Eamon Keenan

Psychosocial Interventions for Alcohol Use Among Problem Drug Users: Protocol for a Feasibility Study in Primary Care

Background Alcohol use is an important issue among problem drug users. Although screening and brief intervention (SBI) are effective in reducing problem alcohol use in primary care, no research has examined this issue among problem drug users. Objective The objective of this study is to determine if a complex intervention including SBI for problem alcohol use among problem drug users is feasible and acceptable in practice. This study also aims to evaluate the effectiveness of the intervention in reducing the proportion of patients with problem alcohol use. Methods Psychosocial intervention for alcohol use among problem drug users (PINTA) is a pilot feasibility study of a complex intervention comprising SBI for problem alcohol use among problem drug users with cluster randomization at the level of general practice, integrated qualitative process evaluation, and involving general practices in two socioeconomically deprived regions. Practices (N=16) will be eligible to participate if they are registered to prescribe methadone and/or at least 10 patients of the practice are currently receiving addiction treatment. Patient must meet the following inclusion criteria to participate in this study: 18 years of age or older, receiving addiction treatment/care (eg, methadone), or known to be a problem drug user. This study is based on a complex intervention supporting SBI for problem alcohol use among problem drug users (experimental group) compared to an “assessment-only” control group. Control practices will be provided with a delayed intervention after follow-up. Primary outcomes of the study are feasibility and acceptability of the intervention to patients and practitioners. Secondary outcome includes the effectiveness of the intervention on care process (documented rates of SBI) and outcome (proportion of patients with problem alcohol use at the follow-up). A stratified random sampling method will be used to select general practices based on the level of training for providing addiction-related care and geographical area. In this study, general practitioners and practice staff, researchers, and trainers will not be blinded to treatment, but patients and remote randomizers will be unaware of the treatment. Results This study is ongoing and a protocol system is being developed for the study. This study may inform future research among the high-risk population of problem drug users by providing initial indications as to whether psychosocial interventions for problem alcohol use are feasible, acceptable, and also effective among problem drug users attending primary care. Conclusions This is the first study to examine the feasibility and acceptability of complex intervention in primary care to enhance alcohol SBI among problem drug users. Results of this study will inform future research among this high-risk population and guide policy and service development locally and internationally.

Bloodborne virus infections among drug users in Ireland: a retrospective cross-sectional survey of screening, prevalence, incidence and hepatitis B immunisation uptake

BackgroundInjecting drug users are at high-risk of bloodborne virus infections including hepatitis C (HCV), hepatitis B (HBV) and HIV.AimsTo document screening for and immunisation against bloodborne viruses and to determine the known prevalence and incidence of these infections.MethodsA cross-sectional survey of clients attending 21 specialist addiction treatment clinics in one health board area in greater Dublin. Data collected on demographic characteristics, serology for HCV, HBV and HIV and immunisation against HBV.ResultsA total of 316 (88%) had been tested for anti-HCV antibody, 244 (68%) had been tested for anti hepatitis B core antibody (anti-HBc), 299 (84%) had been tested for hepatitis B surface antigen (HBsAg) and 307 (86%) had been tested for anti-HIV antibody.The prevalence of anti-HCV, anti-HBc, HBsAg, and anti-HIV were: 66%, 17%, 2% and 11% respectively. The incidence of HCV, HBV and HIV infections were: 24.5, 9.0 and 3.4 per hundred person years respectively. Eighty-one per cent of those in whom it was indicated, had started a targeted HBV immunisation programme in the clinics.ConclusionThe proportion of clients screened for HCV, HBV and HIV infection has increased since the introduction of a screening protocol in 1998. Targeted vaccination for opiate users against hepatitis B is more successful than previously shown in Ireland. The prevalence and incidence of bloodborne viruses remains high among opiate users attending addiction treatment services, despite an increase in availability of harm reduction interventions.

Assessment of hepatitis C infection in injecting drug users attending an addiction treatment clinic

BackgroundInjecting drug users represent a high risk group for hepatitis C (HCV) infection. Currently, screening of this group for HCV is inconsistently implemented.AimWe designed a HCV assessment algorithm and sought to determine the frequency with which injecting drug users completed the assessment process.MethodsProspective study of a HCV assessment algorithm in the setting of a specialist outpatient addiction treatment clinic. Participants consisted of consecutive new attenders over a six-month period with a history of injecting.ResultsOnly 21 (18%) of 119 patients reached a satisfactory endpoint of assessment. Forty-eight injectors were tested for antibody to HCV, of whom 26 (54%) tested positive. Thirteen of those with positive test results were no longer attending when the test result became available. Only four of the 19 patients who were referred, attended the on-site hepatology clinic.ConclusionsThorough screening of injecting drug users for HCV within one treatment service is difficult. There is a need for explicit policies on this issue involving co-operation between primary care providers and addiction services and hepatoiogy services.

Enhancing alcohol screening and brief intervention among people receiving opioid agonist treatment: qualitative study in primary care

Purpose Problem alcohol use (PAU) is common and associated with considerable adverse outcomes among patients receiving opioid agonist treatment (OAT). The purpose of this paper is to describe a qualitative feasibility assessment of a primary care-based complex intervention to promote screening and brief intervention for PAU, which also aims to examine acceptability and potential effectiveness. Design/methodology/approach Semi-structured interviews were conducted with 14 patients and eight general practitioners (GPs) who had been purposively sampled from practices that had participated in the feasibility study. The interviews were transcribed verbatim and analysed thematically. Findings Six key themes were identified. While all GPs found the intervention informative and feasible, most considered it challenging to incorporate into practice. Barriers included time constraints, and overlooking and underestimating PAU among this cohort of patients. However, the intervention was considered potentially deliverable and acceptable in practice. Patients reported that (in the absence of the intervention) their use of alcohol was rarely discussed with their GP, and were reticent to initiate conversations on their alcohol use for fear of having their methadone dose reduced. Research limitations/impelications Although a complex intervention to enhance alcohol screening and brief intervention among primary care patients attending for OAT is likely to be feasible and acceptable, time constraints and patients’ reticence to discuss alcohol as well as GPs underestimating patients’ alcohol problems is a barrier to consistent, regular and accurate screening by GPs. Future research by way of a definitive efficacy trial informed by the findings of this study and the Psychosocial INTerventions for Alcohol quantitative data is a priority. Originality/value To the best of the knowledge, this is the first qualitative study to examine the capability of primary care to address PAU among patients receiving OAT.