Category: Community

Posts by Jano Klimas about community, collaboration, charity and social welfare.

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). http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD009269/frame.html 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: lowerthetone.com
 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.

Urban Overdose Hotspots: New Paper out Now

Dublin ambulances see an opioid overdose every day; many times near the methadone clinics. Do people shoot heroin around methadone clinics? Yes. The common sense confirms anecdotal evidence from everyday experience of clinic staff and methadone users. Although this is no rocket science for most of us, it’s much harder to prove it.
Just as the presence of storks doesn’t cause the explosion in birth rates, methadone clinics don’t cause people to use and overdose on heroin at their door steps. Most overdoses in our study were within 1000 metres radius around the clinics, it means that they were not in the immediate vicinity of clinics. Regardless of the location, the high number of overdoses in Dublin calls for an immediate distribution of the heroin antidote – Naloxone. Visit my previous post for more info on our pilot Naloxone project.
Cited study: Urban Overdose Hotspots: A 12-Month Prospective Study in Dublin Ambulance Services http://www.ajemjournal.com/article/S0735-6757(14)00510-5/abstract
Study authors:
Received: June 6, 2014; Received in revised form: June 26, 2014; Accepted: July 2, 2014; Published Online: July 30, 2014

Publication stage: In Press Accepted Manuscript

Tantalizing exhibition: A night when I was a doctor, an artist and a winning writer

On the night of July 3rd, 2014, I was a doctor, an artist and a winning writer.

An artist

After 30 weeks of laborious drawing and preparing our final show, a group of 16 illustrators and picture book makers exhibited their work in the Culture box, Dublin. We were led by Adrienne Geoghegan. The night before, we hanged our show as illustrated by the photos at the bottom of this post. An illustrator Mr. Clarke opened the night with a story about a British writer who once told him that people talk shite at the openings of exhibitions; it’s such an Irish thing. Wine was pouring, but it was just enough to not make people drunk. The DJ Doolittle played hits from the 60’s.

A Doctor

When Mr. Clarke attended to his keynote duties, he chatted with the artists. I told him that I was one of the people that he mentioned in his opening address. I had great difficulties in fitting the drawing into my day as a scientist. “Are you the doctor, then?” he asked. “Well, I’m a psychologist by background, but I work with doctors.” He wished me well in trying to integrate both careers. Combining Art& Science in one life is like churning 2 things at the same time. And yet, I felt a sense of worth, success at the exhibition. I realized that I have an impact on people, they like me and my work. I’ve never fully realized this until that night. “Are you one of the artists?” Somebody asked me at the end of the night. “Yes,” I replied proudly.

The 2014 Aindreas McEntee awarding ceremony: Dr Coughland and Dr Klimas. Photo source: irishmedicalwriters.com

A winning writer

The 2014 Aindreas McEntee prize, is open to members of Irish Medical Writers, a group of doctors and journalists specialising in healthcare. I’ve submitted my entry on the day of the deadline, expecting little more than introducing myself to the arena of Irish medical writing. The third place came as a surprise. The award ceremony was on the same night as the tantalizing illustrations exhibition. Thankfully, they gave me the prize at the beginning and release me to go for the exhibition. At the end of the night, everybody has won and we all got prizes (dodo bird effect).

European Working Group on Drugs Oriented Research Conference: One size does not fit all

“We all need something to help us unwind at the end of the day. You might have a glass of wine, or a joint, or a big delicious blob of heroin, to silence your silly brainbox of its witterings, but there has to be some form of punctuation, or life just seems utterly relentless.”

― Russell Brand, My Booky Wook 
The 15thInternational EWODOR Symposium, on May 22-23, 2014, was hosted by Coolmine therapeutic community (T.C.) at Trinity College Dublin, Ireland. The conference was capped to 100 attendees, 20 more than usual. This post brings a flavour of four key notes (out of 14).

Irish Addiction Treatment vs MacDonald’s

Was Coolmine TC like McDonald’s? Did it stifle it’s openness to change? Did it hinder adaptation to change? 

Through archival sources, meetings, correspondence, interviews with clients, current and former staff, past staff, Prof Butler researched sociological history of the first therapeutic community in Ireland – the Coolmine. The driving force behind Coolmine was Paddy Rossmore who had 2 recovering users from UK to start Coolmine. A complete reordering of Coolmine happened when Sam Anglin from Daytop, New York rejigged Coolmine, quite like a cult. No one opposed it openly – How do you like if your students were critical with you? But the question is “Was it the Daytop-isation or MacDonalds-isation?”
Sociologist, George Ritzer coined the fast food metaphor which has been researched for the past 20 years. It has been used for many problems since then. “Eat it and beat it” philosophy captures the main dimensions of MacDonaldisation – efficiency, calculability, predictability and control. Is this system dehumanising? To answer this question, we would have to answer a bigger question “Are people predictable, controllable, efficient and calculable?” No, but the answers divide helping professionals into 2 camps: one which clearly says “No”, and the second that says “No, but some behaviours can be predicted, controlled, calculated and changed.” Similar to the dichotomy of the left and right side of brain,  the true answer lies probably somewhere in the middle. No one wants to eat like McDonald’s, but addiction treatment can learn a lot from its business model.
What Prof Butler’s presentation showed us was that sticking rigidly to a foreign TC model may be worse than adapting flexibly to changes in society. Universal approach – one-size-fits-all – does not fit the addiction treatment. His presentation, however, did not answer the Gawande’s question modified for the drugs field: “Food chains have managed to combine quality control, cost control, and innovation. Can addiction treatment?” 
 

L-R: Butler, Yates and Pearce

Drug relationships: I love you and heroin

What is a drug relationship? 

DrMayock answered this question through narratives and interviews with women – drug users. It’s a struggle – Suffering on one hand and intimacy on the other hand. Exchange, power and control are the key characters in such relationship. Half of the interviewed women started using drugs in the relationship. Women were often reliant on the partner to administer heroin. They used threats and rewards – leave temporarily or sex for drugs and protection. Women in drugs economies played a supportive role. However, drugs were not the only connection between partners: “but I love him”, said one of the interviewees. Significance of the relationship beyond drugs was clear even after the end of the relationship. What is the true identity of a female drug user – an abused victim or a tender lover? They are both true.

There’s too much morals around women’s drug use, creating stigma and dismissal. Simmons writes that we need a more complex and nuanced understanding of drug-using couples – “drug treatment providers should:
  • establish policies which recognize the existence and importance of interpersonal dynamics between drug users, and
  • work with them to coordinate detoxification and treatment for both partners, and
  • provide additional integrated couples-oriented services”(Simmons& Singer, 2006).  

Can we do clinical trials of TCs? Or why there is a lack of robust evidence on TCs

What is a TC? What are the critical components and active ingredients?

On a practical level, Dr Pearce summarised the scientific literature on TCs. Therapeutic communities are a popular treatment for the rehabilitation of drug users. This Cochrane systematic review showed that “there is little evidence that TCs offer significant benefits in comparison with other residential treatment, or that one type of TC is better than another”, while another review concluded that “TCs can promote change regarding various outcome categories”. The critics of the Cochrane review for only including randomized trials, “while random group allocation appeared to be either not feasible (i.e., significantly higher drop-out among controls), or advisable (i.e., motivation and self-selection are considered to be crucial ingredients of the treatment process), in several studies.”
Pearce’s TACIT trial, unlike many other TCs, studies a day (outpatient) TC for personality disorders in Britain. Its Primary outcome measure is the Number of days in outpatient psychiatric treatment – total hospital days. TACIT faced typical technical problems: you can’t blind people; you can’t conceal people, difficult to standardize the treatment. Blinding is an issue for all psychosocial treatments. There’s a lack of standardisation and quality control in TCs. The staff is not bothered about clinical trials – they really believe in what they are doing. The TC is a complex intervention – all of the technical problems were taken from, and addressed in, the MRC framework, same like diabetes management or parenting. The logical positivist approach is embedded in the RCT approach – control is central. However, TC can be seen as a safe container for other therapeutic interventions. To respect the principles of safety and deep consent, TACIT asked the TCs themselves whether they want to opt out from the study – none of them did so. Inadequate treatment standardisation can be overcome by using a Model for adherence – Community of Communities – peer-opinion-based accreditation. All in all, it’s possible to do it [RCT] and we should do it.
Opposing the RCT evaluations, Dr Yates argued that we know TCs work, “we’ve done them for 50 years and we know it”. The time is now to study how they work and what the basic principles are. Study TCs for new groups: young runaways, trafficked women and children, self-harmers, recidivist, asylum-seekers, survivors of child abuse, etc. In seeing TCs as learning environments – we could use that stuff in other “schools” for other “students”. For better learning, he helped to setup a Drugslibrary.stir.ac.uk.

On a more fundamental level, Dr Yates asserted that TC is one of the few interventions that systematically address all of the components of Zinberg’s “drug, set and setting” model. The main principles: community as method and whole person disorder. Retention in TCs is poor, but that’s the same for all chronic diseases – you find very poor retention, same as addiction treatment. An audience questioned TC as a very safe environment for recovery – does that necessitate residential? It requires level of intensity: You can’t fund a 6 month programme and expect 12 months outcomes.

Cited work:
Gawande, A. (2013) Big Med. New Yorker, August 13th
Smith LA, Gates S, Foxcroft D. Therapeutic communities for substance related disorder. Cochrane Database of Systematic Reviews 2006, Issue 1. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005338.pub2/full
Wouter Vanderplasschen, Kathy Colpaert, Mieke Autrique, et al., “Therapeutic Communities for Addictions: A Review of Their Effectiveness from a Recovery-Oriented Perspective,” The Scientific World Journal, vol. 2013, Article ID 427817 
Simmons, J., & Singer, M. (2006). I love you… and heroin: care and collusion among drug-using couples. Substance abuse treatment, prevention, and policy, 1, 7. doi: 1747-597X-1-7 
Zinberg, N. E. (1986). Drug, Set and Setting: The Basis for Controlled Intoxicant Use. New Haven, CT: Yale University Press.