Vivienne Maskrey

The SUMMIT trial: a field comparison of buprenorphine versus methadone maintenance treatment.

This prospective patient-preference study examined the effectiveness in practice of methadone versus buprenorphine maintenance treatment and the beliefs of subjects regarding these drugs. A total of 361 opiate-dependent individuals (89% of those eligible, presenting for treatment over 2 years at a drug service in England) received rapid titration then flexible dosing with methadone or buprenorphine; 227 patients chose methadone (63%) and 134 buprenorphine (37%). Participants choosing methadone had more severe substance abuse and psychiatric and physical problems but were more likely to remain in treatment. Survival analysis indicated those prescribed methadone were over twice as likely to be retained (hazard ratio for retention was 2.08 and 95% confidence interval [CI] = 1.49-2.94 for methadone vs. buprenorphine), However, those retained on buprenorphine were more likely to suppress illicit opiate use (odds ratio = 2.136, 95% CI = 1.509-3.027, p < .001) and achieve detoxification. Buprenorphine may also recruit more individuals to treatment because 28% of those choosing buprenorphine (10% of the total sample) stated they would not have accessed treatment with methadone.

A cohort study of influences, health outcomes and costs of patients’ health-seeking behaviour for minor ailments from primary and emergency care settings

Objectives To compare health-related and cost-related outcomes of consultations for symptoms suggestive of minor ailments in emergency departments (EDs), general practices and community pharmacies. Design Observational study; prospective cohort design. Setting EDs (n=2), general practices (n=6) and community pharmacies (n=10) in a mix of rural/urban and deprived/affluent areas across North East Scotland and East Anglia. Participants Adults (≥18 years) presenting between 09:00 and 18:00 (Monday–Friday) in general practices and 09:00–18:00 (Monday–Saturday) in pharmacies and EDs with ≥1 of the following: musculoskeletal pain; eye discomfort; gastrointestinal disturbance; or upper respiratory tract-related symptoms. Interventions Participants completed three questionnaires: baseline (prior to index consultation); satisfaction with index consultation and follow-up (2 weeks after index consultation). Main outcome measures Symptom resolution, quality of life, costs, satisfaction and influences on care-seeking behaviour. Results 377 patients participated, recruited from EDs (81), general practices (162) and community pharmacies (134). The 2-week response rate was 70% (264/377). Symptom resolution was similar across all three settings: ED (37.3%), general practice (35.7%) and pharmacy (44.3%). Mean overall costs per consultation were significantly lower for pharmacy (£29.30 (95% CI £21.60 to £37.00)) compared with general practice (£82.34 (95% CI £63.10 to £101.58)) and ED (£147.09 (95% CI £125.32 to £168.85)). Satisfaction varied across settings and by measure used. Compared with pharmacy and general practice use, ED use was significantly (p<0.001) associated with first episode and short duration of symptom(s), as well as higher levels of perceived seriousness and urgency for seeking care. Convenience of location was the most common reason for choice of consultation setting. Conclusions These results suggest similar health-related outcomes and substantially lower costs with pharmacy consultations for minor ailments. Effective strategies are now needed to shift demand for minor ailment management away from EDs and general practices to the community pharmacy setting.

Effect of L-arginine on renal blood flow in normal subjects and patients with hypoxic chronic obstructive pulmonary disease.

BACKGROUND: L-arginine is the precursor of endothelium derived nitric oxide (NO) and increasing the available substrate may increase the production of NO. This has been shown by local infusion in peripheral vascular beds but there are few studies of the effects during systemic infusion. Renal vasoconstriction is known to be important in the pathogenesis of cor pulmonale in patients with hypoxic chronic obstructive pulmonary disease (COPD). The effects of a systemic infusion of L-arginine on renal and aortic haemodynamics were therefore investigated in normal subjects and in patients with hypoxic COPD. METHODS: Ten normal volunteers were recruited from the research staff of Kings College Hospital Six patients with COPD and hypoxia (arterial oxygen tension (PaO2) < 8.5 kPa) were recruited from the thoracic medicine outpatient clinic at Kings College Hospital and five age and sex matched normal subjects were recruited from a group of normal subjects recruited from the database of the Department of Health Care for the Elderly as volunteers for medical research. There was no history of renal, cardiac, or hepatic disease. Baseline values of time averaged mean of the maximum instantaneous velocity (Tamx) and maximum velocity (Vmax) of blood flow in intrarenal arteries were obtained using colour flow Doppler ultrasound. Using the same technique, Vmax was obtained from the abdominal aorta just distal to the xiphisternum before and after infusion of L-arginine via a large peripheral vein (20 g in 100 ml sterile water over 30 minutes). RESULTS: In normal subjects L-arginine increased blood velocity in the intrarenal vessels from a mean of 0.22 m/s to 0.26 m/s, an increase of 19.8%. There was no effect on arterial blood pressure, heart rate, or aortic blood velocity. L-arginine had no effect on intrarenal or aortic blood velocity in patients with hypoxic COPD. In age matched controls L-arginine increased blood velocity in the intrarenal vessels from a mean of 0.20 m/s to 0.26 m/s, an increase of 36.8%. There was no effect on arterial blood pressure, heart rate, or aortic blood velocity. CONCLUSIONS: L-arginine, at the doses administered, increased renal blood flow, as assessed by renal arterial velocity. This effect was not seen in patients with hypoxic COPD but was present in age matched controls. This suggests that the abnormal renal vascular control seen in hypoxic patients with COPD may reflect a disturbance of the L-arginine/nitric oxide pathway.

Estimating the burden of minor ailment consultations in general practices and emergency departments through retrospective review of routine data in North East Scotland

Background. Minor ailment attendances in general practices and emergency departments (EDs) place significant burden on health care resources. Objectives. To estimate the prevalence and type of minor ailment consultations for adults in general practice and ED that could be managed in a community pharmacy. Methods. Retrospective review of routine data from general practices (n = 2) and one ED in North East Scotland. Two independent consensus panels assessed each consultation summary to determine whether it represented a minor ailment. Outcomes included prevalence of consultations for minor ailments in general practice and ED and frequency of different minor ailment type that could be managed in community pharmacies. Results. In total, of the 494 general practice and 550 ED consultations assessed, 13.2% [95% confidence interval (CI): 18.6–25.9%] and 5.3% (95% CI: 4.0–8.0%), respectively, were categorized as minor ailments suitable for management in community pharmacies. Consensus among panel members was moderate for general practice consultations, but fair to poor for ED consultations. Agreement between uni- and multi-disciplinary panels was good. Applied to national data, these estimates would equate to ~18 million general practice and 6500000 ED consultations that could be redirected to community pharmacy, equating to ~£1.1 billion in resources. Conclusion. Minor ailment consultations still present a major burden on higher cost settings. Effective strategies are needed to raise awareness among patients and health professionals regarding conditions that can be managed effectively in pharmacies and to change patient health-seeking behaviour for such conditions.

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.

The needs of problematic drug misusers not in structured treatment - a qualitative study of perceived treatment barriers and recommendations for services

Aims: Little is currently known regarding treatment barriers amongst problematic drug users not in structured treatment. Much previous work accessed samples entering treatment or predates recent service changes. This study sought to access a ‘hard to reach’ out of structured treatment population, exploring reasons for not seeking treatment. Methods: A total of 43 drug users, self-selected as problematic and not currently in structured treatment, were identified via advertising at low-threshold services in Norfolk, and using snowballing methods. Qualitative focus groups and interviews were conducted. Data were thematically analysed aided by NVivo software. Findings: Key reported barriers to treatment are organized around system, social and personal/interpersonal dimensions. Barriers included perception of a long waiting time, stigma, and a perceived lack of understanding. Social barriers relating to localized group membership were particularly important. Conclusions: Identified barriers confirm previous research, sampling a new out of structured treatment rural population. Perceived barriers persist despite recent changes to treatment services. This could be addressed by improved advertising of service expectations and waiting times. Participants suggested, amongst other things, drop in clinics, increased primary care provision and outreach services to capture problematic drug users not in treatment. Simple practices including appointment reminders and flexibility over urine testing may improve treatment retention.

Patients’ perceptions of physical activity before and after joint replacement: a systematic review with meta-ethnographic analysis

Background It has been perceived that people following total hip arthroplasty (THA) or total knee arthroplasty (TKA) have the capability, with reduced pain, to increase their levels of physical activity. Objectives To determine the attitudes and perceptions of people awaiting or having undergone THA or TKA to physical activity post-arthroplasty and to identify potential facilitators or barriers to engage in active living and physical activity pursuits. Methods Systematic review of published and unpublished databases was undertaken from their inception to November 2014. Studies exploring the attitudes and perceptions of people awaiting or having undergone THA or TKA to physical activity post-arthroplasty were included. Data were analysed through a meta-ethnography approach. Results From 528 citations, 13 papers were eligible, sampling 282 people post-THA or TKA. The literature was judged moderate to high quality. Following THA and TKA, people either wished to return to their pre-pathology level of physical activity or simply be able to engage in less physically demanding activities that are meaningful to them and their lifestyles. Barriers to engaging in higher levels of physical activity were largely related to limited information, which culminated in fear surrounding ‘doing the right thing’ both for individuals recovery and the longevity of the joint replacement. Conclusions While many people post-THA or TKA wish to return to pre-pathological physical activity status, there is limited interest in actually undertaking greater levels of physical activity post-arthroplasty either for pleasure or health gains. Improvement in education and awareness of this may be key drivers to improve habitualisation of physical activity post-arthroplasty. Trial registration number CRD42014014995.

A pilot study for a randomized controlled and patient preference trial of buprenorphine versus methadone maintenance treatment in the management of opiate dependent patients

Aims: To assess the feasibility of conducting an RCT comparing buprenorphine and methadone maintenance therapy in Norfolk. Design: Forty‐two opiate dependent patients were given the option of being randomized or choosing between open label buprenorphine or methadone maintenance treatment for 6 months. Dosage was assessed individually using a flexible regime. Findings: No subjects agreed to randomization. At 6 months more methadone patients were retained (68 vs. 55% for buprenorphine), however, after adjustment for baseline differences between the groups results favoured buprenorphine, but were not statistically significant (odds ratio for retention BMT vs. MMT = 1.57, 95% CI, 0.30–8.29, p = 0.60). The buprenorphine group showed a non‐significant advantage in illicit opiate use (45 vs. 66% p = 0.43) and CHRISTO scores at 6 months (−0.85 units lower score, 95% CI, −4.93 to +3.23, p = 0.67). In this study, predictors of retention in treatment at six months were lower (better) CHRISTO score (p = 0.01), age below 29.5 years (p = 0.02) and of borderline statistical significance was being married or cohabiting (p = 0.06). Conclusions: A local RCT is not feasible. As a pilot this study lacked power but the results suggest that, in practice, in the UK, buprenorphine may be more able to retain patients in treatment, suppress illicit opiate use and improve functioning. Given the significantly higher cost of buprenorphine a larger study is needed to answer these questions.

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.

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.