Can medical doctors use scientifically proven treatments for addiction? Can they access and critically appraise the latest advances in the addiction science?
In this letter to the editor, we respond to the editorial by Gordon and Alford (2013), in the recent special issue of the Substance Abuse (Vol. 33, No. 3), provides an insightful reflection on the early attempts at describing curriculum development and implementation of addiction content into various learning environments. We report on preliminary results of our course in addiction medicine research facilitated by a PhD researcher in the University of Limerick. We wanted to help medical students learn how to do and read addiction medicine research. The first cohort of 14 students received the training favourably.…read the full text at: http://www.tandfonline.com/doi/full/10.1080/08897077.2014.939802#.U-JhKfldVAs
J Klimas, W Cullen – Substance Abuse, 2014
Dublin ambulances see an opioid overdose every day; many times near the methadone clinics. Do people shoot heroin around methadone clinics? Yes. The common sense confirms anecdotal evidence from everyday experience of clinic staff and methadone users. Although this is no rocket science for most of us, it’s much harder to prove it.
Just as the presence of storks doesn’t cause the explosion in birth rates, methadone clinics don’t cause people to use and overdose on heroin at their door steps. Most overdoses in our study were within 1000 metres radius around the clinics, it means that they were not in the immediate vicinity of clinics. Regardless of the location, the high number of overdoses in Dublin calls for an immediate distribution of the heroin antidote – Naloxone. Visit my previous post for more info on our pilot Naloxone project.
Received: June 6, 2014; Received in revised form: June 26, 2014; Accepted: July 2, 2014; Published Online: July 30, 2014
Publication stage: In Press Accepted Manuscript
Do we need another educational video about overdose prevention? No. A simple internet search reveals hundreds of these clips. However, as the saying goes “If it hasn’t been done in Ballydehob, it can’t be true.” Of course, I tweaked the saying a bit. My point is that local problems need local(-ised) solutions.
In Dublin, Ireland, ambulance services attend to an opioid overdose every day. No surprises, the third highest rate of deaths due to drugs – 70 per million – in Europe. Reasons are complex – consequences fatal. But there is a simple solution. Naloxone, a heroin antidote, can be sprayed into an overdosed person by anybody. It is safe, harmless and cheap.
|Figure 1 Naloxone
In USA, 10,171 lives have been saved by Naloxone which have been distributed to 53,032 persons. Naloxone saves lives. And yet, “If it hasn’t been done in Ballydehop, it can’t work.” Ballydehob is a small village on the Irish coast, very far from Dublin. We can’t show that Naloxone works there, but we can do so in the University College Dublin. And so we are, developing and piloting an educational intervention on overdose prevention and naloxone distribution by general practice trainees. Why GP trainees? Reasons are complex – consequences fatal. Plus, we need to start somewhere. Irish actors and accents will help us get a buy in from the local stakeholders who can help make naloxone fully available in Ireland.
On July 1st, the UCD Centre for Emergency MedicalScience started production of a short educational video. The video shows 3 steps of response to opioid overdose with Naloxone spray:
- Assembly (Figure 3)
- Administration – spraying (Figure 4)
The purpose of this work was to develop and to process-evaluate an educational intervention designed to help general practitioners (GPs) identify and manage problem alcohol use among problem drug users. The session was facilitated by demonstration of clinical guidelines, presentation, video, group discussion and/or role play. Seventeen participants from three family practices and the Graduate Entry medical school, University of Limerick
participated in four workshops. They perceived the training as most helpful in improving their ability to perform alcohol screening. The positive feedback from General Practitioners opens the gate for integrating addiction treatment into primary care settings and, along with other multi-level implementation interventions, suggests that the addiction medicine education can support addiction health services improvement initiatives. The intervention will be used in our current study
evaluating the impact of psychology-based treatments for substance use disorders.
To read the full article, click on the link below.
Citation: Jan Klimas, Kevin Lally, Lisa Murphy, Louise Crowley, Rolande Anderson, David Meagher, Geoff McCombe, Bobby P Smyth, Gerard Bury, Walter Cullen, (2014) “Development and process evaluation of an educational intervention to support primary care of problem alcohol among drug users”, Drugs and Alcohol Today, Vol. 14 Iss: 2 Link: http://www.emeraldinsight.com/journals.htm?issn=1745-9265&volume=14&issue=2&articleid=17109104&show=pdf
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
8. Field CA, Klimas J, Barry J, Bury G, Keenan E, Lyons S, et al. The management of problem alcohol use among patients receiving opiate substitution treatment: the impact of professionals’ experience, knowledge, attitudes and skills. Annual Symposium of the Society for the Study of Addiction. York, UK, 2013.