Irish GPs support wider use of naloxone to treat opiate addiction
Two thirds of GPs in Ireland support planned initiatives to provide wider availability of naloxone in the community for treating opiate addiction and overdose, a survey by University College Ireland has found.1
More than 200 deaths due to opiate overdose occur each year in Ireland, one of the highest rates in Europe. Naloxone is an effective opiate antagonist that can revert opiate overdose. “Take home” naloxone schemes, in which patients considered at risk …
by Susan Mayor
BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j1103 (Published 03 March 2017)Cite this as: BMJ 2017;356:j1103
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.
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| photocredit: mrmediatraining.com |
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 Ireland. Journal 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.
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| photocredit: methadoneaddiction.com |
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
QUICK FACT:
Over a third of people who receive methadone in primary care and who drink excessively test positive for Hepatitis C
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| asam.org |
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
(http://journals.lww.com/journaladdictionmedicine/Citation/2016/10000/Commentary_on_Zeremski_et_al___2016___.11.aspx)
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.
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| 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.