Category: Career

Posts by Jano Klimas about the academic career and the long and harrowing journeys of academics.

Off the record: addictions in medical schools

If it’s not recorded, it didn’t happen.
An old saying
We wanted to find out how much teaching on addiction get on medical students. In 2011, our colleagues Sarah O’Brien and Professor Cullen searched PubMed (online database of medical papers) for published literature on training of undergraduate medical students in addiction
There is currently no documentation of drug addiction teaching sessions in Irish medical schools.
We looked at other medical databases and we also searched websites of all 6 medical schools in Ireland.  We have searched the literature published after October 2009.
We found nothing in the medical databases. Schools’ homepages did not mention addiction either.
A telephone survey may provide a more accurate representation of how addiction medicine education is incorporated into the medical school curricula.
Substance use disorders are a worldwide problem, and have become a major health concern in Ireland particularly.
In their new position paper on addiction, the Irish Medical Organisation recognized the lacking education and called for “appropriate training of all physicians in treatment of addiction” (Irish Medical Organisation, 2015). Although the science behind addiction treatment has discovered new treatments for addiction, the medical doctors don’t know about them, mainly because they get no training on addiction. As a result, they feel unprepared to treat people with addiction who receive inadequate care.

To cite this article: Mitch Wilson, Walter Cullen, Christine Goodair & Jan Klimas (2016): Off the record: Substance-related disorders in the undergraduate medical curricula in IrelandJournal of Substance Use, DOI: 10.3109/14659891.2015.1112853

Primary care looks at drinking among persons on methadone treatment

How should primary care doctors ask their methadone patients about alcohol use?

We worked with 13 primary care doctors and divided them into two groups. We trained one group on how to ask about and advise on heavy drinking. We looked at whether trained and coached doctors managed patients who drank.

Primary care can look at drinking among persons on methadone treatment and advise on risks of heavy drinking.

We found that the trained doctors asked about and advised on heavy drinking more often than the untrained doctors. Four patients in their care drank less alcohol three months later, compared to two patients of the untrained doctors. Some doctors were reluctant to use their new learning in the practice because it was too complicated.

A bigger and simpler study must prove the positive results of this modest study

Methadone helps people with opioid use disorders use less drugs, but it doesn’t stop them from drinking. About 30% of them drink in excess of the low-risk drinking limits. Drinking makes their treatment harder and their health worse. Primary care doctors who prescribe methadone see patients weekly and can help them drink less.

Reference: Henihan, AM., McCombe, G., Klimas, J., Swan, D., Leahy, D….Cullen, W. (2016)  Feasibility of Alcohol Screening among Patients receiving Opioid Agonist Treatment in Primary Care. BMC Family Practice, 17:153

Hepatitis C unchanged, but drinking soared


What is the study about?

           We wanted to find out how many people receiving treatment for opioid addiction (methadone) have Hepatitis C and other blood borne viruses
           And whether anything changed between the years 2006 and 2013


Over a third of people who receive methadone in primary care and who drink excessively test positive for Hepatitis C

How was the study done?

           In 2013, we have done a secondary analysis of data collected during a feasibility study of an alcohol brief intervention for people attending primary care for methadone treatment
           We looked at two studies done in 2006 and 2013 and compared them

What did the study find?

           We found the proportion of patients with problem alcohol use was much higher (46% v 35%) in 2013.
           37% of people who had Hepatitis C also drank excessively
In 2013, number of people who had Hepatitis C was not different from 2006, but more people drank excessively.

Why is the study important?

           Many people who receive treatment for opioid addiction have Hepatitis C
           Treatment of Hepatitis C is expensive
           Because heavy drinking can make the treatment even more expensive, we should help people drink less
Reference: Improvements in HCV-related Knowledge Among Substance Users on Opioid Agonist Therapy After an Educational Intervention. Journal of Addiction Medicine: September/October 2016 – Volume 10 – Issue 5 – p 363–364

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.


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.

International Society of Addiction Medicine | Congress #isam2015

For the 17thtime, the world has seen the meeting of the International Society of Addiction Medicine (ISAM) in Dundee, Scotland. The congress covered Addiction from biology to recovery with the aim of translating research evidence to improve clinical practice and community resilience. Here, I note my thoughts from three out of the eight keynotes that I attended.

Monday 5 October: Raju Hajela and Ken Roy talked about addiction’s past, present and future (Chair: Kathleen Brady). Dr Hajela opened his talk with photos from his tour of the Edinburgh castle. He combined the treatment of alcohol and drug dependence as a doctor in the Canadian armed forces. At the age of 15, he moved to Canada. From his experience, episodical treatment has been the model. Today, episodic treatment still persists, but punishment, as a form of treatment receded. We have to be careful about how we define disease, remission and cure. Is addiction like diabetes? Before insulin has been discovered, diabetes was a mystery. Insulin replacement is not treatment for all types of diabetes. The state of addiction is not the same as the state of intoxication. Simply put, addiction is not a desired condition.
            Dr Roy claimed that recovery is necessary for abstinence. It is important to recognise that my addiction is stronger than I am. According to the Betty-Ford expert opinion recovery is a voluntary maintained lifestyle. There is no medication for immaturity. Craving is only one part of the whole gestalt of who this recovering person is; yet, most treatment has concentrated on it.
Monday 5 October: Elizabeth Sáenz introduced UNODC’s global projects on drug use prevention and the treatment of drug use disorders. Is it the type and patterns of drug users that we are interested in? What are the challenges? To date, human rights of people with substance use disorders are violated.  Many countries don’t accept addiction treatment in prisons. Respect first is key for the mentality of the change in the community. Many countries spend prevention money on cups and pens. Are these interventions effective? What are we really doing? Training people in prevention and treatment is very difficult when the training materials haven’t been translated into local languages.
            Dr Howard Moss covered the heterogeneity of alcohol dependence and the role of polysubstance misuse. The key point of is talk was that “alcoholic is not an alcoholic.” He described the distinctly different type of a person who uses multiple drugs. Simply using the phenomenology to understand dependence, we’re missing the boat. Who comes to treatment? People with the chronic, severe dependence and multiple other (substance-use) disorders. How did they do in the treatment? Not well. These are the people who present in our problems. The people who have most success treatment are the group who doesn’t present in treatment and who doesn’t experiences the psychosocial consequences of addiction. The saying “drinkers smoke and smokers drink,” seems to be true from the epidemiological perspective. If there are distinct differences between single- and poly-drug users, is it because of exposure to multiple drugs or are we looking at a pre-morbid risk factor. We clearly don’t know the answer to that question. Because clinical trials almost never include poly-drug users, we don’t know much about them. This topic is of utmost importance also for our Cochrane Systematic Review of literature.
Tuesday 6 October Dr Wim van den Brink talked about the addiction and comorbid ADHD. What is the prevalence of adult ADHD among people who have addiction? According to Dr van den Brink’s meta-analysis, it was 23% on average (range 10-50%). The method of assessment and the primary substance of use could explain this variability. Differences between the countries are huge. Which children with ADHD develop addiction? The literature showed that the single most important factor was the age of starting treatment of ADHD.  The treatment of treatment fades out over time, especially if the treatment is discontinued. Whether the treatment decreases the risk or increases the risk is unknown mainly due to the heterogeneity of the literature.  The impulsivity aspects seem to be responsible for the association between addiction and ADHD.
            Dr Brink didn’t enjoy walking in the mountains and by this he demonstrated how some people might be born with a vulnerability to addiction similar to hyperactive nervous system. You just want to do something nice, including drug taking, which in itself may not be bad, but if combined with ADHD – the problems occur. Delay discounting plays an important role in addiction. The comorbidity between the conditions goes in both directions. Van Den Brink thinks we shouldn’t be keeping the medication away from patients who need it. It seems though that at certain stage, the impulsive behavior, it might become an autonomic automatic behavior.
Wednesday 7 October: “Brief interventions started in Scotland,“ Dr Nick Heather opened his morning talk discussing addiction as a disorder of choice. “I am a former addict,” he apologized for using the term addict; we shouldn’t be labelling people. He quit smoking three years ago. Is addiction a choice or a disease? Recently, the research suggested that the truth is somewhere in the middle. Carl Hart’s book The High Price has caused big stir in this debate. Also, the fact that Dr Alexander’s Rat Park work has been replicated and the rats did not choose morphine if they had structured-environment reinforces is of great significance. As Dr Humphreys suggested, the rat park, and the evidence of former Vietnam veterans quitting after return to US, should have changed our views of addiction.

Wednesday 7 October Keith Humphreys started with how met a person who bought his book on mutual help and recovery. Does that really help? The difference is in how people refer. The warm hand-off trial with an impressive follow-up rate of 85% found people randomized to self-help intervention had about 60% better outcomes than treatment as usual. Active coping, motivation to change, changes in friendship networks (specifically encouraging to stop using) seem to be the most active ingredients of, or the mediators of, change that occurs in mutual help groups. Giving people helps is strongly associated with better outcomes. Intensive referral that includes even just calling the person in the session increases people’s chances of going to the group. Transitions are challenging for people. Furthermore, the recovery movement had a huge impact on the expansion of the so-called Obama care to include full coverage for all substance use disorders. During some of these fights, the recovery movement put so many calls to the White House that the line had to be shut down. You can never measure that impact scientifically, but there’s good amount of hope to believe that a group of well-meaning people can influence policy. In conclusion, apart the psychological and social factors of mutual help groups; we really need more choices, more groups for people. We also need more good quality studies, even though we could guess that self-help works given the evidence from other areas where it had impact.

Have you attended the Plenary at the 14th Centre for Addiction Research and Education Scotland (CARES) Conference on Thursday?  Post your thoughts below.