Validating estimates of problematic drug use in England

<p>Abstract</p> <p>Background</p> <p>UK Government expenditure on combatting drug abuse is based on estimates of illicit drug users, yet the validity of these estimates is unknown. This study aims to assess the face validity of problematic drug use (PDU) and injecting drug use (IDU) estimates for all English Drug Action Teams (DATs) in 2001. The estimates were derived from a statistical model using the Multiple Indicator Method (MIM).</p> <p>Methods</p> <p>Questionnaire study, in which the 149 English Drug Action Teams were asked to evaluate the MIM estimates for their DAT.</p> <p>Results</p> <p>The response rate was 60% and there were no indications of selection bias. Of responding DATs, 64% thought the PDU estimates were about right or did not dispute them, while 27% had estimates that were too low and 9% were too high. The figures for the IDU estimates were 52% (about right), 44% (too low) and 3% (too high).</p> <p>Conclusion</p> <p>This is the first UK study to determine the validity estimates of problematic and injecting drug misuse. The results of this paper highlight the need to consider criterion and face validity when evaluating estimates of the number of drug users.</p

Experiential learning in public health: evaluation of a health promotion campaign assessment for pharmacy students

Description: Students in small groups designed, delivered and evaluated real-life health promotion campaigns in the local community. A peer assessed component was included from the fifth cohort onwards. Evaluation: Six successive cohorts of pharmacy students anonymously completed an evaluation questionnaire after finishing the assessment. Descriptive and inferential statistical analyses were undertaken on the data. The results showed that consistently more respondents reported the assessment as a positive experience than a negative experience. Significantly more respondents reported peer assessment as being useful and group members equally contributing to campaign planning in the cohorts with peer assessment compared to the pre-peer assessment cohorts, but peer assessment did not significantly affect enjoyment ratings. Respondents’ reported enjoyment of the assessment was significantly associated with agreement that it prepared them for health promotion in practice. Conclusions: Pharmacy students perceived the health promotion campaign assessment as appropriately challenging and enjoyable preparation for health promotion in practice

Use of path analysis to predict changes to community pharmacy and GP emergency hormonal contraception (EHC) provision in England

ObjectivesIn 2014/2015, 46% of community pharmacies were commissioned by local authorities to provide emergency hormonal contraception (EHC) free without prescription in England. Commissioning EHC services influences EHC prescribing from General Practice (GP)—greater community pharmacy provision reduces GP prescribing. This study aimed to examine predictors of GP and pharmacy EHC activity, describing them using path analysis. From this, commissioners and policy-makers may understand ways to influence this.Study designCross-sectional study of routinely recorded data, obtained through freedom of information requests to local authorities.SettingCommunity pharmacies and general practices in England, UK.ParticipantsAll local authorities in England were included in the study (147 areas). The study population were all girls, adolescents and women aged 12–55. Of the 147 areas, data from 80 local authorities were obtained covering an eligible female population of 9 380 153.Primary and secondary outcome measuresCorrelation between community pharmacy and GP EHC activity.ResultsData from 80 local authorities were analysed, representing 60% of the eligible female population in England. A significant negative correlation was found between rates of community pharmacy provision and GP prescribing (−0.458, p&lt;0.000). Community pharmacy provision and the proportion of pharmacies commissioned were significantly correlated (0.461, p&lt;0.000). A significant correlation was found between increased deprivation and community pharmacy provision (0.287, p=0.010). Standardised total effects on GP prescribing were determined from path analysis including community pharmacy provision (ß=−0.552) and proportion of pharmacies commissioned (ß=−0.299). If all community pharmacies were commissioned to provide EHC, GP EHC prescriptions could decrease by 15%.ConclusionCommunity pharmacy EHC provision has a significant influence on GP EHC prescribing. Increasing the proportion of commissioned community pharmacies should have a marked impact on GP workload. The methodology affords the possibility of examining relationships surrounding other commissioned service activity across different settings and their impact on linked care settings.</jats:sec

Patterns of symptoms before a diagnosis of first episode psychosis: a latent class analysis of UK primary care electronic health records

Background: The nature of symptoms in the prodromal period of first episode psychosis (FEP) remains unclear. The objective was to determine patterns of symptoms recorded in primary care in the 5-years before FEP diagnosis. Methods: The study was set within 568 practices contributing to a UK primary care health record database (Clinical Practice Research Datalink). Patients aged 16-45 years with a first coded record of FEP, and no antipsychotic prescription more than one year prior to FEP diagnosis (n=3,045) were age, gender and practice matched to controls without FEP (n=12,180). 55 symptoms recorded in primary care in the previous 5 years, categorised into eight groups (mood-related, ‘neurotic’, behavioural change, volition change, cognitive change, perceptual problem, substance misuse, physical symptoms), were compared between cases and controls. Common patterns of symptoms prior to FEP diagnosis were identified using latent class analysis. Results: Median age at diagnosis was 30 years, 63% were male. Non-affective psychosis (67%) was the most common diagnosis. Mood-related, ‘neurotic’, and physical symptoms were frequently recorded (>30% of patients) before diagnosis, and behavioural change, volition change, and substance misuse were also common (>10%). Prevalence of all symptom groups was higher in FEP patients than controls (adjusted odds ratios 1.33-112). Median time from first recorded symptom to FEP diagnosis was 2-2.5 years except perceptual problem (70 days). The optimal latent class model applied to FEP patients determined three distinct patient clusters. ‘No or minimal symptom cluster’ (49%) had no or few symptoms recorded; ‘affective symptom cluster’ (40%) mainly had mood-related and ‘neurotic’ symptoms; and ‘multiple symptom cluster’ (11%) consulted for three or more symptom groups before diagnosis. The multiple symptom cluster were more likely to have drug-induced psychosis, be female, obese, and have a higher morbidity burden. Affective and multiple symptom clusters showed a good discriminative ability (C-statistic 0.766; sensitivity 51.2% and specificity 86.7%) for FEP, and many patients in these clusters had consulted for their symptoms several years before FEP diagnosis. Conclusions: Distinctive patterns of prodromal symptoms may help alert general practitioners to those developing psychosis, facilitating earlier identification and referral to specialist care, thereby avoiding potentially detrimental treatment delay

P181 Musculoskeletal pain and prognosis of acute coronary syndrome and cerebrovascular accident: a linked electronic health record cohort study

Abstract Background/Aims There is some evidence of an increased risk of cardiovascular disease in patients with painful musculoskeletal conditions, but it is unclear if musculoskeletal pain also worsens its prognosis. The aim was to determine whether patients with musculoskeletal pain have poorer prognosis following acute coronary syndrome (ACS) or cerebrovascular accident (CVA). Methods Data were obtained from national primary care electronic health records (Clinical Practice Research Datalink; CPRD) with linkage to hospital admissions and mortality records. Patients aged 45 years and over with ACS or CVA recorded in primary care and as the primary reason for hospital admission within ±30 days were included. Patients were grouped by consultations in primary care for painful musculoskeletal conditions (by recency/severity and by condition) in the 24 months prior to ACS or CVA. Severe musculoskeletal pain was defined as prescription of strong analgesia or relevant secondary care referral in the 6 months before ACS or CVA. Short-term outcomes included length of hospital stay, mortality during admission or within 30 days of discharge, and readmission within 30 days of discharge. Management outcomes included procedures during admission and prescriptions for anti-hypertensives, anti-platelets and anti-coagulants in the 3 months following admission. Longer term outcomes included further ACS or CVA and mortality in those who survived &amp;gt;30 days after discharge. Results There were 171,670 patients with ACS (36% females; median age 70 years) and 138,512 patients with CVA (49% females; median age 76 years); 30% of patients in each cohort consulted for a painful musculoskeletal condition prior to admission for ACS or CVA. An increased prevalence of cardiovascular risk factors was observed for patients with severe musculoskeletal pain compared to those without pain for comorbidities such as obesity (ACS 26% vs 16%, CVA 25% vs 15%), diabetes (ACS 24% vs 17%, CVA 23% vs 17%) and lifestyle characteristics such as current/ex-smoker (ACS 58% vs 52%, CVA 52% vs 46%), respectively. Patients with severe musculoskeletal pain had similar lengths of stay, rates of readmission and further ACS/CVA after adjustment for sociodemographic characteristics and comorbidities than those without musculoskeletal pain. They were more likely to receive a procedure during admission for ACS (adjusted risk ratio [aRR] 1.15, 95% confidence interval [CI] 1.03-1.28). Prescriptions for ACS (severe pain aRR 1.01, 95% CI 1.00-1.02; inflammatory condition aRR 1.01, 95% CI 1.00-1.02) and CVA (inflammatory condition aRR 1.04, 95% CI 1.01-1.06) were higher in the 3 months post-admission for those with musculoskeletal pain. Conclusion Musculoskeletal pain did not independently worsen the prognosis following hospitalisation for incident ACS or CVA. The findings are reassuring, but also highlight the need for closer surveillance due to the complexities of patients with severe musculoskeletal presenting with incident ACS or CVA. Disclosure K.J. Mason: None. K.P. Jordan: None. F.A. Achana: None. J. Bailey: None. Y. Chen: None. M. Frisher: None. A.L. Huntley: None. C.D. Mallen: None. M.A. Mamas: None. M. Png: None. S. Tatton: None. S. White: None. J.J. Edwards: None. </jats:sec

Markers of dementia-related health in primary care electronic health records

Objectives: Identifying routinely recorded markers of poor health in patients with dementia may help treatment decisions and evaluation of earlier outcomes in research. Our objective was to determine whether a set of credible markers of dementia-related health could be identified from primary care electronic health records (EHR). Methods: The study consisted of (i) rapid review of potential measures of dementia-related health used in EHR studies; (ii) consensus exercise to assess feasibility of identifying these markers in UK primary care EHR; (iii) development of UK EHR code lists for markers; (iv) analysis of a regional primary care EHR database to determine further potential markers; (v) consensus exercise to finalise markers and pool into higher domains; (vi) determination of 12-month prevalence of domains in EHR of 2328 patients with dementia compared to matched patients without dementia. Results: Sixty-three markers were identified and mapped to 13 domains: Care; Home Pressures; Severe Neuropsychiatric; Neuropsychiatric; Cognitive Function; Daily Functioning; Safety; Comorbidity; Symptoms; Diet/Nutrition; Imaging; Increased Multimorbidity; Change in Dementia Drug. Comorbidity was the most prevalent recorded domain in dementia (69%). Home Pressures were the least prevalent domain (1%). Ten domains had a statistically significant higher prevalence in dementia patients, one (Comorbidity) was higher in non-dementia patients, and two (Home Pressures, Diet/Nutrition) showed no association with dementia. Conclusions: EHR captures important markers of dementia-related health. Further research should assess if they indicate dementia progression. These markers could provide the basis for identifying individuals at risk of faster progression and outcome measures for use in research

Recent trends in the incidence of anxiety and prescription of anxiolytics and hypnotics in children and young people: An e-cohort study

AbstractBackgroundLittle is known regarding the recognition of anxiety in children and young people (CYP) in primary care. This study examined trends in the presentation, recognition and recording of anxiety and of anxiolytic and hypnotic prescriptions for CYP in primary care.MethodA population-based retrospective electronic cohort of individuals aged 6–18 years between 2003 and 2011 within the Secure Anonymised Information Linkage (SAIL) Databank primary care database was created. Incidence rates were calculated using person years at risk (PYAR) as a denominator accounting for deprivation, age and gender.ResultsWe identified a cohort of 311,343 registered individuals providing a total of 1,546,489 person years of follow up. The incidence of anxiety symptoms more than tripled over the study period (Incidence Rate Ratio (IRR)=3.55, 95% CI 2.65–4.77) whilst that of diagnosis has remained stable. Anxiolytic/hypnotic prescriptions for the cohort as a whole did not change significantly over time; however there was a significant increase in anxiolytic prescriptions for the 15–18 year age group (IRR 1.62, 95% CI 1.30–2.02).LimitationsThere was a lack of reliable information regarding other interventions available or received at a primary, secondary or tertiary level such as psychological treatments.ConclusionsThere appears to be a preference over time for the recording of general symptoms over diagnosis for anxiety in CYP. The increase in anxiolytic prescriptions for 15–18 year olds is discrepant with current prescribing guidelines. Specific guidance is required for the assessment and management of CYP presenting with anxiety to primary care, particularly older adolescents

I love you ... and heroin: care and collusion among drug-using couples

BACKGROUND: Romantic partnerships between drug-using couples, when they are recognized at all, tend to be viewed as dysfunctional, unstable, utilitarian, and often violent. This study presents a more nuanced portrayal by describing the interpersonal dynamics of 10 heroin and cocaine-using couples from Hartford, Connecticut. RESULTS: These couples cared for each other similarly to the ways that non-drug-using couples care for their intimate partners. However, most also cared by helping each other avoid the symptoms of drug withdrawal. They did this by colluding with each other to procure and use drugs. Care and collusion in procuring and using drugs involved meanings and social practices that were constituted and reproduced by both partners in an interpersonal dynamic that was often overtly gendered. These gendered dynamics could be fluid and changed over time in response to altered circumstances and/or individual agency. They also were shaped by and interacted with long-standing historical, economic and socio-cultural forces including the persistent economic inequality, racism and other forms of structural violence endemic in the inner-city Hartford neighborhoods where these couples resided. As a result, these relationships offered both risk and protection from HIV, HCV and other health threats (e.g. arrest and violence). CONCLUSION: A more complex and nuanced understanding of drug-using couples can be tapped for its potential in shaping prevention and intervention efforts. For example, drug treatment providers need to 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, whenever possible, as well as provide additional couples-oriented services in an integrated and comprehensive drug treatment system

Distinct Neurobehavioural Effects of Cannabidiol in Transmembrane Domain Neuregulin 1 Mutant Mice

The cannabis constituent cannabidiol (CBD) possesses anxiolytic and antipsychotic properties. We have previously shown that transmembrane domain neuregulin 1 mutant (Nrg1 TM HET) mice display altered neurobehavioural responses to the main psychoactive constituent of cannabis, Δ9-tetrahydrocannabinol. Here we investigated whether Nrg1 TM HET mice respond differently to CBD and whether CBD reverses schizophrenia-related phenotypes expressed by these mice. Adult male Nrg1 TM HET and wild type-like littermates (WT) received vehicle or CBD (1, 50 or 100 mg/kg i.p.) for 21 days. During treatment and 48 h after withdrawal we measured behaviour, whole blood CBD concentrations and autoradiographic receptor binding. Nrg1 HET mice displayed locomotor hyperactivity, PPI deficits and reduced 5-HT2A receptor binding density in the substantia nigra, but these phenotypes were not reversed by CBD. However, long-term CBD (50 and 100 mg/kg) selectively enhanced social interaction in Nrg1 TM HET mice. Furthermore, acute CBD (100 mg/kg) selectively increased PPI in Nrg1 TM HET mice, although tolerance to this effect was manifest upon repeated CBD administration. Long-term CBD (50 mg/kg) also selectively increased GABAA receptor binding in the granular retrosplenial cortex in Nrg1 TM HET mice and reduced 5-HT2A binding in the substantia nigra in WT mice. Nrg1 appears necessary for CBD-induced anxiolysis since only WT mice developed decreased anxiety-related behaviour with repeated CBD treatment. Altered pharmacokinetics in mutant mice could not explain our findings since no genotype differences existed in CBD blood concentrations. Here we demonstrate that Nrg1 modulates acute and long-term neurobehavioural effects of CBD, which does not reverse the schizophrenia-relevant phenotypes

Incidence of Schizophrenia and Other Psychoses in England, 1950–2009: A Systematic Review and Meta-Analyses

Background We conducted a systematic review of incidence rates in England over a sixty-year period to determine the extent to which rates varied along accepted (age, sex) and less-accepted epidemiological gradients (ethnicity, migration and place of birth and upbringing, time). Objectives To determine variation in incidence of several psychotic disorders as above. Data Sources Published and grey literature searches (MEDLINE, PSycINFO, EMBASE, CINAHL, ASSIA, HMIC), and identification of unpublished data through bibliographic searches and author communication. Study Eligibility Criteria Published 1950–2009; conducted wholly or partially in England; original data on incidence of non-organic adult-onset psychosis or one or more factor(s) pertaining to incidence. Participants People, 16–64 years, with first -onset psychosis, including non-affective psychoses, schizophrenia, bipolar disorder, psychotic depression and substance-induced psychosis. Study Appraisal and Synthesis Methods Title, abstract and full-text review by two independent raters to identify suitable citations. Data were extracted to a standardized extraction form. Descriptive appraisals of variation in rates, including tables and forest plots, and where suitable, random-effects meta-analyses and meta-regressions to test specific hypotheses; rate heterogeneity was assessed by the I2-statistic. Results 83 citations met inclusion. Pooled incidence of all psychoses (N = 9) was 31.7 per 100,000 person-years (95%CI: 24.6–40.9), 23.2 (95%CI: 18.3–29.5) for non-affective psychoses (N = 8), 15.2 (95%CI: 11.9–19.5) for schizophrenia (N = 15) and 12.4 (95%CI: 9.0–17.1) for affective psychoses (N = 7). This masked rate heterogeneity (I2: 0.54–0.97), possibly explained by socio-environmental factors; our review confirmed (via meta-regression) the typical age-sex interaction in psychosis risk, including secondary peak onset in women after 45 years. Rates of most disorders were elevated in several ethnic minority groups compared with the white (British) population. For example, for schizophrenia: black Caribbean (pooled RR: 5.6; 95%CI: 3.4–9.2; N = 5), black African (pooled RR: 4.7; 95%CI: 3.3–6.8; N = 5) and South Asian groups in England (pooled RR: 2.4; 95%CI: 1.3–4.5; N = 3). We found no evidence to support an overall change in the incidence of psychotic disorder over time, though diagnostic shifts (away from schizophrenia) were reported. Limitations Incidence studies were predominantly cross-sectional, limiting causal inference. Heterogeneity, while evidencing important variation, suggested pooled estimates require interpretation alongside our descriptive systematic results. Conclusions and Implications of Key Findings Incidence of psychotic disorders varied markedly by age, sex, place and migration status/ethnicity. Stable incidence over time, together with a robust socio-environmental epidemiology, provides a platform for developing prediction models for health service planning