Category: Research

Science posts by Jano Klimas who writes about conferences, evidence based research, systematic reviews, PhD, ethics and clinical trials.

Place matters, teachers and learners #CCME18

mountain climber

We learn best in places that support our learning and our bio psycho socio spiritual development – from toddlers to elders, reports Jan Klimas from the Canadian Medical Education conference #CCME18.

Starting in Toronto, Justin Hsu and colleagues from University of Toronto described how they improved spaces for communities in teaching ambulatory care, or the so called Medical Education Teaching Clinics (METC). They plan to evaluate METC clinics via audit of referrals to the teaching clinic and the learner satisfaction survey.
Presentation title: Creating unique spaces to support community-based ambulatory care education: the E3 experience.
Presentation authors: Jerry Maniate, Elizabeth Wooster, Douglas Wooster, Justin Hsu

British Columbia quality matters

Jan Klimas’ team from University of British Columbia evaluated hospital as a place of learning about substance use disorders. Who learns most about addictions in hospitals? Using mixed-methods approach, this team showed that medical students get more out of a rotation in hospital than residents or senior learners. Especially in the areas of safe prescribing, screening and withdrawal management. Why is that? Do residents know more or are they more resistant to new learning? For many medical students, hospital could be the first place where they see someone with addiction and that could be why they learn more in this setting.
Presentation title: Who learns most about addiction in the hospitals? A mixed methods study.
Presentation authors: Jan Klimas, Evan Wood, Walter Cullen, Will Small, Seonaid Nolan, Annabel Mead, Mark McLean, Christophe Fairgrieve, Keith Ahamad, Huiru Dong, Breanne Reel, Lauren Gorfinkel, Nadia Fairbairn

Derek Wilson and colleagues from the same university focused on the quality of health education learning environment (HELES study). HELES survey tool looked at relationship, personal development and program culture as the key parts of the learning environment at the faculty of medicine. For example, the evaluation asked whether the learners have developed a strong sense of community.
Presentation title: Evaluating the Quality of Health Professions Learning Environments: Validation of the Health Education Learning Environment Survey (HELES).
Presentation authors: Derek Wilson, Shayna Rusticus, Derek Wilson, Oscar Casiro, Kevin Eva, Lisa Hazlett, Chris Lovato

Calgary explores and experiences

Maureen Topps and collaborators from University of Calgary, Cumming School of Medicine, asked whether in addition to focusing on the deficiencies and gaps in education, whether we could research the successful activities related to professionalism. The postgraduate education is a key stage in training the next generation of competent and professional clinicians. Professionalism is hard to define and to define it may “limit it,” as Dr Barnhoorn writes in the Academic Medicine journal (2006, Vol. 91, No. 9). But how does the place of learning make for more professional doctors? Slowing down and taking time to plan interactions appears to foster professionalism among other factors such as communication training.
Presentation title: Contexts and Experiences of Postgraduate Residents that support successfully meeting professionalism challenges.
Presentation authors: Janet de Groot, Maureen Topps, Aliya Kassam, Maureen Topps

Nicole Delaloye and colleagues from the same university presented results from her Masters research of the MSc/MD program. Clinicians should be both polite and respective, but not overly submissive. Why do we follow orders? Resuscitation requires wise action, not passive deference. What happens when learners hold back too much and how does the place of learning impact submissiveness? Mechanisms that underly submission in the moment of revival include learner’s mental state, what was going on inside and outside the room, team and motivation.
Presentation title: An Exploration of Deference Behaviours Exhibited within the Paediatric Resuscitation Environment and the Educational Implications.
Presentation authors: Nicole Delaloye, Elaine Gilfoyle, Rachel Ellaway, Aliya Kassam, Elizabeth Oddone Paolucci

In summary, the best learning places not only support our learning, but also challenge us to learn knew knowledge, adopt the discipline’s values, overcome deference and become successful professionals in our own right.

The opinions and views in this article present the views of the author and not the named persons or the #CCME18 conference organisers.

Correct dose keeps treatment going, study finds

dose

We wanted to find out whether continued use of drugs or alcohol impedes addiction treatment with methadone. We looked at the dose and things that make people stop treatment.

How was the study done?

Between 2005 and 2015, we talked to 823 people receiving methadone who said they used alcohol at least once. We asked about their experiences with interrupting methadone treatment and their drug use.

The VIDUS study involves people who use illicit drugs. The ACCESS study involves people living with HIV who use illicit drugs, mostly living in Vancouver’s Downtown Eastside neighbourhood. Researchers work with participants to look at how social, economic, physical, policy, and individual factors impact the health and well-being of HIV-positive illicit drug users. All participants do an interviewer-administered survey, and a clinic visit with a study nurse, every 6 months. (text taken from: http://www.bccsu.ca/access/ and http://www.bccsu.ca/vidus/)

What did the study find?

48% said they had stopped methadone treatment. Those who were homeless, or injected heroin daily, were more likely to stop methadone treatment. Those who also received other addiction treatment, received doses of at least 60 ml of methadone, or had Hepatitis C, were less likely to stop methadone treatment.

Heavy alcohol use was not linked to treatment discontinuation.

Why is continuous methadone treatment useful?

People who enroll in methadone treatment may continue to use illicit drugs and alcohol. There is a need to understand how to manage continuous drug use while receiving methadone treatment. Receiving therapeutic doses of methadone and also additional addiction treatment may reduce treatment interruption.

Study: Klimas, J., Nosova, E., Socías, E., Nolan, S., Brar, R., Hayashi, K., Milloy, M., Kerr, T., Wood, E. (2018) Factors associated with discontinuation of methadone maintenance therapy (MMT) among persons who also use alcohol in Vancouver, Canada. Drug and Alcohol Dependence, May 1, Volume 186, Pages 182–186

Read about other similar research here.

20 per cent heroin eligible, study finds

medical heroin

This study looked at how many, and what types of people who inject drugs (PWID), in the AIDS Care Cohort to evaluate Exposure to Survival Services Study (ACCESS), would be eligible for medical heroin in Vancouver, Canada.

Medical heroin could possibly help people who have treatment resistant opioid use disorder and who live with HIV/AIDS.

How was the study done?

We looked at how many, and what types of PWID in the ACCESS Study would be eligible for medical heroin. Participants had to meet eligibility criteria from clinical trials of medical heroin.

The ACCESS study involves people living with HIV who use illicit drugs, mostly living in Vancouver’s Downtown Eastside neighbourhood. Researchers work with participants to look at how social, economic, physical, policy, and individual factors impact the health and well-being of HIV-positive illicit drug users. ACCESS participants do an interviewer-administered survey, and a clinic visit with a study nurse, every 6 months. (text taken from: http://www.bccsu.ca/access/)

What did the study find?

478 participants said they injected opioids. 20% met the eligibility criteria for treatment with medical heroin. Those who were homeless, or were involved in the local illicit drug trade, were more likely to be eligible for medical heroin.

20% met the eligibility criteria for treatment with medical heroin and also said they were homeless and dealt drugs.

Why is the medical heroin useful?

Untreated opioid use disorder among people who live with HIV/AIDS can lead to illnesses, overdose, or death. Medical heroin can play an important role in helping people who have treatment resistant opioid use disorders and who live with HIV/AIDS.

Reference: Klimas, J., Dong, H., Fairbairn, N., Socías, E., Barrios, R., Wood, E., Kerr, T., Montaner, J., Milloy, M. (2018) Eligibility for heroin-assisted treatment (HAT) among people who inject opioids and are living with HIV in a Canadian setting. Addiction Science& Clinical Practice. In Press (https://ascpjournal.biomedcentral.com/track/pdf/10.1186/s13722-017-0104-y?site=ascpjournal.biomedcentral.com)

War on drugs, war on wolves

Wolves in cage

Have you ever heard of compound 1080? No? I’m not surprised. Illegal in most countries, this poison (sodium monofluoroacetate) is used to kill wolves in Canada. Read more about a recent visit to the Northern Lights wolf centre near Golden, BC, that opened my eyes to the cruel practices of money and politics – the usual suspects from the war on drugs.

Caribou’s population in Western Canada is dwindling. Some Canadian provinces, like Alberta and British Columbia, have put in place aggressive measures to save Caribou.

wildlife logo wolves
photocredit: northernlightswildlife.com

Wolves are Caribou’s natural predators. To kill them seems logical in the fight for the Caribou’s survival. But only if we forget that Wolves are keystone species. “A keystone in anarch’s crown secures the other stones in place. Keystone species play the samerole in many ecological communities by maintaining the structure and integrityof the community.” This means that their killing will kick-start a chain reaction, leading to extinction not only of Caribou, but also other species and desolation of the land. The Yellowstone example is a worthwhile lesson: when the park eradicated the thriving predators, the antelopes overcrowded and nearly destroyed the grasslands. Predators have been reintroduced successfully.

“The recovery of the gray wolf after its eradication from Yellowstone National Park, almost ninety years ago, demonstrates how crucial keystone species are to the long-term sustainability of the ecosystems they inhabit.”

Drugs have predictable effects on people – the higher the dose, the more toxic they are. This is different from the addictive potential. Even the most dangerous of drugs – like heroin or cocaine – are used by millions of people relatively without problems and without addiction. Nobody becomes addicted after one dose. This means that we have been lied to about drugs and their effects.

Meanwhile, Canadian’s officials keep laying poisoned baits that will be eaten not only by the wolves, but by all other carnivore, such as, foxes, ravens, etc. The 24-hour delay of the poison kills not only the alpha-female, but her cubs too. When she comes back from the hunt, feeds them the food from her stomach, all of them will die. Seems effective. How come that this strategy won’t save the Caribou?

drug policy
photocredit: drugpolicy.org

Our strategy to solve the drug problem has been based on the lies about drugs’ effects. The war on drugs was declared as the most powerful strategy to eliminate them. Research has shown that it doesn’t work. Instead, wrong people are put to jail when the drug laws are enforced selectively. What’s needed is often viewed as bad by the general public. Clean needles, safe injecting rooms and prescribed heroin are seen as helpful to maintaining harmful behaviour of people with addiction. The opposite is truth. They save lives. Because it’s the public opinion, and not the science, that wins elections, politicians will selectively use to please the public and ignore the science in solving the drug problem. Too bad for people who use drugs, but who cares about them anyway?

Not only are wolves the keystone species, they also are not the reason for Caribou’s sudden decline. Who’s to blame? Firstly, it’s the oil and fracking industry. By taking the land where the old-growth forest hosts Caribou, the industry is pushing them out of their natural habitat. Secondly, Caribou thrives in old-growth forest only. It takes 80-100 years for the forest to grow back again. Finally, they’ll die before they could return back.

Most likely, the Caribou will disappear from Canadian’s landscape. People will say that they were destined to die. We have done everything we could. We even killed the wolves. Similarly, many people who use illicit drugs will die or go to prison. People will say that they lacked motivation or were beyond help. We have done everything we could to help them. We banned the drugs and enforced the law.

The bottom line: end war on wolves

 

“We need wolves to have a future; we need the to have water, air and biodiversity.” But they need your help and your voice. Vote! Contact the politicians and ask them about environmental issues. Likewise, people will continue to use drugs in future. We need an open and science-informed discussion about drugs.

Inspired about parallels between animal and addiction research? Read my blog about killer whales and researchers here.

Disclaimer: the organisations and individuals named in this article have not seen or reviewed this article. The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of any agency mentioned.

Training medical students in addiction medicine can help in the opioid crisis

Naloxone

Better medical education is one solution to the opioid overdose crisis, but our new study suggests that few students have direct experience of overdose management although many have been exposed to patients using opioids.

Every year, more people die in Ireland due to opioid overdoses than in car accidents. Over 200 overdose deaths occur annually in Ireland. Naloxone is an effective treatment; lay people can use it. We surveyed 243 undergraduate medical students doing their final professional completion module before graduating from University College Dublin. This survey showed that medical students commonly encounter patients with opioid use disorders and want more naloxone training in the medical school.

Overdose prevention and management, including naloxone provision, should be a priority for health education.

A total of 197 (82.1%) completed the survey. Just under half were male, and most were aged under 25 (63.3%) and of Irish nationality (76.7%). The students felt moderately prepared to recognise opioid use disorder, but felt less prepared to manage other aspects of opioid use disorder care. Most had taken a history from a patient with an opioid use disorder (82.8%), and a third had witnessed at least one opioid overdose. Although 10.3% had seen naloxone administered, most had never administered naloxone themselves (98.5%). Half supported wider naloxone availability; this was lower than support rates among GPs (63.6%) and GP trainees (66.1%).

Over half of the medical students supported wider naloxone availability and its lay distribution to address the growing overdose problem in Ireland.

Most students had taken a history from a patient with an opioid use disorder and a third had witnessed at least one opioid overdose.

Few students had direct experience of overdose management although many met patients using opioids.

High level of student exposure to patients using opiates suggests we have an opportunity to increase addiction content in medical curricula.

Educate students

Medical school offers limited addiction medicine education. Medical graduates may not be adequately prepared to diagnose and manage opioid use disorders and emergency drug overdoses.

Tobin, H., Klimas, J., Barry, T., Egan, M., Bury, G. (2017, In Press) Opiate Use Disorders and Overdose: Medical Students Experiences, Satisfaction with Learning and Attitudes toward Community Naloxone Provision. Addictive Behaviors.