Category: Primary care

New study out now: Replacing heroin with alcohol upon entry to methadone?

April 4: Methadone is a medication used in treatment of people with dependence from heroin or other opioids. Many people who take it drink too much alcohol. We don’t know whether it’s because or in spite of taking this medication. We wanted to know the impact of enrolment in methadone treatment on the onset of heavy drinking among people who use heroin.
photocredit: karger.com/EAR
 Our approach: We analysed information from thousands of interviews from long-term, community-based studies of people who inject drugs in Vancouver, Canada, between December 1, 2005 and May 31, 2014.
What have we found: In total, 357 people who use heroin were included in this study. Of these, 58% enrolled in methadone at some point between 2005-2014, and 32% reported starting to drink heavily. Those who started the treatment said they drank less compared to those who did not start it. It didn’t even make them start drinking faster than those who did not start taking methadone. People who started drinking heavily when they enrolled in methadone were younger than those who did not start drinking heavily. They also used more cannabis.
What does this mean: It is clear that many people in the methadone treatment have problems with alcohol. It seems that they do not drink because they take this medication which may even appear to decrease the initiation of heavy drinking. Our findings suggest younger age and cannabis use may predict heavy drinking. These findings could help inform on-going discussions about the effects of opioid agonist therapy on alcohol consumption among people who use heroin.
This blog is based on article was Accepted for publication in the European Addiction Research Journal on January 31, 2016. The full title of the article is: The Impact of Enrolment in Methadone Maintenance Therapy on Initiation of Heavy Drinking among People who Use Heroin. The authors of the article are following:
Jan Klimas
Evan Wood
Paul Nguyen
Huiru Dong
M-J Milloy
Thomas Kerr

Kanna Hayashi

New paper out now: Primary care distributes life-saving medication for 17 years

The year was 1996 and Ireland was recovering from a recent heroin epidemic. Methadone, a medical replacement drug for heroin, was jut making its way into specialised clinics in Dublin.

Professor Gerard Bury and colleagues had a revolutionary idea that people who use drugs can receive agonist drugs, like methadone, from their family doctors.

photocredit: tandfonline.com/loi/igen20#.VlO9bHarTrc

The opioid agonist treatment has substantially changed the course of the drug use epidemic. Yet, many continue to die and suffer from chronic diseases. In Ireland, everybody who’s prescribed this medication has to be registered with the Central Treatment List.

In this new study, we wanted to revisit a group of people who were the first to receive their agonist medication, i.e., methadone in the primary care in Ireland.
At follow-up in 2013, 27 (27.6%) of the 98 people had died in Ireland and had relevant entries in the Register of Deaths, 19 (19.4%) were currently in OAT and the status of the remaining 52 (53%) was ‘alive,’ as per the Irish death registry.
The 52 patients ‘alive’ had left the Central Treatment List, but no further information was available on their status.

“Our inability to establish the interval data for the retention in treatment is a significant study limitation, but the overall retention of 19 out of the surviving 71 patients is comparable to previous research.”


The deceased died of multiple causes; only six had a single cause. Drug toxicity, overdose, or both, were the most common causes of death.

Cited study:
Jan Klimas, Anna Keane, Walter Cullen, Fergus O’Kelly, and Gerard Bury (2015) Seventeen year mortality in a cohort of patients attending opioid agonist treatment in Ireland. European Journal of General Practice (http://dx.doi.org/10.3109/13814788.2015.1109076)

XXV Annual Meeting & Canadian Scientific Conference 2015 CSAM – SMCA (#WhatTheFentanyl #abhealth)

What is the future of addiction medicine? What is the future addiction specialist going to look like? Nobody knows what the future is going to look like, but the delegates of the 25th CSAM annual conference imagined answers to these questions in Banff, Alberta at the Banff Centre on Tunnel Mountain. As a first comer to the conference, I had a lot to learn and a lot to write down. Read more below.

photocredit: csam-smca.org

Seven high-profile experts explored trends at home and abroad and the scientific topics impacting the future of addiction treatment delivery in their keynote plenaries.

1.         Prescription Abuse (Dr. Roger Weiss)
Dr Weiss updated he delegates on the progress of the Prescription Opioid Addiction Treatment Study (POATS). The outcomes of the first phase of the trial were disastrously low, in contrast with the buprenorphine that was 7 times more effective after 4 weeks. Who did well? If you’d ever been in a treatment, or used not-as-prescribed prescription opioids, or the OxyContin was your most frequently used opioid – that was a bad sign. Older people did better. Interestingly, depression was also a good sign. What initiates the addiction is not necessarily what maintains the addiction.
2.         Marihuana and Anxiety (Dr. Matthew Hill)
Dr Hill introduced the insights from the basic science field. Why people use cannabis? 84% say it helps them relax; to help reduce feelings of stress, tension and anxiety. The endocanabinoids tends to keep the amygdala quiet when it should be quiet. They act as natural regulators of the amygdala. Anxiety may be related to impairment in the endocannabinoid signalling. Dr Hill’s 2014 talk on the same topic has been recorded and posted online.
3.         State of the Science for Technology-Based Approaches to Substance Use: Directions for the future (Dr. Sarah E. Lord)
Internet Electronic Therapy was the focus of the first afternoon plenary. Dr Lord described some of the tools that are out there, gave examples of them and validation data. Brief intervention and CBT-4-CBT were among them. The space of phone applications industry is far ahead of the science.
4.         Integrative Addiction Medicine (Dr. G. Bunt)
The weather conditions worsened in Banff so much that Dr Bunt slipped and fell down on the way to the lecture hall (see Figure 1).
5.         Brain Plasticity and Addiction (Dr. Bryan Kolb)
Dr Kolb kicked off the Saturday conference programme. Brain changes constantly. Anything you learn is going to occur because the brain changes. Play and stress too modify pre-frontal cortex. Interaction of brain and psychoactive drugs keeps fascinating scientists.
6.         Clinical considerations for behavioural addictionsin the settings of DSM-5 and ICD-11 (Dr. Marc Potenza). During the first part of this millennium the perspectives on addiction changed, especially the behavioural addictions. How are they different or similar to substance use disorders? Many are strongly associated with behavioural addictions, e.g., heavy alcohol use and gambling. In addition to the high rates of co-occurrence, there are similar clinical courses, similar clinical characteristics, similar biologies and similar treatments for behavioural addictions.
7.         The Alberta Addiction & Mental Health Review: Current challenges & lessons learned (Dr. David Swann).

Investment into addiction treatment is only a fraction of the Alberta’s budget – 0.1%. The current government of Alberta isn’t doing evidence-based policy but policing evidence. Racism is alive and well in Alberta. Lack of understanding led to the fiasco of the primary care reform in Alberta. It has an ambiguous direction on harm reduction. Dr Swann concluded his talk with 30 questions for the audience.

Figure 1. Banff centre snow

AMERSA 39th Annual National Conference

November 5th, the national conference of the Association for Medical Education and Research in Addiction – AMERSA 39th – took place in Washington, DC. With 75% of the 225 delegates being new to the conference, the conference dynamics enlivened. As a rather small association with only 1 FTE, it is doing great in attracting so many new delegates. To see what lectures they got to hear, read my notes from the Keynote speeches below.

www.amersa.org

There is no room for prosecutors in the delivery room

Dr Paltrow questioned who gets the rights when it comes to pregnant drug users. While the laws in many US states try to protect the unborn child, in reality it is the judge, the county and the attorney who gets the rights. Is this the protection of the unborn or of the system? Dr Paltrow’s mother smoked during pregnancy:

“Maybe if my mom wasn’t smoking throughout her pregnancy, I might have been a for-profit lawyer.”

To reduce the stigmatisation of pregnant women with substance use disorders, make sure to “use the word use” – not Abuse, neither drug-dependent newborn. If you are asked to drug test when you shouldn’t, it is a moral obligation to do civil disobedience. The medical education should include teaching the risks that clinicians carry when they report pregnant women who use drugs.

What is appropriate counselling?

 
Dr Carroll posed some really important questions, such as – How do we really get to good long-term outcomes? Is Medical Management (MM approach) that good? The intensity of MM done in trials is probably not scalable in clinical practice. We shouldn’t give up on the research evaluating psychosocial treatments. Let’s give the therapies a fighting chance, shall we? We’ve just gotta find a way to do better as therapists. Many trials report that people do not finish the treatment. We have to reach to underserved and vulnerable populations. We have to realise that people in buprenorphine treatment are different – they don’t seek counselling. CBT (Cognitive Behavioural Therapy) retains people in treatment 3x better than treatment as usual. Usual treatment does not teach people skills.
 

Betty Ford Award Plenary Session at the AMERSA 39th Annual National Conference

How AMERSA was saved? When Betty Ford learned in 1985 that the association is near extinction due to only $200 left in the kitty, she offered a $10.000 cheque from the royalties of her new biography and personal account. This year, Dr Caetano received award named after her. His Border project, and two other projects, found how the Mexican Americans and the Puerto Ricans drank much more than the other groups of US Hispanics. Women of this origin drank the most of all national groups in this country. 

“No matter what is the dimension of drinking, the diversity is there.”

If you’re in Miami, it’s not gonna be helpful to know the national data. The local authorities need to know.

If you enjoyed reading about this year’s conference, you may like to read my notes from the previous year, 38th meeting in San Francisco, CA, November 4th, 2014.

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.