Reducing drinking in illicit drug users: an impact story @COMETinitiative
Research impact is often hard to prove. It takes years before our findings change the world and the change is often small. This new abstract published in the Trials journal summarizes a poster presentation from the conference of the Core Outcome Measures in Trials (COMET) Initiative. This year the conference was in Calgary, Canada, on May 20-21.
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| credit: trialsjournal.org |
One out of three people who receive methadone in primary care drink in excess of the recommended limits. This poses significant risk to their health, especially to their liver; it complicates their care and increases risk of relapse.
We wanted to inform addiction treatment in primary care with respect to psychosocial interventions to reduce drinking in concurrent problem alcohol and illicit drug users, by: exploring the experience of (and evidence for) psychosocial interventions, developing and evaluating a complex intervention to improve implementation. Evaluation of the intervention tested core feasibility and acceptability outcomes for patients and providers.
Our Cochrane review found only four studies. Having inconclusive evidence, we interviewed 28 patients, 38 physicians and nurses. Patient interviews informed development of a national clinical practice guideline, as well as design and outcomes of the evaluation project. Feasibility outcome measures included recruitment, retention, completion and follow-up rates, as well as satisfaction with the intervention. Secondary outcome was proportion of patients with problem alcohol use at the follow up, as measured by Alcohol Use Disorders Identification Test. Information from the Cochrane review and the qualitative interviews informed an expert panel consultation which developed clinical guidelines for primary care. The guideline became part of a complex intervention to support the uptake of psychosocial interventions by family physicians; the intervention is currently evaluated in a pilot controlled trial. Two new alcohol education programmes were created as a response of the community to the problem and a lack of specialist support services for patients with dual dependencies. Both Coolmine Therapeutic Community and the Community Response Agency run a 10-week group that specifically seeks to include people with dual dependencies, from methadone programmes.
Cite this article as: Klimas et al.: Reducing drinking in concurrent
problem alcohol and illicit drug users: an impact story. Trials 2015
16(Suppl 3):P11. doi:10.1186/1745-6215-16-S3-P11
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.
First European conference on dependencies 2015: Keynotes #LxAddictions15
A major new event in the addictions landscape – the organisers claimed. To date, there hasn’t been a Europe-wide meeting on addictions. Many smaller conferences took place around the old continent, including the Annual Symposium of the Society for the Study of Addiction in York – the oldest addiction society in the world (anno 1884). I hoped that Lisbon can bring together people that attend the other meetings but never together. Here, I note my thoughts from three out of the 17 keynotes that I attended.
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| photocredit: lisbonaddictions.eu |
Robert West (@westr) on Wednesday 23 September 11:00 – 12:30, Plenary Session I (other speakers: Anne Line Bretteville-Jensen, Gabriele Fischer, Mark Kleiman, Marina Picciotto).
| photo credit: rawest.co.uk |
Speaking about the addictions from a multi-disciplinary perspective, Prof West highlighted that the tendency to monetize everything is destructive. We also tend to compartmentalize the models of addiction. Whether we think addiction is a self-medication or a social construct, all of those things have some validity, but we need to bring them together. Whether it’s speaking at a conference or dealing with an addictive behavior, three things are critical in order for change to happen: capability, motivation and opportunity (COM-B model of behavior). How hard can it be? The audience laughed. If we crack the addiction, we crack something that is at the heart of the human civilization. The taxation policies can be informed by the neuroscience, as they can be by counseling. West concluded his talk with a proposal for how we can deploy our resources better. He discouraged people from fighting over the money to be spent on addiction research. At the moment, we tend to direct addiction research towards our own interests, hunches and areas of expertise. This needs to change. A major review of research strategy underpinning approaches to combating addiction as the moment.
Keith Humphreys o (@keithNHumphreys) n Thursday 24 September 09:00 – 10:30, Plenary Session II (other speakers: Linda Bauld, Felix de Carvalho, Marina Davoli, Margriet Van Laar).
| photo credit: stanford.edu |
Translating research into policy and practice, Prof Humphreys reviewed the US science and policy on addiction in the last 7 years, especially the 2008 MHPEA, the 2010 “Obama care” and the 2008 MIPPA that eliminated the co-pays by 2014. Has the science affected the policy in any way? Is parity on everything possible? When kids reach 18, they leave their parents’ health insurance. The ACA changed it to 26 years. The addiction care providers cheered as this critical period in human development became covered. The welcome to Medicare exam introduced by MIPPA includes a depression and problem-drinking screen. Did scholarship in our field contribute to these policy changes? Is science supposed to decide policy by itself? The science doesn’t tell what we care about as a society. “Scientific evidence alone is not sufficient basis for health policy,” as Humphreys and Piot argue in a BMJ analysis. Just because we’re experts in science, it doesn’t make us experts in the governance. The fundamental political decisions are made outside of us and that’s good, because we’re not “Queens and Kings.” Humphreys went on to describe the four routes through which policy was translated into practice: press releases, professional organizations and grassroots advocates, scientists engaging the bureaucracy formally and informally, scientists in policymaking roles. In sum, the policy on alcohol and drugs related care in US is dramatically different than 7 years ago. Scientists didn’t cause that to happen by their own. On the other hand, the political will alone doesn’t guarantee smart policies (Figure 1).
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| Figure 1. Summary slide of Prof Humphrey’s presentation. |
Thomas Babor on Thursday 24 September 16:00 – 17:45, Plenary Session III (other speakers: Gerhard Bühringer, Henrique Lopes, Pia Mäkelä, Susana Jiménez Murcia).
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| photo credit: sea-addiction.org |
Discovering, new frontiers in addiction research, Prof Babor asked why do we pay attention to infrastructure in addiction science? Starting in the 1970’s, there was a gradual increase in the number of addiction research centres. When medical temperance people began to publish articles for peer-reviewed journals, specialized journals emerged. Starting from the 1960’s the number of journals exploded. Large proportion of the article production comes from U.S. and other “developed” countries; hoverer, there’s the bias of the dominance of the English language in the scientific areas. Now, people are starting to think of themselves as addiction specialists, especially if they get specialised training in that area. We’ve got large numbers of people who can be identified as addiction scientists. The science of bibliometrics tells us that there are over from 130.000 Occasional contributors (Bronze league), to 250 Platinum contributors (The Invisible College), who are publishing large numbers of articles per year. Some troubling trends – the predatory publishers corrupt the peer-review process. Science has become interested in the private interest – business model. Industry funding biases and sets the agenda for research. Where does this leave us? It leads to the fact that policy makers seem to be looking for a different kind of science that we’ve been doing. If we put all these trends together, the population and the public health impact of our research has not been demonstrated.
Have you attended the fourth Plenary about Challenges of addiction in an interconnected world on Friday? Post your thoughts below.
Reduce alcohol consumption in illicit drug users: In the news
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.
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.
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.
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.
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 disorder. Journal of Substance Abuse Treatment 2010;39 (2):114–23.
Hartzler B, DonovanDM,Huang Z. Rates and influences of alcohol use disorder comorbidity among primary stimulant misusing treatment-seekers: meta-analytic findings across eight NIDA CTN trials. The American Journal of Drug and Alcohol Abuse 2011;37(5):460–71.
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 study. Substance 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 use. Drug 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]
– 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
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
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| 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