Charlotte Ne Tompkins

The Leeds Evaluation of Efficacy of Detoxification Study (LEEDS) prisons project pilot study: protocol for a randomised controlled trial comparing dihydrocodeine and buprenorphine for opiate detoxification

BackgroundIn the United Kingdom (UK), there is an extensive market for the class A drug heroin. Many heroin users spend time in prison. People addicted to heroin often require prescribed medication when attempting to cease their drug use. The most commonly used detoxification agents in UK prisons are buprenorphine, dihydrocodeine and methadone. However, national guidelines do not state a detoxification drug of choice. Indeed, there is a paucity of research evaluating the most effective treatment for opiate detoxification in prisons. This study seeks to address the paucity by evaluating routinely used interventions amongst drug using prisoners within UK prisons.Methods/DesignThe Leeds Evaluation of Efficacy of Detoxification Study (LEEDS) Prisons Pilot Study will use randomised controlled trial methodology to compare the open use of buprenorphine and dihydrocodeine for opiate detoxification, given in the context of routine care, within HMP Leeds. Prisoners who are eligible and give informed consent will be entered into the trial. The primary outcome measure will be abstinence status at five days post detoxification, as determined by a urine test. Secondary outcomes during the detoxification and then at one, three and six months post detoxification will be recorded.

A review of the evidence for the effectiveness of primary prevention interventions for Hepatitis C among injecting drug users

BackgroundHepatitis C (HCV) prevalence is most common amongst injecting drug users where up to 98% of the population can be infected despite a low prevalence of HIV. This review considers the evidence for the effectiveness of primary prevention interventions to reduce incidence or prevalence of hepatitis C.MethodsSystematic review of the major electronic medical databases: Medline, EMBASE, PsycINFO, CINAHL and the Cochrane Library (Evidence Based Health). Either intervention or observational studies were included if they described an intervention targeting injecting drug using populations with the outcome to reduce either the prevalence or incidence of hepatitis C infection.Results18 papers were included in the final review from 1007 abstracts. Needle exchange programmes reduce the prevalence of HCV though prevalence remains high. Similarly the effectiveness of methadone maintenance treatment is only marginally effective at reducing HCV incidence. There is limited evidence evaluating either the effectiveness of behavioural interventions, bleach disinfectants, or drug consumption rooms.ConclusionPrimary prevention interventions have led to a reduction in HIV incidence, have been less effective at reducing HCV incidence. Global prevalence of HCV remains disturbingly high in injecting drug users. A robust response to the global health problem of HCV will require provision of new interventions. Behavioural interventions; distribution of bleach disinfectant; other injecting paraphernalia alongside sterile needle distribution; and evaluation of drug consumption rooms merit further expansion internationally and research activity to contribute to the emerging evidence base. Whilst the prevalence of HCV remains high, nevertheless many current interventions aimed at primary HCV prevention have been shown to be cost-effective due to their significant positive impact upon prevalence of HIV.

Factors that help injecting drug users to access and benefit from services: A qualitative study

BackgroundInternational research shows that injecting drug users (IDUs) can encounter many barriers when they try to access drug treatment and other services. However, the existing literature is mostly quantitative and does not consider the kinds of factors that injectors themselves identify as enabling them to access and benefit from services. Responding to this gap in knowledge, our paper explores IDUs own suggestions for improving service engagement and their reports of other factors enabling them to seek help.MethodsSemi-structured qualitative interviews were conducted with 75 current illicit drug injectors in three geographically diverse areas of West Yorkshire, England. Recruitment was through needle exchange programmes, with additional snowball sampling to ensure inclusivity of gender, ethnicity and primary drug injected. Transcribed data were analysed thematically using Framework.ResultsAlthough participants were often satisfied with current access to services, they made three broad suggestions for improving engagement. These were: providing more services (more providers and more forms of support); better operation of existing services (including better communication systems and more flexibility around individual needs); and staffing-related improvements (particularly, less judgemental and more understanding staff attitudes). Other factors identified as important enablers of help seeking were: having supporting relationships (particularly with family members); personal circumstances/life events (especially becoming a parent); and an injectors state of mind (such as feeling motivated and positive).ConclusionA range of practical suggestions for improving IDUs access to drug treatment and other services are identified.

“You’re all going to hate the word ‘recovery’ by the end of this”: Service users’ views of measuring addiction recovery

Abstract Aims: To explore how service users’ views of measuring addiction recovery differ from those of service providers. Methods: Five focus groups conducted in two English cities with (i) people currently using Class A drugs (nu2009=u20096); (ii) people currently using alcohol (nu2009=u200912); (iii) individuals in residential detoxification (nu2009=u200912); (iv) individuals in residential rehabilitation (nu2009=u20097); and (v) people who defined themselves as ex drug or alcohol users (nu2009=u20097). Each focus group reviewed 76 measures of recovery previously identified by senior service providers. Findings: Service users identified multiple problems with the 76 measures. Difficulties could be categorized as expecting the impossible of service users; the dangers of progress; the hidden benefits of negative outcomes; outcomes that negate the agency in recovery; contradictory measures; failure to recognise individual differences; entrenched vulnerabilities; the misattribution of feelings and behaviours; and inappropriate language. Conclusions: Service users experience recovery as a process and personal journey that is often more about ‘coping’ than ‘cure’. Involving service users in designing measures of recovery can lessen the likelihood that researchers develop assessment tools that use inappropriate, contradictory or objectionable outcomes, and ambiguous and unclear language. People who have experienced drug or alcohol problems can highlight important weaknesses in dominant recovery discourses.

How should we measure addiction recovery? Analysis of service provider perspectives using online Delphi groups

Aims: To explore ways of measuring addiction recovery and the extent of agreement/disagreement between diverse service providers on potential recovery indicators. Methods: Separate online Delphi groups with (i) addiction psychiatrists (nu2009=u200910); (ii) senior residential rehabilitation staff (nu2009=u20099); and (iii) senior inpatient detoxification unit staff (nu2009=u20096). Each group was conducted by email and followed the same structured format involving three iterative rounds of data collection. Content analyses were undertaken and the results from each group were compared and contrasted. Findings: Indicators of recovery spanned 15 broad domains: substance use, treatment/support, psychological health, physical health, use of time, education/training/employment, income, housing, relationships, social functioning, offending/anti-social behaviour, well-being, identity/self-awareness, goals/aspirations, and spirituality. Identification of domains was very consistent across the three groups, but there was some disparity between, and considerable disparity within, groups on the relative importance of specific indicators. Conclusions: Whilst there is general consensus that recovery involves making changes in a number of broad life areas and not just substance use, there is substantial disagreement on particular measures of progress. Further studies involving other stakeholder groups, particularly people who have personally experienced drug or alcohol dependence, are needed to assess how transferable the 15 identified domains of recovery are.

Non-commercial clinical trials of a medicinal product: can they survive the current process of research approvals in the UK?

Over recent years, considerable attention has been paid to the National Health Service (NHS) research governance and ethics approvals process in the UK. New regulations mean that approval from the Medicines and Healthcare Products Regulatory Agency (MHRA) is now also needed for conducting all clinical trials. Practical experience of gaining MHRA and sponsorship approval has yet to be described and critically explored in the literature. Our experience, from start to finish, of applying for these four approvals for a multicentre randomised controlled trial of two licensed drugs for opiate detoxification in the prison setting is described here. In addition, the implications of the approvals process for research projects, particularly clinical trials, in terms of time and funding, and also indirect implications for NHS patients are discussed. Inconsistencies are discussed and suggestions that could improve and streamline the overall process are made. The current approvals process could now be hindering non-commercial clinical trials, leading to a loss of important evidence-based medical information.

Buprenorphine versus dihydrocodeine for opiate detoxification in primary care: a randomised controlled trial.

BackgroundMany drug users present to primary care requesting detoxification from illicit opiates. There are a number of detoxification agents but no recommended drug of choice. The purpose of this study is to compare buprenorphine with dihydrocodeine for detoxification from illicit opiates in primary care.MethodsOpen label randomised controlled trial in NHS Primary Care (General Practices), Leeds, UK. Sixty consenting adults using illicit opiates received either daily sublingual buprenorphine or daily oral dihydrocodeine. Reducing regimens for both interventions were at the discretion of prescribing doctor within a standard regimen of not more than 15 days. Primary outcome was abstinence from illicit opiates at final prescription as indicated by a urine sample. Secondary outcomes during detoxification period and at three and six months post detoxification were recorded.ResultsOnly 23% completed the prescribed course of detoxification medication and gave a urine sample on collection of their final prescription. Risk of non-completion of detoxification was reduced if allocated buprenorphine (68% vs 88%, RR 0.58 CI 0.35–0.96, p = 0.065). A higher proportion of people allocated to buprenorphine provided a clean urine sample compared with those who received dihydrocodeine (21% vs 3%, RR 2.06 CI 1.33–3.21, p = 0.028). People allocated to buprenorphine had fewer visits to professional carers during detoxification and more were abstinent at three months (10 vs 4, RR 1.55 CI 0.96–2.52) and six months post detoxification (7 vs 3, RR 1.45 CI 0.84–2.49).ConclusionInformative randomised trials evaluating routine care within the primary care setting are possible amongst drug using populations. This small study generates unique data on commonly used treatment regimens.

Needle fear among women injecting drug users: a qualitative study

Objective: To describe elements of needle phobia amongst women injecting dug users and discuss the associated health implications. Design: Qualitative research using in depth interviews. Participants: Forty‐five injecting drug‐using (IDU) women who had experience of being injected with illicit drugs by other drug users. Results/Findings: Women injecting drug users displayed elements of needle phobia as they had a strong fear of needles. Most were fearful of needles prior to their first experience of injecting drug use. For some, their fear of needles continued during their later injecting experiences. Being afraid of needles, however, was not limited to injecting drug use as many women feared medical procedures that involved needles. They responded to this by refusing or delaying medical procedures involving needles, including blood tests and immunizations. Conclusions: Some women IDUs have a strong fear of needles and are concerned about medical procedures involving needles. Clinicians, especially those working with drug users, need to be aware that fear of needles can be a problem for some injecting drug users and this has health and clinical practice implications. Needle fear may potentially affect an injecting drug users engagement with and receipt of health care. Alternative methods of administration should therefore be investigated if this reduces anxiety and ensures that injecting drug using patients receive necessary health care.

The Leeds Evaluation of Efficacy of Detoxification Study (LEEDS) project: An open-label pragmatic randomised control trial comparing the efficacy of differing therapeutic agents for primary care detoxification from either street heroin or methadone [ISRCTN07752728]

BackgroundHeroin is a synthetic opioid with an extensive illicit market leading to large numbers of people becoming addicted. Heroin users often present to community treatment services requesting detoxification and in the UK various agents are used to control symptoms of withdrawal. Dissatisfaction with methadone detoxification [8] has lead to the use of clonidine, lofexidine, buprenorphine and dihydrocodeine; however, there remains limited evaluative research. In Leeds, a city of 700,000 people in the North of England, dihydrocodeine is the detoxification agent of choice. Sublingual buprenorphine, however, is being introduced. The comparative value of these two drugs for helping people successfully and comfortably withdraw from heroin has never been compared in a randomised trial. Additionally, there is a paucity of research evaluating interventions among drug users in the primary care setting. This study seeks to address this by randomising drug users presenting in primary care to receive either dihydrocodeine or buprenorphine.Methods/designThe Leeds Evaluation of Efficacy of Detoxification Study (LEEDS) project is a pragmatic randomised trial which will compare the open use of buprenorphine with dihydrocodeine for illicit opiate detoxification, in the UK primary care setting. The LEEDS project will involve consenting adults and will be run in specialist general practice surgeries throughout Leeds. The primary outcome will be the results of a urine opiate screening at the end of the detoxification regimen. Adverse effects and limited data to three and six months will be acquired.

Exploring motivations to stop injecting in English prisons: qualitative research with former male prisoners

PURPOSEnThis paper aims to explore the cessation of injecting amongst male drug users when in prison in England and uncovers what influenced this behaviour and why.nnnDESIGN/METHODOLOGY/APPROACHnQualitative interviews were conducted with 30 male drug users on release from prison to explore what happened to their injecting drug use in prison. The research was conducted from a pragmatic harm reduction approach using grounded theory.nnnFINDINGSnNot injecting in prison was identified as a pertinent finding and nine overarching themes accounted for this decline. The themes often overlapped with one another, highlighting how the decision not to inject when last in prison was multi-factorial. Running throughout the themes were participants concerns regarding the health and social risks attributed to injecting in prison, alongside an appreciation of some of the rehabilitative measures and opportunities offered to injecting drug users when in prison.nnnORIGINALITY/VALUEnThis qualitative research offers an updated perspective on illicit drug injecting in prison in England from the view of drug users since health and prison policy changes in prescribing and practice. It contributes to evidence suggesting that prisons can be used as a time of reprieve and recovery from injecting drug use.