Paying participants in addiction research: Is cash king?

Research Compensation and Enhanced Contacts in Studies With Persons Who Use Drugs: Lessons From the COVID-19 Pandemic Demand a Reset

Policy changes resulting from the coronavirus 2019 (COVID-19) pandemic have had a substantial and positive impact on the clinical care of persons with opioid use disorder. These innovative paradigm shifts created a ripe environment for re-evaluating traditional approaches to recruiting and retaining persons who use drugs into research studies. For example, changes to methadone prescribing requirements and authorization of buprenorphine prescriptions via telehealth have both increased access to medications. In this commentary, we contribute to ongoing conversations about the ethics of compensation for participants in addiction-related clinical research and share methods of payment that proved successful in research performed during the pandemic. We also discuss approaches to enrollment and follow-up that were implemented during the height of COVID restrictions. These approaches may mutually benefit both participants and researchers in a post-pandemic era.

Transferable learning about patient and public involvement and engagement in gambling support services from health and social care: findings from a narrative review and workshop with people with lived experience

Purpose

The involvement of patients or members of the public within public health, health and social care and addictions services is growing in the UK and internationally but is less common in gambling support services. The purpose of this study was to explore Patient and Public Involvement (PPI) infrastructures and engagement channels used in health and care services and debate their transferability to the gambling support sector (including research, education and treatment).

Design/methodology/approach

A narrative review examined data from six English language electronic databases, NHS evidence and grey literature covering the period 2007–2019. We identified 130 relevant items from UK literature. A workshop was held in London, England, with people with lived experience of gambling harm to seek their views on and applicability of the review findings to gambling services.

Findings

Synthesis of literature and workshop data was undertaken. Main themes addressed “What works” in relation to: building infrastructures and organising involvement of people with lived experience; what people want to be involved in; widening participation and sustaining involvement and respecting people with lived experience.

Practical implications

Examination of the literature about involvement and engagement of patients, service users and the public in public health, health and social care and addiction services provides potentially useful examples of good practice which may be adopted by gambling services.

Originality/value

The involvement of people with lived experience of gambling harms in gambling support services is under-explored, with little published evidence of what constitutes good practice amongst self-organising groups/networks/grassroots organisations or rights-based/empowerment-based approaches.

A peer-delivered intervention to reduce harm and improve the well-being of homeless people with problem substance use: the SHARPS feasibility mixed-methods study

BACKGROUND

For people experiencing homelessness and problem substance use, access to appropriate services can be challenging. There is evidence that development of trusting relationships with non-judgemental staff can facilitate service engagement. Peer-delivered approaches show particular promise, but the evidence base is still developing. This study tested the feasibility and acceptability of a peer-delivered intervention, through 'Peer Navigators', to support people who are homeless with problem substance use to address a range of health and social issues.

OBJECTIVES

The study objectives were to design and implement a peer-delivered, relational intervention to reduce harms and improve health/well-being, quality of life and social functioning for people experiencing homelessness and problem substance use, and to conduct a concurrent process evaluation to inform a future randomised controlled trial.

DESIGN

A mixed-methods feasibility study with concurrent process evaluation was conducted, involving qualitative interviews [staff interviews (one time point), n = 12; Peer Navigator interviews (three or four time points), n = 15; intervention participant interviews: first time point, n = 24, and second time point, n = 10], observations and quantitative outcome measures.

SETTING

The intervention was delivered in three outreach services for people who are homeless in Scotland, and three Salvation Army hostels in England; there were two standard care settings: an outreach service in Scotland and a hostel in England.

PARTICIPANTS

Participants were people experiencing homelessness and problem substance use (n = 68) (intervention).

INTERVENTION

This was a peer-delivered, relational intervention drawing on principles of psychologically informed environments, with Peer Navigators providing practical and emotional support.

MAIN OUTCOME MEASURES

Outcomes relating to participants' substance use, participants' physical and mental health needs, and the quality of Peer Navigator relationships were measured via a 'holistic health check', with six questionnaires completed at two time points: a specially created sociodemographic, health and housing status questionnaire; the Patient Health Questionnaire-9 items plus the Generalised Anxiety Disorder-7; the Maudsley Addiction Profile; the Substance Use Recovery Evaluator; the RAND Corporation Short Form survey-36 items; and the Consultation and Relational Empathy Measure.

RESULTS

The Supporting Harm Reduction through Peer Support (SHARPS) study was found to be acceptable to, and feasible for, intervention participants, staff and Peer Navigators. Among participants, there was reduced drug use and an increase in the number of prescriptions for opioid substitution therapy. There were reductions in risky injecting practice and risky sexual behaviour. Participants reported improvements to service engagement and felt more equipped to access services on their own. The lived experience of the Peer Navigators was highlighted as particularly helpful, enabling the development of trusting, authentic and meaningful relationships. The relationship with the Peer Navigator was measured as excellent at baseline and follow-up. Some challenges were experienced in relation to the 'fit' of the intervention within some settings and will inform future studies.

LIMITATIONS

Some participants did not complete the outcome measures, or did not complete both sets, meaning that we do not have baseline and/or follow-up data for all. The standard care data sample sizes make comparison between settings limited.

CONCLUSIONS

A randomised controlled trial is recommended to assess the effectiveness of the Peer Navigator intervention.

FUTURE WORK

A definitive cluster randomised controlled trial should particularly consider setting selection, outcomes and quantitative data collection instruments.

TRIAL REGISTRATION

This trial is registered as ISRCTN15900054.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 14. See the NIHR Journals Library website for further project information.

Identification of factors influencing tampering of codeine-containing medicines in England: a qualitative study

Background

Tampering of psychoactive medicines presents challenges to regulation and public health. However, little is currently known about what influences the decisions to treat codeine-containing medicines (CCM) with cold water extraction (CWE) from the perspective of individuals employing these techniques. The article identifies factors influencing utilisation of CWE to separate codeine from compounded analgesics, such as paracetamol and ibuprofen, found in CCM.

Methods

Purposive sampling of 27 participants residing in England who took part in a qualitative interview. Of these, 14 individuals (11 males and 3 females) reported tampering of psychoactive medicines, and the relevant transcripts were included in the analyses for the study. Participants were recruited from one addiction treatment service and from an online survey. The mean age of the participants was 31.5 years (range = 18–42 years). Qualitative data analysis followed the processes of iterative categorization (IC). The codes ‘harm reduction’, ‘information sources’ and ‘changes on the drug markets’ were grouped and summarised. The coding of the data was done in a Microsoft® Word document.

Results

Two groups of participants were identified in the data analysis: (i) individuals who used CCM (n = 5), and (ii) individuals who used CCM and heroin (n = 9). Participants in both groups used CWE due to concerns of paracetamol overdose from the use of excessive dosages of CCM. For both of them, information obtained from the internet encouraged the use of CWE. Participants using CCM described how the many steps involved in conducting CWE, including sourcing codeine boxes from pharmacies (over the counter), presented a barrier against using CWE. Participants using CCM and heroin explained how reduced availability in the local heroin supply influenced utilisation of CWE techniques to maintain their use of opioids and avoid withdrawal. Withdrawal symptoms and cravings outweighed the concerns about the quality of the extracted codeine mixtures in this participant group, especially the ability of CWE to remove paracetamol and tablet fillers.

Conclusions

Utilisation of CWE of codeine was influenced by several factors including drug market supply, the availability of detailed information on the internet about CWE and restrictions on codeine sourcing in pharmacies. Risks identified with CWE include consumption of unknown doses of paracetamol if the CWE techniques are not used correctly. Attempts at extracting codeine from CCM should be considered in risk assessments of opioid medicines.

Participatory action research (PAR) research: critical methodological considerations

Purpose

The purpose of this paper is to explore a range of key deliberations with regards to adopting participatory action research (PAR) and privileged access interviewer (PAI) approaches and methodologies within research on substance use.

Design/methodology/approach

This paper is a reflective piece; it adopts a mixture of applied practice and theory considerations. These conceptualisations capture what are still relatively early understandings and uses of such methodologies, acquired across several decades of research and service provision experiences. The paper is structured around some of the sequences of the research process and as such provides a broad framework for such approaches.

Findings

PAR and PAI approaches utilise several key theoretical considerations. There are many critical issues associated with adopting these approaches, including those of ethics, funding, involvement, language, resources and support. Three key principle reasons (moral, political and research based) help explain why the authors should see more adoption of such approaches in substance use-related research.

Research limitations/implications

This paper represents authors’ views which are by their nature very subjective.

Practical implications

Implementation of the key considerations highlighted within this paper can lead to an active adoption of PAR and PAI methodologies within alcohol and drug research. Increasing the use of such methodologies will allow commissioners, researchers and service providers to develop a more nuanced understanding of the experiences of and responses to alcohol and drug use.

Originality/value

This paper captures critical conversations at a time of increased calls for service user involvement across all aspects of alcohol and other drug provision, including evaluation and research

Preventing blood-borne virus infection in people who inject drugs in the UK: systematic review, stakeholder interviews, psychosocial intervention development and feasibility randomised controlled trial

BACKGROUND

Opioid substitution therapy and needle exchanges have reduced blood-borne viruses (BBVs) among people who inject drugs (PWID). Some PWID continue to share injecting equipment.

OBJECTIVES

To develop an evidence-based psychosocial intervention to reduce BBV risk behaviours and increase transmission knowledge among PWID, and conduct a feasibility trial among PWID comparing the intervention with a control.

DESIGN

A pragmatic, two-armed randomised controlled, open feasibility trial. Service users were Steering Group members and co-developed the intervention. Peer educators co-delivered the intervention in London.

SETTING

NHS or third-sector drug treatment or needle exchanges in Glasgow, London, Wrexham and York, recruiting January and February 2016.

PARTICIPANTS

Current PWID, aged ≥ 18 years.

INTERVENTIONS

A remote, web-based computer randomisation system allocated participants to a three-session, manualised, psychosocial, gender-specific group intervention delivered by trained facilitators and BBV transmission information booklet plus treatment as usual (TAU) (intervention), or information booklet plus TAU (control).

MAIN OUTCOME MEASURES

Recruitment, retention and follow-up rates measured feasibility. Feedback questionnaires, focus groups with participants who attended at least one intervention session and facilitators assessed the intervention's acceptability.

RESULTS

A systematic review of what works to reduce BBV risk behaviours among PWID; in-depth interviews with PWID; and stakeholder and expert consultation informed the intervention. Sessions covered improving injecting technique and good vein care; planning for risky situations; and understanding BBV transmission. Fifty-six per cent (99/176) of eligible PWID were randomised: 52 to the intervention group and 47 to the control group. Only 24% (8/34) of male and 11% (2/18) of female participants attended all three intervention sessions. Overall, 50% (17/34) of men and 33% (6/18) of women randomised to the intervention group and 47% (14/30) of men and 53% (9/17) of women randomised to the control group were followed up 1 month post intervention. Variations were reported by location. The intervention was acceptable to both participants and facilitators. At 1 month post intervention, no increase in injecting in 'risky' sites (e.g. groin, neck) was reported by participants who attended at least one session. PWID who attended at least one session showed a trend towards greater reduction in injecting risk behaviours, a greater increase in withdrawal planning and were more confident about finding a vein. A mean cost of £58.17 per participant was calculated for those attending one session, £148.54 for those attending two sessions and £270.67 for those attending all three sessions, compared with £0.86 in the control group. Treatment costs across the centres vary as a result of the different levels of attendance, as total session costs are divided by attendees to obtain a cost per attendee. The economic analysis suggests that a cost-effectiveness study would be feasible given the response rates and completeness of data. However, we have identified aspects where the service use questionnaire could be abbreviated given the low numbers reported in several care domains. No adverse events were reported.

CONCLUSIONS

As only 19% of participants attended all three intervention sessions and 47% were followed up 1 month post intervention, a future definitive randomised controlled trial of the intervention is not feasible. Exposure to information on improving injecting techniques did not encourage riskier injecting practices or injecting frequency, and benefits were reported among attendees. The intervention has the potential to positively influence BBV prevention. Harm reduction services should ensure that the intervention content is routinely delivered to PWID to improve vein care and prevent BBVs.

FUTURE WORK

The intervention did not meet the complex needs of some PWID, more tailoring may be needed to reach PWID who are more frequent injectors, who are homeless and female.

LIMITATIONS

Intervention delivery proved more feasible in London than other locations. Non-attendance at the York trial site substantially influenced the results.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN66453696 and PROSPERO 014:CRD42014012969.

FUNDING

This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 72. See the NIHR Journals Library website for further project information.