Category: Primary care

International Perspectives on Teaching Doctors about Addictions: New abstract out now

April 1st: The Affordable Care Act (2010) brings an opportunity to increase the integration of addiction treatment into the health care system. With the anticipated expansion of addiction care services in primary care, challenges, such as workforce training, can be expected.
A team of researchers from Ireland, Canada and Portland, Oregon, presented their experiences and challenge of addiction medicine training of primary care professionals at a Boston conference in October 2014. The conference was dedicated to Addiction Health Services Research.
The presentation outlined the set up and content of some of the current drug education projects in medical school, fellowship and residency in Ireland, Canada and Portland, Oregon. The speakers used examples from three educational initiatives to generate ideas applicable to each setting and help overcome integration barriers: the St. Paul’s Hospital Goldcorp Addiction Medicine Fellowship (http://www.addictionmedicinefellowship.org), the feasibility study on alcohol screening, brief intervention and referral to treatment (SBIRT) for opioid agonist patients in Ireland (PINTA study), and the team-based SBIRT Oregon project (http://www.sbirtoregon.org).

Read more in the conference proceedings published in a recent supplement of the Addiction Science & Clinical Practice journal. http://www.ascpjournal.org/content/10/S1/A28

Addiction Science & Clinical Practice provides a “forum for clinically relevant research and perspectives that contribute to improving the quality of care for people with unhealthy alcohol, tobacco, or other drug use.” Read the published abstract at: http://www.ascpjournal.org/or

watch the conference presentation at: https://prezi.com/qptvun1i0am0/integrating-addiction-medicine-training-into-medical-school-and-residency-curricula/
Klimas, J., Rieb, L., Bury, G., Muench, J., O’Toole, T., Rieckman, T., & Cullen, W. (2015). Integrating addiction medicine training into medical school and residency curricula. Addiction Science & Clinical Practice, 10(Suppl 1), A28. 

Using Doctors Notes to See How They Treat people with Mental Health Disorders: New study out now

April 9th: Prevention and treatment of mental disorders challenge primary care doctors worldwide. Most of them use electronic medical records (EMRs) to keep track of their patients. A team of students and scientists from University of Limerick was led by Dr Cullen and wanted to see how doctors record mental health disorders in their records. They wanted to find out whether these notes can be used for research.


The researchers randomly sampled 690 patients from seven general practices in Ireland (age from18–95, 52% male, 52% low-income).

A mental disorder (most commonly anxiety/stress, depression and problem alcohol use) was recorded in the clinical records of 139 (20%) during the 2-year study period. While most patients with the common disorders had been prescribed medication (i.e. antidepressants or benzodiazepines), a minority had been referred to other agencies or received psychological interventions. ‘Free text’ consultation notes and ‘prescriptions’ were how most patients with disorders were identified. Diagnostic coding alone would have failed to identify 92% of patients with a disorder.
Although mental disorders are common in general practice, this study suggests their formal diagnosis, disease coding and access to psychological treatments are priorities for future research efforts.
Citation for the original study:  M. Gleeson, A. Hannigan, R. Jamali, K. Su Lin, J. Klimas, M. Mannix, Y. Nathan, R. O’Connor, C. O’Gorman, C. Dunne, D. Meagher and W. Cullen. Using electronic medical records to determine prevalence and treatment of mental disorders in primary care: a database study. Irish Journal of Psychological Medicine, available on CJO2015. doi:10.1017/ipm.2015.10. 
http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=9641472&fulltextType=RA&fileId=S0790966715000105

Encouraging people to take part in studies of drug and mental health problems: New abstract out now

April 1st: Encouraging recruitment to clinical trials is a frequently reported problem. Challenges related to study design, communication, participants, interventions, outcomes and clinician workload hinder recruitment, and the effectiveness of interventions used by scientists to increase recruitment rates is unknown.

 

A team of researchers from Ireland, U.K. and U.S. talked about the methodological challenges and issues in recruiting for mental health and substance use disorders trials in primary care at a Boston conference in October 2014. The conference was dedicated to Addiction Health Services Research.
The presentation recounted authors’ experiences of recruiting for clinical trials in primary care. Methodological challenges, such as clarity of instruction, patient characteristics, patient-doctor relationship, effects of intervention on patients and clinic, and personal benefits for clinicians will be described. The authors discussed how these might be used for peer-learning and peer-support in primary care research.

 

Read more in the conference proceedings published in a recent supplement of the Addiction Science & Clinical Practice journal. http://www.ascpjournal.org/content/10/S1/A21
 
Addiction Science & Clinical Practice provides a “forum for clinically relevant research and perspectives that contribute to improving the quality of care for people with unhealthy alcohol, tobacco, or other drug use.” Read the published abstract at: http://www.ascpjournal.org/or

 

watch the conference presentation at: https://prezi.com/qptvun1i0am0/integrating-addiction-medicine-training-into-medical-school-and-residency-curricula/
Henihan, A., Klimas, J., Bury, G., O’Toole, T., Rieckman, T., Shorter, G., & Cullen, W. (2015). Methodological challenges and issues of recruiting for mental health and substance use disorders trials in primary care. Addiction Science & Clinical Practice, 10(Suppl 1), A21.

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

Patient-Related Drinking and Alcohol Counselling: Do Doctors Own Lifestyle Habits Matter?

The medical degree isn’t a vaccine against addiction.​ ​​“If you don’t drink as much as your GP, you don’t drink too much,” an old saying goes. When it comes to doctors’ own lifestyle habits and patient-related alcohol counselling, the science remains silent.

Personal Experience
Surveys of physicians’ attitudes towards drugs or drinking are multitude. They are relatively easy to do – doctors answer them by circling numbers or ticking the boxes in research questionnaires. While sometimes it’s easy to figure out the purpose of the survey and adjust one’s answers accordingly, other times the survey doesn’t give clues about its underlying goals.
Photocredit: wisequacks.org
​A Boston surveyasked over a hundred family doctors whether they knew someone (other than a patient) with an alcohol or drug problem. Up to 85% knew someone with these problems and about a third of them said this person was “family, a close friend or themselves.” Compared to the rest of the survey, they were more confident in asking patients about alcohol and advising on low-risk drinking. This positive effect did not translate to the other parts of their job, such as “perceived responsibility, attitudes, professional satisfaction, and practices”, though.
When faced with a “human face” of addiction, some medical doctors change their preconceptions:

“I found the workshop really eye opening. It changed my preconceptions of what I thought a ‘drunk Doctor’ would be like; when we were all sat around the table I was wondering to myself when the Doctor would be coming to speak to us and why he wasn’t there already, so I was taken by surprise when it turned out he was sitting right opposite me! I think that shows that this really is an issue that needs to be put in front of medical students as most like me will only have come into contact with alcoholism through seeing patients on wards, or seeing people in the street.”

The Example comments made by students who attended an addictions workshop were taken from http://www.sgul.ac.uk/research/projects/icdp/pdf/smugprojectreport.pdf  The doctor was a member of the Sick Doctors Trust http://sick-doctors-trust.co.uk/
The measurement problem
Two measurement problems hinder research on this topic. How to measure doctors’ drinking? How to measure the alcohol treatment they provide to patients with addiction?
Objective measures of alcohol consumption would be best. The measures we normally use are unreliable – Breathalyzers or ETG (Ethyl Glucuronide) tests. Apart from being perhaps somewhat intrusive for docs, they it pick up recent drinking only. Similar to other alcohol research, we would have to rely on what the doctors tell us.
Actual measures of practice are less worrying than objective measures of drinking. Again, measuring success of doctors’ approach by the number of abstaining patients is extremely difficult. Our best shots are proxy measures, such as number of prescribed medications or number of referrals to specialists. Although audits of doctors’ practice have been found to underestimate the actual care delivered by doctors, the Self-reports of practice seem to inflate the figures.
Other lifestyle habits
A previously published blog post and an article in the Irish Psychologist described two studies that illustrated how doctors’ lifestyle habits matter and how their ambivalence can be boosted. Research at the University of Michigan, cardiovascular centre demonstrated how doctors’ confidence in their ability to advise patients on diet and exercise correspond with their own personal health and fitness levels. Maybe lifestyle habits influence health care (in one paper) for a different issue (diet/exercise), but does that relate in some way to alcohol?
Another team supervised by Hettema and Sorensen used Motivational enhancement therapy (MET) to help medical trainees to resolve their ambivalence around managing alcohol and drug problems. They’ve put a group of nine medical residents through a brief MET therapy before they learned more about alcohol consulting and advice-giving. Five weeks later, their consulting and advice-giving went up, but due to the small numbers, the researchers called for caution with interpretation of their results.
 
No one is immune from addiction. While we know that doctors do get it too, we see little, if any, literature that specifically supports a statistically significant association between physician drinking and physician screening or counselling. In another words, we don’t know whether their own drinking or drug taking influences how they treat addictions. Can you find a paper?