Category: Community

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

Doctors sweat to discover traditions of the first nations

Many doctors see addiction as a disease of body only. If overdone, this view can lead to medicalization of addiction. Some may argue that the latest research proves addiction as a chronic brain disease. This view is supported by brain scans of people who used drugs compared to people who didn’t. The scans show a loss of dopamine neurons after heavy methamphetamine use. Although brain’s plasticity allows it to recover, we don’t know how much of this loss is permanent.

While brain researchers may not mean to reduce addiction to a purely medical condition, its psychological, social and spiritual facets get sometimes overlooked. Not only medical students do not get enough education on addiction, what they get is often focused on the biological aspect.

To bridge this gap, in June 2014, a group of eight medical doctors (five doctors in training and three staff) from Canada went on a three day journey to a remote First Nations (i.e. American Indian) community to hear stories of recovery and participate in traditional healing techniques. After the trip, the Director of their addiction training programme (www.addictionmedicinefellowship.org), analysed the group’s experiences using qualitative research techniques and presented* the narratives at conference of the Association for Medical Education and Research in Substance Abuse.

People from the First Nations reservation shared their experience with the power of spiritual recovery tools – sweat lodges (see Figure 1), community round ups, connection to heritage, family support, and elder-guided self-reflection: “…learning came through creating bonds of friendship with people at Alkali Lake. It was through these bonds that the human face…emerge[d] and the real learning started to happen.”

Figure 1. Sweat lodge (photocredit: fellowship archive)

First Nations communities are over-represented among people with substance use disorders in Canada. Having little sense of cultural competency, clinicians can become discouraged when faced with the suffering and despair of those with substance use disorders: “…the most valuable lesson [of the field trip] was in deepening the understanding that the most effective way of being an addiction physician is by humbling ourselves, relinquishing our titles as doctors and getting to know the person behind the addiction.”

The Director encouraged programmes to “find a local community that has tackled the programme and go out to do a field trip and learn from the community members.”

 

*Text first published at a registration-restricted website: https://www.mariecuriealumni.eu/news/doctors-sweat-discover-traditions-first-nations

Story based on a poster presented at the AMERSA conference November 5th, 2014: Lighting the ember of hope: Integrating field experience and narrative techniques into Addiction Medicine Fellowship training. By Launette Rieb (a,b), MD, MSc, CCFP, FCFP, dip. ABAM; Nitasha Puria (b), MD, CCFP; Marcia Thomson (a), MSc; and Evan Wood (a,c) MD, PhD, ABIM, FRCPC, dip. ABAM

 

Author affiliations:
a)St. Paul’s Hospital Goldcorp Addiction Medicine Fellowship, Vancouver, B.C., Canada. b)Department of Family Practice, and c)Division of HIV/AIDS, Faculty of Medicine, University of British Columbia, Canada

Association’s for Medical Education and Research in Substance Abuse mission is to improve health and well-being through interdisciplinary leadership in substance use education, research, clinical care and policy. Text taken from www.amersa.org
Clinical addiction medicine training is a multidisciplinary addiction medicine fellowship that strives for excellence in clinical training, scholarship, research and advocacy and involves medical education to trainees from Psychiatry, Internal Medicine, Family Medicine and Nursing. For more details, click here.

Which talking therapies work for drug users with alcohol problems? A Cochrane update

Have you ever had an unresolved question and you kept asking again, again and again, until you got the answer? We wanted to find out whether talking therapies have an impact on alcohol problems in adult people who use illicit drugs (mainly opiates and stimulants), and which therapy is the best. We queried the scientific literature in 2012 and this year again.

Drinking above the recommended safe drinking limits can lead to serious alcohol problems or dependence. Excessive drinking in people who also have problems with other drugs is common and often makes these problems worse; their health deteriorates. Talking therapies may help people drink less but their impact in people who also have problems with other drugs is unknown. Talking treatments were the focus for an updated Cochrane review (Figure 1) published today (Dec 3).
Figure 1. Cochrane
We found four studies that included 594 people with drug problems. One study focused on the way people think and act, versus an approach based on Alcoholics Anonymous, aiming to motivate the person to develop a desire to stop using drugs or alcohol. One study looked at a practice that aimed to identify an alcohol problem and motivate the person to do something about it, versus usual treatment. One study looked at a counselling style for helping people to explore and resolve doubts about changing their behaviour (group and individual form), versus hepatitis health promotion. The last study looked at the same style versus assessment only.
In sum, the studies were so different that we could not combine their results to answer our question. As of June 2014, we still don’t know whether talking therapies affect drinking in people who have problems with both alcohol and other drugs because of the low quality of the evidence. We still don’t know whether talking therapies for drinking affect illicit drug use in people who have problems with both alcohol and other drugs. There was not enough information to compare different types of talking therapies. Many of the studies did not account for possible sources of bias. New clinical trials would help us to answer our question.
Citation example: Klimas J, Tobin H, Field C-A, 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 11 . Art. No.: CD009269. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009269.pub3/abstract

Cochrane is a global independent network of health practitioners, researchers, patient advocates and others, responding to the challenge of making the vast amounts of evidence generated through research useful for informing decisions about health. Read more at www.cochrane.org

Conference of the North-American Primary Care Research Group: This is Times Square

“What’s this?” “This is Time Square” an overheard conversation made me smile and think to myself “Yes, this is the centre. North-American Primary Care Research Group conference is the “Times Square” meeting of world’s research elite.

Victor Montori from the Mayo clinic opened the conference on Saturday, November 21stwith a plenary on minimally disruptive Medicine. He urged the audience to consider the work that each patient has to do to comply with treatment. Like a canary in a mine, which stops singing and gets restless when the air in the mine becomes poisonous, the patient can signal when the burden becomes unbearable.
Our presentation was in the first of five concurrent papers sessions on education. Our chair was Janice Bellfrom Australia. One presentation was cancelled and two were merged because they were presented by one investigator (Gretchen Dickson).  Educators talked about a test measuring critical thinking, about research education, expectations of programme directors, geography of supervision and addiction medicine (see Figure 1 below). Approximately 20 people attended, the rest chose another of the competitive list of concurrent forums, workshops and the popular “ask the experts” session.
Here is my prezi (Figure 1):
Joe Selby, the director of the Patient-Centered Outcomes Research Institute, welcomed attendees on Sunday. The institute focuses on funding personalized medicine and outcomes that are meaningful for patients. It aims to speed up the infamous 17-year shelf-life of new research. The director mentioned a research question identified by a diabetic adolescent; the voice of the patient has been represented. Selby outlined what propose to not get funded (for example, effectiveness or methods proposals). The audience asked provoking questions. What’s a successful patient engagement? – (potential for exploitation can be reduced via advocacy groups). What is a patient centred outcome? There’s no validated measure of patient engagement (except the Engagement Activity Inventory enact tool).
SHORTER IS BETTER – The Blah, blah, blah problem
Workshop on writing effective research reports was facilitated by the Annals of Family Medicinejournal’s editorial group (Phillips, W., Bayliss, E., Ferrer, R., Gotler, R., Acheson, L., Balasubraanian, B., Cohen, D., Frey, J., Gill, J., Marino, M., McLellan, L., Peterson, L., Williams, R., and Stange, G.) Editors urged authors to resist the urge to fill the word limit (for example, 2500 words in medical journals). Shorter papers increase readability – more people will read it. There are two useful measures for pruning:

  • Short and familiar words
  • Short sentences
The facilitators continued with examples of short prose. Watson and Crick’slegendary Nature paper from 1953 had 903 words. Hemingway’s challenge was to tell a story in 6 words only: For sale: baby shoes never worn. Simpler writing seems smarter – Oppenheimer’s study showed that the readers can see the smoke of inflated language in research articles. The authors should always ask themselves: Would this work as a shorter piece? Similar to articles, minestrones are good with lots of ingredients but at a certain point, new ingredients do not add anything else. Following a formal lecture, the group broke into smaller groups and edited long and complicated sentences from submitted manuscripts.

NAPCRG is a multidisciplinary organization for primary care researchers. Founded in 1972 and oriented to family medicine, NAPCRG welcomes members from all primary care generalist disciplines and related fields, including epidemiology, behavioral sciences, and health services research. Text taken from www.napcrg.com

How Cochrane Keeps the Addiction Science in Check

Science isn’t infallible. Humans make mistakes even in this highly sophisticated method of understanding the world around us. Thanks God, addiction researchers get a chance to correct their error. If they publish a big error, the publication may be withdrawn. In smaller cases, the publisher issues a correction. It is interesting to see how such a correction has been issued following publication of our Cochrane systematic review of literature which. Probably this helped to keep the addiction science in check. See it for yourself below.

August 2011: “Alcohol-related brief intervention in patients treated for opiate or cocaine dependence: a randomized controlled study”

Before our review included this study, the authors reported the following figures in tables 3 and 7.

November 2011: “Psychosocial interventions to reduce alcohol consumption in concurrent problem alcohol and illicit drug users: a Cochrane review”

 Our review was published in November 2011 and re-stated the findings of the above study as: higher rates of decreased alcohol use at three months (risk ratio (RR) 0.32; 95% confidence interval (CI) 0.19 to 0.54) and nine months (RR 0.16; 95% CI 0.08 to 0.33) in the treatment as usual group– See more at: http://summaries.cochrane.org/CD009269/ADDICTN_which-talking-therapies-counselling-work-for-drug-users-with-alcohol-problems#sthash.RcVZGdQA.dpuf

August 2013 “Correction: Alcohol-related brief intervention in patients treated for opiate or cocaine dependence: a randomized controlled study”

After the publication of our review, the authors corrected their figures in tables 1 and 5. The care-as-usual treatment for the control group was no longer stronger than the experimental intervention, the “alcohol-related brief intervention.”

 –

A note on causality in science

Because causal relationships are hard to prove (i.e. cause -> effect), majority of scientific publications rely on correlations. An example of a correlation is a relationship between shorter living expectancy and male gender. Men die younger than women. Although there are many plausible explanations, we cannot pinpoint a single cause.  Similarly, if an article gets corrected following a review in a major synthesis of scientific evidence – the Cochrane review – it may be a pure coincidence or it may be a consequence of the review. 

Substance Abuse Treatment, Prevention and Policy is an open-access peer-reviewed online journal that encompasses all aspects of research concerning substance abuse, with a focus on policy issues. Text taken from www.substanceabusepolicy.com

Cochrane Collaboration hosts the largest database of systematic reviews to inform healthcare decisions. Cochrane reviews are the jaguars of medical evidence synthesis. Cochrane is a global independent network of health practitioners, researchers, patient advocates and others, responding to the challenge of making the vast amounts of evidence generated through research useful for informing decisions about health. Cochrane is a not-for-profit organisation with collaborators from over 120 countries working together to produce credible, accessible health information that is free from commercial sponsorship and other conflicts of interest. Text taken from www.cochrane.org

Finding the Evidence for Talking Therapies: Article in the Forum magazine

In an attempt to prove that counseling works for reducing drinking in concurrent problem alcohol and illicit drug users, I ended up on a journey through research and review. Read the full article in the November issue of the Forum Magazine (Volume 31, Issue 10)

Figure 1. Photo of the article in the Forum
 

This article was inspired by an essay which won the 4th place in the 2014 Aindreas McEntee prize of the Irish Medical Writers. The competition is open to members of Irish Medical Writers, a group of doctors and journalists specialising in healthcare. Parts of it were posted in my September post here.

The Forum magazine is the official journal of the Irish College of General Practitioners ICGP. Published monthly by MedMedia since 1991, it is Ireland’s premier journal of medical education. Text taken from: http://www.icgp.ie/go/library/library_home/

Founded in 1984, the Irish College of General Practitioners or ICGP is the recognised national professional body for general practice training in Ireland.