Optimizing Treatment in Opiate Dependency: results from a national key stakeholder and expert focus group in Ireland

Background: Treatment for opioid dependence in Ireland is provided predominantly by general practitioners (GP) who have undergone additional training in opioid agonist treatment (OAT) and substance misuse. The National Methadone Treatment Programme (MTP) was introduced in 1998, and was designed to treat the opioid dependent population and to regulate the prescribing regimes at the time. The past two decades have seen the increased prescribing of methadone in primary care and changes in type of opioid abused, in particular, the increased use of over the counter (OTC) and prescription medications. Despite the scaling up of OAT in Ireland, drug related deaths however have increased and waiting lists for treatment exist in some areas outside the capital, Dublin. Two previous MTP reviews have made recommendations aimed at improving and scaling up of OAT in Ireland. This study updates these recommendations and is the first time that a group of national experts have engaged in structured research to identify barriers to OAT delivery in Ireland. The aim was to explore the views of national statutory and non-statutory stakeholders and experts on current barriers within the MTP and broader OAT delivery structures in order to inform their future design and implementation. Methods: A single focus group with a chosen group of national key stakeholders and experts with a broad range of expertise (clinical, addiction and social inclusion management, harm reduction, homelessness, specialist GPs, academics) (n=11) was conducted. The group included national representation from the areas of drug treatment delivery, service design, policy and practice in Ireland. Results: Four themes emerged from the narrative analysis, and centred on OAT Choices and Patient Characteristics; Systemic Barriers to Optimal OAT Service Provision; GP Training and Registration in the MTP, and Solutions and Models of Good Practice: Using What You Have. Conclusion: The study identified a series of improvement strategies which could reduce barriers to access and the stigma associated with OAT, optimise therapeutic choices, enhance interagency care planning within the MTP, utilise the strengths of community pharmacy and nurse prescribers, and recruit and support methadone prescribing GPs in Ireland

General Practitioner perspectives on and attitudes toward the Methadone Treatment Programme in Ireland

Background: Methadone maintenance treatment in Ireland is provided in addiction clinics, and in primary community care settings by Level 1 and 2 specialist trained general practitioners (GPs). The Irish College of General Practitioners (ICGP) provides training and regulates the Methadone Treatment Programme (MTP). Aim: The study aimed to assess and compare GP perceptions of the scale of local illicit drug use, attitudes toward and obstacles in the provision of methadone treatment and preferred adjunct modalities. Methods: In 2006 and 2015, an online survey was undertaken with all Level 1 and 2 registered GPs in the MTP. Results: The majority of participants were male, aged between 35 and 60 years, treated between 1 and 25 patients in urban areas. In 2015, 44.7% with registered methadone patients reported no obstacles to taking on more (32% in 2006). In relation to GPs with no current methadone patients, reasons for not taking patients in 2015 were similar to 2006, and centred on no referrals or demand, and concern for negative affect on private patients. Majority attitudes toward the MTP remained positive, with one exception relating to greater disagreement in 2015 with the statement that supervised daily dispensing prevents patients from working (p < .05). Preferred adjunct services remained constant; addiction counselling, in-patient detoxification, employment schemes and consultant psychiatric services. Conclusions: The study illustrates a generally positive attitude toward the Irish MTP. Efficient referral mechanisms for stabilised patients to primary care settings, and greater psycho-social, vocational and detoxification supports are warranted

Irish General Practitioner (GP) Perspectives Toward Decriminalisation, Legalisation and Cannabis for Therapeutic Purposes (CTP)

Cannabis is the most prevalent illicit drug used globally. Regulatory debate in Ireland on the decriminalisation of cannabis and legalisation for therapeutic purposes (CTP) is on-going. The study aimed to investigate Irish general practitioner (GP) attitudes toward decriminalisation of cannabis and assess levels of support for CTP. An online survey was administered to all GPs in the Irish College of General Practitioner (ICGP) database. A content analysis was conducted on open-ended survey questions, with five themes emerging. GPs were concerned around early onset of use and intergenerational impacts, vulnerabilities to drug induced psychosis, patient self-medication with cannabis and potential for misuse of prescribed cannabis. The study reflects concerns around the mental health consequences of cannabis use and potential for misuse in the event of legalisation, and the need for product regulation and an enhanced evidence base to support treatment decision making. Further research and medical education is warranted. © 2016, Springer Science+Business Media New York

Dependence on Over the Counter (OTC) Codeine Containing Analgesics: Treatment and Recovery with Buprenorphine Naloxone

Misuse and dependence on prescribed and over the counter (OTC) codeine-combination analgesics is an emerging public health concern. We present a clinical case series of four adult patients dependent on OTC codeine combination analgesics in Ireland. Cases (two males/two females, aged 44–57 years) were consuming between 12 and 72 codeine-containing tablets/day. In three cases, consumption was linked to pain, with on-going misuse reflecting dependence on codeine. Cases were initiated on buprenorphine-naloxone (Suboxone®), stabilised on doses of between 4 mg/1 mg and 14 mg/3.5 mg per day and remain on treatment without additional opioid use, as verified by drug screening reports. Although anecdotal, these cases show the potential of effective opioid assisted treatment (OAT) using buprenorphine-naloxone (Suboxone®) to successfully treat this distinct form of opioid dependence disorder. Optimal service provision should recognise unique patient profiles and needs for this form of opioid dependence and incorporate psycho-social supports

Characteristics of methadone related overdose deaths and comparisons between those dying on and off methadone substitution treatment: a national cohort study.

Background: Opioid users, particularly those with a history of injecting and dependence, have a high risk of fatal polysubstance and methadone related overdose. Aim: To describe characteristics of methadone related overdose deaths and assess if differences exist between those dying on and off opioid agonist treatment (OAT). Methods: A descriptive study of all persons dying of drug overdose involving methadone on the Irish National Drug Related Deaths Index (NDRDI) in 2012 and 2013. Results: A total of 182 methadone implicated deaths were recorded . 78% (n=142) were male; with a mean age of 36 years. Of the cohort, 61% (n=111) were not in receipt of opiate agonist treatment (OAT) at the time of death, 15.9% (n=29) had a previous history of non-fatal overdose and 24.7% (n=45) a history of alcohol dependence. Analysis and interpretations are limited by incomplete data on other characteristics but where available show that 89% (n=73) were injecting drug users, with 57.8% (n=26) injecting drugs at the time of death. History of mental illness was recorded in 96.3% (n=77) of cases, with 94.7% (n=107) having history of substance dependency treatment. Polysubstances were implicated in 86.8% (n=158) of deaths. The majority died in a private dwelling (74.7% n= 127) and were not alone 67.4% (n=114). Conclusions: Methadone related fatal overdose is a significant cause of death in young Irish, who share many characteristics with other drug related deaths. Improved monitoring, risk assessment and OAT retention strategies is warranted to inform national drug overdose plans and overdose prevention

Piloting online self-audit of methadone treatment in Irish general practice: results, reflections and educational outcomes

Background: Work based learning underpins the training and CPD of medical practitioners. Medical audit operates on two levels; individual self-assessment and professional/practice development. In Ireland, annual practice improvement audit is an essential requirement for the successful completion of continuous professional development (CPD) as determined by the regulatory body, the Irish Medical Council. All general practice (GP) doctors providing methadone maintenance treatment (MMT) in Ireland have a contractual obligation to partake in a yearly methadone practice audit. The Irish College of General Practitioners (ICGP) as national training provider is tasked to facilitate this annual audit process. The purpose of this audit is to assess the quality of care provided to patients against an agreed set of national standards, enhance learning, and promote practice improvement and reflective practice. The aim was to present an online MTP self-audit and evaluate results from a 12-month pilot among GPs providing MMT in Ireland. Method A mixed method study describing three phases (design and development, pilot/implementation and evaluation) of a new online self –audit tool was conducted. Descriptive and thematic analysis of audit and evaluation data was conducted. Results: Survey Monkey is a suitable software package for the development and hosting of an easy to use online audit for MMT providing doctors. Analysis of the audit results found that the majority of GPs scored 80% or over for the 25 identified essential criteria for MMT provision. The evaluation of the GP audit experience underscores the positive outcomes of the online self-audit in terms of improving practice systems, encouraging reflective practice, enhanced patient care and doctor commitment to continued provision of MMT in addiction clinics and in primary care. Conclusions: Results from this audit demonstrate a high level of compliance with best practise MMT guidelines by Irish GPs providing MMT. The online self-audit process was well received and encouraged reflective practice. The audit process hinged on the individual GP’s ability to review and critically analyse their professional practice, and manage change. This model of audit could be adapted and used to monitor the management of other chronic illnesses in general practice

Irish general practitioner attitudes toward decriminalisation and medical use of cannabis: results from a national survey.

BACKGROUND: Governmental debate in Ireland on the de facto decriminalisation of cannabis and legalisation for medical use is ongoing. A cannabis-based medicinal product (Sativex®) has recently been granted market authorisation in Ireland. This unique study aimed to investigate Irish general practitioner (GP) attitudes toward decriminalisation of cannabis and assess levels of support for use of cannabis for therapeutic purposes (CTP). METHODS: General practitioners in the Irish College of General Practitioner (ICGP) database were invited to complete an online survey. Anonymous data yielded descriptive statistics (frequencies, percentages) to summarise participant demographic information and agreement with attitudinal statements. Chi-square tests and multi-nominal logistic regression were included. RESULTS: The response rate was 15% (n = 565) which is similar to other Irish national GP attitudinal surveys. Over half of Irish GPs did not support the decriminalisation of cannabis (56.8%). In terms of gender, a significantly higher proportion of males compared with females (40.6 vs. 15%; p < 0.0001) agreed or strongly agreed with this drug policy approach. A higher percentage of GPs with advanced addiction specialist training (level 2) agreed/strongly agreed that cannabis should be decriminalised (54.1 vs. 31.5%; p = 0.021). Over 80% of both genders supported the view that cannabis use has a significant effect on patients' mental health and increases the risk of schizophrenia (77.3%). Over half of Irish GPs supported the legalisation of cannabis for medical use (58.6%). A higher percentage of those who were level 1-trained (trained in addiction treatment but not to an advanced level) agreed/strongly agreed cannabis should be legalised for medical use (p = 0.003). Over 60% agreed that cannabis can have a role in palliative care, pain management and treatment of multiple sclerosis (MS). In the regression response predicator analysis, females were 66.2% less likely to agree that cannabis should be decriminalised, 42.5% less likely to agree that cannabis should be legalised for medical use and 59.8 and 37.6% less likely to agree that cannabis has a role in palliative care and in the treatment of multiple sclerosis (respectively) than males. CONCLUSIONS: The majority of Irish GPs do not support the present Irish governmental drug policy of decriminalisation of cannabis but do support the legalisation of cannabis for therapeutic purposes. Male GPs and those with higher levels of addiction training are more likely to support a more liberal drug policy approach to cannabis for personal use. A clear majority of GPs expressed significant concerns regarding both the mental and physical health risks of cannabis use. Ongoing research into the health and other effects of drug policy changes on cannabis use is required

Development of a quality indicator set to measure and improve quality of ICU care for patients with traumatic brain injury.

BACKGROUND: We aimed to develop a set of quality indicators for patients with traumatic brain injury (TBI) in intensive care units (ICUs) across Europe and to explore barriers and facilitators for implementation of these quality indicators. METHODS: A preliminary list of 66 quality indicators was developed, based on current guidelines, existing practice variation, and clinical expertise in TBI management at the ICU. Eight TBI experts of the Advisory Committee preselected the quality indicators during a first Delphi round. A larger Europe-wide expert panel was recruited for the next two Delphi rounds. Quality indicator definitions were evaluated on four criteria: validity (better performance on the indicator reflects better processes of care and leads to better patient outcome), feasibility (data are available or easy to obtain), discriminability (variability in clinical practice), and actionability (professionals can act based on the indicator). Experts scored indicators on a 5-point Likert scale delivered by an electronic survey tool. RESULTS: The expert panel consisted of 50 experts from 18 countries across Europe, mostly intensivists (N = 24, 48%) and neurosurgeons (N = 7, 14%). Experts agreed on a final set of 42 indicators to assess quality of ICU care: 17 structure indicators, 16 process indicators, and 9 outcome indicators. Experts are motivated to implement this finally proposed set (N = 49, 98%) and indicated routine measurement in registries (N = 41, 82%), benchmarking (N = 42, 84%), and quality improvement programs (N = 41, 82%) as future steps. Administrative burden was indicated as the most important barrier for implementation of the indicator set (N = 48, 98%). CONCLUSIONS: This Delphi consensus study gives insight in which quality indicators have the potential to improve quality of TBI care at European ICUs. The proposed quality indicator set is recommended to be used across Europe for registry purposes to gain insight in current ICU practices and outcomes of patients with TBI. This indicator set may become an important tool to support benchmarking and quality improvement programs for patients with TBI in the future

Twenty years on, the Methadone Treatment Protocol in Ireland: Reflections on General Practice

Background: Opioid dependence, characterised by socio economic disadvantage and significant morbidity and mortality, remains a major public health problem in Ireland. Through the methadone treatment protocol (MTP), Irish general practice has been a leader in the introduction and expansion of Irish harm reduction services, including opioid substitution treatment (OST), needle and syringe programs (NSP) and naloxone provision. These services have been effective in engaging opiate users in treatment, reducing human deficiency virus (HIV) and hepatitis C virus (HCV) transmission and reducing drug related morbidities. Challenges remain in relation to choice of substitution treatments, timely access to OST services, adequate coverage of NSP, naloxone provision and increasing drug related deaths.Methods: A narrative review was conducted and designed to present a broad perspective on the Irish MTP, and to describe its history and development in terms of clinical care, stakeholder views and changing trends.Results: Three themes emerged from the analysis; The History of the Methadone Treatment Protocol, Service User and Provider Views, and Challenges and Developments. Despite initial concern about methadone maintenance treatment (MMT) in Ireland, increased participation by Irish GPs in the treatment of opioid dependence is observed over the last two decades. There are now over 10,000 people on methadone treatment in Ireland, with 40% treated in general practice. The MTP provides structure, remuneration and guidance to GPs and is underpinned by; training, ongoing education and a system of quality assurance provided by the Irish College of General Practice (ICGP). Challenges include the negative views of patients around how methadone services are delivered, the stigma associated with methadone treatment, the lack of choice around substitution medication, waiting lists for treatment in certain areas and rates of fatal overdose.Conclusion: Twenty years of the MTP has been the mainstay of harm reduction services in Ireland. It has provided a network of specially trained GPs who provide methadone to over 10,000 patients across Ireland within a structured framework of training, quality assurance and remuneration. With the ongoing commitment of Irish specialists in the field of addiction medicine, further improvements to support and treat patients can be made