Assessing the early influence of COVID-19 in an analysis of the immediate implementation of Minimum Pricing for Alcohol on drinkers in Wales

Background: The Welsh Government has commissioned a number of projects to consider the influence their implementation of Minimum Pricing for Alcohol (MPA) legislation in March 2020 had on the alcohol consumption and related behaviours of drinkers. Given the MPA's overlap with the COVID-19 pandemic and its related lockdown measures and restrictions, this rapidly became a story about the early impact of COVID-19 as it did MPA. This paper captures the core thematic messages from this specific strand of work, and in doing so reflects on (1) how early experiences of COVID-19 and the first lockdown influenced consumption and purchasing of alcohol behaviours and, in turn, (2) how relevant the introduction of MPA was for any of these. Methods: Semi-structured interviews were conducted by telephone with 32 drinkers 9 months after the implementation of the legislation in March 2020. The sample was recruited from three sources: the National Survey for Wales; a third sector organisation offering housing support to the homeless; and through an online survey on MPA. Results: COVID-19 had more relevance than MPA to drinkers. Furthermore, when MPA did have an influence on their behaviour, it was felt most keenly by the harmful drinkers in the study. These drinkers described spending more on alcohol, switching to other potentially more harmful substances, such as crack cocaine and synthetic cannabinoids, and more involvement in acquisitive crime and begging after the price increase. While our results might be an early indication of the influence of MPA on harmful drinkers, the small sample of this group in our study limits the generalisability of the findings. Conclusion: To date, the implementation of MPA has had little influence on the drinking patterns or lives of the drinkers in our sample. It is important that future research examines the longer-term influences of MPA before any conclusions on its effectiveness can be drawn.

Waiting for inpatient detoxification: A qualitative analysis of patient experiences

BACKGROUND

There is limited provision of inpatient detoxification relative to other treatments for alcohol and other drug (AOD) use. This means people often need to wait prior to detoxifying. However, waiting for healthcare is generally perceived as negative and stressful. This paper aims to understand patients' experiences of waiting for inpatient AOD detoxification to ascertain whether and how service-level policies and practices might be improved.

METHODS

Semi-structured telephone interviews were conducted with 32 people (20 males, 12 females; aged 25-67 years) who were waiting for inpatient detoxification. Data collection was part of a wider evaluation of a policy initiative started in 2021 to increase detoxification service capacity in England, UK. Interviews were professionally transcribed and data on waiting experiences were coded using qualitative software. Analyses were informed by new materialist thinking and undertaken via Iterative Categorisation.

RESULTS

We found that waiting was constituted through five dimensions: i. duration; ii. support; iii. information; iv. preparations; and v. emotions. These five dimensions were multi-faceted and operated in and through wider interacting social, material, and affective forces (e.g., professional judgements, formal and informal relationships, the availability of beds and funding, bureaucratic procedures, the utility and relevance of information, and participants' diverse feelings, including desperation for treatment). Not all accounts of waiting were negative. The experience was complex, non-uniform and variable over time. Moreover, it affected how people felt and how they behaved.

CONCLUSIONS

Changes to service-level policies and practices can potentially minimise the stress of waiting for inpatient AOD detoxification. The negative impact of waiting may be reduced if professionals more consistently engage patients in a wider range of constructive pre-treatment activities, offer regular 'check-ins' to mitigate any anxiety, explain changes in wait duration to help with planning and demonstrate fairness, and facilitate contact between those waiting to lessen feelings of isolation.

Views on minimum unit pricing for alcohol before its introduction among people with alcohol dependence in Scotland: A qualitative interview study

INTRODUCTION

Scotland implemented a minimum price per unit of alcohol (MUP) of £0.50 in May 2018 (1 UK unit = 10 mL/8 g ethanol). Some stakeholders expressed concerns about the policy having potential negative consequences for people with alcohol dependence. This study aimed to investigate anticipated impacts of MUP on people presenting to alcohol treatment services in Scotland before policy implementation.

METHODS

Qualitative interviews were conducted with 21 people with alcohol dependence accessing alcohol treatment services in Scotland between November 2017 and April 2018. Interviews examined respondents' current and anticipated patterns of drinking and spending, effects on their personal life, and their views on potential policy impact. Interview data were thematically analysed using a constant comparison method.

RESULTS

Three key themes were identified: (i) strategies used to manage the cost of alcohol and anticipated responses to MUP; (ii) broader effects of MUP; and (iii) awareness and preparedness for MUP. Respondents expected to be impacted by MUP, particularly those on low incomes and those with more severe dependence symptoms. They anticipated using familiar strategies including borrowing and reprioritising spending to keep alcohol affordable. Some respondents anticipated negative consequences. Respondents were sceptical about the short-term benefits of MUP for current drinkers but felt it might prevent harm for future generations. Respondents had concerns about the capacity of treatment services to meet support needs.

DISCUSSION AND CONCLUSIONS

People with alcohol dependence identified immediate concerns alongside potential long-term benefits of MUP before its introduction. They also had concerns over the preparedness of service providers.

'Why would we not want to keep everybody safe?' The views of family members of people who use drugs on the implementation of drug consumption rooms in Scotland

BACKGROUND

People who use drugs in Scotland are currently experiencing disproportionately high rates of drug-related deaths. Drug consumption rooms (DCRs) are harm reduction services that offer a safe, hygienic environment where pre-obtained drugs can be consumed under supervision. The aim of this research was to explore family member perspectives on DCR implementation in Scotland in order to inform national policy.

METHODS

Scotland-based family members of people who were currently or formerly using drugs were invited to take part in semi-structured interviews to share views on DCRs. An inclusive approach to 'family' was taken, and family members were recruited via local and national networks. A convenience sample of 13 family members were recruited and interviews conducted, audio-recorded, transcribed, and analysed thematically using the Structured Framework Technique.

RESULTS

Family members demonstrated varying levels of understanding regarding the existence, role, and function of DCRs. While some expressed concern that DCRs would not prevent continued drug use, all participants were in favour of DCR implementation due to a belief that DCRs could reduce harm, including saving lives, and facilitate future recovery from drug use. Participants highlighted challenges faced by people who use drugs in accessing treatment/services that could meet their needs. They identified that accessible and welcoming DCRs led by trusting and non-judgemental staff could help to meet unmet needs, including signposting to other services. Family members viewed DCRs as safe environments and highlighted how the existence of DCRs could reduce the constant worry that they had of risk of harm to their loved ones. Finally, family members emphasised the challenge of stigma associated with drug use. They believed that introduction of DCRs would help to reduce stigma and provide a signal that people who use drugs deserve safety and care.

CONCLUSIONS

Reporting the experience and views of family members makes a novel and valuable contribution to ongoing public debates surrounding DCRs. Their views can be used to inform the implementation of DCRs in Scotland but also relate well to the development of wider responses to drug-related harm and reduction of stigma experienced by people who use drugs in Scotland and beyond.

'Why would we not want to keep everybody safe?' The views of family members of people who use drugs on the implementation of drug consumption rooms in Scotland

BACKGROUND

People who use drugs in Scotland are currently experiencing disproportionately high rates of drug-related deaths. Drug consumption rooms (DCRs) are harm reduction services that offer a safe, hygienic environment where pre-obtained drugs can be consumed under supervision. The aim of this research was to explore family member perspectives on DCR implementation in Scotland in order to inform national policy.

METHODS

Scotland-based family members of people who were currently or formerly using drugs were invited to take part in semi-structured interviews to share views on DCRs. An inclusive approach to 'family' was taken, and family members were recruited via local and national networks. A convenience sample of 13 family members were recruited and interviews conducted, audio-recorded, transcribed, and analysed thematically using the Structured Framework Technique.

RESULTS

Family members demonstrated varying levels of understanding regarding the existence, role, and function of DCRs. While some expressed concern that DCRs would not prevent continued drug use, all participants were in favour of DCR implementation due to a belief that DCRs could reduce harm, including saving lives, and facilitate future recovery from drug use. Participants highlighted challenges faced by people who use drugs in accessing treatment/services that could meet their needs. They identified that accessible and welcoming DCRs led by trusting and non-judgemental staff could help to meet unmet needs, including signposting to other services. Family members viewed DCRs as safe environments and highlighted how the existence of DCRs could reduce the constant worry that they had of risk of harm to their loved ones. Finally, family members emphasised the challenge of stigma associated with drug use. They believed that introduction of DCRs would help to reduce stigma and provide a signal that people who use drugs deserve safety and care.

CONCLUSIONS

Reporting the experience and views of family members makes a novel and valuable contribution to ongoing public debates surrounding DCRs. Their views can be used to inform the implementation of DCRs in Scotland but also relate well to the development of wider responses to drug-related harm and reduction of stigma experienced by people who use drugs in Scotland and beyond.

Drug Consumption Rooms and Public Health Policy: Perspectives of Scottish Strategic Decision-Makers

There is widespread support for the introduction of Drug Consumption Rooms (DCRs) in Scotland as part of a policy response to record levels of drug-related harm. However, existing legal barriers are made more complex by the division of relevant powers between the UK and Scottish Governments. This paper reports on a national, qualitative study of key decision-makers in both local and national roles across Scotland. It explores views on the political barriers and enablers to the adoption of Drug Consumption Rooms and the potential role of these facilities in the wider treatment system. It also considers approaches to evidence, especially the types of evidence that are considered valuable in supporting decision-making in this area. The study found that Scottish decision-makers are strongly supportive of DCR adoption; however, they remain unclear as to the legal and political mechanisms that would make this possible. They view DCRs as part of a complex treatment and support system rather than a uniquely transformative intervention. They see the case for introduction as sufficient, on the basis of need and available evidence, thus adopting a pragmatic and iterative approach to evidence, in contrast to an appeal to traditional evidence hierarchies more commonly adopted by the UK Government.

Adapting existing behaviour: Perceptions of substance switching and implementation of minimum pricing for alcohol in Wales

Aim

Minimum Pricing for Alcohol (MPA) was enacted in Wales on March 2^nd 2020. During the legislative process (i.e. consultation and parliamentary discussion), concern was expressed about the possibility of some drinkers switching to using other substances in response to any rise in the cost of alcohol. This paper reports on findings from a study which explored these pre-implementation concerns and how the policy was shaped.

Method

The research involved surveys (n=193) and interviews (n=87) with drinkers (predominantly harmful or treatment seeking) and providers of services. Survey responses were detailed, thus when combined with the interviews, provided a wealth of qualitative data, which are drawn upon in this paper.

Results

The findings highlight an expectation that most drinkers would respond to the new policy with adaptations of their coping mechanisms to maintain alcohol use at pre-legislative levels. This was either by switching alcohol products and adjusting their lifestyle to maintain an affordable drinking habit or developing new behaviours to manage additional costs. A small group of those with previous experience of drug use were identified as likely to switch from using alcohol to some other substances.

Conclusions

Prior to the legislation being implemented awareness of the detail of the policy was found to be low, and the perceptions of increased potential harm for certain groups, including switching, were linked to concern about a lack of treatment capacity.

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

Social care legislation as an act of integration

Purpose

– The purpose of this paper is to investigate health and social care integration in North Wales in a short window of time between the assent of the Social Services and Well-being (Wales) Act 2014 and its implementation in 2016.

Design/methodology/approach

– The findings are based on the experiences of health and social care professionals from six Local Authorities and one Regional Health Board working in a management role with strategic responsibility, gathered from an online survey (n=43), semi-structured face-to-face interviews (n=14) and supplemented with reflective interviews with regional coordinators responsible for facilitating cross-organisational working (n=2).

Findings

– Senior managers are devoting considerable energy to understanding the implications of the new legislation, ensuring that their organisations will be ready and able to successfully implement it. This work is perceived to be commensurate with wider agendas to transform and integrate working practices and services, influenced by a range of financial, environmental, organisational, social and policy factors.

Originality/value

– This research has direct implications for stakeholders in North Wales, having already been used to shape conversations about integration in the region, and furthermore builds upon existing knowledge in the academic and professional field of integration, with additional limited wider implications for policy and research.

Patient knowledge about hormone replacement therapy: implications for treatment

OBJECTIVE

To determine whether women's global self-assessment of their knowledge about hormone replacement therapy (HRT) corresponds to their performance on an explicit knowledge test about HRT and to measure associations among knowledge, personal characteristics, decision conflict, and intention to use HRT.

DESIGN

Preintervention telephone survey of 156 women enrolled in a randomized, placebo-controlled trial of HRT decision aids.

RESULTS

The mean rating of menopause knowledge, on a scale from 1 to 10, with 10 indicating being "extremely knowledgeable," was 5.6 (range = 0-10) and of HRT was 4.2 (range = 0-9). The mean summary score for the explicit HRT knowledge test, on a 16-point scale, was 7.8 (range = 0-15). After adjustment for demographic characteristics and exposure to a provider conversation, higher income, white race, and the provider discussion were significant correlates of knowledge. Explicit knowledge was positively correlated with self-assessed menopause knowledge and HRT knowledge (Spearman's correlation coefficient = 0.39 and 0.52, respectively; p < 0.0001). Greater knowledge was not associated with intention to use HRT 1 year later. Women who had greater knowledge reported less conflict about the HRT decision (Spearman's correlation coefficient = -0.32; p < 0.0001).

CONCLUSIONS

A global question about level of knowledge is an effective clinical tool for identifying patients who are in need of additional education about HRT and menopause in this managed care population. Increased knowledge may decrease women's conflict about the HRT decision. Having had a previous conversation about menopause with a primary care provider is associated with greater knowledge about HRT.

Major aphthous-like ulcers in two patients infected with human immunodeficiency virus

Two patients infected with human immunodeficiency virus (HIV) presented with persistent, large, and painful oral ulcers. Results of cultures and examination of a biopsy specimen were negative for infection and malignancy. Major aphthous-like ulcers should be considered in the differential diagnosis of oral ulcers in the HIV-infected patient.

Water on the sun

High-resolution infrared spectra of sunspot umbrae have been recorded with the 1-meter Fourier transform spectrometer on Kitt Peak. The spectra contain a very large number of water absorption features originating on the sun. These lines have been assigned to the pure rotation and the vibration-rotation transitions of hot water by comparison with high-temperature laboratory emission spectra.

New Light on the Heart of Darkness of the Solar Chromosphere

Solar carbon monoxide spectra indicate the existence of a cool (less than 4000 kelvin) component to the solar chromosphere coexisting with the hot, bright gas at 6000 to 7000 kelvin. However, both the existence and the location of the cool component have been controversial. New high-resolution spectra show that carbon monoxide goes into emission just beyond the limb, allowing it to be probed without photospheric contamination. The cool component has temperatures as low as 3000 to 3500 kelvin and appears to cover 50 to 85 percent of the quiet solar surface. There is a steep temperature rise to normal chromospheric temperatures at a height of 900 to 1100 kilometers. Large horizontal velocities are seen, suggesting that the cool component is maintained by the supersonic adiabatic expansion of upwelling gas in overshooting granules.

Use of alternative polyadenylation sites for tissue-specific transcription of two angiotensin-converting enzyme mRNAs

The pulmonary isozyme of rabbit angiotensin-converting enzyme (ACE) is encoded by an mRNA of about 5 kb. cDNA clones corresponding to different parts of this mRNA have been isolated and the complete nucleotide sequences of both the coding and non-coding regions of the mRNA have been determined. The encoded protein has 1309 residues with a 33 amino acids-long signal peptide at the amino terminus and a potential membrane-anchoring domain near the carboxyl terminus. There is a strong sequence homology between two regions of the rabbit cDNA and between the rabbit, human, and mouse cDNAs. Comparison of the nucleotide sequences of the 3' untranslated regions of rabbit pulmonary and testicular ACE cDNAs revealed that the testicular cDNA is nested within the pulmonary cDNA at the 3' end. A rabbit genomic clone encompassing this region was isolated and partially sequenced. It was shown that the gene contains two potential polyadenylation sites 628 bp apart within one exon. Northern analyses with an appropriate oligonucleotide probe confirmed that the proximal polyadenylation site is used exclusively for terminating the testicular mRNA whereas the distal one is used exclusively for the pulmonary mRNA. These results demonstrated that the transcription of the two mRNAs encoding the two ACE isozymes not only initiates at two alternative tissue-specific sites which are 5.7 kb apart but the mRNAs also get polyadenylated at two alternative sites which are 628 bp apart.

Establishment of transfected cell lines producing testicular angiotensin-converting enzyme. Structural relationship between its secreted and cellular forms

Angiotensin-converting enzyme (ACE) is present in endothelial and epithelial cells of various tissues as well as in the circulating plasma. The structural relationship between the cellular and the secreted forms of ACE and the pathways to their biosynthesis have not been determined as yet mainly because of the unavailability of a natural cell line expressing ACE in tissue culture. To circumvent this problem we have permanently transfected a mouse epithelial line with an expression vector containing the recently cloned rabbit testicular ACE cDNA. Clonal derivatives of this line secreted large quantities of enzymatically active ACE. When these cells were cultured in serum-free medium, the only detectable protein in the culture medium was ACE. It has been suggested that a hydrophobic domain near the carboxyl terminus of the enzyme anchors it to the plasma membrane. To test this hypothesis we established cell lines expressing a truncated form of the active enzyme which is missing the putative anchoring domain. Pulse-chase experiments showed that the truncated ACE was secreted from the cells much faster than the native enzyme. Moreover, the secreted form of the native enzyme had a lower molecular weight than the corresponding cellular form. These results are consistent with the hypothesis that the hydrophobic domain is instrumental in keeping the enzyme cell-bound, and secretion is achieved physiologically by removal of this domain from the enzyme by a specific proteolytic cleavage.

Volcanic Ash over Arizona in the Spring of 1982: Astronomical Observations

Astronomical observations in Arizona recorded the passage of one, and possibly more, volcanic dust clouds between January and June 1982. On 15 May the increase in extinction in visible wavelengths at Tucson was more than 40 percent or 0.4 in optical depth. At Flagstaff, 325 kilometers north, the increase in extinction on the same day was 25 percent. A detailed time history of atmospheric extinction plus evidence for nongray absorption from the cloud is presented.

Shigella sonnei gastroenteritis after oral ampicillin therapy for an unrelated disorder

After oral therapy with ampicillin for an unrelated disorder, two patients developed gastroenteritis with an ampicillin-resistant strain of Shigella sonnei. Both patients recovered after treatment with antimicrobial agents to which the Shigella was susceptible by in vitro testing.

Mountain shadow phenomena

Regardless of profile, whether flat topped or pointed, to the summit observer all mountain peaks cast triangular shadows when the sun is low. A theory for such anomalous shadows is developed. The shadow apex angle is shown to depend only on the ratio of the breadth of the mountain to its height.