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.
|photo credit: theconversation.net
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.
“You cannot hope to build a better world without improving the individuals” – Marie Skłodowska-Curie
September 17th – the Irish Research Council is pleased to announce the launch of the International Career Development Awards – the ELEVATE Fellowships. Over 20 awardees confirmed their attendance. The speakers have been invited to give Awardees useful perspectives and food for thought before heading off on the international phase of this Fellowship. The launch has been a nice opportunity to meet fellow Awardees on this cohort.
The event took place in the Irish Research Council’s building, Brooklawn House, Crampton Avenue (off Shelborune Road), Dublin 4, Ireland, from 10am to 4.30pm.
Programme of the day:
10.00am-10.30am: Welcome by the Irish Research Council
Introduction to Council Enterprise Team
Introduction to ELEVATE 2014 cohort
10.30am-12.30pm: Dr. Janet Metcalf, Chair & Head of Vitae, ‘Careers for Researchers’
12.30pm-1.45pm: Lunch and Networking
Dr Metcalf’s talk focused on broadening the Fellows’ career aspirations: “I’ve never had any career plan, any career goal. Only two principles: catch every ball that’s thrown at me and make sure my decisions are widening my options, not narrowing them.”
|Dr Janet Metclaf, photosource: vitae
| ELEVATEFellowship is a funding scheme of Irish Research Council which aims to fund Irish-based experienced researchers who have gained most of their research experience in Ireland so that they can acquire new skills and expertise while conducting high-level research abroad for two years and then return to Ireland for one final year with their newly acquired knowledge and expertise. The Irish Research Council International Career Development Fellowships are Co-funded by European Union through the Marie Sklodowska Curie Actions. In 2013, 15 researchers received the Fellowships for different projects from time travel through nanotechnologies to diamonds. The council funded similar schemes in the past, for example, the EMPOWER 2011-12 or INSPIRE 2009-11. This year, 25 fellowships were awarded to 5 academic and 20 industry-based projects. Text taken from www.research.ie
|Barbara Monynihan, source: onyourfeet
| Irish Research Council (@IrishResearch) funds excellent researchers across all disciplines and encourages interdisciplinary research and engagement with enterprise. The Council facilitates the career development of researchers by funding those at an early stage of their research career to associate with established research teams who have achieved international recognition for their work. The Council aims to support an expertise-driven research system in order to enhance Ireland’s innovation capacity and skills base in a rapidly changing global environment where knowledge is key to economic, social and cultural development. The Council is further committed to facilitating the integration of Irish researchers in all disciplines within the European Research Area.
Text taken from www.research.ie
Maria “Manya” Salomea Sklodowska
© ACJC – Archives Curie et Joliot-Curie
Marie Skłodowska-Curie actions (MSCA) are European research grants for scientists in Europe and abroad. The objective of the MSCA is to support the career development and training of researchers – with a focus on innovation skills – in all scientific disciplines through worldwide and cross-sector mobility. For this, the MSCA provide grants at all stages of researchers’ careers, from PhD candidates to highly experienced researchers, and encourage transnational, intersectoral and interdisciplinary mobility. The MSCA will become the main EU programme for doctoral training, funding 25 000 PhDs.
Endowing researchers with new skills and a wider range of competences, while offering them attractive working conditions, is a crucial aspect of the MSCA. In addition to mobility between countries, the MSCA also seek to break the real and perceived barriers between academic and other sectors, especially business. The MSCA follow a “bottom-up” approach, i.e. individuals and organisations working in any area of research can apply for funding. Several MSCA initiatives promote the involvement of industry etc. in doctoral and post-doctoral research. Text taken from www.ec.europa.eu
I will be awarded the ELEVATE to do research on better addiction medicine education for doctors in Ireland and in Canada (www.addictionmedicinefellowship.org). Watch this space for more information.
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:
The Process of Addiction
- Progression of Alcohol Use
- Stages of alcohol use- Early, Middle, Late
- Alcohol Problems in life
- Justification verses Reasoning
- Withdrawals, Triggers, Cravings
- Learning from relapse
- Wheel of Change
- Interaction of Methadone and Alcohol
- 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).
“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.