Category: Poly-drug use

New paper out now: Alcohol Screening among Opioid Agonist Patients in a Primary Care Clinic and an Opioid Treatment Program

February 25th: Drinking in people who also use other illicit drugs causes serious problems. Their doctors and health professionals can ask about alcohol, provide advice or refer the person to a specialist if the problem is too big. We had a look into medical notes of 200 people screened for an alcohol use disorder in a primary care clinic and another 200 people screened in an opioid treatment program over a two year period.
Chart reviews suggested that most people with opioid dependence (95%) seen in a federally qualified health center completed a routine annual alcohol screening; elevated scores in the Alcohol Use Disorders Identification Test were recorded for six people (3% of those screened) and brief interventions were completed with five of those people. 
 “When you know of … people who are using heroin, there’s a chance they’re using it IV, and if they’re using IV there’s a chance they’re accessing blood …, so if there’s people we have coming with Hep C that have been drinking there’s a whole other level of medical risk associated and it’s hard to stabilize anyone, so people are coming in ill or they have other doctors’ appointments or they’re just not physically able to engage in programs.” Physicians worried about opening up this complex issue and felt the system was not prepared.
The methadone program, in comparison, diagnosed alcohol abuse or dependence at admission in 27% (n = 54) of the patient records reviewed. People treated in the methadone program appeared to have higher rates of serious alcohol use disorders than those who received buprenorphine in the primary care clinic:
“It’s a lot easier to fly under the radar with alcohol than with other drugs.” Focus group participants recognized limitations of screening.
Practitioner focus groups were completed in the with four primary care physicians and eleven counsellors from the opioid treatment program to assess experience with and attitudes towards screening opioid agonist people for alcohol use disorders.
Focus groups suggested organizational, structural, provider, patient and community variables hindered or fostered alcohol screening. 
A primary care physician noted, “When people are in the more severe category and you run out of time and you can hand them a list of AA meetings around the town, but it’s just so unlikely that they are going to access it if they haven’t already. That warm hand off process is huge.”
Alcohol screening is feasible among opioid agonist people:
“Having a consistent way that we treat specific conditions, like alcoholism with this background and this level of care would be great. So that we can develop patterns and know how to treat them as they go.”
Effective implementation, however, requires physician training and systematic changes in workflow.
  A counselor stated, “Engagement is key; how we treat our patient has a lot to do with what they tell us, so if the people feel not judged, if they feel safe, they’re going to be more likely to engage in the treatment process.”

To read the full article, go to the website of the Journal of Psychoactive Drugs: http://www.tandfonline.com/doi/full/10.1080/02791072.2014.991859#abstract

Doctors sweat to discover traditions of the first nations

Many doctors see addiction as a disease of body only. If overdone, this view can lead to medicalization of addiction. Some may argue that the latest research proves addiction as a chronic brain disease. This view is supported by brain scans of people who used drugs compared to people who didn’t. The scans show a loss of dopamine neurons after heavy methamphetamine use. Although brain’s plasticity allows it to recover, we don’t know how much of this loss is permanent.

While brain researchers may not mean to reduce addiction to a purely medical condition, its psychological, social and spiritual facets get sometimes overlooked. Not only medical students do not get enough education on addiction, what they get is often focused on the biological aspect.

To bridge this gap, in June 2014, a group of eight medical doctors (five doctors in training and three staff) from Canada went on a three day journey to a remote First Nations (i.e. American Indian) community to hear stories of recovery and participate in traditional healing techniques. After the trip, the Director of their addiction training programme (www.addictionmedicinefellowship.org), analysed the group’s experiences using qualitative research techniques and presented* the narratives at conference of the Association for Medical Education and Research in Substance Abuse.

People from the First Nations reservation shared their experience with the power of spiritual recovery tools – sweat lodges (see Figure 1), community round ups, connection to heritage, family support, and elder-guided self-reflection: “…learning came through creating bonds of friendship with people at Alkali Lake. It was through these bonds that the human face…emerge[d] and the real learning started to happen.”

Figure 1. Sweat lodge (photocredit: fellowship archive)

First Nations communities are over-represented among people with substance use disorders in Canada. Having little sense of cultural competency, clinicians can become discouraged when faced with the suffering and despair of those with substance use disorders: “…the most valuable lesson [of the field trip] was in deepening the understanding that the most effective way of being an addiction physician is by humbling ourselves, relinquishing our titles as doctors and getting to know the person behind the addiction.”

The Director encouraged programmes to “find a local community that has tackled the programme and go out to do a field trip and learn from the community members.”

 

*Text first published at a registration-restricted website: https://www.mariecuriealumni.eu/news/doctors-sweat-discover-traditions-first-nations

Story based on a poster presented at the AMERSA conference November 5th, 2014: Lighting the ember of hope: Integrating field experience and narrative techniques into Addiction Medicine Fellowship training. By Launette Rieb (a,b), MD, MSc, CCFP, FCFP, dip. ABAM; Nitasha Puria (b), MD, CCFP; Marcia Thomson (a), MSc; and Evan Wood (a,c) MD, PhD, ABIM, FRCPC, dip. ABAM

 

Author affiliations:
a)St. Paul’s Hospital Goldcorp Addiction Medicine Fellowship, Vancouver, B.C., Canada. b)Department of Family Practice, and c)Division of HIV/AIDS, Faculty of Medicine, University of British Columbia, Canada

Association’s for Medical Education and Research in Substance Abuse mission is to improve health and well-being through interdisciplinary leadership in substance use education, research, clinical care and policy. Text taken from www.amersa.org
Clinical addiction medicine training is a multidisciplinary addiction medicine fellowship that strives for excellence in clinical training, scholarship, research and advocacy and involves medical education to trainees from Psychiatry, Internal Medicine, Family Medicine and Nursing. For more details, click here.

Which talking therapies work for drug users with alcohol problems? A Cochrane update

Have you ever had an unresolved question and you kept asking again, again and again, until you got the answer? We wanted to find out whether talking therapies have an impact on alcohol problems in adult people who use illicit drugs (mainly opiates and stimulants), and which therapy is the best. We queried the scientific literature in 2012 and this year again.

Drinking above the recommended safe drinking limits can lead to serious alcohol problems or dependence. Excessive drinking in people who also have problems with other drugs is common and often makes these problems worse; their health deteriorates. Talking therapies may help people drink less but their impact in people who also have problems with other drugs is unknown. Talking treatments were the focus for an updated Cochrane review (Figure 1) published today (Dec 3).
Figure 1. Cochrane
We found four studies that included 594 people with drug problems. One study focused on the way people think and act, versus an approach based on Alcoholics Anonymous, aiming to motivate the person to develop a desire to stop using drugs or alcohol. One study looked at a practice that aimed to identify an alcohol problem and motivate the person to do something about it, versus usual treatment. One study looked at a counselling style for helping people to explore and resolve doubts about changing their behaviour (group and individual form), versus hepatitis health promotion. The last study looked at the same style versus assessment only.
In sum, the studies were so different that we could not combine their results to answer our question. As of June 2014, we still don’t know whether talking therapies affect drinking in people who have problems with both alcohol and other drugs because of the low quality of the evidence. We still don’t know whether talking therapies for drinking affect illicit drug use in people who have problems with both alcohol and 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. New clinical trials would help us to answer our question.
Citation example: Klimas J, Tobin H, Field C-A, O’Gorman CSM, Glynn LG, Keenan E, Saunders J, Bury G, Dunne C, Cullen W. Psychosocial interventions to reduce alcohol consumption in concurrent problem alcohol and illicit drug users. Cochrane Database of Systematic Reviews 2014 , Issue 11 . Art. No.: CD009269. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009269.pub3/abstract

Cochrane is a global independent network of health practitioners, researchers, patient advocates and others, responding to the challenge of making the vast amounts of evidence generated through research useful for informing decisions about health. Read more at www.cochrane.org

How Cochrane Keeps the Addiction Science in Check

Science isn’t infallible. Humans make mistakes even in this highly sophisticated method of understanding the world around us. Thanks God, addiction researchers get a chance to correct their error. If they publish a big error, the publication may be withdrawn. In smaller cases, the publisher issues a correction. It is interesting to see how such a correction has been issued following publication of our Cochrane systematic review of literature which. Probably this helped to keep the addiction science in check. See it for yourself below.

August 2011: “Alcohol-related brief intervention in patients treated for opiate or cocaine dependence: a randomized controlled study”

Before our review included this study, the authors reported the following figures in tables 3 and 7.

November 2011: “Psychosocial interventions to reduce alcohol consumption in concurrent problem alcohol and illicit drug users: a Cochrane review”

 Our review was published in November 2011 and re-stated the findings of the above study as: higher rates of decreased alcohol use at three months (risk ratio (RR) 0.32; 95% confidence interval (CI) 0.19 to 0.54) and nine months (RR 0.16; 95% CI 0.08 to 0.33) in the treatment as usual group– See more at: http://summaries.cochrane.org/CD009269/ADDICTN_which-talking-therapies-counselling-work-for-drug-users-with-alcohol-problems#sthash.RcVZGdQA.dpuf

August 2013 “Correction: Alcohol-related brief intervention in patients treated for opiate or cocaine dependence: a randomized controlled study”

After the publication of our review, the authors corrected their figures in tables 1 and 5. The care-as-usual treatment for the control group was no longer stronger than the experimental intervention, the “alcohol-related brief intervention.”

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A note on causality in science

Because causal relationships are hard to prove (i.e. cause -> effect), majority of scientific publications rely on correlations. An example of a correlation is a relationship between shorter living expectancy and male gender. Men die younger than women. Although there are many plausible explanations, we cannot pinpoint a single cause.  Similarly, if an article gets corrected following a review in a major synthesis of scientific evidence – the Cochrane review – it may be a pure coincidence or it may be a consequence of the review. 

Substance Abuse Treatment, Prevention and Policy is an open-access peer-reviewed online journal that encompasses all aspects of research concerning substance abuse, with a focus on policy issues. Text taken from www.substanceabusepolicy.com

Cochrane Collaboration hosts the largest database of systematic reviews to inform healthcare decisions. Cochrane reviews are the jaguars of medical evidence synthesis. Cochrane is a global independent network of health practitioners, researchers, patient advocates and others, responding to the challenge of making the vast amounts of evidence generated through research useful for informing decisions about health. Cochrane is a not-for-profit organisation with collaborators from over 120 countries working together to produce credible, accessible health information that is free from commercial sponsorship and other conflicts of interest. Text taken from www.cochrane.org

How to go about getting a postdoc position? Finding funding

There probably isn’t a simple answer to this question. Everybody has a different experience. My path was one of finding my own funding to do what I liked. Other people get postdocs via other routes, but I’d hope that my story bellow illustrates one of the paths people can take.

My mentor helped me identify funding calls and write funding applications. Then, I applied for everything and some of the applications were successful. Keeping up with the current funding calls via Research Newsletters and email alerts, such as Find A Phd, helped me too. I met the collaborators for my projects at conferences and seminars.

 
My experience is from Ireland, although I have a Slovakian PhD in Social Psychology(04/2011).
First, as a Research Assistant, I applied for and was successful with getting a Cochrane Training Fellowship to complete a Cochrane Systematic review over two years – 2 days p/week – from the Health Research Board Ireland (2010-12). The fellowship examined psychosocial interventions to reduce alcohol consumption in concurrent problem alcohol and illicit drug users. The absence of evidence on the subject helped us to identify priorities for research.  To find out more about the Cochrane Systematic reviews of literature, go to: www.cochranecollaboration.org
Towards the end of my two-year Cochrane Fellowship, my Irish supervisors offered me two complementary part-time postdoc positions, both of which I accepted. The first was a three-year position in emergency medical science research. The second was a one-year position developing new projects in primary care settings and supervising medical students (2012-13). From a personal perspective, teaching literature reviews to medical students taught me how to address a training gap through addiction research education for medical students.
At the same time, I applied for two other grants. First was a three-year feasibility study in primary care from Health Research Board Ireland (Co-applicant). Second, an INVEST drug abuse fellowship from the National Institute for Drug Abuse – NIDA (Fellow). The feasibility study was a direct result of our efforts to highlight the problem of alcohol consumption among people receiving methadone treatment. We’ve trained family physicians in psychosocial interventions for concurrent problem and drug use disorders. Hence the title for the PINTA study.
Both were successful. Thanks to the patience and flexibility of my supervisors, I was able to combine and merge all of these opportunities. The INVEST postdoctoral fellowship was a six months job in at Oregon Health and Science Universityin Portland, OR, studying implementation of alcohol SBIRT in primary- versus secondary-care based opioid agonist treatment (2013). Our poster at the Annual Symposium of the Society for the Study of Addiction described qualitative component of the study. Training health care professionals in delivering alcohol SBIRT is feasible and acceptable for implementation among opioid agonist patients; however, it is not sufficient to maintain a sustainable change. After INVEST, I returned back to my composite Irish postdoc.
Eight months after the return back to Ireland, and one year before the end of my three-year Irish postdoc, I received another fellowship from the Irish Research Council. This International Career Development Award is co-funded by a European Union scheme called Marie Sklodowska Curie Actions. To improve the addiction medicine education for doctors (BEAMED), I’ll do an external and independent evaluation of the addiction medicine fellowship and plan a similar training in Ireland (2014-17). To learn more about the Marie Cure awards, go to: http://ec.europa.eu/research/mariecurieactions/