Hacia una mayor incorporación de la perspectiva del paciente en el diseño de los instrumentos de evaluación de la efectividad y calidad de los cuidados

Sin duda alguna, nadie está mejor situado que el paciente mismo a la hora de aprehender su propio punto de vista sobre la experiencia y el resultado de unos cuidados o unas intervenciones. Por ello solo mirando a través de los ojos del paciente veremos cómo mejorar los cuidados que dispensamos. Posibilitar unos cuidados realmente centrados en el paciente requiere una evaluación de dichos cuidados igualmente centrada en el paciente. Dicha evaluación únicamente será posible si, entre otros requisitos como el de la firmeza psicométrica, se considera el grado de incorporación de la perspectiva de los pacientes en el instrumento antes de seleccionar alguno entre los disponibles, o se estima previamente el grado de sensibilidad hacia dicha perspectiva en el caso de que únicamente existan cuestionarios desarrollados sin la participación directa de los pacientes. Asimismo, si el objetivo de alguna de vuestras investigaciones futuras fuera desarrollar un nuevo instrumento de medida, dicho grado de incorporación de la perspectiva del paciente es un aspecto primordial a considerar y fortalecer

A critical analysis of user satisfaction surveys in addiction services: Opioid maintenance treatment as a representative case study

Background: Satisfaction with services represents a key component of the user's perspective, and user satisfaction surveys are the most commonly used approach to evaluate the aforementioned perspective. The aim of this discursive paper is to provide a critical overview of user satisfaction surveys in addiction treatment and harm reduction services, with a particular focus on opioid maintenance treatment as a representative case. Methods: We carried out a selective critical review and analysis of the literature on user satisfaction surveys in addiction treatment and harm reduction services. Results: Most studies that have reported results of satisfaction surveys have found that the great majority of users (virtually all, in many cases) are highly satisfied with the services received. However, when these results are compared to the findings of studies that use different methodologies to explore the patient's perspective, the results are not as consistent as might be expected. It is not uncommon to find that "highly satisfied" patients report significant problems when mixed-methods studies are conducted. To understand this apparent contradiction, we explored two distinct (though not mutually exclusive) lines of reasoning, one of which concerns conceptual aspects and the other, methodological questions. Conclusion: User satisfaction surveys, as currently designed and carried out in addiction treatment and harm reduction services, do not significantly help to improve service quality. Therefore, most of the enthusiasm and naiveté with which satisfaction surveys are currently performed and interpreted - and rarely acted on in the case of nonoptimal results - should be avoided. A truly participatory approach to program evaluation is urgently needed to reshape and transform patient satisfaction surveys. Keywords: patient satisfaction, substance abuse treatment services, harm reduction services, patient-centered evaluation, service user perspective, user involvemen

Aproximacions a la perspectiva de la persona en tractament de manteniment amb metadona: Reflexions a propòsit de 10 anys de recerca

Els tractaments de manteniment amb metadona (TMM) són un autèntic tractament psicofarmacològic de la dependència d'heroïna i, a la vegada, un element indispensable de les polítiques i les intervencions de reducció de danys. L'efectivitat dels TMM ha estat avaluada, gairebé de manera exclusiva, mitjançant la utilització d'indicadors anomenats durs. Intentant anar més enllà d'aquest enfocament tradicional, hem portat a terme, durant els darrers 10 anys, diversos estudis emprírics i assaigs teòrics que s'emmarquen dins d'un objectiu global de generar coneixement al voltant de -i amb- la perspectiva de la persona en TMM. En aquest article, resumim de manera selectiva les troballes més rellevants d'aquesta línia de recerca per discutir després algunes de les seves principals implicacions. Finalment, abordem alguns dels reptes -i suggerim alguns dels canvis necessaris- per a una avaluació dels TMM realment centrada en el pacient

Feasibility of Double-Blind Clinical Trials with Oral Diacetylmorphine: A Randomized Controlled Phase II Study in an Inpatient Setting

The aim of this study was to evaluate the feasibility of conducting double-blind controlled randomized clinical trials using twice-a-day immediate-release oral diacetylmorphine (DAM) in heroin-dependent patients, by means of measuring the capacity of oral DAM to block opiate withdrawal and clinicians' ability to distinguish it from morphine and methadone. This was a randomized, phase II, double-blind, multicenter pilot study comparing immediate-release oral DAM, slow-release oral morphine and oral methadone administered twice a day during 10 days. Forty-five heroin-dependent patients were randomly assigned to these three treatment groups in an inpatient regime. Patients were stabilized with a mean of 350 mg (SD = 193) of immediate-release oral DAM, 108 mg (SD = 46.2) of slow-release oral morphine and 40 mg (SD = 17.9) of methadone. No statistically significant differences were found between any studied medication in clinical outcome. Neither patients nor clinicians were able to identify the administered medication. This study shows the feasibility of double-blind clinical trials using b.i.d. immediate-release oral DAM allowing further phase III clinical trials in the process of introducing oral DAM as a medication for heroin-dependent patients not responding to standard maintenance treatments

Mindfulness-based Interventions For The Treatment Of Substance And Behavioral Addictions: A Systematic Review

Background: Emotion (dys) regulation as well as the interventions for improving these difficulties are receiving a growing attention in the literature. The aim of the present paper was to conduct a systematic review about the efficacy of mindfulness-based interventions (MBIs) in both substance and behavioral addictions (BAs). Method: A literature search was conducted using Cochrane, PubMed, and Web of Science. Fifty-four randomized controlled trials published in English since 2009 to April 2017 were included into a narrative synthesis. Results: Mindfulness-based interventions were applied in a wide range of addictions, including substance use disorders (from smoking to alcohol, among others) and BAs (namely, gambling disorder). These treatments were successful for reducing dependence, craving, and other addiction-related symptoms by also improving mood state and emotion dysregulation. The most commonly used MBI approaches were as follows: Mindfulness-Based Relapse Prevention, Mindfulness Training for Smokers, or Mindfulness-Oriented Recovery Enhancement, and the most frequent control group in the included studies was Treatment as Usual (TAU). The most effective approach was the combination of MBIs with TAU or other active treatments. However, there is a lack of studies showing the maintenance of the effect over time. Therefore, studies with longer follow-ups are needed. Conclusion: The revised literature shows support for the effectiveness of the MBIs. Future research should focus on longer follow-up assessments as well as on adolescence and young population, as they are a vulnerable population for developing problems associated with alcohol, drugs, or other addictions

Allelic and genotypic associations of DRD2 Taq I A polymorphism with heroin dependence in Spanish subjects: a case control study

Background: Conflicting associations with heroin dependence have been found involving the A1 allele of dopamine D2 receptor gene ( DRD2) TaqI A polymorphism. Methods: We compared two samples of unrelated Spanish individuals, all of European origin: 281 methadone-maintained heroin-dependent patients ( 207 males and 74 females) who frequently used non-opioid substances, and 145 control subjects ( 98 males and 47 females). Results: The A1-A1 genotype was detected in 7.1% of patients and 1.4% of controls ( P = 0.011, odds ratio = 5.48, 95% CI 1.26-23.78). Although the A1 allele was not associated with heroin dependence in the entire sample, the frequency of A1 allele was higher in male patients than in male controls ( 24.4% vs. 16.3%, P = 0.024, odds ratio = 1.65, 95% CI 1.07-2.57). A logistic regression analysis showed an interaction between DRD2 alleles and gender ( odds ratio = 1.77, 95% CI 1.15-2.70). Conclusion: Our results indicate that, in Spanish individuals, genotypes of the DRD2 TaqI A polymorphism contribute to variations in the risk of heroin dependence, while single alleles contribute only in males

Aproximacions a la perspectiva de la persona en tractament de manteniment amb metadona: millora percebuda i satisfacció amb el tractament com a indicadors, i participació en el desenvolupament dels instruments de mesura com a eina

[cat] Els tractaments de manteniment amb metadona (TMM) són un autèntic tractament psicofarmacològic de la dependència d’heroïna i, a la vegada, un element indispensable i fonamental de les polítiques i les intervencions de reducció de danys. L’efectivitat dels TMM ha estat avaluada, quasi de manera exclusiva, mitjançant la utilització d’indicadors anomenats durs. Intentant trencar el motlle d’aquest enfocament tradicional, aquesta tesi pretén contribuir al procés de generar coneixement al voltant de —i amb— la perspectiva de la persona en TMM. El nucli del treball doctoral està format per sis articles publicats en revistes internacionals, els resultats principals dels quals són: (1) l’avaluació realitzada pel clínic de la millora del pacient en TMM presenta una dèbil concordança amb la realitzada pel pacient mateix; (2) la versió espanyola del Treatment Satisfaction Questionnaire for Medication és un instrument breu, genèric i psicomètricament robust per a l’avaluació, de manera multidimensional, de la satisfacció dels pacients en TMM amb la metadona com a medicament; (3) els pacients tractats en centres amb un nombre més gran d’usuaris, que es perceben a si mateixos com a participants en certa mesura actius a l’hora de prendre decisions relatives al tractament i que presenten un menor deteriorament quant a funcionament psicosocial, es mostren més satisfets amb el TMM; (4) les mesures de resultats comunicats pels pacients (MRCP) poden classificar- se, en funció del nivell de reconeixement i incorporació de la perspectiva del pacient en el procés de disseny i desenvolupament de l’instrument, en les quatre categories següents: MRCP generades pels pacients, MRCP centrades en els pacients, MRCP valorades pels pacients i MRCP irrellevants per als pacients; (5) les enquestes de satisfacció dels pacients amb els TMM, tal com s’implementen en l’actualitat, no són una eina útil per a la millora de la qualitat assistencial; (6) una avaluació de resultats que no incorpori instruments rellevants per al pacient pot comportar l’obtenció d’informació incompleta, si no errònia, fet que problematitza qualsevol avaluació dels TMM. La conclusió principal d’aquesta tesi és que els instruments de mesura de resultats comunicats pels pacients han de dissenyar-se i desenvolupar-se mitjançant metodologies realment participatives. Subsegüentment, l’avaluació de l’efectivitat dels TMM requereix un equilibri entre els indicadors/instruments desenvolupats de manera tradicional i els rellevants per als pacients; si no, difícilment es possibilitarà una avaluació de resultats que incorpori realment la perspectiva del pacient.[eng] Methadone maintenance treatment (MMT) is both a specific psychopharmacological treatment of heroin dependence and a core harm-reduction intervention. By breaking the mould of the traditional focus on the so-called hard indicators of MMT effectiveness, the present dissertation makes room for the consideration of the perspectives of methadone-maintained patients. This dissertation compiles the main findings of six papers: (1) MMT patients’ perception of improvement shows low concordance with the clinical staff’s perspective; (2) The Spanish version of the Treatment Satisfaction Questionnaire for Medication is a brief, generic, and psychometrically sound instrument to assess satisfaction with methadone as a medication in a multidimensional manner; (3) Patients are more likely to be satisfied with MMT if they come from large centres, perceive themselves as participating to some extent in treatment decisions, and show lower deterioration in social functioning; (4) Patient-reported outcome measures (PROMs) can be classified according to the degree to which they genuinely incorporate and measure patient perspectives. These can be sorted out into four distinct categories: Patient-generated PROMs, Patient-centred PROMs, Patient-valued PROMs, and Patient-irrelevant PROMs; (5) User satisfaction surveys —as currently designed and carried out in MMT centres— do not significantly help improving treatment quality; (6) A lack of patient-relevant outcome measurement instruments can lead to incomplete, if not misleading, information that problematizes any evaluation of MMT. The main conclusion of this dissertation is that patient-reported outcome measurement instruments should be developed in a truly participatory manner. Subsequently, MMT effectiveness should be evaluated using traditionally-derived and patient-oriented indicators/instruments simultaneously, so as to provide outcomes assessment that genuinely includes the patient perspective