We learn best in places that support our learning and our bio psycho socio spiritual development – from toddlers to elders, reports Jan Klimas from the Canadian Medical Education conference #CCME18.
Starting in Toronto, Justin Hsu and colleagues from University of Toronto described how they improved spaces for communities in teaching ambulatory care, or the so called Medical Education Teaching Clinics (METC). They plan to evaluate METC clinics via audit of referrals to the teaching clinic and the learner satisfaction survey.
Presentation title: Creating unique spaces to support community-based ambulatory care education: the E3 experience.
Presentation authors: Jerry Maniate, Elizabeth Wooster, Douglas Wooster, Justin Hsu
British Columbia quality matters
Jan Klimas’ team from University of British Columbia evaluated hospital as a place of learning about substance use disorders. Who learns most about addictions in hospitals? Using mixed-methods approach, this team showed that medical students get more out of a rotation in hospital than residents or senior learners. Especially in the areas of safe prescribing, screening and withdrawal management. Why is that? Do residents know more or are they more resistant to new learning? For many medical students, hospital could be the first place where they see someone with addiction and that could be why they learn more in this setting.
Presentation title: Who learns most about addiction in the hospitals? A mixed methods study.
Presentation authors: Jan Klimas, Evan Wood, Walter Cullen, Will Small, Seonaid Nolan, Annabel Mead, Mark McLean, Christophe Fairgrieve, Keith Ahamad, Huiru Dong, Breanne Reel, Lauren Gorfinkel, Nadia Fairbairn
Derek Wilson and colleagues from the same university focused on the quality of health education learning environment (HELES study). HELES survey tool looked at relationship, personal development and program culture as the key parts of the learning environment at the faculty of medicine. For example, the evaluation asked whether the learners have developed a strong sense of community.
Presentation title: Evaluating the Quality of Health Professions Learning Environments: Validation of the Health Education Learning Environment Survey (HELES).
Presentation authors: Derek Wilson, Shayna Rusticus, Derek Wilson, Oscar Casiro, Kevin Eva, Lisa Hazlett, Chris Lovato
Calgary explores and experiences
Maureen Topps and collaborators from University of Calgary, Cumming School of Medicine, asked whether in addition to focusing on the deficiencies and gaps in education, whether we could research the successful activities related to professionalism. The postgraduate education is a key stage in training the next generation of competent and professional clinicians. Professionalism is hard to define and to define it may “limit it,” as Dr Barnhoorn writes in the Academic Medicine journal (2006, Vol. 91, No. 9). But how does the place of learning make for more professional doctors? Slowing down and taking time to plan interactions appears to foster professionalism among other factors such as communication training.
Presentation title: Contexts and Experiences of Postgraduate Residents that support successfully meeting professionalism challenges.
Presentation authors: Janet de Groot, Maureen Topps, Aliya Kassam, Maureen Topps
Nicole Delaloye and colleagues from the same university presented results from her Masters research of the MSc/MD program. Clinicians should be both polite and respective, but not overly submissive. Why do we follow orders? Resuscitation requires wise action, not passive deference. What happens when learners hold back too much and how does the place of learning impact submissiveness? Mechanisms that underly submission in the moment of revival include learner’s mental state, what was going on inside and outside the room, team and motivation.
Presentation title: An Exploration of Deference Behaviours Exhibited within the Paediatric Resuscitation Environment and the Educational Implications.
Presentation authors: Nicole Delaloye, Elaine Gilfoyle, Rachel Ellaway, Aliya Kassam, Elizabeth Oddone Paolucci
In summary, the best learning places not only support our learning, but also challenge us to learn knew knowledge, adopt the discipline’s values, overcome deference and become successful professionals in our own right.
The opinions and views in this article present the views of the author and not the named persons or the #CCME18 conference organisers.
This study looked at how many, and what types of people who inject drugs (PWID), in the AIDS Care Cohort to evaluate Exposure to Survival Services Study (ACCESS), would be eligible for medical heroin in Vancouver, Canada.
Medical heroin could possibly help people who have treatment resistant opioid use disorder and who live with HIV/AIDS.
How was the study done?
We looked at how many, and what types of PWID in the ACCESS Study would be eligible for medical heroin. Participants had to meet eligibility criteria from clinical trials of medical heroin.
The ACCESS study involves people living with HIV who use illicit drugs, mostly living in Vancouver’s Downtown Eastside neighbourhood. Researchers work with participants to look at how social, economic, physical, policy, and individual factors impact the health and well-being of HIV-positive illicit drug users. ACCESS participants do an interviewer-administered survey, and a clinic visit with a study nurse, every 6 months. (text taken from: http://www.bccsu.ca/access/)
What did the study find?
478 participants said they injected opioids. 20% met the eligibility criteria for treatment with medical heroin. Those who were homeless, or were involved in the local illicit drug trade, were more likely to be eligible for medical heroin.
20% met the eligibility criteria for treatment with medical heroin and also said they were homeless and dealt drugs.
Why is the medical heroin useful?
Untreated opioid use disorder among people who live with HIV/AIDS can lead to illnesses, overdose, or death. Medical heroin can play an important role in helping people who have treatment resistant opioid use disorders and who live with HIV/AIDS.
Reference: Klimas, J., Dong, H., Fairbairn, N., Socías, E., Barrios, R., Wood, E., Kerr, T., Montaner, J., Milloy, M. (2018) Eligibility for heroin-assisted treatment (HAT) among people who inject opioids and are living with HIV in a Canadian setting. Addiction Science& Clinical Practice. In Press (https://ascpjournal.biomedcentral.com/track/pdf/10.1186/s13722-017-0104-y?site=ascpjournal.biomedcentral.com)
Better medical education is one solution to the opioid overdose crisis, but our new study suggests that few students have direct experience of overdose management although many have been exposed to patients using opioids.
Every year, more people die in Ireland due to opioid overdoses than in car accidents. Over 200 overdose deaths occur annually in Ireland. Naloxone is an effective treatment; lay people can use it. We surveyed 243 undergraduate medical students doing their final professional completion module before graduating from University College Dublin. This survey showed that medical students commonly encounter patients with opioid use disorders and want more naloxone training in the medical school.
Overdose prevention and management, including naloxone provision, should be a priority for health education.
A total of 197 (82.1%) completed the survey. Just under half were male, and most were aged under 25 (63.3%) and of Irish nationality (76.7%). The students felt moderately prepared to recognise opioid use disorder, but felt less prepared to manage other aspects of opioid use disorder care. Most had taken a history from a patient with an opioid use disorder (82.8%), and a third had witnessed at least one opioid overdose. Although 10.3% had seen naloxone administered, most had never administered naloxone themselves (98.5%). Half supported wider naloxone availability; this was lower than support rates among GPs (63.6%) and GP trainees (66.1%).
Over half of the medical students supported wider naloxone availability and its lay distribution to address the growing overdose problem in Ireland.
Most students had taken a history from a patient with an opioid use disorder and a third had witnessed at least one opioid overdose.
Few students had direct experience of overdose management although many met patients using opioids.
High level of student exposure to patients using opiates suggests we have an opportunity to increase addiction content in medical curricula.
Medical school offers limited addiction medicine education. Medical graduates may not be adequately prepared to diagnose and manage opioid use disorders and emergency drug overdoses.
Tobin, H., Klimas, J., Barry, T., Egan, M., Bury, G. (2017, In Press) Opiate Use Disorders and Overdose: Medical Students’ Experiences, Satisfaction with Learning and Attitudes toward Community Naloxone Provision. Addictive Behaviors.
Youth opioid addiction, and related harms continue to rise in North America. With an increasing number of opioid overdoses, there remain significant barriers to care for youth with addiction. The time for evidence-based treatment of youth opioid addiction is now.
Based on the extensive literature on treatment of opioid use disorder among adults, medicated-assisted treatment is likely to be an important or even essential component of treatment of opioid use disorder for most youth. This post summarises a recent article in the American Journal of Drug and Alcohol Abuse, where we outline the current dilemmas and questions regarding the use of medication-assisted treatment for youth opioid addiction and propose some potential solutions based on the current evidence.
The prevalence of risky opioid use, opioid use disorder, and related harms continue to rise among youth in North America (age 15–25). These growing harms point to an urgent need to expand and scale-up early access to evidence-based treatments for youth opioid addiction. Treatment of youth opioid addiction may be different than treatment of adults because neurodevelopment of brain regions, associated with motivation and impulsivity, happens mainly during adolescence and young adulthood.
Strategies that reduce barriers to treatment commonly experienced by youth and that address clinical care dilemmas when treating youth opioid addiction are urgently needed.
Medications for youth opioid addiction
The American Academy of Paediatrics recently supported buprenorphine/naloxone and methadone for youth opioid addiction. Although research has shown their effectiveness in adults, only a few studies did so among youth.
Based on the strong evidence in the adults and available evidence to date among youth, first-line OAT for youth should be buprenorphine/naloxone, with methadone as an alternative treatment option when buprenorphine/naloxone cannot be used.
Minimum age requirement needs re-evaluation
The literature still disagrees regarding the minimal age requirement to prescribe OAT. For instance, buprenorphine/naloxone is currently approved for opioid addiction at age 16 in the United States and at age 18 in Canada. But the U.S. youth has to fail addiction treatment twice before they can be prescribed methadone under the age of 18. Also, treatment with medications has been prescribed to 10 times more adults than youth although it’s the first line of treatment in many guidelines. This underscores the urgent need to improve medication-assisted treatment access for youth. We still need safety data regarding use of OAT among youth. But the pros are likely to outweigh the cons given the lethality and multiple harms associated with opioid addiction.
Longer tapers are more effective than shorter tapers
How long should be the successful tapers and how to do them effectively? These questions are still unanswered by scientific literature. Studies to date have shown that longer tapers are more effective to reduce opioid use and prevent relapse For this reason, our provincial guidelines in British Columbia, Canada, recommend that tapers for adults, if undertaken, “occur over a minimum 52 weeks duration and with close monitoring during and after the taper given overdose risk is increased.”
Naltrexone injectable versus implantable
Opioid antagonists, such as Naltrexone, have not been evaluated widely among youth. Oral Naltrexone has many problems, such as low compliance, increased risk for relapse and overdose. The researchers should compare methadone or buprenorphine/naloxone with extended-release injectable or implantable naltrexone in youth. This information will help clinicians select the best treatment for youth opioid addiction.
Psychosocial interventions: retention on OAT remains a challenge
Psychosocial interventions are common for treating youth opioid addiction, but are done in a way that is not supported by science. For example, they consist of short-term detox with a referral to individual or group therapy in rehab or outpatient settings. Youth drop out from such treatment frequently. But retention on OAT remains a challenge. For example, one study found that only “56% of youth aged 18–25 years were retained on buprenorphine at 6 months, compared with a 78% of people aged 26 years or more.” OAT seems more efficacious in retaining youth in treatment. Psychosocial intervention is better done in combination with pharmacologic treatment. We need more trials involving youth.
The Prescription Opioid Addiction Treatment Study – POATS
The Prescription Opioid Addiction Treatment Study (POATS) showed that tapering off buprenorphine/naloxone (even after 12 weeks of treatment), was associated with a 90% relapse rate. Ongoing counselling did not make a difference. Based on the adult POATs study, it seems that keeping people on buprenorphine/naloxone is better than tapering them without supports. Psychosocial interventions may help people receiving OAT. Many studies found contingency management helpful. Researchers should do more studies on contigency management.
When in doubt, do not taper
Based on the above, we need more research to better understand optimal treatment approaches for OPIOID ADDICTION in youth. Based on the current evidence, buprenorphine/naloxone appears to be a safe and efficacious option for youth and we propose this should be first-line treatment for OPIOID ADDICTION. More studies comparing OAT and extended-release naltrexone are needed in this population. When treatment is initiated, longer duration (>52 weeks) of OAT is recommended. Decision to taper should be governed by the principle “when in doubt, do not taper” while taking into account the potential risks of relapse and overdose as well as access to chronic relapse prevention care; close monitoring is essential during and after the taper completion. We suggest psychosocial interventions be routinely offered in combination with OAT. Lastly, given the efficacy of OAT, we recommend these medications be provided based on the risk and benefit assessment of each case, regardless of age.
Cited study: Derek C. Chang, Jan Klimas, Evan Wood & Nadia Fairbairn. (In Press) Medication-assisted treatment for youth with opioid use disorder: Current dilemmas and remaining questions. The American Journal of Drug and Alcohol Abuse Vol. 0 , Iss. 0,0
What is the state of the art in addiction research? How do we measure recovery? These, and other questions dominated presentations on systematic reviews of literature at the 2nd European conference on addictive behaviours and dependencies on October 24-26th, 2017, in Lisbon.
This post outlines the many presentations.
Systematic reviews at Lisbon 2017:
– Which individual, social and environmental influences shape different pathways of amphetamine type stimulant use over the life course? A systematic review and thematic synthesis of the qualitative literature. Amy O´Donnell and Michelle Addison, United Kingdom
– Determining the efficacy of an intervention to reduce IPV perpetration by men who misuse substances: a systematic review and meta-analysis. Gail Gilchrist, United Kingdom
– Drug use and infectious diseases: reviewing the evidence; Sarah Larney, Australia
Paper session 16
− Injecting and sexual risk-taking amongst people who inject drugs: a global review. Amy Peacock, Australia
− Needle syringe programmes and opioid substitution therapy for prevention HCV transmission among people who inject drugs: Cochrane systematic review. Matthew Hickman, United Kingdom
− Recent incarceration and risk of hepatitis C and HIV transmission amongst people who inject drugs: a systematic review and meta-analysis. Jack Stone, United Kingdom
− A systematic review and meta-analysis of psychosocial interventions to reduce drug and sexual blood borne virus risk behaviours among people who inject drugs. Gail Gilchrist, United Kingdom
− HIV prevention, treatment and care for people who inject drugs: a systematic review of coverage of interventions. Sarah Larney, Australia
– Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. Marica Ferri, EMCDDA
– What is the base for evidence-based treatment of opioid dependence? A systematic review of outcomes from longitudinal observational studies. Lucas Wiessing, EMCDDA
– Health outcomes for clients of needle and syringe programs in prisons: a systematic review. Heino Stöver, Germany
− Worldwide drug use decriminalization practices: a scoping review. Marta Pinto, Portugal
− Review of the effectiveness of treatment alternatives to incarceration for drug-involved persons. Roger Peters, United States
− Factors related to binge drinking in adolescence: integrative literature review. Tereza Barroso, Portugal
Systematic reviews posters at Lisbon 2017:
October 24th: 13:15 – 14:15 POSTER SESSIONS:
– Alcohol use disorders identification test (audit) and mortality risk in US Veterans and international population: a systematic review and meta-analysis. Sören Kuitunen-Paul, Germany
– Contingency management for drug use in treatment for opiate addiction: a systematic review and meta-analysis. Tom Ainscogh, United Kingdom
24th: 14:30 – 16:00 POSTER SESSIONS:
– A systematic review of internet addiction prevention interventions. Roman Gabrhelík, Czech Republic
October 25th: 11:00 – 12:30 POSTER SESSIONS:
– Prevalence and psychosocial predictors of performance enhancing substances use in physical activity settings: a systematic review. Ana Tavares, Portugal
October 25th: 14:30 – 16:00 POSTER SESSIONS:
– What works in the treatment of women with alcohol-use problems? Systematic review of evidence-based studies. Eva Hoch, Germany
Thank you all presenters for your reviews and conference presentations.