Category: Writing

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

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.

Building research leaders and supervisors with Hugh Kearns

Are you sometimes worried about the progress of your research students and what happens with them?

Hugh Kearns, a Sligo-born research coach from Australia, ran two courses on this topic in the last week of January in Dublin: Building research leaders and Research supervisor support& development workshop. Hugh gave us best-practice tips, some of which I bring in this post.

Figure 1. The long road to project completion
  1. Supervisor vs advisor
    Language matters. While both of the above terms imply a person who ‘sees’ more than the other person, nobody’s view is really super-ior in science. A more experienced researcher can provide an add-itional perspective on student’s work only.
  2. PhD students never die; they just fade away
    Proper supervision perfects students. Busy advisors often overlook this simple truth. A PhD research project is a long-distance run that requires a lot of motivation and support. The former can be instilled by the latter. Think about your time before you take on a research student.
  3. Give them small victories
    Midway through the project, many students fade away simply because of the time that it takes to complete it. Breaking the bigger task into smaller steps creates opportunities for instilling a sense of mastery when students complete a smaller step, for example, a paper on a related subject.
  4. That’s enough – stop now
    The advisor’s perspective and experience is most valuable here. Data collection can go on forever. The literature review can reveal new and interesting studies all the time. This way, the research project won’t end. The golden rule applies to this problem perfectly: Less is more.
  5. GYO PhDs…
    Mentoring relationship and quality of the mentor are the most important factors of a successful student project. If the student and mentor have a chance to work together on a smaller project first, they can better decide whether they want to continue working on a PhD. A great way to start growing your own PhDs is to advertise your research topics on your website or notice board: “Here are the topics that I’m interested in supervising”
  6. Listen to your tummy
    Our research intuition is often the best indicator when deciding about a new student or when the progress is slow. If your tummy tells you something’s wrong, step back and take a moment to think about what caused it.
  7. Meetings build structure into a relationship
    Each mentoring meeting should have an agenda. Ask to student to take the ownership of agendas and meeting minutes, e.g., send in advance, remind me of what I’m supposed to do? Where’s the agenda?
  8. Airtime?
    If your speech takes too much of the meeting airtime, the student might not learn anything. Good questions for prompting students are:
    Tell me what you’ve been doing? Tell me what you think we’ve agreed? Tell me what you’re going to do next.
  9. Quick sneak peek at your results
    Some students might find it intimidating to send whole chapters for review by their mentor. To make it easier for them, you could ask then to send you an outline, a draft or bring a copy to the meeting. The key is to instill hope that the review won’t be shredded their work into pieces.
  10. Grains of sand on the beach
    Some PhD projects lead to Nobel prizes, but most don’t. Most graduate students understand the impact they can make on the world, but it’s no harm to emphasize that however small, their work counts.

The second workshop was part of the new Research support and supervisor development programme at the University College Dublin. This programme is targeted at both new, inexperienced research supervisors and those more experienced staff who would like to refresh their knowledge in the area. The 6 last-Friday workshops will be based on sharing of practices with experienced supervisors and students, case studies, open forum discussions and knowledge sharing with colleagues on policy in the research supervisory field. Watch this space for my observations from these workshops.

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.