Category: Collaboration

See What Happens: My First Week in the Addiction Research Paradise

Abundance of data, army of eager support staff, in-house statisticians and hi-tech infrastructure – what else could an addiction researcher dream of? The Urban Health Program at the British Columbia Centre of Excellence in HIV/AIDS offers endless opportunities for investigators. My first week in this paradise was full of awe, new learning and new people.

Starting on Tuesday, October 21st, Carmen Rock, the Project Coordinator, gave me an orientation to the Urban Health Research Initiative (UHRI), tour of office, and let me sign the confidentiality agreement. UHRI is located on the top, 6th, floor of the St Paul’s hospital, which was recently renovated to meet the needs of researchers. As we walked down the hallway, Carmen stopped for a moment and we could “hear” the data buzzing in the ether.
Chanson Brumme, Data Analyst, gave me a tour of the laboratory. More precisely, tour of laboratories. Although lab research isn’t my specialty, I soon realised the importance and extent of the blood analyses that went on around us. Robots and laboratory assistants were lifting, extracting, ejecting and processing samples taken from the research participants.
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Mint Ti, Research Associate, sat down and went through a UHRI 101 tutorial with me. This introductory set of slides is available to all staff and faculty through the local intranet. Having seen the slides in advance, I was able to ask her more focused questions, such as the process of research product development and data requests to statisticians.
My last meetings of the day were with Drs. Evan Wood, Director, and Michaela Montaner, Special Projects Coordinator. Michaela’s work focuses on knowledge translation, including the Addiction Medicine education, which will be the focus of my fellowship. With Dr Wood, we were able to sketch out and quickly dip into the endless opportunities which the centre offers for investigators.
Continuing on Wednesday, October 22nd, Cody Callon, Research Coordinator, told us about the At-Risk Youth Study (ARYS), and its office systems; Amy, a Master’s student, joined us. Together, we travelled to the VIDUS (Vancouver Injection Drug Users Study) office. Elaine Fernandes, Clinical Trials Research Coordinator and Steve Kain, Nurse Coordinator, briefed us on the history of the study and new studiesthat take place in the building.

Ethnographic Tour with Ryan McNeil, Postdoctoral Research Fellow, finished my orientation on Tuesday, October 28th.  Downtown Eastside (DTES) is a well-known deprived area. We walked by and talked about the key agencies and objects of the area: the Vancouver Drug Users Union (VANDU), Insite supervised injecting room and many single-room occupancy hotels SRO’s. Ryan’s radiated excitement as he described the socio-cultural phenomena happening in the area which give an ethnographer a chance to study them in vivo. Gentrification of the area is a problem for many neighbourhood citizens. The policy of the Canadian conservative government poses serious challenges for the injecting room. The authorities try to push the scene out of downtown, for example by relocating the bottle depo site. The scientists are eager to “see what happens” next.

Does it work? When doctors need evidence

Healthcare professionals can generate important clinical questions for addiction research. Answering such questions by conducting a Cochrane review of evidence is a satisfying learning process and can contribute to drugs policy. This article summarises the experiences of an addiction medicine researcher conducting a Cochrane review, developing and evaluating a researcher-facilitated programme for medical student research activity in general practice.

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One summer afternoon in 2010, an interview with a family physician in Dublin opened my eyes about talking therapies for drink problems among people who also used other drugs. “Does counselling work for these people?” the doctor asked.  “Yes”, I was absolutely convinced about it, but I had no evidence for my faith. Surprised by his interest, I sent him the only two studies on the topic that I knew of; never heard back from him.

I searched for more studies without success. Many studies on general population showed up in my internet search, but none for people who also used other drugs.
This made me doubt my beliefs. At that time, a national funding agency announced a call for Cochrane training fellowships. Cochrane collaboration hosts the largest database of systematic reviews to inform healthcare decisions. Cochrane reviews are the jaguars of medical evidence synthesis. The fellowship was a godsend. I could use the funding to learn from Cochrane gurus and answer the Dublin doctor’s question by making the most of all available literature. My supervisor introduced me to a Cochrane author, Dr Liam Glynn, who reviewed self-management strategies for high blood pressure. He agreed to mentor my fellowship. We booked the title for our review with the Cochrane Drug andAlcohol Review Group in Italy and started to work on it when we got the funding.
The review found very few studies, most of which didn’t have a control group or randomised patients without drink problems; we could not give any recommendations to doctors.
The next step in the quest for the answer, we approached patients with dual drug and alcohol problems and fed their ideas back to the experts. Expert consensus recommendations are standard in the absence of scientific studies. The group had to rely on semi-structured interviews with doctors and patients and “B class” evidence from my review. The result of their consensus was a manual for family doctors.
Having developed the manual, we tested its value to answer our original question: “Does it work?” The new pilot trial encourages doctors to ask people who use illicit drugs about alcohol and to help those with mild problems; severe problems are best treated by a specialist.  Sixteen general practices (GPs) in two deprived regions will be randomised to receive the manual-based training or to keep doing what they do. The latter group will be trained later.
When I finished my Cochrane training and review, it was time for me to give back and teach medical students because the fellowships worked on the pay-it-forward model. Equipping the new generation of doctors with critical literature review and appraisal skills was my contribution to the improvement of addiction healthcare delivery. The aim of our teaching project was to create and evaluate a training-through-research programme for medical students, facilitated by a seasoned researcher.
We offered online webinars, methodological advice, mentoring, and one-one interaction. Our medical school emailed all students and we randomly selected a handful needed for our research projects. Collaborators from biostatistics, psychiatry and public health aided the programme. The students presented their work at four conferences and wrote three academic papers for medical journals.
Teaching literature reviews to medical students was a rewarding learning experience. I learned that the quality and commitment of students varies; different expectations led to different work processes and outputs. Some students submitted their work in more finished stage than others; competing priorities precluded achievement of higher standards. The manuscript preparation, submission and publication processes were too long for short student projects, although some students persevered and remained involved until the end.
From a personal perspective, I still don’t know whether counselling works for drink problems in people who also use other drugs, but I’ve learned how to query the literature when doctors need evidence.

This post is based on our presentation at the INMED conference in Belfast, and o recent article in the Substance Abuse journal. References:
  • Klimas, J., & Cullen, W. (2014). Addressing a Training Gap through Addiction Research Education for Medical Students: Letter to editor. Substance Abuse. doi: 10.1080/08897077.2014.939802
  • Klimas, J., & Cullen, W. (2014). Teaching literature reviews: researcher-facilitated programme to support medical student research activity in general practice. Poster presented at the Annual scientific meeting of the Irish Network of Medical Educators, February 21, Belfast, NI.


Alcohol and opioid agonist treatment: A community response

September 9th, 2014 – From research to practice: The Community Response organisation in Dublin is pleased to announce a new stabilization programme for people who are in Opioid Agonist Treatment and also who have alcohol problems. The programme aims to assist service users either reduce the amount that they drink, the frequency, or both. It shows that discoveries made by UCD’s researchers have real impact.

I welcome this new programme with great joy, because family doctors in our PINTA feasibility study complained about a high prevalence of alcohol problems in agonist patients and a lack of specialist services where they could get more help. At a 3-way meeting between Coolmine, Community Response and PINTA team yesterday, Nicholas – one of the facilitators – said “the group will aim to reduce drinking as opposed to complete abstinence.”

In 2009, our research group picked a random group of patients receiving agonist treatment in family practice. Three out of every 10 of these patients had drink problems. Recent developments in the addiction research brought effective tools to doctors who treat such patients – they are called the brief interventions. Brief alcohol interventions are for people who drink in excess of the recommended limits, but who don’t have addiction. Ever since our national prevalence study, we struggled with specialist treatments for patients with alcohol addiction, whom family doctors couldn’t help. First, we looked into the medical literature – no success. We asked the patients, interviewed their doctors and even consulted the experts in a national guideline development process, including Nicola Perry from Community Response. The result of the process was a clinical guideline for family doctors and a new study piloting the guideline in 13 family practices (check my previous post about this research). Despite all of these efforts, many services refused to treat problem drug users with concurrent alcohol addiction. This new course is a godsend for the patients and for our work.

For 10 Tuesdays, ten participants of the new course will come to Community Response for a 1.5 hours (10-11.30am) group sessions to learn about:

  1. The Process of Addiction
  2. Progression of Alcohol Use
  3. Stages of alcohol use- Early, Middle, Late
  4. Alcohol Problems in life
  5. Justification verses Reasoning   
  6. Withdrawals, Triggers, Cravings
  7. Learning from relapse
  8. Wheel of Change
  9. Interaction of Methadone and Alcohol
  10. Coping with cravings – “Urge Surfing” technique

Two experienced facilitators will lead the meetings. They will see participants individually too. Community Response’s Peer Support and Life Ring will provide aftercare. Treacy and David, who run a similar group in the Coolmine, focus their group on complete abstinence from alcohol, but they allow “certain percentage of slips. Slips are an opportunity to talk about what they [participants] can do if they relapse.”

How to get on the programme?

Go to www.communityresponse.ieand download a referral form. Complete it and E-mail it to [email protected], or post to 14 Carmans Court, Carmans Hall, Dublin 8. You will then be contacted to make an appointment for an assessment. The 20-minute assessments are every Friday between 9.00 am – 1.00pm, until Friday, 5th September, 2014. For more info, call 01 4549772 and ask for Nicholas, or e-mail [email protected].

Community Response Ltd, established in 1990, based in the Liberties in the South Inner City of Dublin, provides a comprehensive programme for primary alcohol and Hepatitis C services.

To stay updated on the alcohol stabilisation and other courses, follow @CommResponseon Twitter or Facebook

Work of the Primary Mental Healthcare Research Group cited in this article:
  • Klimas, J., Lally, K., Murphy, L., Crowley, L., Anderson, R., Meagher, D., . . . Cullen, W. (2014). Development and process evaluation of an educational intervention to support primary care of problem alcohol among drug users. Drugs and Alcohol Today, 14(2), 76-86.
  • Klimas, J., Cullen, W., Field, C. A., & the PADU-GDG (2014). Problem alcohol use among problem drug users: development and content of clinical guidelines for general practice. Irish Journal of Medical Science, 183(1), 89-101. doi: 10.1007/s11845-013-0982-2
  • Klimas, J., Anderson, R., Bourke, M., Bury, G., Dunne, C., Field, C. A., . . . Cullen, W. (2013). Psychosocial interventions for problem alcohol use among problem drug users (PINTA): protocol for a feasibility study in primary care. Research Protocols, 2(2), e26. doi: 10.2196/resprot.2678
  • Field, C. A., Klimas, J., Barry, J., Bury, G., Keenan, E., Smyth, B., & Cullen, W. (2013). Problem alcohol use among problem drug users in primary care: a qualitative study of what patients think about screening and treatment. BMC Family Practice, 14(1), 98.
  • Klimas, J., Field, C. A., Cullen, W., O’Gorman, C. S. M., Glynn, L. G., Keenan, E., . . . Dunne, C. (2012). Psychosocial interventions for problem alcohol use in concurrent illicit drug users. Cochrane Database of Systematic Reviews, (11). doi:10.1002/14651858.CD009269
  • Ryder, N., Cullen, W., Barry, J., Bury, G., Keenan, E. and Smyth, B. P. (2009). Prevalence of problem alcohol use among patients attending primary care for methadone treatment. BMC Family Practice, 10, (42).

Take precautions: improve or improv-ise?

“A ship is safe in harbor, but that’s not what ships are for.” ― William G.T. Shedd

How much uncertainty can you live with? A lot, at least I thought so until I started a new course in improvisation. Improv is a bit like acting without a script. Scary? Here’s how this new experience helped me to lighten up my life.

Uncertainty is the only certainty there is, and knowing how to live with insecurity is the only security.” – J. A. Paulos

Before the improv course, precaution was my modus operandi. I was prepared, over-prepared and hyper-prepared for anything and everything. Like many other people, over-preparation was my way of coping with the uncertainty of life. I learned that careful preparation improved my performance and outcomes. This improvement, however, had limits and I couldn’t do better regardless of how much time I spent with preparation.

Life is what happens to you while you’re busy making other plans” – J Lennon

Figure 1 Neil Curran (R) photo credit:
 The Improv course with NeilCurran re-defined perfection for me. Over-preparation can often lead to a stilted impression. As if the spirit of doing things evaporated the moment you get in front of your audience, committee, boss or panel – you replace the addressee. Furthermore, you can only prepare for things you can foresee. But there are always unforeseen events. Improvisation helps you react to those challenges. Like any other art, it gives you the freedom of being here and now and reacting to whatever comes your way. It’s a way of being. An other paradigm. Some critics may say improvisation is lousiness, lack of knowledge or skill, neglect or laziness – something that should be avoided. The opposite is truth; improv skills allow you to respond when you run out of your prepared responses – to transcend yourself.

Improv and medical profession

The role of improv in medical profession is bigger than you might think. Although there are strict procedures and guidelines for most medical procedures, there’s still a lot that we don’t know and therefore – cannot regulate. Clinical intuition is invaluable in unregulated or over-regulated situations. Similar to improv, intuiting is reacting to the situation based on previous knowledge, experience and trust in the process. Atul Gawande, in his book The Checklist Manifesto, advocates using checklist to make sure the basics are done. This creates room for clinical wisdom and intuition to deal with unforeseen events. Instead of making rigid orders to doctors and thereby stripping their responsibility and clinical judgment away, the Checklist helps people make sure they do the basic and essential things, leaving enough space for intuition and … you’ve guessed it – for improvisation.