Category: Primary care

Addiction Health Services Research Conference 2015 | #AHSR2015

The healthcare landscape is changing. The delegates at the 2015 Addiction Health Services Research conference met to exchange ideas about how to navigate this change. Here, I note my thoughts from my favourite keynotes.
 

Photocredit: http://www.uclaisap.org/ahsr

Pre-conference workshop on Wednesday, October 14th about publishing in addiction health services research was facilitated by Deborah Garnick, Carmen Masson, Mark McGovern, Richard Saitz, Jeffrey Samet and James Sorensen (chair).
Garnick asked why is publishing not a linear process. It’s really about management. It’s also about making people read review and suggest references. If you’re looking at tenure and professorship, you want to be thinking of the top journals. Some aspects change, others not. The peer review started in 1930-40s with the Journal of the American Medical Association. Publishing is a marketing activity. It’s also a group activity and an individual activity at the same time: somebody needs to sit down and write. Publishing is somewhat like a puzzle; it’s fun to try to figure out how to sell the paper.
Masson talked about writing seminars. Why do early-stage investigators get little training in writing? She answered her talk using the recent paper by Guydish et al: Scientific Writing Seminar for Early-stage Investigators in Substance Abuse Research. For future research about writing groups, we need to develop an outcome measure for evaluating such groups first.
McGovern covered working with journal editors. How to deal with conflicting advice from peer reviewers? Chose the one you like. How to make better reviewers? [LINK MY 50 SHADES]. Get your junior researchers to co-review with you as the senior reviewer. Or apply for the JSAT editorial fellowship.
Saitz about responding to revision requests: Editors are people too! Do everything possible to make it as easy as possible. The editors and reviewers are right probably half of the time. The opposite of easy for editors is annoying. They may be doing the editing at night, in their spare time. When you revise your paper, some fatal flaws of your paper may come to light. Universal Rejection is the most prestigious journal in the world because it accepts 0% of their submissions. Read more about dealing with rejection in my recent blog.
Samet talked about open access journals and journal selection. In ISAJE, 38 journals meet their criteria of doing things right. Of those, 10 are open access journals. Only 3 of them have an impact factor. It takes time to publish enough papers for the impact factor to be assigned to the journal. Beware predatoryjournals!
Lawrence Palinkas kicked off the conference on Thursday morning, October 15th with a keynote describing implementation science as a tool for navigating a changing healthcare landscape. Practitioners don’t have enough time, resources and training to Evidence-based practice (EBP). They don’t have access to and time for reading the scientific journals. Is the art of medicine lost in all this EBP? EBP is a manualised way to treat a patient. Clinicians often don’t like rigidity and single-focus of EBP that makes it hard to use. Many have seen an answer to all these problems in the implementation science. In the old days, the process of dissemination was through company reps, now modern and online strategies are used for reviews of EBP. He then went on to describe the implementation science in his own research. First was a randomised trial of a multidimensional treatment foster care. The early adopters of EBP utilise the relationship within their networks for information and advice. The follow-on study found that those who use research evidence more also do more EBP. Where did they get information about EBP? At conferences, from internet searches and from people they trusted. The third study found a modular approach to dissemination of EBP effective in reducing the internalising behaviour of children.  Clinicians favoured this approach. It allowed for a cultural exchange. Both clinicians and researchers were flexible with the application of the EBP into routine care, i.e., they went out for a lunch together and talked about how and whether the EBP could be changed. Modules gave them more license to negotiate application. If you are going to navigate the changing landscape successfully, you need to focus on the social networks, their use of research, their interactions with researchers and their decisions whether or not to implement EBP.

In the panel discussion on Thursday, October 15th after lunch, the speakers navigated the changing healthcare landscape via experiences from the field of addiction health services. They were Thomas E. Freese (Moderator), Clayton Chau, H. Westley Clark, Vitka Eisen, Tami Mark and David Pating.

Chau said that sometimes even the clinicians have a hard time navigating the system of care. There are multiple case managers helping to navigate the system, but who’s coordinating the case managers? It is us who crazy system for people to navigate and blame the patient if they can’t navigate it.
Clark felt that, as an African American, integration is fun. 19 million people with addictions in States do not perceive the need for treatment. We think they need treatment. Who’s right? How can the system respond to the needs of the SafetyNet populations?
Eisen achieved the recovery through SafetyNet organisation that she became a CEO of 30 years later. Clients don’t fail treatment; treatment fails clients if they don’t improve. The payment is a huge issue. If we want to achieve some kind of parity in outcomes, we need some kind of parity in salaries.
Mark talked from a perspective of an economist. Buprenorphine is replacing prescription opioids in the so called ‘pill mills’ and becoming more and more prescribed; this raises questions in insurance companies.

Pating highlighted four different trends that are associated with the Medicaid expansion. In the last 2 years, they’re seeing 700000 more people. The workforce is challenged. Do we need a nIAtx or a totally different, new problem? Quality of care is another issue. The expansion was a leap of faith. We don’t know whether integration is effective. What is integration and how do we know that we’re integrated. Lastly, even though California expanded, there are still many people out of treatment.

Have you attended any of the Plenary sessions at the AHSR Conference on Friday?  Post your thoughts below.

Reduce alcohol consumption in illicit drug users: In the news

glass, dollar bill and cocaine

In 2012, we reviewed the evidence for talking therapies to reduce drinking among people who also use other drugs.  This review was published by the Cochrane collaboration and updated in November 2014. Seven months ago, Olivia Maynard, a research associate from the University of Bristol, gives a wonderful summary of the updated review.

Whilst we all know that excessive alcohol consumption is bad for our health, illicit drug users are one group for whom problem alcohol use can be especially harmful, causing serious health consequences.

The prevalence of the hepatitis C virus is high among illicit drug users and problem alcohol use contributes to a poorer prognosis of this disease by increasing its progression to other diseases. In addition, rates of anxiety, mood and personality disorders are higher among illicit drug users, each of which is exacerbated by problem alcohol use.
Despite these health consequences, the prevalence of problem alcohol use is high among illicit drug users, with around 38% of opiate- and 45% of stimulant-using treatment-seeking individuals having co-occurring alcohol use disorders (Hartzler 2010; Hartzler 2011).
Previous Cochrane reviews have investigated the effectiveness of psychosocial interventions (or ‘talking therapies’) for either problem alcohol use, or illicit drug use alone. However, none have investigated the effectiveness of these therapies for individuals with concurrent problem alcohol and illicit drug use. Given the significant health risk and the high prevalence of concurrent problem alcohol and illicit drug use, a Cochrane review of this kind is long over-due.
Luckily, Kilmas and colleagues have done the hard work for us and their comprehensive Cochrane review of the literature evaluates the evidence for talking therapies for alcohol reduction among illicit drug users (Klimas et al, 2014).
This updated Cochrane review looks at psychotherapy for concurrent problem alcohol and illicit drug use.
This updated Cochrane review looks at psychotherapy for concurrent problem alcohol and illicit drug use.
The talking therapies we’re concerned with here are psychologically based interventions, which aim to reduce alcohol consumption without using any pharmacological (i.e. drug-based) treatments. Although there’s a wide range of different talking therapies currently used in practice, the ones which are discussed in this Cochrane review are:
  • Motivational interviewing (MI): this uses a client-centered approach, where the client’s readiness to change and their motivation, is a key component of the therapy.
  • Cognitive-behavioural therapy (CBT): this focuses on changing the way a client thinks and behaves. To address problem alcohol use, CBT approaches identify the triggers associated with drug use and use behavioural techniques to prevent relapse.
  • Brief interventions (BI): often BIs are based on the principles of MI and include giving advice and information. However, as implied by the name, BIs tend to be shorter and so are more suitable for non-specialist facilities.
  • The 12-step model: this is the approach used by Alcoholics Anonymous and operates by emphasising the powerlessness of the individual over their addiction. It then uses well-established therapeutic approaches, such as group cohesiveness and peer pressure to overcome this addiction.

Methods

  • The Cochrane review included all randomised controlled trials which compared psychosocial interventions with another therapy (whether that be other psychosocial therapies (to allow for comparison between therapies), pharmacological therapies, or placebo). Participants were adult illicit drug users with concurrent problem alcohol use
  • Four studies were included, involving 594 participants in total
  • The effectiveness of these interventions were assessed and the authors were most interested in the impact of these therapies on alcohol use, but were also interested in their impact on illicit drug use, participants’ engagement in further treatment and differences in alcohol related harms
  • The quality of the studies was also assessed
The quality of trials included in this review could certainly have been a lot better.
The quality of trials included in this review could certainly have been a lot better.

Results

The four studies were very different, each comparing different therapies:
  • Study 1: cognitive-behavioural therapy versus the 12-step model (Carroll et al, 1998)
  • Study 2: brief intervention versus treatment as usual (Feldman et al 2013)
  • Study 3: group or individual motivational interviewing versus hepatitis health promotion (Nyamathi et al, 2010)
  • Study 4: brief motivational intervention versus assessment only (Stein et al, 2002)
Due to this heterogeneity, the results could not be combined and so each study was considered separately. Of the four studies, only Study 4 found any meaningful differences between the therapies compared. Here, participants in the brief motivational intervention condition had reduced alcohol use (by seven or more days in the past month at 6-month follow up) as compared with the control group (Risk Ratio 1.67; 95% Confidence Interval 1.08 to 2.60; P value = 0.02). However, no other differences were observed for other outcome measures.
Overall, the review found little evidence that there are differences in the effectiveness of talking therapies in reducing alcohol consumption among concurrent alcohol and illicit drug users.
The authors of this review also bemoan the quality of the evidence provided by the four studies and judged them to be of either low or moderate quality, failing to account for all potential sources of bias.
The review found no evidence that any of the four therapies was a winner when it came to reducing alcohol consumption in illicit drug users.
The review found no evidence that any of the four therapies was a winner when it came to reducing alcohol consumption in illicit drug users.

Conclusions

So, what does this all mean for practice?
In a rather non-committal statement, which reflects the paucity of evidence available, the authors report that:
based on the low-quality evidence identified in this review, we cannot recommend using or ceasing psychosocial interventions for problem alcohol use in illicit drug users.
However, the authors suggest that similar to other conditions, early intervention for alcohol problems in primary care should be a priority. They also argue that given the high rates of co-occurrence of alcohol and drug problems, the integration of therapy for these two should be common practice, although as shown here, the evidence base to support this is currently lacking.
And what about the comparison between the different talking therapies?
Again, rather disappointingly, the authors report that:
no reliable conclusions can be drawn from these data regarding the effectiveness of different types of psychosocial interventions for the target condition.
How about the implications for research? What do we still need to find out?
This review really highlights the scarcity of well-reported, methodologically sound research investigating the effectiveness of psychosocial interventions for alcohol and illicit drug use and the authors call for trials using robust methodologies to further investigate this.
Choosing a therapy for this group of patients is difficult with insufficient evidence to support our decision.
Choosing a therapy for this group of patients is difficult with insufficient evidence to support our decision.

Links

Klimas J, Tobin H, Field CA, 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 12. Art. No.: CD009269. DOI: 10.1002/14651858.CD009269.pub3.
Hartzler B, Donovan DM, Huang Z. Comparison of opiate-primary treatment seekers with and without alcohol use disorderJournal of Substance Abuse Treatment 2010;39 (2):114–23.
Carroll, K.M., Nich, C. Ball, S.A, McCance, E., Rounsavile, B.J. Treatment of cocaine and alcohol dependence with psychotherapy and dislfram. Addiction 1998; 93(5):713-27. [PubMed abstract]
Feldman N, Chatton A, Khan R, Khazaal Y, Zullino D. Alcohol-related brief intervention in patients treated for opiate or cocaine dependence: a randomized controlled studySubstance Abuse Treatment, Prevention, and Policy 2011;6(22):1–8.
Nyamathi A, Shoptaw S,Cohen A,Greengold B,Nyamathi K, Marfisee M, et al. Effect of motivational interviewing on reduction of alcohol useDrug Alcohol Dependence 2010;107(1):23–30. [1879–0046: (Electronic)]
Stein MD, Charuvastra A, Makstad J, Anderson BJ. A randomized trial of a brief alcohol intervention for needle exchanges (BRAINE). Addiction 2002;97(6):691. [:09652140] [PubMed abstract]

 

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Olivia Maynard

Olivia Maynard
Olivia is a Research Associate in the Tobacco and Alcohol Research Group at the University of Bristol, United Kingdom. Her research interests are primarily in the area of investigating the causes and consequences of unhealthy behaviours, and developing interventions to encourage healthy behaviour change, with a particular focus on tobacco and alcohol use. Her PhD, focussed on assessing the effects of plain packaging of tobacco products on behaviour. You can follow her on Twitter @OliviaMaynard17 and the research group she is part of @BristolTARG.

– See more at: http://www.thementalelf.net/mental-health-conditions/substance-misuse/reducing-alcohol-consumption-in-illicit-drug-users-new-cochrane-review-on-psychotherapies/#sthash.nhqsnqPW.dpuf

Reducing alcohol consumption in illicit drug users

New BMJ personal view out now: Training in addiction medicine should be standardised and scaled up

Most health systems lack sufficiently trained doctors to reduce the public health consequences of this problem, writes J Klimas

photocredit: bmj.com


Substance use disorders represent a substantial social and public health burden. An estimated 149 million to 271 million people use illicit drugs worldwide and the related physical and psychological morbidity places challenging demands on healthcare systems.

Addiction science has identified approaches to treat substance use disorders, particularly through early identification and treatment. Most interventions are underused, however. Adequate diagnosis and treatment by healthcare providers fails partly because of lack of knowledge and accredited training in addiction medicine.5 The public health consequences stemming from high rates of untreated addiction result from a lack of addiction treatment, secondary to a lack of trained physicians. Training doctors better is likely to improve accurate diagnosis and appropriate treatment; it may also help reduce the public health epidemics that can result from improper prescribing, such as the current epidemic of opioid analgesic dependence in the United States…

Read the full article at: www.bmj.com
Cite this as: BMJ 2015;351:h4027

Writing Together: Do Too Many Cooks Spoil the Broth?

July 29: Nurse Liz Charalambous has shown how a Facebook group can really help boost writing (careers, June 3). We would like to take this idea one step further and argue that, contrary to a commonly held notion, ‘too many cooks do not spoil the broth’ when it comes to group writing. Instead, this approach fosters collaboration between writers, as Ms Charalambous suggests, and which has also been our experience.
Nursing Standard is the UK’s best selling nursing journal and the ultimate resource for students and fully qualified nurses.

The University of Limerick and University College Dublin primary mental healthcare research writing group recently skyped bimonthly to discuss a short piece of research written by one of four post-doctoral members.
The group read the sample in advance and discussed it with the author, facilitating her to think through her ideas in a supportive environment. Once the group reviewed and discussed the text, the author revised it, combined it with the rest of the article, and emailed it to the principal investigator.
The principal investigator and the author then finished the paper and emailed it out for review to all named co-authors. This way, the authorship was clearly defined, managed and assigned as per the necessary guidelines. The broth was ready and we had all helped to cook it.
J Klimas, D Swan, G McCombe and AM Henihan, University of Limerick, University College Dublin, Kings College London and University of British Columbia 

Read the article in the Nursing Standard Volume 29, Issue 48, 29 July 2015 at: http://journals.rcni.com/loi/ns 

New paper out now: Psychosocial Interventions for Alcohol use among problem drug users

May 18thMany people in methadone treatment receive it through their primary care provider. As many also drink alcohol excessively, there is a need to address alcohol use to improve health outcomes for these individuals. We examined problem alcohol use and its treatment among people attending primary care for methadone maintenance treatment, using baseline data from a feasibility study of an evidence-based complex intervention to improve care.
 


What have we found: Clinical records indicated that 24 patients (19%) were screened for problem alcohol use in the 12 months prior to data collection, with problem alcohol use identified in 14 (58% of those screened, 11% of the full sample). Of those who screened positive for problem alcohol use, five received a brief intervention by a GP, and none were referred to specialist treatment.
Scores on the Alcohol Use Disorders Identification Test (AUDIT) revealed the prevalence of hazardous, harmful and dependent drinking to be 25% (n=26), 6% (n=6), and 16% (n=17) respectively.
Only 12 (11.3%) AUDIT questionnaires concurred with corresponding clinical records that a patient had any/ no problem alcohol use. Regular use of primary care was evident, as 25% had attended their GP more than 12 times during the past three months.

What does this mean: Comparing clinical records with patients’ experience of SBIRT can shed light on the process of care.  Alcohol screening of people who attend primary care for substance use treatment is not routinely conducted.   Interventions that enhance the care of problem alcohol use among this high-risk group are a priority.
To read the full article, go to the website of the Journal of Dual Diagnosis:  http://www.tandfonline.com/doi/full/10.1080/15504263.2015.1027630#.VVtIBpO6eJY
Cite as: Klimas, J., Henihan, AM., McCombe, G., Swan, D., Anderson, R., Bury, G., Dunne, C., Keenan, E., Saunders, J., Shorter, GW., Smyth, B.,  Cullen, W. (2015) Psychosocial INTerventions for Alcohol use among problem drug users (PINTA): Baseline feasibility data. Journal of Dual Diagnosis 11(2):96-106