences University. Read this post about how I got there.
Lessons learned from junior post-doc
1) Write a lot. Like some teenagers, I used to write poems, songs and short stories. Then I stopped for many years. In Oregon, my wife surprised me with a Prompt-based creative writing course for my birthday. She thought it would be good for me and that I would enjoy it. Dr McCartyencouraged me to submit an essay to the Wellcome Trust Science Writing competition and to write a lot. Since then, writing became the core of my work.
2) Learn a lot. If you think of life as a huge learning experience, you welcome trouble as a gift.
3) Keep at it. Perseverance is critical in science. Progress takes years. New knowledge accumulates slowly. And the desired change is uncertain. While I was distributing clean needles to injecting drug users in inner-city Bratislava, Slovakia, I could see the effect of my work immediately. Now I have to wait ages and the change may not come in my life.
I’ve learned many more lessons than just these three, but I’ve learned how to separate the weed from the wheat from the chaff too. I don’t write about the minor lessons.
Future plans for senior post-doc
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To stay true to myself
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To reach a position of independence by:
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conducting a randomized controlled trial
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supervising work of junior investigators
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To maintain a happy work-life balance
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To pass the accumulated knowledge and skills on other:
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Doctors and helping professions, by helping them become more competent and confident in addiction medicine research
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Medical students, by helping them discover and master addiction medicine research
Re-entry shock – you can’t go home again
Culture shock is defined by Wikipedia as the “difficulty people have adjusting to a new culture that differs markedly from their own. A reverse culture shock a.k.a. “re-entry shock” or “own culture shock” is a state when returning to one’s home culture after growing accustomed to a new one produces the same effects.
First culture shock hit me when I arrived to Portland, Oregon, in March. I thought it was over then and that there will be no more surprises about adjusting to my normal life in Europe. I did not know that the second culture shock comes when people return to their home country. Many students on exchange programs experience it. Here’s my rant.
Big surprise
The shock of the transition to Portland, OR, was surprisingly weak. It took me only a couple of days to adjust and embrace the new life there. The easier this transition went, the more difficult the second transition was. It was new and unexpected for me. The beginnings were really difficult, manifesting in confusion and other negative feelings.
Business as usual – as if we never left
My normal life, as I knew it before, was over. Most things remained the same. The things I hated before are still there and I still hate them. But I was not the same at all. I could not avoid a feeling of disconnect between the past and the present life. Another fellow told me a story of how on her first day at work, everything turned as it was in a split second. There was just one word of her boss and just one look of her colleague and she was back to her old relationships.
Repulsion
Stereotyping and hostility towards host nationals were not as new to me as other re-entry symptoms. When we came to Ireland first time, everything and everybody looked very different. This time, my eyes became very critical this time, though; every small weakness of the new-old country seemed like a giant disadvantage.
Physiological stress reactions
I was lucky not to have any serious stress reactions, but some of my friends suffered. Depression was lurking in the background and sometimes jumped into Facebook statuses, e.g. “I have grown two wings but I can’t fly”. Examples of what happened to people who came back included divorce, no house, no job, mood swings, or people at work are not welcoming them. Compulsive eating/ drinking/ weight gain occurred too: another fellow have lost 5 kg while on fellowship but upon her arrival she toured her family for 2 weeks and gained that weight again. My mother in law lived in UK for five years and when she came back home, she wanted to return to UK immediately.
Disappointment – inability to apply new knowledge and skills
People aren’t interested in my experiences from abroad. I will never be able to use the knowledge I have gained abroad. Ambitions and competition hinder cooperation, people see you like their enemy. In the previous country, if they saw you being good at something, they supported you. Here, they envy you and try to make it harder for you. This country is broke and there are no growth opportunities. There are no money, no jobs. I could do much more if I stayed there. Smart people struggle to survive here. How can they live in such miserable conditions?
Rootlessness – I don’t belong here
Feelings of alienation and withdrawal are common symptoms of culture shock. I felt that people aren’t nice here. They don’t appreciate if I smile at them or if I start talking to them. They don’t like me and don’t understand me. I feel so weak here, so helpless and isolated. I need their response or feedback. I need to engage with them. People see the “wrong” changes when they look at me. “You’ve lost weight” somebody said and I didn’t believe her. Three other people said it later. This was not the type of change I was proud of or that I wanted them to recognize.
Boredom
The shift from a big town in a big country to a smaller country was dramatic. This is a small town, there’s nothing here. This is nothing. No life, no culture, no fun. It is boring. Services are undeveloped, ineffective and slow. They are not customer orientated. People are dull and everything is made on such a small scale that it doesn’t even matter. Everything is small. Cars, trains, houses are small; I need more space to live better. Bicycling is unsafe, there are no bike lines and cars don’t share the road with cyclists. The streets are dirty and the greens are overgrown; nobody cuts them regularly.Our flat is very small; we need to move out to a better place. I don’t like this area; I don’t understand how I could live here before. We threw away most of our things when we came back home. Our home was not our home any more. This state is well phrased in the saying “you can’t go home again,” first coined by Thomas Wolfe in his book of the same name.
Hope
When people return home after living abroad, it can take a while to adjust to their home country. Some don’t get used to it at all. I had the privilege to meet people who succeeded in bending their new lives. The new life wasn’t great. They lived in small apartments and struggled financially. But at least some of them enjoyed what they worked on. It was a demanding and low-salaried job, and often not just one. This gives me hope that things can get better. This country doesn’t have big events, venues or communities, but there are many small, which can serve the same purpose.
Going home
West coast and East coast of the U.S. are very different, people always told me. West coast was my home for 6 months – spring and summer. At the summer’s end, I took a long trip home to explore the East coast. This blog is about our journey to NYC, Ocean City (NJ), Millstone and back.
On Monday, we went from Portland, Oregon, to New York City. The Portland cab couldn’t find our address and stopped at the bottom of the block, leaving us to carry our heavy luggage alone. This was his second day at work, and his first airport ride – as we discovered later. He played in a heavy metal band for 11 years, since he came to Portland, and he was a vegan. To our great surprise, he knew many towns in our homeland – Bratislava, Prague and Brno – because he played there with his band. His intimate knowledge of those places made us feel closer to him, as we talked about the live in Portland. People who move to Portland are … bums, they are different. What is it about the city that attracts this special breed of humans? We couldn’t find an answer to that question, but agreed that it is the best city in the States. The driver wanted to give us 5$ discount because of the address issues, but we refused recognizing that starting a new job requires learning new skills, which takes time.
NYC was dirty, crowded and noisy. Our red-eye flight drained away all our energy and motivation to explore the city, so our greatest experience there was a long, morning nap in the Central park.
On Tuesday morning, we woke up in the Ocean City, New Jersey. I chose to stay in the Crossings Motor Inn long time ago. Ten years ago, I spent a summer working in its laundry room. It was my liberation summer, when I gained independence and self-reliance, changing my lifestyle forever. I was just a kid when I was here the first time. I didn’t realize it until now; 10 years of independence. As an adult artist-scientist, I am much more self-aware; I’m also very thankful that my research job allowed me to get here after 10 years and to have a great time, and to relax my tired scientific brain.Crossings changed me; how has the motel changed?
The motel was no longer owned by my Italian friends; staff and housekeepers were different too. Our housekeeper was Kayla – a quiet student from Russia. J1 students, like her, were experiencing increasingly more problems with obtaining visas for this type of work/ region. Sandy damaged the Jersey shore and left its mark on the Crossings too; the lobby was painted and refurnished. Should I have come back last summer – before the Sandy storm – I would still see the ugly pink countertop in the reception. The season ends in Crossings on September 29th, the receptionist stays with her daughter during winter. The handyman hopes to get a job in the construction; he was able to do so during the last 2 winters
On Friday, we went to visit my cousin in the Millstone Township, in the Lakewood area. After dinner, and a short card game with Cassandra, they drove us to the JFK airport. Journey to the airport was never-ending. The traffic was really bad. We needed to pee badly and struggled to find a toiled. So we left the free-way and found a supermarket, where we were the only white customers. The bathroom smelled badly. Half of the toilet desk was missing and so were the bath tissue and soap. Nobody wanted to use the toilet and when I opened the door to get in, a nearby girl told me to save myself. Under these circumstances, there was no discussion about finding another toiled; we did it there. Luckily, we had just enough time to catch our flight back home. Our home away from home – a second home in Ireland.