Christos Kouimtsidis

Substance use in the general hospital.

INTRODUCTION People misusing substances are overrepresented in health settings. Substance misuse can also be an underlying factor complicating medical diagnosis and management. AIMS (i) To establish the prevalence of substance misuse in the general hospital inpatient population; and (ii) to examine the relationship between medical diagnosis and substance misuse problem as identified by screening tools. METHOD This study adopted a three-step screening approach including a prospective questionnaire survey, interview, and case note review. Subjects included all adult patients admitted to a London teaching hospital over a 1-week period. RESULTS Seventy percent completed the questionnaire. Twenty-three percent was currently smoking, 14% was rated positive for alcohol misuse, and 12% positive for drug misuse. Only 65% of patients was screened for smoking, 54% for alcohol, and 9% for other substances. CONCLUSIONS People misusing one substance were more likely to be misusing others, hence the importance of screening all patients for all substances. Doctors were screening a small percentage of patients and they identified and intervened with only the severe ones.

Regaining control: the patient experience of supervised compared with unsupervised consumption in opiate substitution treatment.

INTRODUCTION AND AIMS Supervised consumption of opiate substitution treatment is standard practice in the UK yet little is known about the patient experience of this treatment modality. This study aimed to assess the patient experience of receiving supervised compared with unsupervised consumption of methadone or buprenorphine. DESIGN AND METHODS A qualitative study utilising a grounded theory approach to analysis. Participants (29) were theoretically sampled from 293 opioid-dependent patients entering a randomised controlled trial of opiate substitution treatment across four urban and community drug treatment services in England. Multidisciplinary staff were recruited for interviews and focus groups (55). RESULTS Supervised consumption was accepted by patients, despite causing practical limitations and raising issues of privacy and stigma. Patients recognised that establishing a daily routine away from illicit drugs was useful early in treatment. However, having flexibility to move away from supervision was important. Unsupervised patients reported that they ultimately preferred this treatment approach and appreciated the trust and sense of reward that unsupervised treatment bought. Clinicians expressed confidence in supervised prescribing and reduced risk for their patients, but also concern that a minority of individuals may remain inappropriately supervised for lengthy time periods. DISCUSSION AND CONCLUSIONS This study provides an important patient perspective and is the first in-depth qualitative investigation directly comparing supervision with unsupervised treatment to consider both patient and professional perspectives. Overall, our qualitative findings suggest that flexibly timed discontinuation of supervision may have positive benefits.

How important are positive and negative outcome expectancies in the treatment of addiction: a narrative review of the literature

Purpose – The purpose of this paper is to review the substance misuse literature on how outcome expectancies are measured, how they are related with the level of use and other factors as well as their role into treatment and recovery. Design/methodology/approach – A narrative review of the literature for all major substances of abuse was undertaken. Findings – Existing measurement tools are substance specific. Most research has been in the field of alcohol, and involved students or light and moderate drinkers. Positive expectancies have been found to be related to initiation and level of alcohol, nicotine and cannabis use and also to be modifiable with repeated cue exposure. Negative expectancies have been found to be associated with prevention of smoking, positive changes in drinking and positive effect on treatment outcome for alcohol. Research limitations/implications – Both positive and negative outcome expectancies have been found to predict development of substance misuse and recovery from it respec...

Treatment retention, drug use and social functioning outcomes in those receiving 3 months versus 1 month of supervised opioid maintenance treatment. Results from the Super C randomized controlled trial

AIM Supervised consumption of opioid maintenance treatment (OMT) is standard in many drug centres reducing drug diversion, but is costly. We aimed to determine whether supervised consumption of OMT improved retention and other measures of drug use. DESIGN Pragmatic randomized controlled trial comparing 3 months of daily supervised consumption of OMT with 1 month or less of daily supervised OMT, then daily unsupervised consumption. SETTING Four community drug services in the United Kingdom. PARTICIPANTS A total of 293 opioid-dependent patients entering OMT. MEASUREMENTS PRIMARY OUTCOME retention in treatment at 12 weeks. Secondary: retention at 6 months; illicit drug use [Maudsley Addiction Profile (MAP)]; quality of life (SF-12 and MAP); criminality (MAP); and social functioning. FINDINGS No significant between-group difference was observed for the primary outcome: 69% (100 of 145) supervised and 74% (109 of 148) unsupervised were retained [odds ratio (OR) = 0.74, 95% confidence interval (CI) = 0.43-1.27]. Per protocol survival analysis suggested that supervised patients were less well retained (hazard ratio for retention = 0.71, 95% CI = 0.51-1.00). Illicit opioid use reduced in both groups and, while not statistically significant by intention-to-treat analysis, favoured unsupervised patients in per protocol analysis (odds of positive opioid screen for supervised versus unsupervised = 2.07, 95% CI = 1.05-4.06). Data on criminal activity also favoured unsupervised patients with 21% supervised patients committing crime versus 9% unsupervised (OR = 3.37, 95% CI = 1.28-8.86). CONCLUSIONS There was no evidence of a difference in treatment retention or opioid use rates between patients whose consumption of opioid maintenance treatment was supervised for 3 months daily (except Saturdays) compared with supervision for 1 month. There was some evidence that longer periods of supervised consumption were associated with higher levels of criminality.

Can outcome expectancies be measured across substances? Development and validation of a questionnaire for populations in treatment

Purpose – The purpose of this paper is to develop a brief outcome expectancies questionnaire applicable across nicotine, alcohol, opioid and stimulant users seeking or willing to seek treatment and to assess its construct and predictive validity. Design/methodology/approach – The items were generated using semi-structured interviews. A cross-sectional study was used to determine the factor structure and internal reliability, to compare the factor structure across the groups and to assess construct validity. Scores were used to predict reduction in dependence at three-month follow-up. Findings – The qualitative study produced 98 items. For the cross-sectional study 99 nicotine, 96 alcohol, 98 opioid and 77 stimulant misusers were recruited. Factor analysis produced a two-factor (positive and negative expectancies) solution, similar across groups. A 28-item common version had scale correlations above 0.94 with the long versions of each group, and high internal consistency (Cronbachs α>0.90). The Positive e...

An exploratory qualitative study seeking participant views evaluating group Cognitive Behavioral Therapy preparation for alcohol detoxification

Abstract Aims: There is a strong consensus that detoxification from alcohol should be planned. Six sessions of Group Cognitive Behavioral Therapy as structured preparation for detoxification for alcohol dependence have been developed and evaluated. To our knowledge this is the only structured preparation intervention reported in the literature. The aim of this study was to provide a client centered evaluation of this intervention to build upon initial quantitative evidence. Methods: Eleven telephone and two face to face qualitative interviews were conducted in four community alcohol teams in South England. Detailed inductive coding, and coding around CBT concepts, of all transcripts was undertaken. Participants were purposively sampled after completion of the six week group intervention. Results: Key benefits of group attendance from the participant perspective included not feeling “alone”, being supported by, and supporting peers. Participants demonstrated self-efficacy and coping strategies for reducing drinking and managing high-risk situations. Some reported pre-group anxiety, or difficult group experiences due to disruptive clients. Conclusions: Although the study has limitations, the intervention appears to be well accepted, and appears to prepare participants for detoxification. These exploratory findings suggest that both generic groups as well as theory specific factors are important. Effectiveness and cost-effectiveness of the intervention need to be further assessed.

Path analysis of cognitive behavioural models in substance misuse. What is the relationship between concepts involved

Abstract Introduction: The aims were (i) to assess if data support the propositions about the assumed causal relationships deduced from Cognitive Behaviour Therapy models; (ii) to explore the potential inclusion of negative expectancies in those; and (iii) to assess if data supports one model better than others. Method: Patients dependent on alcohol, opioids and stimulants were recruited. Mediational Path analysis was performed. Change of dependence at 3 months was the outcome. Results: Ninety-six alcohol, ninety-four opioid and seventy-seven stimulant participants were recruited. Multi group analysis indicated that the three substance groups could be collapsed and analysed together. The multiple regression model, based on Marlatt’s relapse prevention model, was the best to fit the data. Urges had a strong negative effect and negative expectancies a weaker positive effect on outcome. An exploratory model incorporating causal relationships between the variables was tested, with urges and negative expectancies as the final mediators. This model though was not better than the multiple regression one. Conclusion: Comparison across models suggested that the regression model based on the original Relapse prevention was the best, with urges and negative expectancies having the highest effect in opposite directions.

Drug misuse among patients admitted to a general hospital

Aims In this paper we report the prevalence of prescribed drugs of misuse and illicit drugs used by patients admitted to a general hospital and the level of detection of drug problems by general medical staff. Design This is a prospective questionnaire survey, interview and case note review. Setting This study is a snapshot of one weeks admission to a general hospital. Findings Of the 408 people approached, 285 (70%) participated in the study. One hundred and sixty‐six people (62%) reported misuse of drugs at some time in their lives. Of these, 46 (17%) reported use of illegal drugs at some time in their lives, 22 (8%) in the past year, and 7 (2.6%) in the previous month. The most frequently reported drug type used ever, in the past year, and in the previous month, was over‐the‐counter medication and sedatives. All nine dependent patients identified by the interview were polydrug users and were significantly younger. Two of these patients were assessed for substance misuse by the medical staff. Conclusion This study suggests that younger patients should be asked about their drug use, especially their use of more readily available drugs. At present, few questions are being asked by health professionals, leaving drug misuse to continue to drain both healthcare and societys resources.

An investigation of descriptive and experimental aspects of intrusive thoughts in a sample of substance-dependent inpatients

Aims: Thought processes have been hypothesised to play a role in addiction and relapse (Salkovskis and Reynolds (1994)). Thought suppression and smoking cessation showed that suppression was associated with an increase in smoking-related intrusive thoughts, whilst a distracting task (relaxation) reduced intrusion frequency. This is a report of a similar study with a substance-dependent sample undergoing detoxification. Design: Subjects were randomly allocated to one of three groups (mention control, relaxation and suppress) and respectively were asked to monitor, suppress and do relaxation exercises, and suppress substance-related intrusive thoughts in period 1. In period 2 they were told that they could think about anything. Subjects recorded all substance-related intrusions in both periods. Participants and Setting: Inpatient opiate or multisubstance-dependent sample undergoing detoxification. Findings: Deliberate suppression of substance-related intrusive thoughts did not result in an increase in the frequency of the same for the suppression group compared to the mention control group. Relaxation facilitated thought suppression in the first period, but this effect was not carried over to the second period. Conclusions: In the absence of the task which acted as an effective structured distracter, feeling relaxed may act as a trigger for drug-related thoughts. This may have some implications for the use of relaxation as a form of distraction in the treatment for substance misusers.

Structured intervention to prepare dependent drinkers to achieve abstinence: results from a cohort evaluation for six months post-detoxification

Abstract Background: NICE guidelines advise against rushed detoxifications for clients dependent on alcohol, and emphasise the importance of planned detoxifications with aftercare plans to be in place. Unfortunately, around only 60% of detoxified clients will attend aftercare interventions. There is also increasing evidence supporting the negative effects of repeated detoxifications (medically assisted or not) on the brain and on the long-term prognosis. Therefore, it is crucial to maximise the long-lasting effect of any alcohol detoxification. Methods: Data for all clients with alcohol dependence entering treatment during a six months period (July to December 2013) was analysed. The initial cohort was followed up at 1 month, 3 and 6 months following cessation of drinking. Results: Fifty-nine clients entered the structured programme. From those clients, 46 (77%) finished the Abstinence Preparation Group (APG). Thirty-nine clients achieved abstinence from alcohol and 32 entered aftercare interventions. Twenty-six (44%) were completely abstinent at 1 month, 22 (38%) at 3 months and 23 (39%) at 6 months. Eighteen clients achieved guided self-detox and had better outcomes that the rest of the cohort. Conclusion: In line with the previous evaluation, it seems that a structured approach towards abstinence with emphasis on preparation before medically assisted withdrawal improves engagement and has good abstinence outcomes at 3 months and 6 months post-detoxification.