A qualitative study of experiences with physical activity among people receiving opioid agonist therapy

BACKGROUND

Physical or mental health comorbidities are common among people with substance use disorders undergoing opioid agonist therapy. As both a preventive and treatment strategy, exercise offers various health benefits for several conditions. Exercise interventions to people with substance use disorders receiving opioid agonist therapy are limited. This study aims to explore experiences with physical activity, perceived barriers, and facilitators among people receiving opioid agonist therapy.

METHOD

Fourteen qualitative interviews were conducted with individuals receiving opioid agonist therapy in outpatient clinics in Western Norway.

RESULTS

Most were males in the age range 30 to 60 years. Participants had diverse and long-term substance use histories, and most received buprenorphine-based opioid agonist therapy. The identified themes were (1) Physical limitations: Participants experienced health-related problems like breathing difficulties, pain, and reduced physical function. (2) Social dynamics: Social support was essential for participating in physical activities and many argued for group exercises, but some were concerned about the possibility of meeting persons influenced by substances in a group setting, fearing temptations to use substances. (3) Shift in focus: As participants felt the weight of the health burden, their preference for activities shifted from sports aiming for "adrenaline" to a health promoting focus. (4) COVID-19's impact on exercise: because of the pandemic, group activities were suspended, and participants described it as challenging to resume. (5) Implementation preferences in clinics: Not interfering with opioid medication routines was reported to be essential.

CONCLUSION

This study offers valuable insights for the development of customized exercise interventions aimed at enhancing the health and well-being of patients undergoing opioid agonist therapy. These findings underscore the significance of addressing social dynamics, overcoming physical limitations, and implementing a practical and effective exercise regimen.

Healthy eating among people on opioid agonist therapy: a qualitative study of patients' experiences and perspectives

People with substance use disorders often have unhealthy diets, high in sweets and processed foods but low in nutritious items like fruits and vegetables, increasing noncommunicable disease risks. This study investigates healthy eating perceptions and barriers among individuals with opioid use disorder undergoing opioid agonist therapy. Interviews with 14 participants at opioid agonist therapy clinics in Western Norway, using a semi-structured guide and systematic text condensation for analysis, reveal that most participants view their diet as inadequate and express a desire to improve for better health. Barriers to healthy eating included oral health problems, smoking habits, and limited social relations, while economic factors were less of a concern for the participants. Participants did find healthy eating easier when they were in social settings. This study underscores the importance of understanding and addressing these barriers and facilitators to foster healthier eating patterns in this population, potentially enhancing overall health and well-being.

Integrated exercise program in opioid agonist therapy clinics and effect on psychological distress: study protocol for a randomized controlled trial (BAReAktiv)

BACKGROUND

Substance use disorder is associated with unhealthy lifestyle choices, resulting in adverse social and health consequences. People with opioid use disorder receiving opioid agonist therapy, in particular, have high morbidity and reduced quality of life. Physical activity is recommended as an adjunctive treatment for people with substance use disorder, but there is minimal evidence from randomized controlled trials on the effects of this among people with substance use disorder receiving opioid agonist therapy.

METHODS

BAReAktiv is a multicentre randomized controlled trial. The study aims to recruit 324 patients receiving opioid agonist therapy (parallel groups randomized 1:1 to integrated exercise intervention or control, superiority trial). A 16-week group-based integrated exercise intervention with workouts twice a week. The exercise program consists of endurance and resistance training. The target group will be patients 18 years and older receiving opioid agonist therapy in outpatient clinics in several centers in Western Norway. The primary outcome of the study is the effect on psychological distress measured by Hopkins' symptom checklist with ten items. Secondary outcome measures include physical functioning assessed with a 4-min step test, activity level, fatigue symptoms, quality of life, and changes in inflammation markers. This study will provide improved knowledge on the effects of an integrated exercise program in opioid agonist therapy.

DISCUSSION

Systematically integrating exercise programs for people receiving opioid agonist therapy could lead to a shift towards a stronger focus on health behaviors in outpatient care. Integrating exercise could benefit patient recovery and reduce disease burden. Further scale-up will be considered if the provided exercise program is safe and effective.

TRIAL REGISTRATION

ClinicalTrials.gov. NCT05242848. Registered on February 16, 2022.

Psykiske lidelser og plager ved vedvarende opioidbruk for langvarige ikke-kreftrelaterte smerter – en registerstudie

Background

Knowledge of mental disorders among patients with persistent opioid use for the treatment of chronic non-cancer pain is essential, as mental disorders and symptoms can exacerbate or perpetuate pain and impact on the ability of patients to manage their illness. We have studied the prevalence of mental disorders and symptoms, including substance use disorders, in patients with persistent opioid use in 2019.

Material and method

Persons ≥ 18 years with persistent opioid use and persons ≥ 18 years with at least one registered mental disorder in the specialist healthcare service in 2019 were included. Data were retrieved from national health registries in Norway. Patients who received opioids reimbursed for the treatment of chronic pain were compared with those who received opioids without reimbursement.

Results

The prevalence of mental disorders and symptoms was 34 % among 14 403 persons who received reimbursed opioids, and 42 % among 38 001 persons who received opioids without reimbursement. This is equivalent to a two to threefold increase in prevalence compared to the general population. There was a particularly higher prevalence of anxiety disorders and substance use disorders. The prevalence of mental disorders and symptoms was highest in the age group 18-44 years (49-55 %).

Interpretation

Among patients with persistent opioid use, a large proportion had mental disorders and symptoms, which are known risk factors for developing problematic opioid use and opioid use disorder.

Update of statistical analysis plan for: Integration of smoking cessation into standard treatment for patients receiving opioid agonist therapy who are smoking tobacco: protocol for a randomised controlled trial (ATLAS4LAR)

This protocol paper presents an updated statistical analysis plan of the protocol of a randomised controlled trial. The randomised controlled trial investigates the effect of integrating smoking cessation interventions at outpatient opioid agonist therapy (OAT) clinics for persons with opioid dependency receiving OAT medication. The intervention group receives weekly follow-up including a short behavioural intervention and provision of nicotine replacement products. The control group receives standard treatment. The duration of the intervention is 16 weeks and the follow-up was completed by the end of October 2023. The primary outcome is defined as the proportion of participants reducing the number of cigarettes smoked by at least a 50% at week 16 of the intervention period. The primary outcome will be analysed according to intention-to-treat principles. Missing outcome data will be set equal to the baseline values. Development and reporting of the statistical analysis plan follow the Guidelines for the Content of Statistical Analysis Plans in Clinical Trials.Trial registration ClinicalTrials.gov NCT05290025. Registered on 22 March 2022.

A qualitative study on people with opioid use disorders' perspectives on smoking and smoking cessation interventions

Introduction

Smoking-related diseases are major contributors to disability and shorter life expectancy among opioid-dependent patients. Smoking prevalence is considerably higher for opioid-dependent persons than among the general population, and only a minority quit smoking in treatment settings. Studies show that pharmacological smoking cessation interventions have modest success rates. This study aimed to investigate patients' receiving opioid agonist therapy perspectives on factors affecting behavior and decisions related to smoking cessation, and their experiences with smoking cessation.

Methods

This is a qualitative study using semi-structured individual interviews. The participants were asked, among others, to elaborate on the participants' thoughts about smoking, previous attempts to quit tobacco use, and what could prompt a smoking cessation attempt. We analyzed the transcripts with systematic text condensation. The Standards for Reporting Qualitative Research and the Consolidated Criteria for Reporting Qualitative Research guidelines were followed. Opioid-dependent patients receiving opioid agonist therapy in outpatient clinics were invited to participate using a purposive sampling method. In total, fourteen individuals participated in this study.

Results

We identified six themes which were: (1) reflections on how smoking affected decisions, (2) smoking and its impact on physical and mental health, (3) the economy as a motivator to stop smoking, (4) emotions, desires, and habits related to smoking, (5) knowledge of smoking, smoking cessation, and quit attempts, and (6) social factors influencing the participants' choices and activities. The participants were well informed about the consequences of smoking and had some knowledge and experience in quitting. The participants' pulmonary health was an important motivational factor for change. Withdrawal symptoms, anxiety, and fear of using other substances discouraged several from attempting to quit smoking. In contrast, social support from partners and access to meaningful activities were considered important factors for success. Few reported being offered help from health professionals to make a smoking cessation attempt.

Discussion

Experiencing social support, being encouraged to quit smoking, and patients' concerns for their physical health were important reasons for wanting to quit smoking. Smoking cessation interventions based on patient preferences and on the behavior change wheel may enable a higher success rate among patients receiving opioid agonist therapy.

Governing by commissioning services - Implementing alcohol screening and brief interventions in hospital settings in Norway

Norwegian health services have undergone marked logistical changes in organization and funding over recent decades. One significant change was the new public management-inspired commissioner's document, first issued in 2013 by the Norwegian Ministry of Health and Care Services, to establish medical and surgical departments' identification of patients with underlying substance abuse problems (Ministry of Health and Care Services, 2013). Herein, we investigate how multiple stakeholders and actors, who bear responsibility in regional and local health trusts, have responded to the commissioned services to establish routines for identifying alcohol and substance abuse problems among patients admitted to medical and surgical wards. First, an extensive literature search was conducted. Second, we conducted qualitative interviews with informants who have responsibility for applying the commissioner's document in regional health authorities and local hospitals. The study results demonstrate that responsible actors at all levels take establishing alcohol routines seriously, and that hospitals' self-assessment of their achievements on internal goals indicate that they have made satisfactory progress. Nevertheless, improvement is needed to meet the goal of discussing alcohol use with all patients admitted to medical and surgical wards within local health trusts. Recommendations for the next steps, based on these findings, include further research and training priorities.

Mental disorder prevalence in chronic pain patients using opioid versus non-opioid analgesics: A registry-linkage study

BACKGROUND

Chronic pain and mental disorders are leading causes of disability worldwide. Individuals with chronic pain are more likely to experience mental disorders compared to individuals without chronic pain, but large-scale estimates are lacking. We aimed to calculate overall prevalence of mental health diagnoses from primary and secondary care among individuals treated for chronic pain in 2019 and to compare prevalence among chronic pain patients receiving opioid versus non-opioid analgesics, according to age and gender.

METHODS

It is a population-based cohort study. Linked data from nationwide health registers on dispensed drugs and diagnoses from primary (ICPC-2) and secondary (ICD-10) health care. Chronic pain patients were identified as all patients over 18 years of age filling at least one prescription of an analgesic reimbursed for non-malignant chronic pain in both 2018 and 2019 (N = 139,434, 69.3% women).

RESULTS

Prevalence of any mental health diagnosis was 35.6% (95% confidence interval: 35.4%-35.9%) when sleep diagnoses were included and 29.0% (28.8%-29.3%) when excluded. The most prevalent diagnostic categories were sleep disorders (14% [13.8%-14.2%]), depressive and related disorders (10.1% [9.9%-10.2%]) and phobia and other anxiety disorders (5.7% [5.5%-5.8%]). Prevalence of most diagnostic categories was higher in the group using opioids compared to non-opioids. The group with the highest overall prevalence was young women (18-44 years) using opioids (50.1% [47.2%-53.0%]).

CONCLUSIONS

Mental health diagnoses are common in chronic pain patients receiving analgesics, particularly among young individuals and opioid users. The combination of opioid use and high psychiatric comorbidity suggests that prescribers should attend to mental health in addition to somatic pain.

SIGNIFICANCE

This large-scale study with nation-wide registry data supports previous findings of high psychiatric burden in chronic pain patients. Opioid users had significantly higher prevalence of mental health diagnoses, regardless of age and gender compared to users of non-opioid analgesics. Opioid users with chronic pain therefore stand out as a particularly vulnerable group and should be followed up closely by their physician to ensure they receive sufficient care for both their mental and somatic symptoms.

Traumatic experiences and PTSD symptoms in substance use disorder: A comparison of recovered versus current users

Introduction: The aim of this study was to investigate the prevalence of traumatic experiences and symptoms of posttraumatic stress disorder (PTSD) in treatment-seeking individuals with ongoing substance use disorder (SUD) compared to individuals who have recovered from SUD. Methods: Patients with SUD recruited from the STAYER study (N = 114) underwent an examination of alcohol and drug use, childhood trauma, negative life events and PTSD symptomatology. In this study, only participants with 12-month concurrent polysubstance use was included. Using historical data from the STAYER study, alcohol and drug trajectories were dichotomised as (1) current SUD (current SUD) or (2) recovered from substance use disorder (recovered SUD). Crosstabs and chi-tests were used to measure differences between groups. Results: Childhood maltreatment, traumatic experiences later in life and symptoms of concurrent PTSD were highly prevalent in the study population. We found no significant difference between the current and recovered SUD groups. Recovered women reported a lower prevalence of physical neglect (p = 0.031), but a higher prevalence of multiple lifetime traumas (p = 0.019) compared to women with current SUD. Both women with current SUD and recovered women reported a significantly higher prevalence of sexual aggression than men (p < 0.001 and p < 0.001, respectively). In addition, men who have recovered from SUD reported a lower prevalence of PTSD symptoms over cut-off 38 (p = 0.017), of re-experiencing (p = 0.036) and of avoidance (p = 0.015), compared to recovered women. Conclusion: Reported trauma did not differ between persons with current SUD and those who had recovered from SUD. Gender differences discovered in this study indicate the importance of developing individualised and gender-specific treatment models for comorbid PTSD/SUD.

Problematic alcohol use in post-bariatric patients - a qualitative study

BACKGROUND

Research shows an increased risk of alcohol use disorders in post-bariatric patients. This study aims to gain insight into what post-bariatric patients receiving treatment for substance use think are the possible causes for developing problematic alcohol consumption after surgery.

MATERIAL AND METHOD

Ten in-depth interviews were held with post-bariatric patients receiving treatment for substance use in 2020 (six men and four women). The data material was transcribed and analysed using the stepwise deductive-inductive (SDI) method.

RESULTS

The participants first started to experience problematic alcohol consumption after bariatric surgery. They described new, intense feelings of intoxication and how their body responded differently to alcohol. Alcohol now functioned as an appetite stimulant, pain reliever and food replacement. Most participants had positive experiences during the initial post-operative period, but they described an ambivalence towards their bodily changes and an increased mental vulnerability in the years following the surgery.

INTERPRETATION

The new effect and function of alcohol after the procedure may have made the participants more vulnerable to problematic alcohol consumption.

Relationship Between Educational Level and Attitudes Towards Alcohol Conversations in Healthcare: A Cross-Sectional Survey Conducted in Four European Countries

Objectives: To examine the association between educational level and attitudes towards alcohol conversations in healthcare using population-based surveys of adults in England, the Netherlands, Norway, and Sweden; and to compare attitudes towards alcohol conversations in healthcare between these four countries. Methods: Cross-sectional surveys were conducted amongst adults in the general population in England (n = 3,499), the Netherlands (n = 2,173), Norway (n = 1,208), and Sweden (n = 3,000). Logistic regression analysis was used to examine associations between attitudes towards alcohol conversations in healthcare and educational level, key demographic variables, alcohol consumption, and country of residence. Results: In all four countries, low educational level (p < 0.001) and male gender (p < 0.001) were associated with holding negative attitudes towards discussing alcohol in healthcare. Risky drinkers had more negative attitudes than low risky drinkers towards discussing alcohol in healthcare (p < 0.001) in all countries except England (p = 0.48), and also reported low levels of perceived honesty and confidence in healthcare (p < 0.001). Conclusion: These findings highlight the importance of considering patients' socio-economic status when developing and implementing alcohol prevention interventions in healthcare.

Cohort Description: Preventing an Opioid Epidemic in Norway - Focusing on Treatment of Chronic Pain (POINT) - A National Registry-Based Study

AIM

The POINT project aims to provide evidence to optimise chronic pain management, prevent adverse consequences of opioids, and improve chronic pain patients' pain relief, functional capacity, and quality of life. We describe the outline of the project and its work packages. More specifically, we describe a cohort of persons with chronic pain and a cohort of long-term opioid users identified from a national registry linkage.

DATA SOURCES

The project utilises data from nationwide healthcare and population registers in Norway. Using the Norwegian Prescription Database, we identified a cohort of persons who have been dispensed drugs reimbursed for chronic pain and a cohort of persons who used opioids long term from 2010 to 2019. Data from the Norwegian Registry for Primary Health Care and the Norwegian Patient Registry (2008-2019), Cancer Registry (1990-2018) Cause of Death Registry (2010-2019) and demographic and socioeconomic registers from Statistics Norway (2010-2019) were linked to the cohorts.

STUDY POPULATION

There were 568,869 participants with chronic pain. Sixty-three percent of the cohort was women, and the mean age was 57.1 years. There were 336,712 long-term opioid users (58.6% women; 60.9 years). In chronic pain and long-term opioid user cohorts, the most frequent musculoskeletal diagnosis was back pain diagnosed in primary care (27.6% and 30.7%). Psychiatric diagnoses were also common.

MAIN VARIABLES

Upcoming studies will utilise psychiatric and somatic diagnoses from the patient registers, drug use from the prescription register, causes of death, demographics, and socioeconomic status (eg, education, income, workability, immigrant status) as exposures or outcomes.

CONCLUSION AND FUTURE PLANS

The two cohorts have numerous pain-related diagnoses, especially in the musculoskeletal system, and noticeably frequent somatic and psychiatric morbidity. The POINT project also includes later work packages that explore prescriber and patient perspectives around safe and effective treatment of chronic pain.

Effect of fruit smoothie supplementation on psychological distress among people with substance use disorders receiving opioid agonist therapy: protocol for a randomised controlled trial (FruktBAR)

BACKGROUND

People with substance use disorders generally have unhealthy diets, including limited intake of fruit and vegetables. Evidence shows substantial health benefits from increasing fruit and vegetable consumption on various indicators and possibly also psychological distress. A pilot study has indicated that supplementation with fruit smoothie could be promising also among people receiving opioid agonist therapy for opioid dependence. FruktBAR will compare the efficacy of added fruit smoothie supplementation to people receiving opioid agonist therapy compared to standard treatment without added supplementation.

METHODS

FruktBAR is a multicentre, randomised controlled trial. The trial will aim to recruit 302 patients receiving opioid agonist therapy. The intervention involves daily supplementation with 250 ml fruit smoothie including a variety of fruits such as apple, pineapple, mango, bananas, orange, blueberries, passion fruit, coconut, lime, and blackcurrant. The main endpoints are 16 weeks after intervention initiation. Participants will be included and followed up during and after the intervention. The target group will be patients with opioid dependence receiving opioid agonist therapy from involved outpatient clinics in Bergen and Stavanger, two of the largest cities in Norway. The main outcome is psychological distress assessed with Hopkins Symptom Checklist (SCL-10) at the end of the intervention period 16 weeks after initiation, and will be compared between the intervention and control arms. Secondary outcome measures are changes in fatigue, physical functioning assessed with a 4-minute step-test, health-related quality of life, biochemical indicators of inflammation, and biochemical indicators of fruit intake.

DISCUSSION

This study will inform on the relative advantages or disadvantages of fruit supplementation in addition to the current medically and psychologically oriented treatment of people receiving opioid agonist therapy. If the supplementation is efficacious, it can be considered for further scale-up.

TRIAL REGISTRATION

Registered 2022-02-08 in ClinicalTrials.gov , identifier NCT05229770.

Integration of smoking cessation into standard treatment for patients receiving opioid agonist therapy who are smoking tobacco: protocol for a randomised controlled trial (ATLAS4LAR)

BACKGROUND

About 85% of patients receiving opioid agonist therapy (OAT) for opioid dependence are smoking tobacco. Although smoke-related pulmonary diseases are significant contributors to morbidity and mortality, few smoking cessation interventions are evaluated within this group, and few OAT patients are offered smoking cessation as an integrated part of their addiction treatment. This study protocol describes an integrated smoking cessation intervention aimed at patients receiving OAT and smoking tobacco.

METHODS

This is a multicentre, randomised controlled clinical trial that will recruit 266 daily tobacco smoking patients receiving OAT in OAT outpatient clinics in Bergen and Stavanger, Norway. The patients randomised for the intervention arm will be offered smoking cessation therapy consisting of weekly brief behavioural interventions and prescription-free nicotine replacement products. In the control arm, patients will receive standard care without any added interventions related to smoking cessation. The smoking cessation intervention includes psychoeducational techniques with components from motivational interviewing, and nicotine replacement products such as nicotine lozenges, patches, and chewing gum. The duration of the intervention is 16 weeks, with the option of extending it by a further 8 weeks. The main outcomes are measured at 16 weeks after initiation of the intervention, and sustained effects are evaluated 1 year after intervention initiation. The primary outcome is smoking cessation verified by carbon monoxide (CO) levels or at least a 50% reduction in the number of cigarettes smoked. Secondary outcomes are changes in psychological well-being, biochemical inflammation markers, changes in physical health, quality of life, and fatigue.

DISCUSSION

Integration of other treatments to standard OAT care improves adherence and completion rates providing another rationale for integrated smoking cessation treatment. Thus, if integrated smoking cessation treatment is superior to standard care, this trial provides important information on further scale-up.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05290025. Registered on 22 March 2022.

Public perceptions of how alcohol consumption is dealt with in Swedish and Norwegian health care

Aims:

The aims of this study were to evaluate and compare popular beliefs and attitudes regarding alcohol conversations in healthcare in Sweden and Norway; and to explore which factors were associated with different levels of support for alcohol-prevention work in the two countries.

Methods:

Population-based cross-sectional surveys were conducted in Sweden (n = 3000) and Norway (n = 1208). Logistic regression was used to identify the characteristics of participants who were supportive of routine alcohol screening and brief intervention delivery.

Results:

A higher proportion of Swedish respondents agreed to a large extent that healthcare professionals should routinely ask about alcohol consumption. In addition, a higher proportion of Swedish respondents compared to respondents from Norway agreed that healthcare providers should only ask about patient’s alcohol consumption if this was related to specific symptoms. There were similar correlates of being supportive of routine alcohol screening and brief intervention delivery in both countries. Support was lower in both countries amongst moderate and risky drinkers, and among single adults or those on parental leave, but higher amongst older individuals. Having had an alcohol conversation in healthcare increased the level of support for alcohol prevention in routine healthcare among risky drinkers.

Conclusions:

There is a high level of support for preventative alcohol conversations in routine healthcare in Norway and Sweden, although there was a lower proportion of respondents who were positive to alcohol prevention in routine healthcare in Norway compared to Sweden. Experiencing alcohol conversation may positively affect risky drinkers’ attitudes towards and support for alcohol prevention. Thus, more frequent alcohol conversations in routine healthcare may also result in increased level of support for alcohol prevention among risky drinkers.

General practitioners' reflections on using PSA for diagnosis of prostate cancer. A qualitative study

OBJECTIVE

To investigate how GPs use the PSA test as a diagnostic tool in daily practice.

DESIGN

Qualitative study using focus group interviews, the transcripts being analyzed by systemic text condensation.

SUBJECTS

A total of 17 Norwegian GPs in three CME groups.

MAIN OUTCOME MEASURES

Exploring GPs' attitudes to national guidelines and the practical use of the PSA test.

RESULTS

Detecting prostate cancer in general practice is a common and important, but difficult diagnostic issue. Our participants experienced uncertainty regarding the test when to use it, how to interpret the results and when to refer to specialist health services.

CONCLUSION

The study revealed a general ambivalence to the use of PSA. Many patients present urological problems, and many are afraid of having cancer. PSA is commonly used, but sometimes generates problems rather than solving them.

IMPLICATIONS

The use of the PSA test should be based on a thorough clinical assessment and in close collaboration with the patient.Key pointsMany patients in general practice present urological problems, and many are afraid of having cancer.GPs have a general ambivalence to the use of PSA when to use it, how to interpret the results and when to refer to specialist health services.The use of PSA sometimes generates problems rather than solving them.

Individuals Dying of Overdoses Related to Pharmaceutical Opioids Differ from Individuals Dying of Overdoses Related to Other Substances: A Population-Based Register Study

BACKGROUND

Pharmaceutical opioid (PO) overdose deaths have increased in many Western countries. There are indications that those dying from a PO overdose differ from those dying from other types of overdoses. These differences might pose a challenge as the majority of current preventive measures are tailored toward those with the characteristics of "conventional" overdose deaths.

OBJECTIVE

We investigated differences in the characteristics of persons who died from PO overdoses compared to all other overdoses.

MATERIAL AND METHODS

Using the Norwegian Cause of Death Registry, we retrieved information on overdoses classified according to ICD-10 and identified PO overdoses (T40.2; T40.4) and all other overdoses (T40.X; T43.6) in 2010-2019. By linking data from nationwide registers, we analyzed data on opioid dispensations and the history of mental and behavioral disorders. 1,224 persons were registered with PO overdoses and 1,432 persons with other overdoses.

RESULTS

Persons in the PO overdose group were older and were more frequently women (35.0% vs. 20.5%) than persons with other overdoses. They had a higher prevalence of chronic pain (35.8% vs. 13.2%), history of cancer (8.1% vs. 1.8%), filled prescriptions of analgetic opioids more frequently the month before death (38.8% vs. 12.0%), and used threefold higher doses of prescribed opioids compared to individuals in all other overdose group (66 vs. 26 oral morphine equivalents/day). In the PO overdose group, oxycodone and fentanyl were more frequently dispensed, while codeine was more frequently dispensed in the other overdose groups. A lower proportion of those in the PO overdose group had recorded diagnoses of substance use disorders, schizophrenia, and hyperkinetic disorder compared to the other overdose groups.

CONCLUSION

Persons dying from overdoses on POs often differ from the population targeted by existing prevention strategies, as they are more frequently older women with chronic pain and using high doses of prescription opioids.

Pragmatic approaches for addressing alcohol in general practice: Development of a tailored implementation intervention

Introduction

Alcohol consumption is a leading global risk factor for ill-health and premature death. Alcohol screening and brief interventions (SBI) delivered in primary care is effective at reducing alcohol consumption, but routine implementation remains problematic. Screening all patients for excessive drinking (universal screening) is resource-intensive and may be at odds with general practitioners' (GPs') perceived professional role. This study aimed to develop a tailored, theory-based training intervention to strengthen GPs' ability to address alcohol and to manage alcohol-related health problems through a pragmatic approach based on clinical relevance.

Methods

A qualitative study design involving focus group interviews and a structured questionnaire for free text replies with GPs in Norway. Behavioral analysis assessed factors influencing delivery of SBI according to the 'capability, opportunity, motivation and behavior' (COM-B) model to inform intervention development using the Behavior Change Wheel. Qualitative data were analyzed using framework analysis and an iterative approach was adopted to develop the training.

Results

A purposive sample of GPs attended the focus groups (n = 25) and completed the questionnaire (n = 55). Four areas required additional support including: understanding the link between alcohol use and health problems; opening up the conversation on alcohol use; addressing alcohol and dealing with obstacles; and following-up and maintaining change. Findings informed the development of a four-session interactive training intervention and a digital intervention for providing support for patients between consultations to address the identified needs.

Conclusion

This work highlights the value of pragmatic, relevance-based clinical strategies, as opposed to universal screening approaches to addressing alcohol in primary care. A pragmatic approach is more in line with GPs existing sclinical skill set and holds the potential to improve widespread uptake and implementation of SBI in routine primary care.

Effects of Nutritional Interventions in Individuals with Chronic Obstructive Lung Disease: A Systematic Review of Randomized Controlled Trials

Background

The role of nutrition and dietary patterns has been widely investigated in cancer, cardiovascular disease, and diabetes, but there are limited data on nutritional impact on COPD. This systematic review (PROSPERO-reg. no: CRD42020172712) aimed to investigate the effect of nutritional interventions on pulmonary and physical function, inflammation, and health-related quality of life among individuals with COPD.

Methods

Systematic searches were conducted in Medline, Embase, and Cochrane, resulting in 3861 references. Studies focusing exclusively on inpatient-stays, underweight or obese patients were excluded. Double screening, extraction and bias assessment were conducted. Bias was assessed according to the Cochrane risk of bias tool for randomized controlled trials. Thirteen randomized controlled trials with 916 participants were included.

Results

These trials investigated effects of protein supplementation, beetroot juice, increased fruit and vegetable intake, black seed oil, Tualang honey, Chlorella vulgaris-extract, whey-peptide containing nutritional drink, and increased macronutrient intake. The durations of the interventions were from weeks to a few months, and only one with duration >1 year (investigating increased fruit/vegetable intake). The intervention increasing fruit/vegetables found improvement in pulmonary function tests. Some interventions observed effects on systemic inflammation, health-related quality of life and physical function, although with some mixed results. Five were classified as poor, five as fair, and three as good in terms of risk of bias and quality.

Conclusion

Increasing intake of fruits and vegetables over prolonged periods might have positive effects on lung function in individuals with COPD. Some nutritional interventions also observed effects on systemic inflammation, health-related quality of life, and physical function, although with some mixed results. Many of the trials were underpowered, had high dropout rates, or had a high risk of bias. Further research should investigate effect of prolonged dietary interventions.

Addressing Patients' Alcohol Consumption-A Population-Based Survey of Patient Experiences

Objectives: To identify the proportion of the population that had experienced that alcohol was addressed in health care the previous year, to explore experiences and perceived effects of addressing alcohol, and to investigate the proportion of risky drinkers in the population. Methods: Cross-sectional national web-based survey with 1,208 participants. Socio-demographic data, alcohol consumption (AUDIT-C), and experiences with alcohol conversations were investigated. Results: Approximately four in five respondents had visited health care the past 12 months, and one in six reported having experienced addressing alcohol. Women and older respondents were less likely to report having experienced alcohol conversations compared to other groups. Risky drinkers were not more likely to have experienced an alcohol conversation, but reported longer duration of alcohol conversations and more frequently perceived addressing alcohol as awkward or judgmental. Almost a third of respondents were classified as risky drinkers. Conclusion: The proportion experiencing addressing alcohol in routine health care is low, also among risky drinkers, and risky drinkers more frequently experienced the conversations as judgmental. More sensitive and relevant ways of addressing alcohol in health care is needed.

Bruk av andre vanedannende legemidler blant opioidbrukere med langvarige smerter

Bakgrunn: Opioider for behandling av langvarige smerter kan forskrives på blå resept, men bør ikke brukessamtidig med andre vanedannende legemidler.Hensikt: Å undersøke bruk av opioider på blå resept i perioden 2009-2019, samt å studere bruk av andre vanedannendelegemidler (benzodiazepiner og z-hypnotika) blant dem som fikk opioider på blå resept i 2019.Metode: Data ble hentet fra Reseptregisteret. En prevalent opioidbruker i 2019 ble definert som en person medminst én utlevering av et smertestillende opioid på blå resept for langvarige smerter også i 2018. Bruk av andrevanedannende legemidler ble definert som minst én utlevering av et annet vanedannende legemiddel i løpet avsamme år.Resultater: Totalt 18 443 personer (67% kvinner) fikk utlevert opioider på blå resept i 2019, en økning fra5 568 i 2009 via 10 693 i 2016 og 16 133 i 2017. Av de 18 443 var 14 202 (77%) prevalente opioidbrukere.Blant de prevalente brukerne fikk 88% utlevert 100 mg orale morfinekvivalenter (OMEQ) eller mindre perdag. Totalt fikk 54% av de prevalente opioidbrukerne utlevert minst ett annet vanedannende legemiddel i 2019.Z-hypnotika var oftest forekommende blant de som brukte 100 mg OMEQ eller mindre per dag, mens benzodiazepineralene eller i kombinasjon med z-hypnotika dominerte blant opioidbrukerne som fikk utlevert merenn 100 mg OMEQ per dag. Mengden utlevert av andre vanedannende legemidler økte med mengden opioiderbrukt per dag. En større andel kvinner enn menn fikk utlevert andre vanedannende legemidler i 2019.Konklusjon: Studien indikerer at bruk av andre vanedannende legemidler forekommer hos en stor andel avdem som får forskrevet opioider på blå resept. Dette er tegn på et uheldig forskrivningsmønster som børstuderes nærmere.

Effects of replacing PSA with Stockholm3 for diagnosis of clinically significant prostate cancer in a healthcare system - the Stavanger experience

OBJECTIVE

To describe early experience of replacing PSA with Stockholm3 for detection of prostate cancer in primary care.

DESIGN AND METHODS

Longitudinal observations, comparing outcome measures before and after the implementation of Stockholm3.

SETTING

Stavanger region in Norway with about 370,000 inhabitants, 304 general practitioners (GPs) in 97 primary care clinics, and one hospital.

INTERVENTION

GPs were instructed to use Stockholm3 instead of PSA as standard procedure for diagnosis of prostate cancer.

MAIN OUTCOME MEASURES

Proportion of GP clinics that had ordered a Stockholm3 test. Number of men referred to needle biopsy. Distribution of clinically significant prostate cancer (csPC) (Gleason Score ≥7) and clinically non-significant prostate cancer (cnsPC) (Gleason Score 6), in needle biopsies. Estimation of direct healthcare costs.

RESULTS

Stockholm3 was rapidly implemented as 91% (88/97) of the clinics started to use the test within 14 weeks. After including 4784 tested men, the percentage who would have been referred for prostate needle biopsy was 29.0% (1387/4784) if based on PSA level ≥3ng/ml, and 20.8% (995/4784) if based on Stockholm3 Risk Score (p < 0.000001). The proportion of positive biopsies with csPC increased from 42% (98/233) before to 65% (185/285) after the implementation. Correspondingly, the proportion of cnsPC decreased from 58% (135/233) before to 35% (100/285) after the implementation (p < 0.0017). Direct healthcare costs were estimated to be reduced by 23-28% per tested man.

CONCLUSION

Replacing PSA with Stockholm3 for early detection of prostate cancer in primary care is feasible. Implementation of Stockholm3 resulted in reduced number of referrals for needle-biopsy and a higher proportion of clinically significant prostate cancer findings in performed biopsies. Direct healthcare costs decreased. KEY POINTS A change from PSA to Stockholm3 for the diagnosis of prostate cancer in primary care in the Stavanger region in Norway is described and assessed. •Implementation of a new blood-based test for prostate cancer detection in primary care was feasible. A majority of GP clinics started to use the test within three months. •Implementation of the Stockholm3 test was followed by: -a 28% reduction in number of men referred for urological prostate cancer work-up -an increase in the proportion of clinically significant cancer in performed prostate biopsies from 42 to 65% -an estimated reduction in direct health care costs between 23 and 28%.

Can routine information from electronic patient records predict a future diagnosis of alcohol use disorder?

OBJECTIVE

To explore whether information regarding potentially alcohol-related health incidents recorded in electronic patient records might aid in earlier identification of alcohol use disorders.

DESIGN

We extracted potentially alcohol-related information in electronic patient records and tested if alcohol-related diagnoses, prescriptions of codeine, tramadol, ethylmorphine, and benzodiazepines; elevated levels of gamma-glutamyl-transferase (GGT), and mean cell volume (MCV); and new sick leave certificates predicted specific alcohol use disorder.

SETTING

Nine general practitioner surgeries with varying size and stability.

SUBJECTS

Totally 20,764 patients with active electronic patient record until data gathering and with a history of at least four years without a specific alcohol use disorder after turning 18 years of age.

METHODS

The Cox proportional hazard analysis with time-dependent covariates of potential accumulated risks over the previous four years.

MAIN OUTCOME MEASURES

Time from inclusion until the first specific alcohol use disorder, defined by either an alcohol specific diagnostic code or a text fragment documenting an alcohol problem.

RESULTS

In the unadjusted and adjusted Cox-regression with time-dependent covariates all variables were highly significant with adjusted hazard ratios ranging from 1.25 to 3.50. Addictive drugs, sick leaves, GGT, MCV and International Classification for Primary Care version 2 (ICPC-2), and International Classification of Diseases version 10 (ICD-10) diagnoses were analyzed. Elevated GGT and MCV, ICD-10-diagnoses, and gender demonstrated the highest hazard ratios.

CONCLUSIONS

Many frequent health problems are potential predictors of an increased risk or vulnerability for alcohol use disorders. However, due to the modest hazard ratios, we were unable to establish a clinically useful tool. KEY POINTS Alcohol is potentially relevant for many health problems, but current strategies for identification and intervention in primary health care have not been successful. Many frequent clinical problems recorded in electronic patient records may indicate an increased risk for alcohol related health problems. The hazard ratios were modest and the resulting predictive model was unsatisfactory for diagnostic purposes. If we accepted a sensitivity as low as 0.50, the specificity slightly exceeded 0.75. With a low prevalent condition, it is obvious that the false positive problem will be vast. In addition to responding to elevated blood levels of liver enzymes, general practitioners should be aware of alcohol as a potentially relevant factor for patients with repeated events of many mental and psychosocial diagnoses and new sick leaves and repeated prescriptions of addictive drugs.

When general practitioners talk about alcohol: exploring facilitating and hampering factors for pragmatic case finding

BACKGROUND

The aim was to explore individual and system factors facilitating or hampering pragmatic case finding, an identification strategy based on clinical signs and targeted screening.

STUDY DESIGN

Two focus groups with general practitioners were interviewed twice, in the context of a four-session seminar on alcohol and complex drug problems, and an additional focus group interview with general practitioners not attending the seminar. Interviews focused mainly on conditions for talking about alcohol, views on collaboration with colleagues, how they deal with complex issues, and strategies for learning and quality improvement.

RESULTS

The participants presented many deliberate strategies for quality improvement and learning together, but there was a tendency to avoid discussing complex case stories or potentially controversial topics with colleagues. Possible barriers to change were presented. The majority of their stories on talking about alcohol coincided well with the concept of pragmatic case finding. The duality between shame and normality, time constraints and a need for structure were the most important individual barriers to an open and respectful conversation about alcohol with patients.

CONCLUSIONS

Our study supports pragmatic case finding as a relevant and viable strategy for talking about alcohol in general practice, and as an alternative to screening and brief intervention. Quality improvement in practice is strengthened when it is adapted to the clinical setting, and builds on and stimulates the GPS' and staff's own strategies for learning and quality work.

Alcohol-related hospital admissions: missed opportunities for follow up? A focus group study about general practitioners' experiences

AIMS

To explore general practitioners' (GPs') follow-up experiences with patients discharged from hospital after admittance for alcohol-related somatic conditions.

DESIGN AND PARTICIPANTS

Two focus groups with GPs (four women and 10 men), calling for stories about whether the intervention given in the hospital had been recognised by the GP and how this knowledge affected their follow up of the patient's alcohol problem. Systematic text condensation was applied for analysis.

FINDINGS

A majority of the GPs had experienced patients with already recognised alcohol problems being rediscovered by the hospital staff. Still, they presented examples of how seeing the patient in a different context might present new opportunities. Few participants had received adequate information from the hospital about their patient's alcohol status, and they emphasised that a report about what had happened and what was planned was needed for follow up. Care pathways for patients with alcohol problems were seen as fragmented. Yet they described how alcohol-related hospital admissions might function as an eye-opener for the patient and a window of opportunity for lifestyle change.

CONCLUSIONS

Hospital admittances provide important opportunities for change, but hospital care is seen as fragmented and poorly communicated to the GPs. For shared responsibility and follow up, all participating agents, including the patient, must be sufficiently informed about what has happened and what will follow. For the patient, hospital admittance is usually brief, while the relationship with their GP is long term, even lifelong. GPs are therefore key partners for programme development.

General practitioners' strategies to identify alcohol problems: a focus group study

OBJECTIVE

To explore general practitioners' (GPs') experiences with addressing alcohol in the consultation without prior invitation from the patient.

DESIGN AND SETTING

Two focus group interviews were conducted with a purposive sample of 13 Norwegian GPs in the Stavanger region. Participants were invited to talk about situations where the doctor initiated discussion of alcohol. Systematic text condensation was applied for analysis.

RESULTS

Participants presented a broad range of examples of what made GPs initiate discussion of alcohol, how they brought up the subject, and what happened when they did so. Sometimes they were just acting on a hunch. Family members were also occasionally prompting the doctor to act, or recent serious incidents worked as cues for asking. Routinely taking or creating an opportunity to explore was also common. Directly confronting the patient was a challenging task, and the participants disclosed experiences of how this had been achieved.

CONCLUSIONS

Pragmatic case-finding appears to be a field of competence which can be further developed, but should be adapted to the clinical setting and the GP's personal style. It is suggested that strategies for dealing with alcohol problems in general practice should be based on a proper understanding of this specific medical context, and be adaptable to different clinical situations and the individual patient.

"I recognise myself in that situation..." Using photographs to encourage reflection in general practitioners

Photographs can elicit strong emotions and encourage reflection, but what effect can such self reflection have on a general practitioner's identity?