Category: Primary care

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.
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

  • To stay true to myself
  • To reach a position of independence by:
    • conducting a randomized controlled trial
    • supervising work of junior investigators
  • To maintain a happy work-life balance
  • To pass the accumulated knowledge and skills on other:
    • Doctors and helping professions, by helping them become more competent and confident in addiction medicine research
    • Medical students, by helping them discover and master addiction medicine research

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

The purpose of this work was to develop and to process-evaluate an educational intervention designed to help general practitioners (GPs) identify and manage problem alcohol use among problem drug users. The session was facilitated by demonstration of clinical guidelines, presentation, video, group discussion and/or role play. Seventeen participants from three family practices and the Graduate Entry medical school, University of Limerickparticipated in four workshops. They perceived the training as most helpful in improving their ability to perform alcohol screening. The positive feedback from General Practitioners opens the gate for integrating addiction treatment into primary care settings and, along with other multi-level implementation interventions, suggests that the addiction medicine education can support addiction health services improvement initiatives. The intervention will be used in our current study evaluating the impact of psychology-based treatments for substance use disorders.
To read the full article, click on the link below.

Citation:               Jan Klimas, Kevin Lally, Lisa Murphy, Louise Crowley, Rolande Anderson, David Meagher, Geoff McCombe, Bobby P Smyth, Gerard Bury, Walter Cullen, (2014) “Development and process evaluation of an educational intervention to support primary care of problem alcohol among drug users”, Drugs and Alcohol Today, Vol. 14 Iss: 2 Link: http://www.emeraldinsight.com/journals.htm?issn=1745-9265&volume=14&issue=2&articleid=17109104&show=pdf

How to measure performance in the addiction and mental health services? A new paper out now

As part of her final year research project in the Graduate Entry Medical School, University of Limerick, Dr Carla Henderson queried the literature about the methods of development and content of key performance indicators for MESUDS – the mental and substance use disorders – as she named them.

Figure 1. Journal cover

Her searches revealed a great variety in the methodologies of indicator development for MESUDS – including expert opinion, literature review, stakeholder consultation, and the structured consensus method. 

The paper in Mental Health and Substance use journal (see Figure 1) highlighted several problems in the performance indicators: (1) A bias in the level of performance assessment toward system/health plan evaluation followed by program/service evaluation; (2) Similarly, there was a large skew toward indicators that reflected evaluation of processes. Especially in the addiction health services research, we don’t know whether improvement of care processes is linked to improvement of patients’ health: “such changes have thus far demonstrated only minimal impact on patient outcomes” (Humphreys et al, 2011, see Figure 2). 

Figure 2. Dr Keith Humphreys

Read the full paper at the journal’s website:  http://www.tandfonline.com/doi/abs/10.1080/17523281.2014.901402#.U0LiuvldWg4

Cited works:

  • Carla Henderson, Jan Klimas, Colum Dunne, Des Leddin, David Meagher, Thomas O’Toole, Walter Cullen (2014). Key performance indicators for mental health and substance use disorders: a literature review and discussion paper. Mental Health and Substance Use, Early Online. 
  • Keith Humphreys, A. Thomas McLellan (2011). A policy-oriented review of strategies for improving the outcomes of services for substance use disorder patients. Addiction, Volume 106, Issue 12, pages 2058–2066

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

What has the doctor done well? A different type of Masterclass on youth mental health for family doctors in Ireland

A typical master class involves a Master and a Class. Unlike other masters, the organisers of this master-class chose a problem-based learning approach and encouraged all attendees to bring cases relating to youth mental health or addiction issues for the class discussion. My classmates were doctors and other health or community care professionals from the Mid-West of Ireland. From 2.00pm-4.30pm, on 1st April 2014, The Graduate Entry Medical Schoolof the University of Limerick, in association with the Youth Mental Health in Primary Care research team, hosted a master-class on interacting with young people around areas of mental health and addiction. 

Following welcomes and introductions by the organisers (shown in Figure 1), three small groups discussed patient scenarios. In the scenario about cough, they recognised that the cough can be only a symptom of a bigger issue that brought the patient to see the doctor. The focus of such consultation should be on making the patient come back, because the bigger issue can’t be resolved in just one consultation. Our need to gather information can be a barrier for reaching this objective. The main issue in the disordered eating scenario was how to ask a parent to leave the surgery so that the adolescent can talk with the doctor alone.
Figure 1. Dr Andrew O’Regan (L) and Prof Walter Cullen (R).
Dr Liz Schaffalitzky (not pictured) co-organized the session.
The 36 participants learned how to conduct a youth-friendly session with a young person, and how to use a brief intervention to address youth mental health and substance use in consultations. The importance and cost-effectiveness of early intervention in youth mental health and addiction and the role of general practice in early intervention were also discussed.


The class concluded by an extended Q & A session with youth mental health experts Dr Declan Aherne (Director of Oakwood Psychological Services), Dr Rachel Davis (Consultant Child and Adolescent Psychiatrist), Mr Rory Keane (Regional Drug Coordinator), Mr David McPhillips, (Community Substance Misuse Team), and Dr Patrick Ryan (Clinical Psychologist).