Category: USA

New paper out now: Alcohol Screening among Opioid Agonist Patients in a Primary Care Clinic and an Opioid Treatment Program

February 25th: Drinking in people who also use other illicit drugs causes serious problems. Their doctors and health professionals can ask about alcohol, provide advice or refer the person to a specialist if the problem is too big. We had a look into medical notes of 200 people screened for an alcohol use disorder in a primary care clinic and another 200 people screened in an opioid treatment program over a two year period.
Chart reviews suggested that most people with opioid dependence (95%) seen in a federally qualified health center completed a routine annual alcohol screening; elevated scores in the Alcohol Use Disorders Identification Test were recorded for six people (3% of those screened) and brief interventions were completed with five of those people. 
 “When you know of … people who are using heroin, there’s a chance they’re using it IV, and if they’re using IV there’s a chance they’re accessing blood …, so if there’s people we have coming with Hep C that have been drinking there’s a whole other level of medical risk associated and it’s hard to stabilize anyone, so people are coming in ill or they have other doctors’ appointments or they’re just not physically able to engage in programs.” Physicians worried about opening up this complex issue and felt the system was not prepared.
The methadone program, in comparison, diagnosed alcohol abuse or dependence at admission in 27% (n = 54) of the patient records reviewed. People treated in the methadone program appeared to have higher rates of serious alcohol use disorders than those who received buprenorphine in the primary care clinic:
“It’s a lot easier to fly under the radar with alcohol than with other drugs.” Focus group participants recognized limitations of screening.
Practitioner focus groups were completed in the with four primary care physicians and eleven counsellors from the opioid treatment program to assess experience with and attitudes towards screening opioid agonist people for alcohol use disorders.
Focus groups suggested organizational, structural, provider, patient and community variables hindered or fostered alcohol screening. 
A primary care physician noted, “When people are in the more severe category and you run out of time and you can hand them a list of AA meetings around the town, but it’s just so unlikely that they are going to access it if they haven’t already. That warm hand off process is huge.”
Alcohol screening is feasible among opioid agonist people:
“Having a consistent way that we treat specific conditions, like alcoholism with this background and this level of care would be great. So that we can develop patterns and know how to treat them as they go.”
Effective implementation, however, requires physician training and systematic changes in workflow.
  A counselor stated, “Engagement is key; how we treat our patient has a lot to do with what they tell us, so if the people feel not judged, if they feel safe, they’re going to be more likely to engage in the treatment process.”

To read the full article, go to the website of the Journal of Psychoactive Drugs: http://www.tandfonline.com/doi/full/10.1080/02791072.2014.991859#abstract

Conference of the North-American Primary Care Research Group: This is Times Square

“What’s this?” “This is Time Square” an overheard conversation made me smile and think to myself “Yes, this is the centre. North-American Primary Care Research Group conference is the “Times Square” meeting of world’s research elite.

Victor Montori from the Mayo clinic opened the conference on Saturday, November 21stwith a plenary on minimally disruptive Medicine. He urged the audience to consider the work that each patient has to do to comply with treatment. Like a canary in a mine, which stops singing and gets restless when the air in the mine becomes poisonous, the patient can signal when the burden becomes unbearable.
Our presentation was in the first of five concurrent papers sessions on education. Our chair was Janice Bellfrom Australia. One presentation was cancelled and two were merged because they were presented by one investigator (Gretchen Dickson).  Educators talked about a test measuring critical thinking, about research education, expectations of programme directors, geography of supervision and addiction medicine (see Figure 1 below). Approximately 20 people attended, the rest chose another of the competitive list of concurrent forums, workshops and the popular “ask the experts” session.
Here is my prezi (Figure 1):
Joe Selby, the director of the Patient-Centered Outcomes Research Institute, welcomed attendees on Sunday. The institute focuses on funding personalized medicine and outcomes that are meaningful for patients. It aims to speed up the infamous 17-year shelf-life of new research. The director mentioned a research question identified by a diabetic adolescent; the voice of the patient has been represented. Selby outlined what propose to not get funded (for example, effectiveness or methods proposals). The audience asked provoking questions. What’s a successful patient engagement? – (potential for exploitation can be reduced via advocacy groups). What is a patient centred outcome? There’s no validated measure of patient engagement (except the Engagement Activity Inventory enact tool).
SHORTER IS BETTER – The Blah, blah, blah problem
Workshop on writing effective research reports was facilitated by the Annals of Family Medicinejournal’s editorial group (Phillips, W., Bayliss, E., Ferrer, R., Gotler, R., Acheson, L., Balasubraanian, B., Cohen, D., Frey, J., Gill, J., Marino, M., McLellan, L., Peterson, L., Williams, R., and Stange, G.) Editors urged authors to resist the urge to fill the word limit (for example, 2500 words in medical journals). Shorter papers increase readability – more people will read it. There are two useful measures for pruning:

  • Short and familiar words
  • Short sentences
The facilitators continued with examples of short prose. Watson and Crick’slegendary Nature paper from 1953 had 903 words. Hemingway’s challenge was to tell a story in 6 words only: For sale: baby shoes never worn. Simpler writing seems smarter – Oppenheimer’s study showed that the readers can see the smoke of inflated language in research articles. The authors should always ask themselves: Would this work as a shorter piece? Similar to articles, minestrones are good with lots of ingredients but at a certain point, new ingredients do not add anything else. Following a formal lecture, the group broke into smaller groups and edited long and complicated sentences from submitted manuscripts.

NAPCRG is a multidisciplinary organization for primary care researchers. Founded in 1972 and oriented to family medicine, NAPCRG welcomes members from all primary care generalist disciplines and related fields, including epidemiology, behavioral sciences, and health services research. Text taken from www.napcrg.com

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

Not one, but two conferences in Puerto Rico made my trip fantastic. As usual, the NIDA International forum happened for the 15th time on the weekend before the Conference of the College on Problems of Drug Dependence. The lines below offer some insights from these meetings.

Integration of addiction treatment into primary care: the portals of entry

Is abstinence related with good health? Is decreased drug use related with good health?
Tae Woo Park and Richard Saitz asked these questions in a secondary analysis of data from a clinical trial of 589 patients using cocaine or cannabis with very low dependence proportion among the sample (ASSIST score >27). To answer their questions, they used clinical measures of good health, such as, SIP-D, PHQ-9, and EUROQoL. Health outcomes were associated with decreases in illicit drug use in primary. However, abstinence and decreased use may represent very different magnitudes. Self-reports related dysphoria could also play a role in the differences. It takes a long time to make improvement in those consequences? 6 months of follow up observations may not be enough. Patient-preferred outcomes are paramount: do they want to have a score lower than XY on PHQ-9? What outcomes are important for them?
The TOPCARE (www.mytopcare.org) project implemented guidelines for potential opioid misuse (Jan Liebschutz). Her slides blew up half-way through the presentation but she delivered the talk excellently. Nurse care management was a component of the guideline implementation trial. Academic detailing (45min, with opioid prescribing expert) included principles of prescribing brochure and difficult case discussion. Is academic detailing effective? The Cochranesystematic review of literature found small-to-medium variable effects. The preliminary results of the project show that the nurse manager programme is a no brainer.
Rich Saitz commented on the sad state of affairs in the addiction treatment, where only 10% of people with addiction are in treatment. Integrated care is the best thing since the sliced bread, but where’s the evidence? His research showed no added benefit of integrated versus care as usual. Why? Maybe, addiction is not a one thing, but we treat it like one thing. Dr Tai provoked the audience with a question: “Do our patients with addiction have the capability to participate in the treatment planning and referral?” If they seek medical care for their broken leg and we refer them to an addiction specialist, will they go? most likely not.
But it is the same with hypertension. Referral is a process and not a once-off thing. Although they may not follow our advice at the first visit, a rapport built by a skilled professional over a series of discussions can help them get the most appropriate care.

Does the efficacy of medications for addiction decrease over time?

An old saying among doctors states “One should prescribe a new medication quickly before it loses its efficacy”. Elias Klemperer pooled the data from several Cochrane systematic reviews on addiction medicines, such as, NIRT gum, Acamprosate, or Buproprion. Their effectiveness decreased over time. The changes in methodologies might have caused the decline; also the sponsorship of trials, target populations or publication bias.

Write, wrote, written

Primary author is in the driver’s seat, others are passengers. Primary author pulls the train. Dr Adam Carrico(UCSF) asked us “What are you really passionate about?” Find it and use your passion for those themes to drive your writing habit. Decide to be fearless& fabulous. Develop a writing routine. Put together a queue of writing projects and don’t churn out 2 products at the same time, one of them will suffer. Schedule writing retreats with colleagues. Set Timelines for writing grant and programme time for reviews by trusted people, give people a warning that this is what you’re planning to do. The JAMA June 2014 issue offers useful tips on how to write an editorial.

Dr Knudsen reported on the editorial internship of the Journal of Substance Abuse Treatment – JSAT, which started in 2006, with Dr McGovern (current editor) and Knudsen as the 1stfellows. Success rate of the fellowship applications is 2/30-45, prior involvement is appreciated (peer reviewer, submission). The new 2014 fellows are: Drs Madson and Rash. In the one year of the fellowship, the fellows typically review 12-15 manuscripts, some years, as a managing editor of a special issue. The Drug and Alcohol Dependence journal has a similar scheme.

Check out the http://www.cpddblog.com/

Dennis McCarty won the 2014 NIDA International Program Award of Excellence

 June 14, 2014 ― Professor Dennis McCarty, Ph.D., professor in the Department of Public Health and Preventive Medicine at Oregon Health & Sciences University (OHSU), and director of the Substance Abuse Policy Center in the Center for Health Systems Effectiveness, has been awarded by the 2014 National Institute on Drug Abuse (NIDA) International Program.

The award is for Excellent Mentoring. Dr. McCarty mentors clinicians and researchers who test emerging drug abuse treatments in community settings through the Western States Node of the NIDA Clinical Trials Network, which he codirects. He extends his mentoring to state and local policymakers through his role as director of the Substance Abuse Policy Center in the Center for Health Systems Effectiveness, which works to link policy, practice, and research on substance abuse treatment.

Dr. McCarty also is scientific director of the University of Amsterdam Summer Institute on Alcohol, Drugs and Addiction. I met Dennis in Amsterdam in 2011. He lectured for several days on different policy models and evidence based treatments. Two years later, on March 1, 2013, I joined Dennis as a NIDA CTN INVEST Fellow. INVEST is International Visiting Scientists & Technical Exchange Program for drug abuse research. Oregon Health & Sciences University hosted my six months fellowship during which I assessed the use of Screening and Brief Intervention (SBIRT) for alcohol use disorders among patients receiving agonist medication for opioid use disorders. Visit this post to read more about how I got here. I did not think that the summer school would lead to a fellowship in Portland, OR and I’m most grateful that it did.

With Dennis, I have learned about things I thought did not exist. For example, about researchers who enjoy writing. Writing up research projects is a task that many new researchers fear the most. Dennis is a master writer and his craft is contagious; I’ve discovered a need in me, a strong urge to write a lot and in many different formats. Dennis received the award today, at the 19th annual NIDA International Forum in San Juan, Puerto Rico. The 2014 Forum focused on “Building International Collaborative Research on Drug Abuse.”

Four other experts were awarded 2014 NIDA International Awards of Excellence. Mr. O’Keeffe, a professor at Virginia Commonwealth University, was honored for Excellence in International Leadership. The award for Excellence in Collaborative Research went to Dr. Chawarski, Ph.D., Yale School of Medicine, and Dr. Kasinather, Ph.D., Universiti Sains Malaysia. A special award was presented to Dr. Dewey, Ph.D., Virginia Commonwealth University, in recognition of his service to the addiction research community as founder of the Friends of NIDA, and his research on how opioids and marijuana change brain and contribute to tolerance and addiction.

NIDA International Awards of Excellence winners are selected based on contributions to areas essential to the mission of the NIDA International Program: mentoring, international leadership, and collaborative research. Anybody can suggest a nomination to NIDA. Read more at www.drugabuse.gov/international/awards-excellence.

The NIDA International Program connects people across continents to find evidence-based solutions for addiction, and drug-related HIV/AIDS. NIDA is part of the National Institutes of Health – the principal research agency of the U.S. Government and a component of the U.S. Department of Health and Human Services.

Story first released by OHSU Newsroom: http://www.ohsu.edu/xd/about/news_events/news/index.cfm

Three years post doctorate

27 April 2014
Transitions are life changes that allow us to pause, reflect and plan. Here’s a short history of my transition from the pre-doctoral to the post-doctoral stage. Read the full story here.
Hungary 2007. My Hungarian adventurewas a real turning point in my career. I had to commute to work and spent long hours in trams. Bored of watching cars and people, I started to read open-access articles about addiction. When I found something really relevant to my PhD, I felt like a gold miner who just dug his jewel out of piles of dirt. My passion grew stronger with every new paper.
Figure 1. Jano in transition
Ireland 2008. When we arrived to Ireland in late 2008, I had a small EU grant, with a budget of 3000 euros, and an unclear host organization. We survived for almost a year living from my wife’s EVSstipend and seasonal part-time jobs. My PhD and the EU grant took most of my time, leaving only a couple of hours for job-hunting. When I eventually ran out of money, it was late winter and the job market had dried up. Finally, I found an academic job, initially advertised as a PhD in Translational Medicine but my potential boss – Prof Walter Cullen – told me at the interview that I should apply for a p/t job on the same project. That’s how I came to research drinking among methadone patients in primary care at UCD.
Oregon 2013. In July 2011, only two months after receiving PhD, I have attended a summer school on addiction in Amsterdam, Netherlands. Dr McCarty, the school director, lectured about various policy models and evidence-based treatments for several days. Two years later, I did a NIDA fellowship with Dr McCarty at Oregon Health& Sciences University. Read this post about how I got there.

Lessons learned from junior post-doc

1) Write a lot. Like some teenagers, I used to write poems, songs and short stories. Then I stopped for many years. In Oregon, my wife surprised me with a Prompt-based creative writing course for my birthday. She thought it would be good for me and that I would enjoy it. Dr McCartyencouraged me to submit an essay to the Wellcome Trust Science Writing competition and to write a lot. Since then, writing became the core of my work.
2) Learn a lot. If you think of life as a huge learning experience, you welcome trouble as a gift.
3) Keep at it. Perseverance is critical in science. Progress takes years. New knowledge accumulates slowly. And the desired change is uncertain. While I was distributing clean needles to injecting drug users in inner-city Bratislava, Slovakia, I could see the effect of my work immediately. Now I have to wait ages and the change may not come in my life.
I’ve learned many more lessons than just these three, but I’ve learned how to separate the weed from the wheat from the chaff too. I don’t write about the minor lessons.

Future plans for senior post-doc

  • To stay true to myself
  • To reach a position of independence by:
    • conducting a randomized controlled trial
    • supervising work of junior investigators
  • To maintain a happy work-life balance
  • To pass the accumulated knowledge and skills on other:
    • Doctors and helping professions, by helping them become more competent and confident in addiction medicine research
    • Medical students, by helping them discover and master addiction medicine research