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Campopiano von Klimo M, Nolan L, Corbin M, Farinelli L, Pytell JD, Simon C, Weiss ST, Compton WM. Physician Reluctance to Intervene in Addiction: A Systematic Review. JAMA Netw Open 2024; 7:e2420837. [PMID: 39018077 PMCID: PMC11255913 DOI: 10.1001/jamanetworkopen.2024.20837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 05/07/2024] [Indexed: 07/18/2024] Open
Abstract
Importance The overdose epidemic continues in the US, with 107 941 overdose deaths in 2022 and countless lives affected by the addiction crisis. Although widespread efforts to train and support physicians to implement medications and other evidence-based substance use disorder interventions have been ongoing, adoption of these evidence-based practices (EBPs) by physicians remains low. Objective To describe physician-reported reasons for reluctance to address substance use and addiction in their clinical practices using screening, treatment, harm reduction, or recovery support interventions. Data Sources A literature search of PubMed, Embase, Scopus, medRxiv, and SSRN Medical Research Network was conducted and returned articles published from January 1, 1960, through October 5, 2021. Study Selection Publications that included physicians, discussed substance use interventions, and presented data on reasons for reluctance to intervene in addiction were included. Data Extraction and Synthesis Two reviewers (L.N., M.C., L.F., J.P., C.S., and S.W.) independently reviewed each publication; a third reviewer resolved discordant votes (M.C. and W.C.). This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines and the theoretical domains framework was used to systematically extract reluctance reasons. Main Outcomes and Measures The primary outcome was reasons for physician reluctance to address substance use disorder. The association of reasons for reluctance with practice setting and drug type was also measured. Reasons and other variables were determined according to predefined criteria. Results A total of 183 of 9308 returned studies reporting data collected from 66 732 physicians were included. Most studies reported survey data. Alcohol, nicotine, and opioids were the most often studied substances; screening and treatment were the most often studied interventions. The most common reluctance reasons were lack of institutional support (173 of 213 articles [81.2%]), knowledge (174 of 242 articles [71.9%]), skill (170 of 230 articles [73.9%]), and cognitive capacity (136 of 185 articles [73.5%]). Reimbursement concerns were also noted. Bivariate analysis revealed associations between these reasons and physician specialty, intervention type, and drug. Conclusions and Relevance In this systematic review of reasons for physician reluctance to intervene in addiction, the most common reasons were lack of institutional support, knowledge, skill, and cognitive capacity. Targeting these reasons with education and training, policy development, and program implementation may improve adoption by physicians of EBPs for substance use and addiction care. Future studies of physician-reported reasons for reluctance to adopt EBPs may be improved through use of a theoretical framework and improved adherence to and reporting of survey development best practices; development of a validated survey instrument may further improve study results.
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Affiliation(s)
| | - Laura Nolan
- JBS International, Inc, North Bethesda, Maryland
| | - Michelle Corbin
- National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland
| | - Lisa Farinelli
- National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland
| | - Jarratt D. Pytell
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Caty Simon
- National Survivors Union, Greensboro, North Carolina
- NC Survivors Union, Greensboro, North Carolina
- Whose Corner Is It Anyway, Holyoke, Massachusetts
| | - Stephanie T. Weiss
- National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland
| | - Wilson M. Compton
- National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland
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Paroz S, Monnat M, Panese F, Saraga M, Daeppen JB. Caring for patients with substance use disorders: a qualitative investigation of difficulties encountered by hospital-based clinicians. J Addict Dis 2023:1-12. [PMID: 37369578 DOI: 10.1080/10550887.2023.2227307] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
Background: Caring for patients with substance use disorders (SUD) is held in low regard and many clinicians resist treating them. To address this situation, numerous research projects assessed training program gaps and professional attitudes. In contrast, this study explored the actual clinical difficulties that a variety of hospital-based professionals encounter when treating patients with SUD. Methods: Qualitative multiple method design including: (1) individual semi-structured interviews with SUD experts and educators; (2) video-elicited, cross self-confrontation interviews with clinicians working in a specialist addiction unit; (3) paired semi-structured interviews with clinicians working in non-specialist units. Participants were recruited within one university hospital. Data collected at stages (1) and (3) relied on an interview guide and were analyzed using conventional content analyses. Data collected at stage (2) consisted of discussions of video recorded clinical interviews and were analyzed based on a participatory approach. Results: Twenty-three clinicians from seven hospital units participated. Forty-four difficulties were reported that we classified into six categories: knowledge-based; moral; technical; relational; identity-related; institutional. We identified seven cross-category themes as key features of SUD clinical complexity: exacerbation of patient characteristics; multiplication of medical issues; hybridity and specificity of medical discipline; experiences of stalemate, adversity, and role reversal. Conclusions: Our study, providing a comprehensive analysis of the difficulties of caring for patients with SUD, reveals a highly challenging clinical practice for a diversity of healthcare providers. They represent a complementary approach to addressing resistance as an important feature of a complex clinical system, and valuable material to discussing professional preparedness.
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Affiliation(s)
- Sophie Paroz
- Service of Addictions Medicine, Lausanne University Hospital and University of Lausanne, Canton of Vaud, Switzerland
| | - Martine Monnat
- Service of Community Psychiatry, Lausanne University Hospital and University of Lausanne, Canton of Vaud, Switzerland
- Public Health Service of Canton de Vaud, Department of Health and Social Action, Canton of Vaud, Lausanne, Switzerland
| | - Francesco Panese
- Institute of Humanities in Medicine, Lausanne University Hospital and University of Lausanne, Canton of Vaud, Switzerland
- Institute of Social Sciences, University of Lausanne, Canton of Vaud, Switzerland
| | - Michael Saraga
- Service of General Psychiatry, Lausanne University Hospital and University of Lausanne, Canton of Vaud, Switzerland
| | - Jean-Bernard Daeppen
- Service of Addictions Medicine, Lausanne University Hospital and University of Lausanne, Canton of Vaud, Switzerland
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Nguyen DB, Nguyen TT, Lin C, Dinh TTT, Le GM, Li L. Challenges of methadone maintenance treatment decentralisation from Vietnamese primary care providers' perspectives. Drug Alcohol Rev 2023; 42:803-814. [PMID: 36851865 PMCID: PMC10191884 DOI: 10.1111/dar.13613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 12/07/2022] [Accepted: 12/29/2022] [Indexed: 03/01/2023]
Abstract
INTRODUCTION Decentralising methadone maintenance treatment to primary care improves patients' access to care and their drug and HIV treatment outcomes. However, primary care providers (PCP), especially those working in limited-resource settings, are facing great challenges to provide quality methadone treatment. This study explores the challenges perceived by PCP providing methadone treatment at commune health centres in a mountainous region in Vietnam. METHOD We conducted in-depth interviews with 26 PCP who worked as program managers, physicians, counsellors, pharmacists and medication dispensing staff at the methadone programs of eight commune health centres in Dien Bien, Vietnam, in November and December 2019. We used the health-care system framework in developing the interview guides and in summarising data themes. RESULTS Participants identified major challenges in providing methadone treatment in commune health centres at the individual, clinic and environmental levels. Individual-level challenges included a lack of confidence and motivation in providing methadone treatment. Clinic-level factors included inadequate human resources, lack of institutional support, insufficient technical support, lack of referral resources and additional support for patients. Environment-level factors comprised a lack of reasonable policies on financial support for providers at commune health centres for providing methadone treatment, lack of regulations and mechanisms to ensure providers' safety in case of potential violence by patients and to share responsibility for overdose during treatment. DISCUSSION AND CONCLUSION PCP in Vietnam faced multi-level challenges in providing quality methadone treatment. Supportive policies and additional resources are needed to ensure the effectiveness of the decentralisation program.
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Affiliation(s)
- Diep Bich Nguyen
- Center for Training and Research on Substance Abuse and HIV/AIDS, Hanoi Medical University, Hanoi, Vietnam
- Department of Epidemiology, Institute of Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam
| | - Trang Thu Nguyen
- Center for Training and Research on Substance Abuse and HIV/AIDS, Hanoi Medical University, Hanoi, Vietnam
| | - Chunqing Lin
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience & Human Behavior, University of California Los Angeles, Los Angeles, USA
| | - Thuy Thi Thanh Dinh
- Center for Training and Research on Substance Abuse and HIV/AIDS, Hanoi Medical University, Hanoi, Vietnam
| | - Giang Minh Le
- Center for Training and Research on Substance Abuse and HIV/AIDS, Hanoi Medical University, Hanoi, Vietnam
- Department of Epidemiology, Institute of Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam
| | - Li Li
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience & Human Behavior, University of California Los Angeles, Los Angeles, USA
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Jones NR, Nielsen S, Farrell M, Ali R, Gill A, Larney S, Degenhardt L. Retention of opioid agonist treatment prescribers across New South Wales, Australia, 2001-2018: Implications for treatment systems and potential impact on client outcomes. Drug Alcohol Depend 2021; 219:108464. [PMID: 33360851 PMCID: PMC7855715 DOI: 10.1016/j.drugalcdep.2020.108464] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 11/19/2020] [Accepted: 11/21/2020] [Indexed: 01/27/2023]
Abstract
BACKGROUND There has been much research on the efficacy and effectiveness of opioid agonist treatment (OAT), but less on its implementation and sustainability. A challenge internationally has been recruiting and retaining prescribers. This paper aims to characterise the prescribers in terms of OAT prescribing behaviours. METHODS Retrospective cohort study in New South Wales, Australia. Participants were 2199 OAT prescribers between 1 st August 2001-19th September 2018.We examined trends in initiation and cessation of OAT prescribers. Adjusted hazard ratios were calculated to estimate prescriber retention, adjusting for year of initiation, practice type, client load and treatment prescribed. RESULTS The rate of prescribers ceasing OAT prescribing has been increasing over time: a prescriber who initiated between 2016-2017 had over four times the risk of cessation compared with one who initiated before 2001, AHR: 4.77; [3.67-6.21]. The highest prescriber cessation rate was in prescribers who had prescribed for shorter time periods. The annual percentage of prescribers who ceased prescribing among those who prescribed for ≤5 years increased from 3% in 2001 to 20 % in 2017. By 2017 more prescribers were discontinuing prescribing than new prescribers were starting. Approximately 87 % (n = 25,167) of OAT clients were under the care of 20 % of OAT prescribers (n = 202); half had been prescribing OAT for 17+ years. CONCLUSIONS OAT prescribing is increasingly concentrated in a small group of mature prescribers, and new prescribers are not being retained. There is a need to identify and respond to the reasons that contribute to newer prescribers to cease prescribing and put in place strategies to increase retention and broaden the base of doctors involved in such prescribing.
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Affiliation(s)
- Nicola R Jones
- National Drug and Alcohol Research Centre, University of NSW, Sydney NSW 2052, Australia.
| | - Suzanne Nielsen
- Monash Addiction Research Centre and Eastern Health Clinical School, Monash University, Melbourne, Australia.
| | - Michael Farrell
- National Drug and Alcohol Research Centre, University of NSW, Sydney NSW 2052, Australia.
| | - Robert Ali
- National Drug and Alcohol Research Centre, University of NSW, Sydney NSW 2052, Australia; School of Medicine, The University of Adelaide, Australia.
| | - Anthony Gill
- NSW Ministry of Health, Level 6, 100 Christie St, St Leonards NSW 2065, Australia.
| | - Sarah Larney
- National Drug and Alcohol Research Centre, University of NSW, Sydney NSW 2052, Australia; Department of Family Medicine and Emergency Medicine, Université de Montréal and Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Canada.
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, University of NSW, Sydney NSW 2052, Australia.
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Cioe K, Biondi BE, Easly R, Simard A, Zheng X, Springer SA. A systematic review of patients' and providers' perspectives of medications for treatment of opioid use disorder. J Subst Abuse Treat 2020; 119:108146. [PMID: 33138929 PMCID: PMC7609980 DOI: 10.1016/j.jsat.2020.108146] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 07/02/2020] [Accepted: 09/10/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The opioid epidemic is a public health crisis. Medications for opioid use disorder (MOUD) include: 1) buprenorphine, 2) methadone, and 3) extended-release naltrexone (XR-NTX). Research should investigate patients' and providers' perspectives of MOUD since they can influence prescription, retention, and recovery. METHODS This systematic review focused on patients' and providers' perceptions of MOUD. The review eligibility criteria included inclusion of the outcome of interest, in English, and involving persons ≥18 years. A PubMed database search yielded 1692 results; we included 152 articles in the final review. RESULTS There were 63 articles about buprenorphine, 115 articles about methadone, and 16 about naltrexone. Misinformation and stigma associated with MOUD were common patient themes. Providers reported lack of training and resources as barriers to MOUD. CONCLUSION This review suggests that patients have significant misinformation regarding MOUD. Due to the severity of the opioid epidemic, research must consider the effects of patients' and providers' perspectives on treatment for OUD, including the effects on the type of MOUD prescribed, patient retention and adherence, and ultimately the number of patients treated for OUD, which will aid in curbing the opioid epidemic.
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Affiliation(s)
- Katharine Cioe
- Frank H. Netter MD School of Medicine, 370 Bassett Road, North Haven, CT 06473, United States of America
| | - Breanne E Biondi
- Yale School of Medicine, Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, United States of America
| | - Rebecca Easly
- Frank H. Netter MD School of Medicine, 370 Bassett Road, North Haven, CT 06473, United States of America
| | - Amanda Simard
- Frank H. Netter MD School of Medicine, 370 Bassett Road, North Haven, CT 06473, United States of America
| | - Xiao Zheng
- Yale University, New Haven, CT 06520, United States of America
| | - Sandra A Springer
- Yale School of Medicine, Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, United States of America; Center for Interdisciplinary Research on AIDS, Yale University School of Public Health, New Haven, CT, United States of America.
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Fraeyman J, Symons L, Van Royen P, Van Hal G, Peremans L. How to overcome hurdles in opiate substitution treatment? A qualitative study with general practitioners in Belgium. Eur J Gen Pract 2016; 22:134-40. [PMID: 26799738 DOI: 10.3109/13814788.2015.1120286] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Opiate substitution treatment (OST) is the administration of opioids (methadone or buprenorphine) under medical supervision for opiate addiction. Several studies indicate a large unmet need for OST in general practice in Antwerp, Belgium. Some hurdles remain before GPs engage in OST prescribing. OBJECTIVES Formulate recommendations to increase engagement of GPs in OST, applicable to Belgium and beyond. METHODS In 2009, an exploratory qualitative research was performed using focus group discussions and interviews with GPs. During data collection and analysis, purposive sampling, open and axial coding was applied. The script was composed around the advantages, disadvantages and conditions of engaging in OST in general practice. RESULTS We conducted six focus groups and two interviews, with GPs experienced in prescribing OST (n = 13), inexperienced GPs (n = 13), and physicians from addiction centres (n = 5). Overall, GPs did not seem very willing to prescribe OST for opiate users. A lack of knowledge about OST and misbehaving patients creates anxiety and makes the GPs reluctant to learn more about OST. The GPs refer to a lack of collaboration with the addiction centres and a need of support (from either addiction centres or experienced GP-colleagues for advice). Important conditions for OST are acceptance of only stable opiate users and more support in emergencies. CONCLUSION Increasing GPs' knowledge about OST and improving collaboration with addiction centres are essential to increase the uptake of OST in general practice. Special attention could be paid to the role of more experienced colleagues who can act as advising physicians for inexperienced GPs.
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Affiliation(s)
- Jessica Fraeyman
- a Department or Epidemiology and Social Medicine , Research Unit Medical Sociology and Health Policy, University of Antwerp , Antwerp , Belgium
| | - Linda Symons
- b Department of Primary and Interdisciplinary Care , Faculty of Medicine and Health Sciences, University of Antwerp , Antwerp , Belgium
| | - Paul Van Royen
- b Department of Primary and Interdisciplinary Care , Faculty of Medicine and Health Sciences, University of Antwerp , Antwerp , Belgium
| | - Guido Van Hal
- a Department or Epidemiology and Social Medicine , Research Unit Medical Sociology and Health Policy, University of Antwerp , Antwerp , Belgium
| | - Lieve Peremans
- b Department of Primary and Interdisciplinary Care , Faculty of Medicine and Health Sciences, University of Antwerp , Antwerp , Belgium ;,c Department of Public Health , Faculty of Medicine, Vrije Universiteit Brussel , Brussels , Belgium ;,d Department of Nursing and Midwifery , Faculty of Medicine and Health Sciences, University of Antwerp , Antwerp , Belgium
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Teoli R, Haller DM, Ingrand P, Binder P. Comparaison des représentations et comportements des médecins généralistes du Canton de Genève et du Poitou-Charentes. SANTE PUBLIQUE 2016. [DOI: 10.3917/spub.162.0187] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Lang K, Neil J, Wright J, Dell CA, Berenbaum S, El-Aneed A. Qualitative investigation of barriers to accessing care by people who inject drugs in Saskatoon, Canada: perspectives of service providers. SUBSTANCE ABUSE TREATMENT PREVENTION AND POLICY 2013; 8:35. [PMID: 24079946 PMCID: PMC3850796 DOI: 10.1186/1747-597x-8-35] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Accepted: 09/17/2013] [Indexed: 11/20/2022]
Abstract
Background People who inject drugs (PWID) often encounter barriers when attempting to access health care and social services. In our previous study conducted to identify barriers to accessing care from the perspective of PWIDs in Saskatoon, Canada: poverty, lack of personal support, discrimination, and poor knowledge and coordination of service providers among other key barriers were identified. The purpose of the present investigation was to explore what service providers perceive to be the greatest barriers for PWIDs to receive optimal care. This study is an exploratory investigation with a purpose to enrich the literature and to guide community action. Methods Data were collected through focus groups with service providers in Saskatoon. Four focus groups were held with a total of 27 service providers. Data were transcribed and qualitative analysis was performed. As a result, concepts were identified and combined into major themes. Results Four barriers to care were identified by service providers: inefficient use of resources, stigma and discrimination, inadequate education and the unique and demanding nature of PWIDs. Participants also identified many successful services. Conclusion The results from this investigation suggest poor utilization of resources, lack of continuing education of health care providers on addictions and coping skills with such demanding population, and social stigma and disparity. We recommend improvements in resource utilization through, for example, case management. In addition, sensitivity training and more comprehensive service centers designed to meet PWID’s complex needs may improve care. However, community-wide commitment to addressing injection drug issues will also be required for lasting solutions.
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Affiliation(s)
- Katherine Lang
- College of Pharmacy and Nutrition, University of Saskatchewan, Thorvaldson Building, 110 Science Place, Saskatoon, SK S7N 5C9, Canada.
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Schulte B, Schmidt CS, Kuhnigk O, Schäfer I, Fischer B, Wedemeyer H, Reimer J. Structural barriers in the context of opiate substitution treatment in Germany--a survey among physicians in primary care. SUBSTANCE ABUSE TREATMENT PREVENTION AND POLICY 2013; 8:26. [PMID: 23875627 PMCID: PMC3723909 DOI: 10.1186/1747-597x-8-26] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Accepted: 07/15/2013] [Indexed: 11/10/2022]
Abstract
Background Opiate substitution treatment (OST) is the most widely used treatment for opioid dependence in Germany with substantial long-term benefits for the patient and for society. Due to lessened restrictive admission criteria, the number of registered OST patients in Germany has increased continuously in the recent years, whereas the number of physicians providing OST has remained constant. Previous data already indicated a deteriorating situation in the availability or quality of OST delivered and that structural barriers impede physicians in actively providing OST. The present survey among a sample of primary care physicians in Germany aimed to identify and assess potential structural barriers for the provision of health care in the context of OST. Methods An anonymous written questionnaire was sent out to a sample of 2,332 physicians across Germany providing OST. Physicians contacted were identified through databases of the Federal State Chambers of Physicians and/or of the Federal Associations of Statutory Health Insurance Physicians. Data obtained were analysed descriptively. Results The response rate was 25,5% and the majority of 596 physicians sampled viewed substantial problems in terms of the regulatory framework of OST care in the German context. Furthermore, financial remuneration, insufficient qualification, as well as inadequate interdisciplinary cooperation in the treatment of comorbidities of opiate substituted patients were regarded as problematic. The number of physicians providing OST in Germany is expected to substantially decrease in the near future. Conclusion Despite less restrictive admission criteria for OST in Germany, the legal regulation framework for OST is still a limiting factor through raising concerns on the provider and consumer side to be unable to adhere to the strict rules. To avoid future shortages in the provision of OST care on the system level in Germany, revisions to the legal framework seem to be necessary. In regards to adequate care for drug use-related infectious diseases and psychiatric comorbidities commonly found in opiate substituted patients, efforts are required to improve professional qualifications of physicians providing OST as well as respective interdisciplinary collaboration.
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Affiliation(s)
- Bernd Schulte
- Centre for Interdisciplinary Addiction Research, Hamburg University, University Medical Centre Hamburg-Eppendorf, Martinistrasse 52, Hamburg, D-20246, Germany.
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LARANCE BRIONY, DEGENHARDT LOUISA, O'BRIEN SUSANNAH, LINTZERIS NICK, WINSTOCK ADAM, MATTICK RICHARDP, BELL JAMES, ALI ROBERT. Prescribers' perceptions of the diversion and injection of medication by opioid substitution treatment patients. Drug Alcohol Rev 2011; 30:613-20. [DOI: 10.1111/j.1465-3362.2010.00274.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Koekkoek B, Hutschemaekers G, van Meijel B, Schene A. How do patients come to be seen as 'difficult'?: a mixed-methods study in community mental health care. Soc Sci Med 2010; 72:504-12. [PMID: 21208704 DOI: 10.1016/j.socscimed.2010.11.036] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2010] [Revised: 11/16/2010] [Accepted: 11/26/2010] [Indexed: 11/29/2022]
Abstract
Across all health care settings, certain patients are perceived as 'difficult' by clinicians. This paper's aim is to understand how certain patients come to be perceived and labelled as 'difficult' patients in community mental health care, through mixed-methods research in The Netherlands between June 2006 and October 2009. A literature review, a Delphi-study among experts, a survey study among professionals, a Grounded Theory interview study among 'difficult' patients, and three case studies of 'difficult' patients were undertaken. Analysis of the results of these qualitative and quantitative studies took place within the concept of the sick role, and resulted in the construction of a tentative explanatory model. The 'difficult' patient-label is associated with professional pessimism, passive treatment and possible discharge or referral out of care. The label is given by professionals when certain patient characteristics are present and a specific causal attribution (psychological, social or moral versus neurobiological) about the patient's behaviours is made. The status of 'difficult' patient is easily reinforced by subsequent patient and professional behaviour, turning initial unusual help-seeking behaviour into 'difficult' or ineffective chronic illness behaviour, and ineffective professional behaviour. These findings illustrate that the course of mental illness, or at least the course of patients' contact with mental health professionals and services, is determined by patient and professional and reinforced by the social and mental health care system. This model adds to the broader sick role concept a micro-perspective in which attribution and learning principles are incorporated. On a practical level, it implies that professionals need to look into their own role in the perpetuation of difficult behaviours as described here.
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Affiliation(s)
- B Koekkoek
- Gelderse Roos Mental Health Care, Institute for Professionalization, Heelsumseweg 1, 6874 BE Wolfheze, The Netherlands.
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Koekkoek B, van Meijel B, Schene A, Hutschemaekers G. Development of an intervention program to increase effective behaviours by patients and clinicians in psychiatric services: Intervention Mapping study. BMC Health Serv Res 2010; 10:293. [PMID: 20973985 PMCID: PMC2987792 DOI: 10.1186/1472-6963-10-293] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2010] [Accepted: 10/25/2010] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Health clinicians perceive certain patients as 'difficult' across all settings, including mental health care. In this area, patients with non-psychotic disorders that become long-term care users may be perceived as obstructing their own recovery or seeking secondary gain. This negative perception of patients results in ineffective responses and low-quality care by health clinicians. Using the concept of illness behaviour, this paper describes the development, implementation, and planned evaluation of a structured intervention aimed at prevention and management of ineffective behaviours by long-term non-psychotic patients and their treating clinicians. METHODS The principles of Intervention Mapping were applied to guide the development, implementation, and planned evaluation of the intervention. Qualitative (individual and group interviews), quantitative (survey), and mixed methods (Delphi-procedure) research was used to gain a broad perspective of the problem. Empirical findings, theoretical models, and existing evidence were combined to construct a program tailored to the needs of the target groups. RESULTS A structured program to increase effective illness behaviour in long-term non-psychotic patients and effective professional behaviour in their treating clinicians was developed, consisting of three subsequent stages and four substantial components, that is described in detail. Implementation took place and evaluation of the intervention is being carried out. CONCLUSIONS Intervention Mapping proved to be a suitable method to develop a structured intervention for a multi-faceted problem in mental health care.
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Affiliation(s)
- Bauke Koekkoek
- ProPersona Mental Health Care, Pro Persona Centre for Education and Science, Wolfheze
- Altrecht Mental Health Care, Zeist, The Netherlands
| | - Berno van Meijel
- InHolland University for Applied Sciences, Research Group Mental Health Nursing, Amsterdam, The Netherlands
| | - Aart Schene
- Department of Psychiatry, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Giel Hutschemaekers
- ProPersona Mental Health Care, Pro Persona Centre for Education and Science, Wolfheze
- Radboud University, Academic Centre of Social Sciences, Nijmegen, The Netherlands
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Sheridan J, Goodyear-Smith F, Butler R, Wheeler A, Gohns A. Barriers to, and incentives for, the transfer of opioid-dependent people on methadone maintenance treatment from secondary care to primary health care. Drug Alcohol Rev 2008; 27:178-84. [PMID: 18264879 DOI: 10.1080/09595230701829538] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
AIM To explore barriers to, and incentives for, clients on methadone-maintenance treatment (MMT) in Auckland, New Zealand to transfer from secondary care to general practitioner (GP) care. DESIGN Surveys (with free text response sections) of MMT secondary care staff, stabilised clinic clients, authorised GPs and GP patients. RESULTS High response rates from secondary care staff (77%) and GPs (74%). Barriers to stable clients' transfer included financial cost and attitudes of secondary care staff and clients. Incentives for patient transfer included confidentiality, a holistic approach to their care, continuity of care, increased patient control, convenience and avoidance of contact with other opioid-dependent people. Distrust in the quality of care provided by authorised GPs was a major barrier for some secondary care staff and their clients, despite prerequisite training for authorisation. In contrast, patients rated primary better than secondary care with none stating a likelihood to return to the secondary service within 6 months. CONCLUSIONS Progression from secondary to primary care should be incorporated in MMT planning from the outset, with secondary services staff reassured about the quality of primary care. An integrated transition period and exploration of funding options to assist transfer from largely publicly funded secondary to largely privately funded primary care are also recommended.
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Affiliation(s)
- Janie Sheridan
- School of Pharmacy, The University of Auckland, New Zealand.
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Palfreyman SJ, Tod AM, King B, Tomlinson D, Brazier JE, Michaels JA. Impact of intravenous drug use on quality of life for patients with venous ulcers. J Adv Nurs 2007; 58:458-67. [PMID: 17484747 DOI: 10.1111/j.1365-2648.2007.04251.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM This paper is a report of a study to examine, from the perspective of patients, the impact of venous leg ulcers on health-related quality of life in current and former intravenous drug users and the general population. BACKGROUND Venous ulceration can be caused by intravenous drug use. There has been little examination on how this affects the quality of life of this group of patients and how they compare with other patients who have venous ulcers. METHOD A qualitative approach was adopted, using framework analysis. Semi-structured interviews with 19 participants who had a venous leg ulcer were conducted between August 2005 and February 2006. Interview audiotapes were analysed to identify recurring themes relating to the impact of venous leg ulcers on overall quality of life. FINDINGS A complex interaction between symptoms, social restriction and attribution of illness influenced the impact of venous leg ulcers. Smell and pain were the symptoms that had the most profound impacts. In addition to the physical and psychological consequences, participants' activities and social interactions were restricted. Intravenous drug users experienced more social isolation and difficulties in accessing treatment for their venous ulcers. CONCLUSION While leg ulcer services remain focused on the needs of older people, services for young intravenous drug users are unlikely to improve. A more coherent and earlier intervention, when the ulcers are not as difficult to treat, would decrease time and costs to the health service. The challenge is to find new ways of providing effective and accessible care to this growing population.
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Affiliation(s)
- Simon J Palfreyman
- Academic Vascular Unit, Coleridge House, Northern General Hospital, Sheffield, UK.
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Soyka M, Apelt SM, Wittchen HU. Die unzureichende Beteiligung von Psychiatern an der Substitutionsbehandlung. DER NERVENARZT 2006; 77:1368-72. [PMID: 17024480 DOI: 10.1007/s00115-006-2149-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Results of a nationally representative study in 2,694 patients reveal that most physicians (n=223) involved in substitution treatment of opioid-dependent patients are general practitioners, while only 16% have a psychiatric/psychotherapeutic background and only 21% of the addictive patients are treated by psychiatrists. This contrasts with the remarkably complex pattern of co- and multimorbidity with other mental disorders in such patients. Most psychiatrists engaged in substitution treatment work in specialized outpatient wards (51.3%), and few were operative in their own or private practice (7.2%). Implications of these critical findings are discussed.
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Affiliation(s)
- M Soyka
- Psychiatrische Universität München, Nussbaumstrasse 7, 80336 München.
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