Category: Evidence based treatment

Conference of Cochrane Evidence: Useful, Usable & Used #CE3U

My journey with Cochrane started one summer afternoon in 2010, when I interviewed a Tallaghtdoctor (Tallaght is a rough suburb in Dublin, Ireland) about treatments for drinking problems of people who also use other drugs. I emphasized that brief psychosocial interventions were the treatment of choice for patients who don’t use other drugs and that there’s no reason why this should be different for drug users. He asked me whether I was Swedish, because of my accent, and replied by a single question which kept me awake at night and started my career as an addiction investigator: “Does it work?” I decided to celebrate the four years of trying to find an answer to his question at the Cochrane conference in Manchester, UK.
Wednesday 23rd April 2014
This year’s conference of UK and Irish Cochrane contributors’ swapped plenaries and workshops – Wednesday kicked off with two sessions of developmental workshops. The motto of the priority setting workshop was  “Don’t start a journey that you can’t finish”. Pragmatism is a very important part of priority setting. The value of setting priorities in healthcare is the expected gain from reducing the uncertainty. In another words, to reduce the probability that somebody somewhere is getting a wrong treatment.
Figure 1. Bees were the theme of Cochrane conference
The key question of the public health workshop was How to produce good reviews quickly? Growing number of people are interested in doing reviews under the public health group. Most public health studies are non-randomised. Evidence forms just one part of the complex process of public health policy – timeliness is the big factor. The idea of local context permeates all policies – is this relevant to your local area? All of us, as Cochrane reviewers, give shades of grey and they [policy makers] want black& white answers.
The first afternoon plenary started a faithful member of the Cochrane family, Nicky Cullum. She described how easy reviews were in the past. Her talk inspired 12 new tweets in the first 5 minutes of the plenary (#CE3Useful). The beginning of Cochrane nursing group was accompanied by skepticism “Are RCTs possible in nursing?  Is experimentation at odds with caring?” The explosion of nursing trials in the recent years posed new challenges “How on earth do we help non-academic clinicians to have both clinical and academic career?” Trisha Greenhalghconcluded the first with provocative lecture about boringness of Cochrane reviews. She used the example of young doctor Archie Cochrane in a German camp to demonstrate that the art of rhetoric consists of logos, ethos and pathos. Her other work on how innovations rise and how they spread further supported the rhetoric argument. While a logo is the only thing in scholarship rhetoric, factual knowledge can be rarely separated from ethical or social context. By trying to do so, the Cochrane researchers are stripping away the very thing they need to be exploring – how to change the world through science. The methodological fetishism developed in Cochrane collaboration (linked to control, rationalism and accountability) hinders production of more realist and interesting reviews.
Thursday morning plenaries helped the delegates to confer after the gala dinner last night. Rich Rosenfeld, a Professor and Chairman of Otolaryngology, explained how Cochrane reviewers can help policy makers by rapid reviews – Good is ok, perfect we don’t need [for guidelines]. A health economist, Karl Claxton, continued the discussion on when no more evidence is needed. Research takes long time and evidence that we already have can inform allocation of research funds for new projects. However, we should be cautious about judging the usefulness trials with hindsight, it’s wrong because we don’t know the context. Neal Maskery made the audience “lol” with very entertaining and interactive plenary which focused on what we know about how people make decisions. Our brain is so good at patterns recognition – it wants to do it all the time. This phenomenon is called Base rate neglect – a cognitive bias. Biases such as this one hinder innovation and affect our decisions in all areas from buying a car to prescribing medicines. Al Mulley, an expert on shared decision making, finished morning lectures with a story of how every patient brings their own context by using examples from his research on how bothersome is urinary dysfunction.

The special addition to the conference was presence of Students 4 Best Evidence, some of whom won prizes from UK Cochrane centre, including free travel and conference participation. Read more about their winning entries on prostatecancer, dentalhealth, smoking, and long-term illness.

From a personal perspective, starting a Cochrane review took me on a journey which led from a clinical question (from the Tallaght doctor), to policy development, medical education and further research in a very short time. I still don’t know whether counselling works for drink problems in people who also use other drugs, but I’ve learned how to find an answer using the Cochrane methodology.

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

What has the doctor done well? A different type of Masterclass on youth mental health for family doctors in Ireland

A typical master class involves a Master and a Class. Unlike other masters, the organisers of this master-class chose a problem-based learning approach and encouraged all attendees to bring cases relating to youth mental health or addiction issues for the class discussion. My classmates were doctors and other health or community care professionals from the Mid-West of Ireland. From 2.00pm-4.30pm, on 1st April 2014, The Graduate Entry Medical Schoolof the University of Limerick, in association with the Youth Mental Health in Primary Care research team, hosted a master-class on interacting with young people around areas of mental health and addiction. 

Following welcomes and introductions by the organisers (shown in Figure 1), three small groups discussed patient scenarios. In the scenario about cough, they recognised that the cough can be only a symptom of a bigger issue that brought the patient to see the doctor. The focus of such consultation should be on making the patient come back, because the bigger issue can’t be resolved in just one consultation. Our need to gather information can be a barrier for reaching this objective. The main issue in the disordered eating scenario was how to ask a parent to leave the surgery so that the adolescent can talk with the doctor alone.
Figure 1. Dr Andrew O’Regan (L) and Prof Walter Cullen (R).
Dr Liz Schaffalitzky (not pictured) co-organized the session.
The 36 participants learned how to conduct a youth-friendly session with a young person, and how to use a brief intervention to address youth mental health and substance use in consultations. The importance and cost-effectiveness of early intervention in youth mental health and addiction and the role of general practice in early intervention were also discussed.


The class concluded by an extended Q & A session with youth mental health experts Dr Declan Aherne (Director of Oakwood Psychological Services), Dr Rachel Davis (Consultant Child and Adolescent Psychiatrist), Mr Rory Keane (Regional Drug Coordinator), Mr David McPhillips, (Community Substance Misuse Team), and Dr Patrick Ryan (Clinical Psychologist).

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

Retention versus continuity of care?

Retention in treatment has been traditionally regarded as a key outcome measure of addiction treatment. Thinking about this indicator brings us to fundamental questions of what a success in treatment is and how it can be measured.
The longer drug users stay in treatment, the higher their chances of success. Their health improves; they commit less crime and have more stable daily routine. Early identification and treatment of drug problems is also associated with better outcomes. NIATx, for instance, is an easy to use model of process improvement designed specifically for behavioral health. It helps substance abuse and mental health treatment organizations improve user access to and retention in treatment, defined as “attendance at the second, third, or fourth outpatient treatment sessions”. Others regard 12-month retention in care as success.
Rowdy Yates said, at the INEF conference in Dublin, 2011 that drug users seeking treatment want to give up drugs and what they get from us? Methadone [a replacement opioid]. This statement reflects the inability of many treatment systems to offer a menu of options and tailor them to individual needs of drug users. Medicating drug problem is one of the solutions that work for a large population of treatment seekers. Other options should be offered too.
Dr Okruhlica, in Slovakia, agrees with the diagnosis of addiction by the International Classification of Disorders (ICD) or Diagnostic and Statistical Manual DSM. This definition lists several symptoms of addiction. If somebody has certain number of these symptoms, they receive the diagnosis. If the person doesn’t have symptoms for a year, they cannot be regarded as ill any longer. Harm reduction experts believe that while the medical diagnosis of addiction could be helpful in understanding the problem, even the most dependent users have control over their drug use and choice plays an important role in their life. Dr Zinbergwas a pioneer of this approach with his monograph The Basis for Controlled Intoxicant Use. Studies on uncontrolled drug use followed. These views are regarded as extreme by many. Their believability is further undermined by the fact that non-problem drug users live in anonymity. For example, very few scientific studies manage to engage with non-problematic heroin users.
On the other hand, the recovery-oriented movements, especially AA, maintain that once a person “gets” addiction, they will become ill forever. This opinion can be very helpful for people in treatment, but can actually harm people out of treatment. Ex-users seeking re-integration into job markets are viewed as irresponsible and incapable of holding jobs for long time – result of a society stigmatization.
Because retention in treatment, as a robust outcome indicator, is highly esteemed in the drug addiction field, most professionals working in the addiction are able to place them somewhere on the continuum delineated by the two extremes – illness for life vs. uncontrolled drug use. See figure 1 below.
Figure 1 Continuum of opinions
Alongside the controversy around medicalization of drug use runs another debate about language. For many, language doesn’t matter too much and is a matter of political correctness. Opposite to them, I would like to hope, stand the language-believers. For them, the words we use shape and influence the world we live in. If we call drug users “junkies” they will become “junkies” – whatever that word represents to those who use it. Similarly, the term retention could be too close to detention; people are not kept in treatment to help them regain life, but to help sustain the treatment centre. Just like in the prison, where the inmates have little control over their length of stay, the people detained or retained in treatment have little control over length of their treatment. Opponents of the word retention propose continuity of care as an alternative, more humane, term to describe this golden-standard treatment outcome indicator. For them, it incorporates also the individual willingness to receivecare. But, are patients aware of it? I ask.

Language shapes and influences the drug treatment systems that we study or work for. It is important to recognize that even though retention and continuity of care could be the same thing – looked at from different angles – we have to choose the words we use in treatment carefully and make sure people who use our services are aware of it.