Human Psychopharmacology Clinical and Experimental, 2023
Introduction: Treatment retention is associated with better outcomes and reduced risk amongst peo... more Introduction: Treatment retention is associated with better outcomes and reduced risk amongst people experiencing opioid use disorder (OUD). Despite this, treatment retention remains low amongst this population. Methods: We carried out an international cross-sectional survey of substance use disorder (SUD) treatment service workers. We aimed to understand the barriers to treatment retention in the context of OUD from the provider perspective, identify differences in response preference between professional groups, and describe regional differences in treatment provision. Results: We report data from 497 respondents based in the USA and the UK. Personality disorders, low motivation to change and social problems were the most
Background: Fatal opioid overdose is a significant public health problem with increasing incidenc... more Background: Fatal opioid overdose is a significant public health problem with increasing incidence in developed countries. This study aimed to describe demographic and service user characteristics of decedents of opioid overdose in Wales to identify possible targets for behaviour modification and life-saving interventions. Methods: A retrospective cross-sectional analysis was conducted of a census sample of opioid overdose-related deaths recorded between January 01, 2012, and October 11, 2018, in Wales. UK Office for National Statistics, Welsh Demographic Service, and National Health Service datasets were linked deterministically. Decedents' circumstances of death, demographic characteristics, residency, and health service use were characterized over 3 years prior to fatal overdose using descriptive statistics. Results: In total, 638 people died of opioid overdose in Wales between January 01, 2012, and October 11, 2018, with an incidence rate of 3.04 per 100,000 people per year. Decedents were predominantly male (73%) and middle aged (median age 50 years). Fatal overdoses predominantly occurred in the community (93%) secondary to heroin (30%) or oxycodone derivative use (34%). In the 3 years prior to death, decedents changed address frequently (53%) but rarely moved far geographically. The majority of decedents had recently visited the emergency department (83%) or were admitted to the hospital (64%) prior to death. Only a minority had visited specialist drug services (32%). Conclusions: Deaths from opioid overdose typically occur in middle-aged men living peripatetic lifestyles. Victims infrequently visit specialist drug services but often attend emergency medical services. Emergency department-based interventions may therefore be important in prevention of opioid overdose fatalities in the community.
We sought to explore the sociodemographics and primary care service utilization among people who ... more We sought to explore the sociodemographics and primary care service utilization among people who died from opioid overdose and to assess the possibility of using this information to identify those at high risk of opioid overdose using routine linked data. Methods: Data related to decedents of opioid overdose between January 1, 2012 and December 31, 2015 were linked with general practitioner (GP) records over a period of 36 months prior to death. Results: Of n = 312 decedents of opioid overdose, 73% were male (n = 228). Average age at death was 40.72 (SD 11.92) years. A total of 63.8% of the decedents were living in the 2 most deprived quintiles according to the Welsh Index of Multiple Deprivation. Over 80% (n = 258) of the decedents were recorded as having at least 1 GP episode during the 36-month observation period prior to death. The median number of episodes per decedent was 75 [38-118]. Overall, 31.8% (n = 82) of decedents with at least 1 GP episode received a prescription for a proton pump inhibitor and 31% (n = 80) were prescribed a broadspectrum antibiotic. According to their GP records, less than 10% were referred to or receiving specialist drug treatment (n = 24, 9.3%); or were known to be drug dependent (n = 21, 8.14%), or a drug user (n = 5, 1.94%). In all, 81% were recorded as smokers (n = 209) and 10.5% as ex-smokers (n = 27). Conclusions: The majority of decedents of opioid overdose were in contact with GP services prior to death. GPs are either often unaware of high-risk opioid use, or rarely record details of opioid use in patient notes. It is possible that GP awareness of high-risk opioid use could be increased. For example, awareness of the risks associated with opioid use, and the relationship between the sociodemographic and clinical characteristics of opioid overdose decedents could be raised using educational materials prominently displayed in waiting areas. Clinicians in primary care may be in an excellent position to intervene in problematic opioid use.
Background: Opioids, such as heroin, kill more people worldwide by overdose than any other type o... more Background: Opioids, such as heroin, kill more people worldwide by overdose than any other type of drug, and death rates associated with opioid poisoning in the UK are at record levels (World Drug Report 2018 [Internet].
Background: Ambulance services have a vital role in the shift towards the delivery of health care... more Background: Ambulance services have a vital role in the shift towards the delivery of health care outside hospitals, when this is better for patients, by offering alternatives to transfer to the emergency department. The introduction of information technology in ambulance services to electronically capture, interpret, store and transfer patient data can support out-of-hospital care. Objective: We aimed to understand how electronic health records can be most effectively implemented in a pre-hospital context in order to support a safe and effective shift from acute to community-based care, and how their potential benefits can be maximised. Design and setting: We carried out a study using multiple methods and with four work packages: (1) a rapid literature review; (2) a telephone survey of all 13 freestanding UK ambulance services; (3) detailed case studies examining electronic health record use through qualitative methods and analysis of routine data in four selected sites consisting of UK ambulance services and their associated health economies; and (4) a knowledge-sharing workshop. Results: We found limited literature on electronic health records. Only half of the UK ambulance services had electronic health records in use at the time of data collection, with considerable variation in hardware and software and some reversion to use of paper records as services transitioned between systems. The case studies found that the ambulance services' electronic health records were in a state of change.
The prevalence of schizophrenia among high risk opioid users was investigated as part of a wider ... more The prevalence of schizophrenia among high risk opioid users was investigated as part of a wider investigation into opioid-related deaths. We found that over 6% of our sample of 312 decedents of opioid overdose had received a schizophrenia related diagnosis over a 36 month period prior to their death. This represents a near 8× increase on previously estimated period prevalence of schizophrenia in the general population. Though not conclusive, our findings raise questions about the extent to which opioid drugs are used by people with schi-zophrenia, and about how to best address high risk opioid use in people with schizophrenia.
Background: Trauma-focused cognitive behavioral therapy (TF-CBT) is a first-line treatment for po... more Background: Trauma-focused cognitive behavioral therapy (TF-CBT) is a first-line treatment for posttraumatic stress disorder (PTSD). Despite a solid evidence base, TF-CBT response and attrition rates vary considerably. Plasticity-focused interventions, including the use of serious games, have the potential to improve TF-CBT response and treatment retention.
We sought to investigate situation-specific inflated sense of responsibility and explanatory styl... more We sought to investigate situation-specific inflated sense of responsibility and explanatory style in social anxiety disorder (SAD) according to the cognitive model. Participants aged 17-68 years (mean = 31.9, SD = 11.1) included waiting list patients referred to a primary care mental health service for cognitive behavioural therapy for SAD (n = 18) and non-anxious control participants (n = 65). A battery of psychometric measures, including a bespoke measure of responsibility beliefs, was used. Compared with controls, participants with SAD were more likely to demonstrate an inflated sense of responsibility (p ≤ 0.001), and to adopt a negative explanatory style specific to social interaction (p ≤ 0.01). Inflated sense of responsibility was found to correlate with SAD symptomatology (r = 0.47, p ≤ 0.05), and with increased usage of safety behaviours (r = 0.47, p ≤ 0.05). Caseness (β = 1.45, p ≤ 0.01) and stability of causal attribution (β = 0.25, p ≤ 0.001) were found to predict inflated responsibility in our sample. To our knowledge this study represents the first attempt to investigate inflated responsibility within the context of SAD. Our results support the notion of inflated responsibility as a feature of SAD. Key learning aims (1) To understand the cognitive behavioural components of Clark and Wells' model of SAD, and their bi-directional nature. (2) To understand what the term 'inflated sense of responsibility' refers to, and how it relates to CBT. (3) To understand what the term 'explanatory style' refers to, and how this concept can also relate to CBT.
on behalf of the TIER Trial Research Management Group To cite: Evans BA, Ali K, Bulger J, et al. ... more on behalf of the TIER Trial Research Management Group To cite: Evans BA, Ali K, Bulger J, et al. Referral pathways for patients with TIA avoiding hospital admission: a scoping review. ABSTRACT Objective: To identify the features and effects of a pathway for emergency assessment and referral of patients with suspected transient ischaemic attack (TIA) in order to avoid admission to hospital. Design: Scoping review. Study selection: Reports of primary research on referral of patients with suspected TIA directly to specialist outpatient services. Data extraction: We screened studies for eligibility and extracted data from relevant studies. Data were analysed to describe setting, assessment and referral processes, treatment, implementation and outcomes. Results: 8 international studies were identified, mostly cohort designs. 4 pathways were used by family doctors and 3 pathways by emergency department physicians. No pathways used by paramedics were found. Referrals were made to specialist clinic either directly or via a 24-hour helpline. Practitioners identified TIA symptoms and risk of further events using a checklist including the ABCD2 tool or clinical assessment. Antiplatelet medication was often given, usually aspirin unless contraindicated. Some patients underwent tests before referral and discharge. 5 studies reported reduced incident of stroke at 90 days, from 6-10% predicted rate to 1.3-2.1% actual rate. Between 44% and 83% of suspected TIA cases in these studies were referred through the pathways. Conclusions: Research literature has focused on assessment and referral by family doctors and ED physicians to reduce hospitalisation of patients with TIA. No pathways for paramedical use were reported. We will use results of this scoping review to inform development of a paramedical referral pathway to be tested in a feasibility trial.
Human Psychopharmacology Clinical and Experimental, 2023
Introduction: Treatment retention is associated with better outcomes and reduced risk amongst peo... more Introduction: Treatment retention is associated with better outcomes and reduced risk amongst people experiencing opioid use disorder (OUD). Despite this, treatment retention remains low amongst this population. Methods: We carried out an international cross-sectional survey of substance use disorder (SUD) treatment service workers. We aimed to understand the barriers to treatment retention in the context of OUD from the provider perspective, identify differences in response preference between professional groups, and describe regional differences in treatment provision. Results: We report data from 497 respondents based in the USA and the UK. Personality disorders, low motivation to change and social problems were the most
Background: Fatal opioid overdose is a significant public health problem with increasing incidenc... more Background: Fatal opioid overdose is a significant public health problem with increasing incidence in developed countries. This study aimed to describe demographic and service user characteristics of decedents of opioid overdose in Wales to identify possible targets for behaviour modification and life-saving interventions. Methods: A retrospective cross-sectional analysis was conducted of a census sample of opioid overdose-related deaths recorded between January 01, 2012, and October 11, 2018, in Wales. UK Office for National Statistics, Welsh Demographic Service, and National Health Service datasets were linked deterministically. Decedents' circumstances of death, demographic characteristics, residency, and health service use were characterized over 3 years prior to fatal overdose using descriptive statistics. Results: In total, 638 people died of opioid overdose in Wales between January 01, 2012, and October 11, 2018, with an incidence rate of 3.04 per 100,000 people per year. Decedents were predominantly male (73%) and middle aged (median age 50 years). Fatal overdoses predominantly occurred in the community (93%) secondary to heroin (30%) or oxycodone derivative use (34%). In the 3 years prior to death, decedents changed address frequently (53%) but rarely moved far geographically. The majority of decedents had recently visited the emergency department (83%) or were admitted to the hospital (64%) prior to death. Only a minority had visited specialist drug services (32%). Conclusions: Deaths from opioid overdose typically occur in middle-aged men living peripatetic lifestyles. Victims infrequently visit specialist drug services but often attend emergency medical services. Emergency department-based interventions may therefore be important in prevention of opioid overdose fatalities in the community.
We sought to explore the sociodemographics and primary care service utilization among people who ... more We sought to explore the sociodemographics and primary care service utilization among people who died from opioid overdose and to assess the possibility of using this information to identify those at high risk of opioid overdose using routine linked data. Methods: Data related to decedents of opioid overdose between January 1, 2012 and December 31, 2015 were linked with general practitioner (GP) records over a period of 36 months prior to death. Results: Of n = 312 decedents of opioid overdose, 73% were male (n = 228). Average age at death was 40.72 (SD 11.92) years. A total of 63.8% of the decedents were living in the 2 most deprived quintiles according to the Welsh Index of Multiple Deprivation. Over 80% (n = 258) of the decedents were recorded as having at least 1 GP episode during the 36-month observation period prior to death. The median number of episodes per decedent was 75 [38-118]. Overall, 31.8% (n = 82) of decedents with at least 1 GP episode received a prescription for a proton pump inhibitor and 31% (n = 80) were prescribed a broadspectrum antibiotic. According to their GP records, less than 10% were referred to or receiving specialist drug treatment (n = 24, 9.3%); or were known to be drug dependent (n = 21, 8.14%), or a drug user (n = 5, 1.94%). In all, 81% were recorded as smokers (n = 209) and 10.5% as ex-smokers (n = 27). Conclusions: The majority of decedents of opioid overdose were in contact with GP services prior to death. GPs are either often unaware of high-risk opioid use, or rarely record details of opioid use in patient notes. It is possible that GP awareness of high-risk opioid use could be increased. For example, awareness of the risks associated with opioid use, and the relationship between the sociodemographic and clinical characteristics of opioid overdose decedents could be raised using educational materials prominently displayed in waiting areas. Clinicians in primary care may be in an excellent position to intervene in problematic opioid use.
Background: Opioids, such as heroin, kill more people worldwide by overdose than any other type o... more Background: Opioids, such as heroin, kill more people worldwide by overdose than any other type of drug, and death rates associated with opioid poisoning in the UK are at record levels (World Drug Report 2018 [Internet].
Background: Ambulance services have a vital role in the shift towards the delivery of health care... more Background: Ambulance services have a vital role in the shift towards the delivery of health care outside hospitals, when this is better for patients, by offering alternatives to transfer to the emergency department. The introduction of information technology in ambulance services to electronically capture, interpret, store and transfer patient data can support out-of-hospital care. Objective: We aimed to understand how electronic health records can be most effectively implemented in a pre-hospital context in order to support a safe and effective shift from acute to community-based care, and how their potential benefits can be maximised. Design and setting: We carried out a study using multiple methods and with four work packages: (1) a rapid literature review; (2) a telephone survey of all 13 freestanding UK ambulance services; (3) detailed case studies examining electronic health record use through qualitative methods and analysis of routine data in four selected sites consisting of UK ambulance services and their associated health economies; and (4) a knowledge-sharing workshop. Results: We found limited literature on electronic health records. Only half of the UK ambulance services had electronic health records in use at the time of data collection, with considerable variation in hardware and software and some reversion to use of paper records as services transitioned between systems. The case studies found that the ambulance services' electronic health records were in a state of change.
The prevalence of schizophrenia among high risk opioid users was investigated as part of a wider ... more The prevalence of schizophrenia among high risk opioid users was investigated as part of a wider investigation into opioid-related deaths. We found that over 6% of our sample of 312 decedents of opioid overdose had received a schizophrenia related diagnosis over a 36 month period prior to their death. This represents a near 8× increase on previously estimated period prevalence of schizophrenia in the general population. Though not conclusive, our findings raise questions about the extent to which opioid drugs are used by people with schi-zophrenia, and about how to best address high risk opioid use in people with schizophrenia.
Background: Trauma-focused cognitive behavioral therapy (TF-CBT) is a first-line treatment for po... more Background: Trauma-focused cognitive behavioral therapy (TF-CBT) is a first-line treatment for posttraumatic stress disorder (PTSD). Despite a solid evidence base, TF-CBT response and attrition rates vary considerably. Plasticity-focused interventions, including the use of serious games, have the potential to improve TF-CBT response and treatment retention.
We sought to investigate situation-specific inflated sense of responsibility and explanatory styl... more We sought to investigate situation-specific inflated sense of responsibility and explanatory style in social anxiety disorder (SAD) according to the cognitive model. Participants aged 17-68 years (mean = 31.9, SD = 11.1) included waiting list patients referred to a primary care mental health service for cognitive behavioural therapy for SAD (n = 18) and non-anxious control participants (n = 65). A battery of psychometric measures, including a bespoke measure of responsibility beliefs, was used. Compared with controls, participants with SAD were more likely to demonstrate an inflated sense of responsibility (p ≤ 0.001), and to adopt a negative explanatory style specific to social interaction (p ≤ 0.01). Inflated sense of responsibility was found to correlate with SAD symptomatology (r = 0.47, p ≤ 0.05), and with increased usage of safety behaviours (r = 0.47, p ≤ 0.05). Caseness (β = 1.45, p ≤ 0.01) and stability of causal attribution (β = 0.25, p ≤ 0.001) were found to predict inflated responsibility in our sample. To our knowledge this study represents the first attempt to investigate inflated responsibility within the context of SAD. Our results support the notion of inflated responsibility as a feature of SAD. Key learning aims (1) To understand the cognitive behavioural components of Clark and Wells' model of SAD, and their bi-directional nature. (2) To understand what the term 'inflated sense of responsibility' refers to, and how it relates to CBT. (3) To understand what the term 'explanatory style' refers to, and how this concept can also relate to CBT.
on behalf of the TIER Trial Research Management Group To cite: Evans BA, Ali K, Bulger J, et al. ... more on behalf of the TIER Trial Research Management Group To cite: Evans BA, Ali K, Bulger J, et al. Referral pathways for patients with TIA avoiding hospital admission: a scoping review. ABSTRACT Objective: To identify the features and effects of a pathway for emergency assessment and referral of patients with suspected transient ischaemic attack (TIA) in order to avoid admission to hospital. Design: Scoping review. Study selection: Reports of primary research on referral of patients with suspected TIA directly to specialist outpatient services. Data extraction: We screened studies for eligibility and extracted data from relevant studies. Data were analysed to describe setting, assessment and referral processes, treatment, implementation and outcomes. Results: 8 international studies were identified, mostly cohort designs. 4 pathways were used by family doctors and 3 pathways by emergency department physicians. No pathways used by paramedics were found. Referrals were made to specialist clinic either directly or via a 24-hour helpline. Practitioners identified TIA symptoms and risk of further events using a checklist including the ABCD2 tool or clinical assessment. Antiplatelet medication was often given, usually aspirin unless contraindicated. Some patients underwent tests before referral and discharge. 5 studies reported reduced incident of stroke at 90 days, from 6-10% predicted rate to 1.3-2.1% actual rate. Between 44% and 83% of suspected TIA cases in these studies were referred through the pathways. Conclusions: Research literature has focused on assessment and referral by family doctors and ED physicians to reduce hospitalisation of patients with TIA. No pathways for paramedical use were reported. We will use results of this scoping review to inform development of a paramedical referral pathway to be tested in a feasibility trial.
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