Category: Motivation

Can GPs help problem drinkers who also use other drugs? Article in the Forum magazine

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.

In January, the journal published a clinical review by McGowan et al (2014)1 which provides a reader-friendly summary of the evidence on the brief interventions in primary care. We commend the authors for that but also wish to highlight the additional challenges involved in implementing brief interventions for at-risk groups including people who also use other drugs, in economically challenging times.

In Ireland, we rank first in the use of heroin in Europe2. With more than 3000 patients attending general practice for methadone treatment, Ireland has a well-established and internationally recognised good example of primary-care based opioid substitution programme 3. Internationally, excessive drinking by patients recovering from drug dependence, is often overlooked and underestimated4. In Ireland, a national survey of primary-care based methadone treatment found 35% prevalence of ‘problem drinking’5. Although effective brief interventions for the general population are available, when it comes to other drugs – we’re still guessing.

To explore the scientific evidence on brief interventions for people who also use other drugs, we conducted a Cochrane systematic review6. Drinking in methadone treatment is probably as old as the methadone treatment itself, but only four clinical trials evaluated effectiveness of interventions to tackle it. Those trials were so different, that we couldn’t pool their results together and come up with a definitive answer. Since the literature couldn’t give us a conclusive answer, we asked patients and their GPs what they think of alcohol interventions in methadone treatment. Surprisingly, the patients didn’t oppose being asked about drinking and welcomed it as a sign of GP caring about them as whole persons7. GPs reported issues that were similar to other countries – time, lack of specialist staff and training8. With increasing workload demands, time is certainly a big issue for GPs, although clear guidance and training on delivering effective ‘brief’ interventions for problem alcohol use can help GPs address this issue within the constraints of a ten-minute consultation.
The information from the Cochrane review and qualitative interviews helped us to formulate clinical guidelines for primary care 9. The guideline development group recommended that all patients in methadone treatment are screened for alcohol annually, that thresholds for screening and referral are lowered for this patient group and that the screening process is more proactive. No matter how good such guidelines are, they never implement themselves10. Structural, organisational and individual barriers hinder the process of implementing innovation in general practice – similar to other clinical areas 11.
Given these barriers, our group developed a ‘complex intervention’ to support care of problem alcohol and drug users 12, consisting of a brief alcohol intervention for people who also use other drugs, coupled with additional practice support with care and referral. The next step in developing the complex intervention is its testing in a controlled feasibility study 13. The study, ‘Are Psychosocial INTerventions Effective for Problem Alcohol Use among Problem Drug Users’ (the PINTA study) involves 16 practices in Ireland’s Midwest and Eastern regions14. The focus of this study is to evaluate the impact of psychology based treatments as opposed to the approach of medicating patients dealing with drug and alcohol addiction. There is a significant knowledge gap in this area internationally and we hope this study will help practitioners in Ireland assist their patients to deal with this issue 15… Read more at www.icgp.ie
Bibliography

Beg, steel or borrow: getting physicians to recruit patients in clinical trials

Leaflets, adverts and phone calls have all been used to recruit patients in clinical trials with some results. Still, the personal contact remains the most reliable method, if you can get the recruiter to do it. In this post, I explore some of the barriers of clinicians’ recruitment activity in randomised controlled trials.

Lack of time, specialist staff and patient motivation are the most frequently reported barriers that prevent clinicians to recruit their patients into clinical trials. Even though the physician signs up for the study and is informed about what is involved, they often do not complete the job. Some are distracted by competing clinical priorities, while others cannot get a positive answer from their patients. Regardless of the reason, the research suffers because of low participation numbers and prolonged study set-up.
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Researchers from the University Of Birmingham, UK, looked at all ways that improve the clinicians’ recruitment activity. Their systematic reviewof scientific literature compared the impact of different recruitment strategies and underlying clinician attitudes. To recruit successfully, the clinicians should be incentivised or supported in some way. Unfortunately, many researchers use supports that don’t work. What’s more worrying is that nobody knows how to boost clinicians’ recruitment rates. The study authors recommend that each clinical trial uses qualitative methods to ask clinicians what would work for them and use their suggestions. Another issue was what clinicians think of clinical trials. Misconceptions about trials methods still prevail and clinicians do not see the positives of trials; nor do their patients. Improved education and communication from researchers to physicians can overcome these issues.

Paying research participants for taking part can increase the number of people who agree to take part in the study, the so-called consent rate. It has become a norm in the Western world studies. Still, some studies and countries are unable to provide financial incentives to patients who volunteer for research. Direct payments may also be viewed as introducing unwanted bias into research results. Some may think that people who get paid for research would not participate if they did not get anything. Human motivation is a mysterious subject and money is part of it. It is the currency of modern society.

Is it ethical?

The healing relationship between the patient and doctor can be viewed as unsuitable for recruiting patients into clinical trials. Patients may feel obliged to agree, without making a fully informed decision. Ideally, the recruitment should be done by someone who isn’t involved in patients’ care; however, this is often not feasible in the real life. On one hand, the participants should make an informed decision about their participation and decide voluntarily. On the other hand, the researchers should not surprise patients who attend medical services for non-research purposes. The way to overcome this problem is through a two-stage recruitment process, as used in our study. The first step is to give information. The care provider gives a leaflet with information about the study to potential participants. The person goes home and reads the leaflet at their leisure. When they come to see their doctor next time, they can ask questions about the study, and decide to take, or not to take, part in the study.

Recruitment to randomised trials will probably always remain an issue for science. With an open mind, the investigators and clinicians can seek better solutions for creating trials that would attract human participants and help advance science for the benefit of all.

Cited articles:
Ben Fletcher, Adrian Gheorghe, David Moore, Sue Wilson, Sarah Damery: Improving the recruitment activity of clinicians in randomised controlled trials: a systematic review. BMJ Open 2012;2:1 e000496 doi:10.1136/bmjopen-2011-000496

Klimas J, Anderson R, Bourke M, Bury G, Field CA, Kaner E, Keane R, Keenan E, Meagher D, Murphy B, O’Gorman CSM, O’Toole TP, Saunders J, Smyth BP, Dunne C, Cullen W: Psychosocial Interventions for Alcohol Use Among Problem Drug Users: Protocol for a Feasibility Study in Primary Care. JMIR Res Protocols 2013;2(2):e26
doi: 10.2196/resprot.2678

Do talking treatments help problem drinkers who also use illicit drugs? We’re still guessing – by Sarah Chapman

19 Nov 2012

Do talking treatments help problem drinkers who also use illicit drugs? We’re still guessing

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Alcohol Awareness Week starts today, with the theme ‘It’s time to talk about drinking’, so I thought we’d kick-start the week in this bit of the woodland by doing just that. Alcohol Concern’s Hair of the Dog campaign poster displays facts which may well achieve their aim of prompting conversation on this subject, including the surprising information that around 200,000 people will have turned up to work with a hangover today (and people who work are more likely to drink alcohol than unemployed people).
Talking treatments were the focus for a new Cochrane review, published last week, which looked at different psychosocial interventions to reduce alcohol consumption in people with problem alcohol and drug use. Four studies with 594 people were included, comparing cognitive-behavioural coping skills training with 12-step facilitation, a brief intervention with treatment as usual, motivational interviewing with hepatitis health promotion and brief motivational interviewing with assessment only.
Here’s what they found:
  • The only study finding a significant difference found that people in the control group receiving ‘treatment as usual’ drank less alcohol at three and nine months than those receiving a brief intervention.
  • The evidence is weak, coming from low quality studies
  • Studies differed too much for their results to be combined
I was rather surprised to read a positive result favouring the control group, until I discovered that the only additional intervention for the intervention group was a single one-hour talking session. Otherwise, everyone in the trial received ‘treatment as usual’ which included a barrage of things including drugs, medical and psychiatric follow-up AND, wait for it, psychosocial interventions…
The reviewers, not surprisingly, said that
 no conclusion can be made because of the paucity of the data and the low quality of the retrieved studies.
So targeting drug and alcohol use together may be a logical approach, given the high rate of these problems occuring together, but one that still lacks an evidence base. If you want to talk about drinking this week, check-out the drinkaware website for some facts about alcohol and you could use the MyDrinkaware feature to track or cut down your drinking. I’m off now to grab a glass of water, something I definitely don’t drink enough.

Links:

Klimas J, Field CA, Cullen W, O’Gorman CSM, Glynn LG, Keenan E, Saunders J, Bury G, Dunne C. Psychosocial interventions to reduce alcohol consumption in concurrent problem alcohol and illicit drug users. Cochrane Database of Systematic Reviews 2012, Issue 11. Art. No.: CD009269. DOI: 10.1002/14651858.CD009269.pub2. Cochrane summary 

Sarah Chapman

My name is Sarah Chapman. I have worked on systematic reviews and other types of research in many areas of health for the past 17 years, for the Cochrane Collaboration and for several UK higher education institutions including the University of Oxford and the Royal College of Nursing Institute. I also have a background in nursing and in the study of the History of Medicine.

Read the full article here

Evidence-based solutions for #alcoholharm: Campaigning for change seminar

The wide acceptance of alcohol harms in the Irish society is worrying. Is the proposed public health alcohol bill a step change opportunity for Irish people? Alcohol Action Ireland, an advocacy charity which has been around for more than 10 years, hosted a public seminarwith experts and politicians in the Royal Irish Academy on March 3rd.
Campaigning for Change seminar in Dublin, March 3, 2014 
Minister White opened the night by pledging the government’s goal to reduce the national consumption of alcohol below the OECD average by 2020. The new public health alcohol bill proposes radical measures, such as minimum unit pricing and alcohol advertising ban, which will cause discomfort. Therefore, the government should proceed with evidence-based consensus. A new North-South minimum unit pricing study will bring concrete evidence for the regulations that the bill proposes.
Dil Wickremasinghe, the second-to-speak activist, broadcaster and Director of Insight Matters, shared her story of coming out as a teenage lesbian. Alcohol companies are behind the sponsoring for many LGBT events. The sponsors and culture create an enormous pressure on immigrants to keep up drinking with the local community. Alcohol and socializing go hand in hand in Ireland – We’re Irish, we need a pint to have a good time.
A public health specialist, Dr Bedford talked about his life-long experience of campaigning for alcohol regulations, such as random breathalyzing, which brought immediate drop in the alcohol harms. Because of the success with previous campaigns, he recommended the public health advocacy tool.  If we organize ourselves well, we can get results, but we need to keep the campaign message simple. Celebrities can draw audience to our campaigns, such as Gay Byrne did for the RSA random breath testing. If you’re not in the media in this business, you don’t exist. Repeat the message; repeat the message – same simple message all the time. The public health campaigning is for marathon runners, not sprinters.

Alastair Campbell, a writer, campaigner and a former Director of Communications and Strategy for Tony Blair, pondered when the change comes and how the countries are similar to individuals in their alcohol denial. The leadership comes from people who decide to make change happen; the countries have to admit that they have a problem. Countries’ leaders hesitate with changes, as Mr Campbell recalled a Tony Blair anecdote about the introduction of smoking ban law in UK “let’s see how it works in Ireland”. UK failed with introducing the prepared minimum pricing policy because of the alcohol industry pressure. Ireland can learn from that failure. Unless we understand that we are all paying for fixing of harms caused by alcohol, we won’t understand the minimum pricing. Low-risk drinkers – don’t be afraid of minimum pricing.

How attractive are you for postgraduate students?

700 active research supervisors provide support to post/graduate students in University College Dublin. 17 of them took part in the second out of five last Friday afternoons about research supervisor development. Today’s topic was how to optimise quality applicant attraction. Mr Justin Synnott, Ms Una Condron and Professor Tadhg O’Keeffe explored characteristics of an ‘ideal’ or successful research student:

ii)                   Considering the measurement of applicant ‘success’
iii)                 Optimising your ability to attract desirable applicants
iv)                 Managing applicant expectations
v)                  What International students look for / have concerns about – case study
vi)                 Who sets the doctoral funding agenda / what is Europe’s approach?

Danger on the road

If I knew then… the presentation warned developing supervisors about the dangers of making wrong choices based on wrong expectations. The promotions metrics pressurize some scientists to take many doctoral students. Under pressure, many supervisors make wrong choices. A stressed supervisor typically fears three main things: i) whether the student would complete PhD, ii) if they don’t complete, whether the supervisor would be blamed for it, and iii) whether the thesis would meet the quality standards. A student’s dissertation can be a disaster or a success based on two early warning signs:
1. Ability (motivation is part of ability)
2. Writing – if students’ work isn’t written well, you’re in trouble

As supervisors and scientists, we grow. The speaker illustrated his growth using the PEED model shown in Figure 1 below. With age, concern for Promotions decreases and so do Ego (I care less) and Experience. But the Experience increases over years. The Danger of making wrong choices is biggest at the start. Midway through the career, the conditions for supervising students, as well as supervisors’ ability to make choices, improve.


Figure 1. Peed model


Going international

1.2 billion people live in India, where over 600 universities and 20000 colleges fail to satisfy the growing demand for research training. University College Dublin reached out and started to recruit Indian students. Several roadshows explain the advantages of studying in Ireland to Indian students every year. One of the benefits for supervisors who decide to take on an international student is attracting better fit candidates.

Funding agenda and policy setting

Internationalisation of the university environment remains on the top of agendas of post/graduate research funders. More and more people complete funded doctoral programmes every year. Although the number of PhDs awarded in US over the last couple of years reached 50000, the number of faculty positions didn’t grow so rapidly and stagnates at 5000. The situation is similar in Europe. The question is whether we need so many new PhDs? The growing relationship with industry may offer an answer. A PhD stops being an academia-specific training; acquisition of transferable skills is coming to the forefront of doctoral training, because they can be utilised anywhere outside academia. The challenge for supervisors and universities failing to employ the PhDs is whether they can at least prepare students for some sort of a zig-zag career in- or outside academia.
This post summarised my observations from the UCD Research Supervisor Support and Development Programme Workshop 2: 28-2-14.