Category: Community

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

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.

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.

 

Think Broad: Irish Research Council ELEVATE Postdoctoral Fellowship Awards launched today

“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
1.45pm-4.00pm:          Barbara Moynihan, On Your Feet ‘Present with Power’
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.

Shoes off! You’re in Iceland

Barefooted or not, Iceland is a country for adventure seekers. Planning a trip to Iceland? Our narrated itinerary might help you.

Sunday, 31.8. Skógar

Our Gatwick flight was delayed by 90 minutes due to strong winds. We enjoyed our delay though. The best thing about our flight was a prolonged break in the Gatwick, discovery of a public footpath around a small lake with water lilies and harvest of blackberries. 

Starved by the flight, we bought super healthy bread with walnuts at the Keflavik airport. Fair car Rental Companypicked us up. Gave us printed maps and weather focused. We opted for a used car with “Scratches and dents all over the place”. We managed to drive the 200km to be in the Skógar hostel just before the bedtime. The hostel was very basic, with dorm rooms only.

Monday, 1.09. Hvoll

Nothing is better than a room on your own, especially after the first night in a super basic hostel. Hiking around the Skogar waterfall wasn’t really great fun. After about 2 hours, we finished the hike, exhausted and wet. The wetness wasn’t obvious until we came down and rested for a while when the high wind started again.  The rest of the day, we spent in the Skogar folk museum – a safe haven while the elements had their time outside. 


There were so many things in the museum that we wondered whether they know about all of them. You could spend hours learning about Iceland across several themed buildings plus an open air museum. The Vik finished our day with my hot pool treat and a quick stop in the Icewear which proved to be too expensive for our budget. Missing the grocery store just by 20 mins, we went on a scenic journey by the sea, crossing lava fields under the Laki volcanoes.

 

Our hosts in the Hvoll hostel, Hannes and Guony, have been living there since 1975. Since 1999, they started renting rooms and shortly build the nearby hostel. They still have a farm with a few sheep.

Tuesday, 2.09. Selfoss

After half an hour driving from the Hvoll hostel to the Skatfafell national park, we headed for the looped walk. The walk was well marked with knee-high yellow-end-painted poles. Also very busy with other hikers, especially at the start and end.  The Skatfafellsheiq loop was 15.5 km long and we had about 7 showers on the way, we thought there was no point in taking our raingear off. It took us about 5.5 hours to do the loop walk. At times, we had luck to see bits of the huge Skatfafell glacier pushing its way through the valley. The glacier greeted us with cold wind, the descending side of the walk and mountain Kristínartindar was colder. The trail was rocky at times, especially going down.


On our way to Sellfoss,we stopped to take pictures of the Skatfafell waterfall – foss in Icelandic. We gave a ride to a couple of hikers from France, only to Skogar; happy to see it again in the daylight, we said bye to the youths right in front of the campsite. They told us that they had to stand only 20 mins in the rain and their rides were mostly tourists. But the guy had rides by locals in the past.

Finally arrived to Selfoss at 9.30PM, hungry but happy. In the hostel, again, was a very large kitchen. Surprisingly everybody was hanging out in a tiny lobby/ office because it was warm and the signal was strong enough. The night was crystal clear

Wednesday, 3.09. Golden circle – Geysir, Gullfoss, Pingvellir national park, Borgarnes

Listed in the sub-heading above are the 3 most popular attractions in Iceland.  


The underwater tunnel to Borgarnes was surprisingly long. We went all this way to find that all we needed was in the Borgarness– a great hostel, beautiful town with sunset and a hot tub. Was it safe for women? We asked twice, they immediately replied yes, without even thinking about it. A natural reaction. A well hidden secret which we discovered was the 90.50 FM RUV R2 Radio with programmes for all hard rock lovers. The local settlement museum below the restaurant with a gift shop offered 1 hour tours and good insights into early history – the first 60 years and the Icelandic sagas.

Thursday, 4.09 Grundarfjörður

Our car engine oil started to drip. We went into a garage and they called the car rental company to replace our car. The new car arrived very quickly, in about 3.5 hours. We gave a ride to another couple, they were Germans. We learned from them why there were so many German tourists in Iceland; the return flight from Berlin was only 120EUR.  “Come back next year!” said the notice on the closed restaurant in Hellisandur. The next seafood place in Ólafsvík was served by very young women. Even staff at the gas station was the same age, we wondered why? The explanation came later in the evening.

 

The hostel TV was turned off in the evening. This was the same in hostels yesterday and the day before yesterday. A Hungarian receptionist, Zsuzsi, found a job in Iceland within two hours of her jobhunt, after living for 3 years in Ireland. She wanted to change. Her contract will be over in 4 weeks, after which she’s moving to Reykjavik. “If you say you will do any work, you can find a job there easily,” she said. The fisheries are always looking for people. Some Islanders are overeducated (100% literacy), and they don’t want to do manual labour, such as cleaning. That explained the underage staff in the previous services. We wished her best of luck and went to sleep in the Forest, or Skogur (Icelandic name of our room).

Friday, 5.09. Reykjavik

On the way to Reykjavik, we stopped in the Stykkishólmur for a brisk walk around the harbour hills; everything else was closed for season. The farm in Erpsstadir was supposed to be opened from 1pm, but when the farm lady saw us coming, she opened the shop at 12noon. They have woofers through the helpex.net site every year. Their strawberry ice cream tasted like it was made just yesterday. The dirt road to the farm was safe enough for the maximum speed of 80 kph.

 

 

In the capital, we saw an exhibition of arctic photography by Rangar Alexonn. It documented a slowly disappearing world of melting glaciers and shrinking communities of Inuit. The Flora café in the Botanic gardens, with their resident cat, is the 2014 best kept secret in the town. In the past, women used to wash the clothes in a nearby hot spring which is commemorated by a volcanic sculpture and information boards.

We couldn’t leave Iceland without Bjork’s early and rare GlingGló (1990) album. 

Hope you found this short narration useful. If you’re planning a longer trip to Iceland, check out my friend’s, John Fitzgerald’s blog. It inspired our journey a lot.

John Fitzgerald Images

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.