Addiction training provision must meet training needs
Closing the gap between training needs and training provision in addiction medicine
Substance use disorders pose a significant global social and economic burden. Although effective interventions exist, treatment coverage remains limited.
The lack of an adequately trained workforce is one of the prominent reasons.
Recent initiatives improved training nationally, but further efforts are required to build curricula that are internationally applicable. We therefore believe that the training needs of professionals in the area have not yet been explored in sufficient detail.
Addiction training provision must meet training needs
We propose that a peer-led survey to assess those needs, using a standardised structured tool, would help to overcome this deficiency.
The findings from such a survey could be used to develop a core set of competencies which is sufficiently flexible in its implementation to address the specific needs of the wide range of professionals working in addiction medicine worldwide.
Source: Arya, S., Delic, M., Ruiz, B., Klimas, J., Papanti, D., Stepanov, A., . . . Krupchanka, D. (2019). Closing the gap between training needs and training provision in addiction medicine. BJPsych International, 1-3. doi:10.1192/bji.2019.27
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Why most opioid risk tools fail?
How many of you had a flu this winter? Anyone took antibiotics for that? But some people can’t take them because they are allergic. Now, imagine someone suffering from pain, being prescribed opioids and having a negative reaction to them. What if this reaction was addiction to opioids? What if we could measure the risk for addiction the same way we can measure allergy to antibiotics? This article describes why opioid addiction is not an allergy to opioids and that we should not think about it that way, nor try to measure it using opioid risk tools.
The Problem
We wanted to find out whether we can tell which adult will go into opioid addiction when prescribed opioids for pain. Why? Prescription opioid addiction can have devastating consequences but it is not clear how to identify patients with pain among whom prescription opioids can be safely prescribed.
The Study
The Journal of the American Medical Association – JAMA Network Open – commissioned us to do a very special kind of review that is called Diagnostic Accuracy Review. For this study, we chose only the best studies. To illustrate diagnostic performance, data from higher quality studies were extracted and used to calculate likelihood ratios (LR). What are likelihood ratios? Likelihood Ratios bigger than 1 increase the probability of a disease. Likelihood ratio of 1 equals roughly zero increase. Likelihood of 2 equals just about 15% increase.
Opioid Risk Tools
The opioid risk screening tools that are in widespread use are based on low quality studies and are not helpful in identifying patients at higher risk. Among them, the pain medication questionnaire had likelihood ratio of 2.6 (slight increase in likelihood, about 15%). Some risk factors were found in a single high quality study:
A history of opioid or non-opioid use disorder, a mental health diagnosis and concomitant prescription of certain psychiatric medications may increase the risk of prescription opioid addiction.
However, only the absence of a mood disorder appeared useful for identifying lower risk patients (and assessment tools incorporating combinations of patient characteristics and risk factors were not useful).
Take home?
There are few valid ways to identify patients who can be safely prescribed opioid analgesics. Given the lack of good tools and the mounting evidence that opioids are not effective for chronic pain, such as the recent JAMA trial called Space, prescribers should be aware of tools’ limitations when prescribing opioids for pain. Opioid addiction is not an allergic reaction. Don’t try to measure risk for it and whether it’s safe to prescribe. De-implement opioid risk tools!
| Reference: Klimas, J., Gorfinkel, L., Fairbairn, N., Amato, L., Ahamad, K., Nolan, S., Simel, D., Wood, E. (2019) Strategies to identify patient risks of prescription opioid addiction when initiating opioids for pain: A Systematic review. JAMA Network Open. 2(5):e193365. Doi: 10.1001/jamanetworkopen.2019.3365 |
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