Category: Writing

Posts on writing by a writer Jano Klimas, primarily on books, poetry, slams and science writing.

European Working Group on Drugs Oriented Research Conference: One size does not fit all

“We all need something to help us unwind at the end of the day. You might have a glass of wine, or a joint, or a big delicious blob of heroin, to silence your silly brainbox of its witterings, but there has to be some form of punctuation, or life just seems utterly relentless.”

― Russell Brand, My Booky Wook 
The 15thInternational EWODOR Symposium, on May 22-23, 2014, was hosted by Coolmine therapeutic community (T.C.) at Trinity College Dublin, Ireland. The conference was capped to 100 attendees, 20 more than usual. This post brings a flavour of four key notes (out of 14).

Irish Addiction Treatment vs MacDonald’s

Was Coolmine TC like McDonald’s? Did it stifle it’s openness to change? Did it hinder adaptation to change? 

Through archival sources, meetings, correspondence, interviews with clients, current and former staff, past staff, Prof Butler researched sociological history of the first therapeutic community in Ireland – the Coolmine. The driving force behind Coolmine was Paddy Rossmore who had 2 recovering users from UK to start Coolmine. A complete reordering of Coolmine happened when Sam Anglin from Daytop, New York rejigged Coolmine, quite like a cult. No one opposed it openly – How do you like if your students were critical with you? But the question is “Was it the Daytop-isation or MacDonalds-isation?”
Sociologist, George Ritzer coined the fast food metaphor which has been researched for the past 20 years. It has been used for many problems since then. “Eat it and beat it” philosophy captures the main dimensions of MacDonaldisation – efficiency, calculability, predictability and control. Is this system dehumanising? To answer this question, we would have to answer a bigger question “Are people predictable, controllable, efficient and calculable?” No, but the answers divide helping professionals into 2 camps: one which clearly says “No”, and the second that says “No, but some behaviours can be predicted, controlled, calculated and changed.” Similar to the dichotomy of the left and right side of brain,  the true answer lies probably somewhere in the middle. No one wants to eat like McDonald’s, but addiction treatment can learn a lot from its business model.
What Prof Butler’s presentation showed us was that sticking rigidly to a foreign TC model may be worse than adapting flexibly to changes in society. Universal approach – one-size-fits-all – does not fit the addiction treatment. His presentation, however, did not answer the Gawande’s question modified for the drugs field: “Food chains have managed to combine quality control, cost control, and innovation. Can addiction treatment?” 
 

L-R: Butler, Yates and Pearce

Drug relationships: I love you and heroin

What is a drug relationship? 

DrMayock answered this question through narratives and interviews with women – drug users. It’s a struggle – Suffering on one hand and intimacy on the other hand. Exchange, power and control are the key characters in such relationship. Half of the interviewed women started using drugs in the relationship. Women were often reliant on the partner to administer heroin. They used threats and rewards – leave temporarily or sex for drugs and protection. Women in drugs economies played a supportive role. However, drugs were not the only connection between partners: “but I love him”, said one of the interviewees. Significance of the relationship beyond drugs was clear even after the end of the relationship. What is the true identity of a female drug user – an abused victim or a tender lover? They are both true.

There’s too much morals around women’s drug use, creating stigma and dismissal. Simmons writes that we need a more complex and nuanced understanding of drug-using couples – “drug treatment providers should:
  • establish policies which recognize the existence and importance of interpersonal dynamics between drug users, and
  • work with them to coordinate detoxification and treatment for both partners, and
  • provide additional integrated couples-oriented services”(Simmons& Singer, 2006).  

Can we do clinical trials of TCs? Or why there is a lack of robust evidence on TCs

What is a TC? What are the critical components and active ingredients?

On a practical level, Dr Pearce summarised the scientific literature on TCs. Therapeutic communities are a popular treatment for the rehabilitation of drug users. This Cochrane systematic review showed that “there is little evidence that TCs offer significant benefits in comparison with other residential treatment, or that one type of TC is better than another”, while another review concluded that “TCs can promote change regarding various outcome categories”. The critics of the Cochrane review for only including randomized trials, “while random group allocation appeared to be either not feasible (i.e., significantly higher drop-out among controls), or advisable (i.e., motivation and self-selection are considered to be crucial ingredients of the treatment process), in several studies.”
Pearce’s TACIT trial, unlike many other TCs, studies a day (outpatient) TC for personality disorders in Britain. Its Primary outcome measure is the Number of days in outpatient psychiatric treatment – total hospital days. TACIT faced typical technical problems: you can’t blind people; you can’t conceal people, difficult to standardize the treatment. Blinding is an issue for all psychosocial treatments. There’s a lack of standardisation and quality control in TCs. The staff is not bothered about clinical trials – they really believe in what they are doing. The TC is a complex intervention – all of the technical problems were taken from, and addressed in, the MRC framework, same like diabetes management or parenting. The logical positivist approach is embedded in the RCT approach – control is central. However, TC can be seen as a safe container for other therapeutic interventions. To respect the principles of safety and deep consent, TACIT asked the TCs themselves whether they want to opt out from the study – none of them did so. Inadequate treatment standardisation can be overcome by using a Model for adherence – Community of Communities – peer-opinion-based accreditation. All in all, it’s possible to do it [RCT] and we should do it.
Opposing the RCT evaluations, Dr Yates argued that we know TCs work, “we’ve done them for 50 years and we know it”. The time is now to study how they work and what the basic principles are. Study TCs for new groups: young runaways, trafficked women and children, self-harmers, recidivist, asylum-seekers, survivors of child abuse, etc. In seeing TCs as learning environments – we could use that stuff in other “schools” for other “students”. For better learning, he helped to setup a Drugslibrary.stir.ac.uk.

On a more fundamental level, Dr Yates asserted that TC is one of the few interventions that systematically address all of the components of Zinberg’s “drug, set and setting” model. The main principles: community as method and whole person disorder. Retention in TCs is poor, but that’s the same for all chronic diseases – you find very poor retention, same as addiction treatment. An audience questioned TC as a very safe environment for recovery – does that necessitate residential? It requires level of intensity: You can’t fund a 6 month programme and expect 12 months outcomes.

Cited work:
Gawande, A. (2013) Big Med. New Yorker, August 13th
Smith LA, Gates S, Foxcroft D. Therapeutic communities for substance related disorder. Cochrane Database of Systematic Reviews 2006, Issue 1. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005338.pub2/full
Wouter Vanderplasschen, Kathy Colpaert, Mieke Autrique, et al., “Therapeutic Communities for Addictions: A Review of Their Effectiveness from a Recovery-Oriented Perspective,” The Scientific World Journal, vol. 2013, Article ID 427817 
Simmons, J., & Singer, M. (2006). I love you… and heroin: care and collusion among drug-using couples. Substance abuse treatment, prevention, and policy, 1, 7. doi: 1747-597X-1-7 
Zinberg, N. E. (1986). Drug, Set and Setting: The Basis for Controlled Intoxicant Use. New Haven, CT: Yale University Press.

Two years on blogger Today

Time to celebrate and take stock of my blogging activity

Join me and have a look at my top posts, page views and the audience.
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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

How attractive are you for postgraduate students?

700 active research supervisors provide support to post/graduate students in University College Dublin. 17 of them took part in the second out of five last Friday afternoons about research supervisor development. Today’s topic was how to optimise quality applicant attraction. Mr Justin Synnott, Ms Una Condron and Professor Tadhg O’Keeffe explored characteristics of an ‘ideal’ or successful research student:

ii)                   Considering the measurement of applicant ‘success’
iii)                 Optimising your ability to attract desirable applicants
iv)                 Managing applicant expectations
v)                  What International students look for / have concerns about – case study
vi)                 Who sets the doctoral funding agenda / what is Europe’s approach?

Danger on the road

If I knew then… the presentation warned developing supervisors about the dangers of making wrong choices based on wrong expectations. The promotions metrics pressurize some scientists to take many doctoral students. Under pressure, many supervisors make wrong choices. A stressed supervisor typically fears three main things: i) whether the student would complete PhD, ii) if they don’t complete, whether the supervisor would be blamed for it, and iii) whether the thesis would meet the quality standards. A student’s dissertation can be a disaster or a success based on two early warning signs:
1. Ability (motivation is part of ability)
2. Writing – if students’ work isn’t written well, you’re in trouble

As supervisors and scientists, we grow. The speaker illustrated his growth using the PEED model shown in Figure 1 below. With age, concern for Promotions decreases and so do Ego (I care less) and Experience. But the Experience increases over years. The Danger of making wrong choices is biggest at the start. Midway through the career, the conditions for supervising students, as well as supervisors’ ability to make choices, improve.


Figure 1. Peed model


Going international

1.2 billion people live in India, where over 600 universities and 20000 colleges fail to satisfy the growing demand for research training. University College Dublin reached out and started to recruit Indian students. Several roadshows explain the advantages of studying in Ireland to Indian students every year. One of the benefits for supervisors who decide to take on an international student is attracting better fit candidates.

Funding agenda and policy setting

Internationalisation of the university environment remains on the top of agendas of post/graduate research funders. More and more people complete funded doctoral programmes every year. Although the number of PhDs awarded in US over the last couple of years reached 50000, the number of faculty positions didn’t grow so rapidly and stagnates at 5000. The situation is similar in Europe. The question is whether we need so many new PhDs? The growing relationship with industry may offer an answer. A PhD stops being an academia-specific training; acquisition of transferable skills is coming to the forefront of doctoral training, because they can be utilised anywhere outside academia. The challenge for supervisors and universities failing to employ the PhDs is whether they can at least prepare students for some sort of a zig-zag career in- or outside academia.
This post summarised my observations from the UCD Research Supervisor Support and Development Programme Workshop 2: 28-2-14.

Vztahy a drogy pred liecbou v recosializacii / What clients in therapeutic communities think about their past relationships

This blog post is in Slovakian*. For English version click here.

Na úvod

Na úvod by sme chceli poďakovať všetkým klientom a klientkám z resocializácie, ktorých výpovede boli použité v tomto článku a tiež personálu resocializačného strediska, ktorí nám láskavo umožnili rozprávať sa s klientmi/-tkami.
 
Predstavy o sociálnom fungovaní aktívnych užívateľov/-iek drog (UD) sú často sprevádzané stereotypmi a predsudkami, ktoré stigmatizácii UD. Tradičný, moralizujúci prístup na základe týchto stereotypných predstáv považuje všetky vzťahy UD za dysfunkčné a utilitárne. Na menej stigmatizujúci prístup je potrebné kvalitné porozumenie vzťahom počas užívania drog. Takýto realistickejší pohľad musí brať do úvahy: a. heterogenitu, ktorá existuje vo vzťahoch UD (typ a kvalita vzťahu), b. dôvody, prečo sú tieto vzťahy cenné a hodnotné pre všetkých UD, ktorí/-é sa v nich angažujú (okrem materiálnych dôvodov)1.  
 
Preto sme sa v nasledujúcom článku, spolu s klientmi/-tkami nemenovaného resocializačného strediska (RS), poobhliadli za ich vzťahmi pred liečbou v resocializácii. Našim cieľom bolo zamerať sa na dynamickú interakciu medzi užívaním drog, závislosťou a vzťahovým fungovaním u užívateľov/-iek drog (UD). Ich výpovede sme nahrávali na diktafón počas osobných rozhovorov a neskôr dôkladne analyzovali kvalitatívnym spôsobom pomocou tzv. „deskriptívno-interpretatívnej analýzy“, t.j. psychologickej metódy na spracovanie nahrávok osobných výpovedí2.
 
Skôr než začneme hovoriť o ich vzťahoch pred resocializáciou, priblížime priebeh rozhovorov s klientmi/-tkami. Pred každým rozhovorom sme účastníkov/-čky informovali o priebehu rozhovoru a ubezpečili ich, že účasť je dobrovoľná a anonymná. Do pilotných rozhovorov bolo zapojených celkovo päť účastníkov/-čiek s priemerným vekom 27,8 rokov, u ktorých dĺžka pobytu v resocializácii bola 2-6 mesiacov. Takmer všetci mali problémy s viacerými návykovými látkami (Pervitín, heroín, alkohol atď.). V rozhovoroch sme položili klientom/-tkám z resocializácie tieto tri základné otázky:
 
„Aké boli tvoje vzťahy s ostatnými ľuďmi predtým než si začal/-a brať? Čo sa dialo v tvojich vzťahoch počas užívania drog a závislosti? Akú úlohu v nich zohrávali drogy?“
 

Vzťahy a drogy

 
Nasledujúce výsledky boli vytvorené na základe výrokov klientov/-tiek a vyjadrujú spätný pohľad klientov/ klientiek na vzťahové procesy pred liečbou (resocializáciou). V tomto článku uvádzame iba niektoré zo zmien, o ktorých klienti/-tky v našom výskume hovorili. Rozsah tohto článku bohužiaľ neumožňuje popísať všetko čo klienti/ klientky uviedli, vybrali sme len najpočetnejšie a podľa nás najdôležitejšie vzťahové zmeny. Pre lepšiu názornosť sú výsledky analýzy rozdelené do dvoch období: (1) pred začiatkom užívania drog a (2) počas aktívneho užívania drog a závislosti (viď zoznam nižšie).
 
Vzťahy pred začiatkom užívania drog:
1. K mal pretrvávajúci až výlučný vzťah s rodinným príslušníkom (mama, sestra, babka)
2. K vníma vzťahy s rovesníkmi, v práci ako bezproblémové
3. Kolektív rovesníkov je priestorom pre experimentovanie s mäkkými drogami
Vzťahy užívateľov/-iek drog (UD) počas aktívneho užívania drog a závislosti:
4. K hodnotí vzťahy počas užívania drog ako neúprimné voči rodine a priateľom/-kám.
5. K rodina a kamaráti podporujú, motivujú k liečbe.
6. K „nerieši“ vzťahy počas užívania drog, t.j. nezaoberá sa nimi, ani nie sú prioritou.
7. Zmena okruhu kamarátov vytvára prostredie pre užívanie drog a relapsy.
Pozn. K= klient/-ka. Pre obmedzený priestor uvádzame len zmeny, o ktorých vypovedali aspoň 4 klienti/-tky.
V prvom období, t.j. pred začiatkom užívania drog, klienti/-tky opisovali celkové vzťahové nastavenie v rodine ako aj vzťahy s jednotlivými členmi rodiny a rovesníkmi/-čkami. Klient/-ka mal/a blízky až výlučný vzťah s rodinným príslušníkom/-čkou (napr. mama, sestra, babka), ktorý pretrval až do súčasnosti:
„starká bola vždycky nejaký môj azyl, to je to, bolo tak, že keď bolo neviem ako zle, tak som vždycky došla k starkej, jak mi bolo zle, tak som išla k nej“.
 
Účastníci/-čky vnímali svoje vzťahy s rovesníkmi/-čkami v škole a neskôr aj v práci ako bezproblémové:
„V rodine vzťahy super, s mamou, s otcom dobré vzťahy dodnes. V škole tiež normálne, priemerný prospech“.
 
Kolektív rovesníkov/-čok bol pre viacerých priestorom pre experimentovanie s mäkkými drogami:
„ja som bol s ňou a s jej kamarátmi a s tými kamarátmi som bol až do konca. S nimi to začalo a nejaký čas som chodil stále len s nimi, potom som naučil ja svojich kamarátov v mojom veku“.
 
V druhom období sa striedali fázy aktívneho užívania, návyku a pokusov o liečbu závislosti. Toto striedanie bolo prítomné aj v priateľských/ kamarátskych vzťahoch a najlepšie by sa dalo opísať ako oscilácia, či fluktuácia medzi svetom „normálnych“ ľudí a svetom „feťákov“ (podľa slov účastníkov/-čok):
„Potom som už prestal aj medzi nich chodiť, chodil som medzi úplne iných ľudí, čo mne vyhovovali, ktorí niečo brali“
 
Vzťahy s rodinou alebo s kamarátmi/-tkami hodnotili niektorí klienti/-tky s odstupom času ako neúprimné, pretože im nehovorili o svojom užívaní drog:
„to je inak strašné, jak som bola neúprimná, lebo ona mi hovorila, pýtala sa ma, že aké to bolo, jak som s tým dokázala prestať, ako som sa cítila a pritom som bola v období, kedy som zase brala tie drogy“.
 
Hlavnou témou tohto premenlivého obdobia boli zmeny v pozícii vzťahov na rebríčku priorít užívateľa/-ky drog (UD), kedy dochádzalo k tzv. re-prioritizácii. Účastníci/ -čky to opisovali ako „neriešenie“ vzťahov počas aktívneho užívania drog, ako otázku priorít a preferencie zaobstarávania drog. Miesto vzťahov na rebríčku priorít UD sa často mení, dochádza k re-prioritizácii, inými slovami čas/ energia venovaná zaobstaraniu drog je nevyhnutne bariérou pre vytváranie/ udržiavanie vzťahov:
„Proste som tie vzťahy neriešil, možno že som mal rodinu, lebo som bol naučený tak, že rodine môžeš veriť, tá ti môže jediná pomôcť, ale inak tie vzťahy, mal som zopár priateľov z ktorejkoľvek časti spoločnosti“
 
A práve rodina zohrávala dôležitú úlohu pri klientovej motivácii liečiť sa:
„Prišla na mňa kríza, tak mamka sa o mňa starala 3 dni, som tam krízoval, zvracal. Ten terapeut prišiel, lebo on bol na Vianoce tiež doma, on to sľúbil, tak sem zavolal, že príde, vybavil to tu a išiel som. Mamka sa pýtala, že keď chcem, nech idem, že ona to zaplatí a išiel som sem“
 
Závery analýzy priniesli niekoľko zaujímavých vhľadov do zmien, ktorými prechádza vzťahové fungovanie počas užívania drog tak, ako ich vnímali klienti/-tky s odstupom niekoľkých mesiacov po príchode do resocializácie. Najdôležitejšie sa týkali rodinného prostredia, opory a pomoci pri liečbe, prežívania blízkosti vo vzťahoch, a priorít v oblasti vzťahov.
 
Zapojenie klientov/-tiek v prvých mesiacoch resocializácie do nášho pilotného výskumu predstavuje zároveň silnú aj slabú stránku štúdie. Limitáciou je, že ich výpovede môžu byť skreslené selektívnym rozpamätávaním sa na minulé udalosti, t.j. vzťahy počas užívania drog. Silnou stránkou je, že takto sme získali výpovede aj od takých klientov/-tiek, ktorí z resocializácie odídu predčasne. Zistilo sa, že pacienti/ -tky, ktorí zostanú v liečbe dlhšie sa môžu líšiť v podstatných črtách od tých, ktorí liečbu ukončia predčasne3.
 

Prečo je dôležité rozprávať sa o vzťach počas užívania drog

 

 
Kvalitatívne rozhovory, ako výskumná metóda, neumožňujú zovšeobecnenie výsledkov na všetkých UD kvôli nízkemu počtu účastníkov/-čok. Na druhej strane kvalitatívny výskum pomáha prekonávať obmedzenia kvantitatívne orientovaného prístupu, tým že nachádza jedinečnosť, preveruje predsudky, mýty a nuanse interpersonálneho fungovania. Vytvára tak lepšie porozumenie v oblastiach, ktoré sú ťažko prístupné vedeckému skúmaniu. Porozumieť vzťahom znamená pre pomáhajúce profesie pristupovať bez predsudkov, lepšie pomáhať a zabraňovať udržiavaniu stereotypných predstáv o UD. Pre samotných klientov/-tky liečebných zariadení to uľahčuje vyrovnávať sa s vlastnou minulosťou a umožňuje rýchlejšie zakomponovať obdobia užívania drog do obrazu o sebe, či do osobnej histórie. A nakoniec, prínos pre širšiu verejnosť spočíva v zlepšení postavenia UD v spoločnosti, znížení marginalizácie a tým pádom prispieva k uľahčeniu prístupu k pomáhajúcim organizáciám.
 

Poznámky a literatúra:

6. Klimas, J. (2013). Vztahy, drogy a socialna prevencia v resocializacii. Socialna Prevencia, (1):25-26.
*Základ tohto článku tvoria príspevok prednesený na kvalitatívnej konferencii v Brne, 21. Januára 20104 a články v časopisoch Adiktologiea Sociálna prevencia6. Pri tejto príležitosti by som sa rád poďakoval Dr. Petrovi Halamovi za konzultacie a Dr. Matúšovi Bieščadovi za pomoc s analýzou rozhovorov.