Finding evidence for talking therapies

In an attempt to prove that counselling works for reducing drinking in concurrent problem alcohol and illicit drug users, Jan Klimas ended up on a journey through research and revie

Helping problem drinkers

Under the guidance of brief interventions, how best can GPs help problem drinkers who also use other drugs, ask Jan Klimas and Walter Culle

Digital network of writers helps to foster spirit of collaboration.

Nurse Liz Charalambous has shown how a Facebook group can help boost writing (careers, June 3). We would like to take this idea one step further and argue that, contrary to a commonly held notion, 'too many cooks do not spoil the broth' when it comes to group writing. Instead, this approach fosters collaboration between writers, as Ms Charalambous suggests, and which has also been our experience

The prevalence of common mental and substance use disorders in general practice: a literature review and discussion paper

Enhanced primary care management of common mental and substance use disorders is a key healthcare target. Though primary care may be well placed to achieve this target, a greater understanding of the prevalence and profile of common mental and substance use disorders in primary care settings is needed. We searched the MEDLINE database (2002–2012) to provide an update on biomedical literature describing the prevalence of common mental and substance use disorders in European general practice. Following “PRISMA” guidelines, 17 studies were kept for qualitative synthesis. Prevalence, profile, screening instruments, associated co-morbidities, and gender distribution were tabulated. Depending on the screening method, the prevalence of common mental and substance use disorders ranged from 10.4% (Luxemburg) to 53.6% (Spain). Mood disorders were the most common. High co-morbidity with anxiety and somatisation hindered early identification and management. The continuing burden of common mental and substance use disorders, coupled with poor identification described in the updated EU biomedical literature, suggests that the unmet need for health care – identified by the World Health Organization a decade ago – remains unmet. Understanding the prevalence of common mental and substance use disorders, associated morbidity, and the extent to which general practice represents an important catchment mechanism can enhance their management at this level. General practitioners should be trained in accurate screening. Short screening instruments for general practitioners should be unified and promoted

High glucose induces HGF-independent activation of Met receptor in human renal tubular epithelium

<p><b>Context:</b> The role of hepatocyte growth factor (HGF) in diabetic kidney damage remains controversial.</p> <p><b>Objective:</b> To test the hypothesis that high glucose levels activate pathways related to HGF and its receptor Met and that this could participate in glucose-induced renal cell damage.</p> <p><b>Materials and methods:</b> HK2 cells, a human proximal tubule epithelial cell line, were stimulated with high glucose for 48 hours. Levels of pMet/Met, pEGFR/EGFR, pSTAT3/STAT3, pAkt/Akt and pERK1/2/ERK1/2 were studied by immunoblotting. Absence of HGF was verified by qRT-PCR and ELISA.</p> <p><b>Results:</b> High glucose level activated Met and its downstream pathways STAT3, Akt and ERK independently of HGF. High glucose induced an integrin ligand fibronectin. HGF-independent Met phosphorylation was prevented by inhibition of integrin α5β1, Met inhibitor crizotinib, Src inhibitors PP2 and SU5565, but not by EGFR inhibitor AG1478. High glucose increased the expression of TGFβ-1, CTGF and the tubular damage marker KIM-1 and increased apoptosis of HK2 cells, effects inhibited by crizotinib.</p> <p><b>Conclusion:</b> High glucose activated Met receptor in HK2 cells independently of HGF, via induction of integrin α5β1 and downstream signaling. This mode of Met activation was associated with tubular cell damage and apoptosis and it may represent a novel pathogenic mechanism and a treatment target in diabetic nephropathy.</p

Alcohol screening among opioid agonist patients in a primary care clinic and an opioid treatment program

Problem alcohol use is associated with adverse health and economic outcomes, especially among people in opioid agonist treatment. Screening, brief intervention and referral to treatment (SBIRT) are effective in reducing alcohol use; however, issues involved in SBIRT implementation among opioid agonist patients are unknown. To assess identification and treatment of alcohol use disorders, we reviewed clinical records of opioid agonist patients screened for an alcohol use disorder in a primary care clinic (n =208) and in an opioid treatment program (n = 204) over a two year period. In the primary care clinic, 193 (93%) buprenorphine patients completed an annual alcohol screening and six (3%) had elevated AUDIT scores. Among the patients treated in the opioid treatment program, an alcohol abuse or dependence diagnosis was recorded for 54 (27%) methadone patients. Practitioner focus groups were completed in the primary care (n = 4 physicians) and the opioid treatment program (n = 11 counsellors) to assess experience with and attitudes towards screening opioid agonist patients for alcohol use disorders. Focus groups suggested organizational, structural, provider, patient and community variables hindered or fostered alcohol screening. Alcohol screening is feasible among opioid agonist patients. Effective implementation, however, requires physician training and systematic changes in workflow

Integrating addiction medicine training into medical school and residency curricula

Background: The Affordable Care Act (2010) brings an opportunity to increase the integration of addiction treatment into the health care system. With the anticipated expansion of addiction care services in primary care, challenges, such as workforce training, can be expected. This presentation discusses challenges and opportunities for addiction medicine training of primary care professionals in Ireland, Canada and Portland, OR. Objectives: To explore ideas for integrating addiction medicine education into medical school, fellowship and residency curricula and to consider how implementation barriers can be addressed. Method: The presentation will outline the set up and content of some of the current addiction medicine education in medical schools and residency programs in Ireland, Canada and Portland, Oregon. Examples from three educational initiatives will be used to generate ideas applicable to each setting and help overcome integration barriers: the St. Paul’s Hospital Goldcorp Addiction Medicine Fellowship (http://www.addictionmedicinefellowship.org), the feasibility study on alcohol SBIRT for opioid agonist patients in Ireland (PINTA), and the team-based SBIRT Oregon project (http://www.sbirtoregon.org). Scenarios that illustrate implementation strategies, such as educational outreach visits to practitioners - based on overcoming obstacles to change - and facilitators of integrating addiction medicine education into medical school and residency curricula, will be described. Conclusion: The presentation will conclude with an overview of how initiatives in which the authors have been involved may be used to improve addiction medicine education

Helpful and unhelpful aspects of eating disorders treatment involving psychological therapy: a meta-synthesis of qualitative research studies.

This meta-analysis, published in June 2013, sought to review and meta-analyse qualitative studies investigating helpful and unhelpful aspects of eating disorders treatment that involved psychological therapy. In total, 25 papers (24 studies) were systematically reviewed to discover what clients with an eating disorder diagnosis identified as helpful or unhelpful in their treatment. The studies involved 1,058 participants with an age range of 11 to 50, across a number of different counties

Key performance indicators for mental health and substance use disorders: a literature review and discussion paper

With increasing recognition of the importance of mental and substance use disorders for population health and health systems and the potential value of systems-based performance indicators in addressing this issue, we aimed to describe the development and content of key performance indicators for mental and substance use disorders. Publications were identified through official websites, Google searches and PubMed. Following ‘PRISMA’ guidelines, twenty-five studies were kept for qualitative synthesis and six for quantitative analysis. We describe their use in practice by comparing their application across a range of public and mixed healthcare systems. Currently, key performance indicator development for mental and substance use disorders adopts several methodologies, including expert opinion, literature review, stakeholder consultation and the structured consensus method. The rationales provided for selection of particular key performance indicators vary greatly between systems. Systems exhibit different levels of key performance indicator adaptability, which is reflective of dynamic changes in evidence-based practices. We noted bias in the level of key performance indicator assessment towards system/health plan evaluation followed by programme/service evaluation. Similarly, there is a large skew towards key performance indicators that reflect evaluation of processes. Collection of data in all systems is nearly exclusively reliant on electronic administrative/medical data. Experiences from these systems are synthesized into methodological recommendations, and considerations for further research and clinical practice are provided

Problem alcohol use among problem drug users in primary care: a qualitative study of what patients think about screening and treatment

Background: Problem alcohol use is common and associated with considerable adverse outcomes among patients who attend primary care in Ireland and other European countries for opiate substitution treatment. This paper aims to describe patients’ experience of, and attitude towards, screening and therapeutic interventions for problem alcohol use in primary care. Methods: This qualitative study recruited problem drug users (N = 28) from primary care based methadone programmes in the Ireland’s Eastern region, using a stratified sampling matrix to include size of general practice and geographical area. Semi-structured interviews were conducted and analysed using thematic analysis, and audited by a third reviewer. Results: We identified three overarching themes relevant to the purpose of this paper: (1) patients’ experience of, and (2) attitude towards, screening and treatment for problem alcohol use in primary care, as well as their (3) views on service improvement. While most patients reported being screened for problem alcohol use at initial assessment, few recalled routine screening or treatment. Among the barriers and enablers to screening and treatment, patients highlighted the importance of the practitioner-patient relationship in helping them address the issue. Nevertheless, patients felt that healthcare professionals should be more proactive in the management of problem alcohol use at a primary care level and that primary care can play an important role in their treatment. Conclusions: Problem alcohol use is an important challenge in the care of problem drug users. While primary care is well placed to address this issue, little data has reported on this topic. The development of interventions which promote screening and brief interventions in practice are likely to benefit this at-risk group and further research and education, that help achieve this goal, are a priority. Strategies such as dissemination of clinical guidelines, educational videos, academic detailing and practice visits, should be explored