Category: College

Drug court and Addiction, AMERSA conference

golden gate bridge

Is drug court meeting the need of the most vulnerable people who use drugs? What is the drug court judge’s hardest decision? What is social detox? How voluntary is drug court treatment?

November 8th, The Association for Multidisciplinary Education and Research in Substance use and Addiction (AMERSA) met for 42nd time in San Francisco, CA. These, and other questions, pondered five AMERSA speakers at the Thursday’s Interdisciplinary panel session.

Meeting the Need: Collaborative Justice and Treatment.

(Interdisciplinary panel, Thursday, November 8th, 2018, 10:15 – 11:45 am)

The panel was presented by:

Judge Eric Fleming, JD – San Francisco Collaborative Courts

Lisa Lightman, MA – Collaborative Courts, San Francisco Superior Court;

Angelica Almeida, PhD – San Francisco Department of Public Health;

Linda Wu, MSW, LCSW – San Francisco Department of Public Health;

Charles Houston – San Francisco Department of Public Health;

Drug Court Judge’s hardest choice.

Judge Eric Fleming, JD

The court calls people who have addictions participants, not defendants. Among others, the key role is to listen as a judge and to show respect. The hardest decision is to decide who’s going to be terminated; terminating very young people is the hardest. Some people have been fighting addiction for 20 years, but not making enough progress. This raises a question: What is enough progress?

It is one of the most important courts in San Francisco, they devoted a chief to it – not just someone pushing them through the system. The court takes high risk clients, those who haven’t done well in previous programs, facing significant punishment.

They understand that there are layers to the individuals, case can be dismissed if it’s the first case, but not the fourth case. If anything happens the system can send them to jail, but it doesn’t; instead, they talk to them and they listen – give them numerous chances. Relapse is considered as part of the process – if judge understands that, it’s good for the client.

The graduation is pretty awesome, it wasn’t easy for anyone. The judge oversees the ceremony, starts with positive remarks, and then problems. I’m proud of you as a judge, I hope you learned from me, because I learned from you. The judge concluded with a story about a young female user, 22-year old, that he had to terminate, before the termination, he made a couple of phonecalls to make sure that she had a place to go when he terminated her.

 

youth opioid addictionWhere does transitional youth belong?

Angelica Almeida, PhD – San Francisco Department of Public Health

Some of the core functions of the drug court system are: (1) Making sure that the services were coordinated, mental health and addiction behavioral health. (2) Trying to keep people in the least restrictive settings by intervening early.

Sometimes, it is a challenge of being a harm reduction city but working in a court that is historically abstinence based. The drug court is offering outpatient and intensive outpatient services. Also, low threshold services – medication assisted treatment.

Harm reduction principles are really what brings people to treatment; not judging them also makes a big difference. Thinking about how they work with transitional age youth, which don’t quite fit to children or adult services, is still evolving. System made to work with adults, really older adults. The transitional age youth drops out of services too much. Next step after residential treatment is always the hard piece.

alcohol drink, methadose

Sobriety doesn’t take a certain number of days.

Linda Wu, MSW, LCSW.

Drug court treatment center has now become a civil service organisation. It is Co-located with community justice and violence intervention programs. It utilizes onsite urinalysis testing, all observed. Four levels of treatment graduation, graduation rate is 20% but 6 months of sobriety required, also housing and income or training – “you can’t be sober if that’s all you’re working on.” After graduation the case manager can help them even after the case is over, because they are part of dept of public health. Clients making significance progress towards recovery despite ongoing use, finding housing or using less harmful drugs such as cannabis. To be able to offer some choices (voluntary program) is really important and confidence-building.

Challenges of drug courts are many. Clients look at the treatment in terms of their sentence – sometimes, they ask how many days I have to serve? Sobriety doesn’t take a certain number of days.

There is a continuous discussion between harm reduction versus abstinence; it’s challenging at times to find the balance between client centered treatment and also making recommendations to the court. One of the ways they make recommendations to the court is through the UA (commitment, process).

Staff is sometimes feeling pressured to become enforcers because they need to write the court notes for court. It’s very different than writing clinical reports. Clinical note is very different from court note. That takes away the awareness from the what am I (staff) doing – to what are you (client) doing. Lack of community resources in a resource-rich city because lack of space (beds) and big stigma of working in drug services.

lisbon

When change came over him

Charles Houston – public health.

Mr Houston, once a drug court participant – now working for the city and county, as a family liaison – spoke about how important drug court is. He was running (there was a warrant), but then change came over him. He called the court himself. They asked him, do you want to try it – drug court? Judge reviewed monthly progress, fostered accountability. They showed him a different way, the strengths that he had, the ability to make change.

While drug courts benefit certain groups of persons who use drugs, the jury is still out there when judging their overall effectiveness and organisation. Yes, treatment is voluntary but court mandated – the other option is jail.

AMERSA – what’s in the name?

AMERSA, formerly known as the association for medical education and research in substance abuse was recently renamed. Now it is The Association for Multidisciplinary Education and Research in Substance use and Addiction. The association’s 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

If you enjoyed reading about this year’s conference, you may like to read my notes from the previous years:

39th meeting in Washington, DC, November 5th, 2015

38th meeting in San Francisco, CA, November 4th, 2014

Systematic reviews enhance drugs conference

conference meeting

Systematic reviews are the cream of the research crop. Those who understand their value thrive at an opportunity to meet the review authors at scientific conferences. This year, the annual meeting of the College on Problems of Drug Dependence (CPDD) in San Diego featured several important reviews. Here’s a listing of all the posters presenting reviews from the session on Wednesday, June 13th, 2018.

Overdose

Non-fatal overdose prevalence among people who inject drugs Samantha Colledge (June 11, 2018);

Prescription drug monitoring programs on nonfatal and fatal drug overdoses David Fink;

Gender

Limited inclusion of women in functional neuroimaging studies of opioid-use disorder Hestia Moningka;

Women’s prescription drug misuse Bridgette Peteet;

Gender differences in HIV, anti-HCV and HBsAg prevalence among people who inject Janni Leung;

Services

Case for hospital teams in treatment of opioid use disorders Kelsey Priest;

Addiction-related characteristics of substances users in harm reduction settings Charlotte Kervran;

STDs and injecting

Extremely low HIV incidence among PWID: Terminology, high/middle income settings, methodology, and addressing new outbreaks Don Des Jarlais;

Use of opioids and stimulants by people who inject drugs Amy Peacock;

Factors associated with uptake or willingness to use pre-exposure prophylaxis (PrEP) among people who inject drugs Yohansa Fernández;

Pre-exposure prophylaxis (PrEP) for people who inject drugs? Angela Bazzi;

Cannabis

Cannabis and cannabinoids for the treatment of people with chronic non-cancer pain conditions Emily Stockings;

Medical marijuana laws and adolescent marijuana use in the US Aaron Sarvet;

Does liberalization of cannabis policy influence adolescents’ levels of use? Maria Melchior;

Other topics

Clinical and toxicological profile of NBOMESs Nino Marchi;

Sensation-seeking personality trait and its association to drug seeking behavior in adolescents Thiago Fidalgo.

Systematic reviews cream of the crop from Brazil through Egypt

NIDA International poster session on Monday, June 11, 2018

Three Australians, two North Americans; an Egyptian, African and Brazilian had one poster on systematic review each. Five were meta-analyses.

The Australian reviews dealt with overdose, STDs and injecting:

Nonfatal overdose prevalence among people who inject drugs S. Colledge, (UK, Australia);

Gender differences in HIV, anti-hepatitis C virus, and hepatitis B virus surface antigen prevalence among people who inject drugs J. Leung, (Australia, UK, Portugal);

Use of opioids and stimulants by people who inject drugs: A. Peacock, (Australia);

 

The North-Americans reviewed drug monitoring programmes:

Global review of drug-checking services 2017 L.J. Maier, (California);

Urinalysis frequency and health outcomes for persons on opioid agonist therapy: J. McEachern, (Canada);

 

Anger, brain stimulation and antipsychotics were reviewed too:

Anger in users of psychoactive substances H.V. Laitano, (Brazil);

Noninvasive brain stimulation in addiction medicine A. Elaghoury.(Egypt);

Atypical versus typical antipsychotics for the treatment of addiction: S. Hanu. (Ghana).

With the increasing demands on scientists’ workloads, systematic reviews are an effective way of staying up to date with the most recent developments in the field. See also my previous blog posts about CPDD from the previous years:

 

2017: Dr Wood tells the forum recipe for research-centre success

2016: Changing the ways of CPDD – College on Problems of Drug Dependence – June 12-16, #CPDD2016

2015: Getting the most out of the Conference of the College on Problems of Drugs Dependence #CPDD2015

2014: 76th Annual Conference of College on Problems of Drug Dependence: Decide to be fearless& fabulous 

2013: My itinerary for the Conference – College on Problems of Drug Dependence, San Diego, June 15-20 

Hospital teaching teams confront iatrogenic opioid addiction

What can hospital teams teach medical students about addiction to help curb the opioid overdose epidemic?

In a new article published by the Substance Abuse journal,  we report findings suggesting that the completion of an elective with a hospital-based Addiction Medicine Consult Team appeared to improve medical trainees’ knowledge which can help routinely establish clinical training teams elsewhere. 


We found that both emerging and established physicians appear to be responsive to this type of training.  The learner self-assessment can provide valuable feedback to the consultants, who can then focus more on the un-improved areas.

The study sample was drawn from medical students, residents and physicians who took part in a month-long rotation with a hospital-based addiction medicine consult team in Vancouver, Canada. Each year, approximately 60 learners go through the programme. Learners are asked to do a before and after self-assessment of their knowledge on addiction. The addiction rotation consisted of 4-12  weeks of full-time clinical training involving intake assessment, treatment planning, referrals to community agencies and starting people on evidence-based medications for substance use disorders. The learners take part in didactic lectures, bedside teaching, journal clubs and some prepare papers for submission to peer-reviewed journals. 

At the end of the learners reported increased knowledge in all but one of the areas of teaching focus, including opioid use disorders;  this increase was statistically significant. These preliminary, first-year results suggest that a structured clinical  training program could lead to an increased knowledge on addiction.

For more info read the full article “Impact of a Brief Addiction Medicine Training Experience on Knowledge Self-assessment among Medical Learners” at: to: http://www.tandfonline.com/doi/full/10.1080/08897077.2017.1296055

Two birds with one stone: physicians training in research

Combined training in addiction medicine and research is feasible and acceptable for physicians – a new study shows; however, there are important barriers to overcome and improved understanding of the experience of addiction physicians in the clinician-scientist track is required.

Addiction care is usually provided by unskilled lay-persons in most countries. The resulting care is inadequate, effective treatments are overlooked and millions of people suffer despite recent discovery of new treatments for substance use disorders. In rare instances when addiction care is provided by medical professionals, they are not adequately trained in caring for people with substance use disorders and, therefore, feel unprepared to provide such care.  Physician scientists are the bridge between science and practice. Despite large evidence-base upon which to base clinical practice, most health systems have not combined training of healthcare providers in addiction medicine and research. 
In recent years, new programmes have emerged to train the comprehensive addiction medicine professionals internationally.

We undertook a qualitative study to assess the experiences of 26 physicians who completed such a training programme in Vancouver, Canada. They included psychiatrists, internal medicine and family medicine physicians, faculty, mentors, medical students and residents. All received both addiction medicine and research training. Drawing on Kirkpatrick’s model of evaluating training programmes, we analysed the interviews thematically using qualitative data analysis software. We identified five themes relating to learning experience that were influential: (i) attitude, (ii) knowledge, (iii) skill, (iv) behaviour and (v) patient outcome. The presence of a supportive learning environment, flexibility in time lines, highly structured rotations, and clear guidance regarding development of research products facilitated clinician-scientist training.  Competing priorities, to include clinical and family responsibilities, hindered training.

Read more here: http://bmcmededuc.biomedcentral.com/articles/10.1186/s12909-017-0862-y
Klimas, J., McNeil, R., Ahamad, K., Mead, A., Rieb, L., Cullen, W., Wood, E., Small, W. (2017) Two birds with one stone: Experiences of Combining Clinical and Research Training in Addiction Medicine. BMC Medical Education, 17:22

Optimizing writing schemes for addiction researchers

The “coolest” science writing isn’t necessarily found in the science press.

– Surgeon and New Yorker contributor Gawande in The Best American Science Writing 2006

Writing constitutes a significant challenge for junior addiction researchers. Writing support programmes appear to improve writing skills and enhance productivity. However, addiction researchers have not benefited from writing support groups to the same extent as other professions, mainly due to the lack of support for and considerable variation among these programmes. 
Given a lack of research about the contribution of writing support programmes to publication productivity among early-stage addiction researchers, this article offers critical insights into the process and outcomes of such programmes, based on the substantial experience accumulated from taking part in several writing support programmes, including the scheme of the International Society of Addiction Journal Editors (ISAJE). 

A better understanding of what makes writing groups effective may help build evidence for writing programs and universities to equip addiction investigators with the skills they need to improve the health of people with substance use disorders via better writing. Read more in the Journal of Substance Use  http://www.tandfonline.com/doi/full/10.1080/14659891.2016.1235735