Reducing Substance Misuse and Related Problems: How Can Unhealthy Alcohol Users and Problem Drug Users Be Effectively Intervened with in General Hospital Settings?
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Reducing substance misuse and related problems: How can unhealthy alcohol users and problem drug users be effectively intervened with in general hospital settings? Noreen Dadirai Mdege, BPharm (Honours), MPH PhD by Publication University of York Health Sciences March 2015 Abstract Background: There is a high prevalence of unhealthy alcohol use and problem drug use among patients presenting to general hospital settings. However, many unhealthy alcohol users and problem drug users in these settings are not even aware, or do not acknowledge that they have such problems. Their presentation to hospital for the treatment of other conditions offers an opportunity to engage with them. However, there is uncertainty over how best to identify, assess and intervene with this population. Aim: To investigate how unhealthy alcohol users or problem drug users can be effectively identified, assessed and intervened with when they present to general hospital settings for the treatment of other conditions. Methods: This thesis is based on six published papers that used systematic review, meta-regression and Delphi methods. Main findings: To date, research on interventions for unhealthy alcohol use in general hospital settings has focused on brief interventions (BIs). Multiple session BIs are likely to be beneficial for unhealthy alcohol use in these settings. Where targeted screening and intervention is the strategy of choice, a focus on gastroenterology and emergency medicine is a promising way to target resources for unhealthy alcohol use. There is lack of evidence on how to effectively identify and intervene with problem drug users. The available evidence favours the ASSIST as the problem drug use screening instrument of choice. There is also lack of evidence to inform which comprehensive substance misuse assessment package to use in these settings. Conclusions: There is still need for robustly designed research on how to effectively identify, assess and intervene with unhealthy alcohol users and problem drug users within general hospital settings. It is to be hoped that the body of work presented in this thesis will, effectively, contribute to the development stage for other primary research in the future. - 2 - Table of contents Abstract…………………………………………………………………………... 2 List of tables……………………………………………………………………… 6 List of boxes……………………………………………………………………… 7 List of figures…………………………………………………………………….. 8 Acknowledgements……………………………………………………………... 9 Author’s declaration…………………………………………………..………… 10 1 Introduction…………………………………………………………………. 13 1.1 Background………………………………………………………….. 15 1.1.1 The extent of the problem…………………………………. 15 1.1.1.1 Alcohol…………………………………………… 15 1.1.1.2 Drugs…………………………………………….. 18 1.1.2 Unhealthy alcohol use and problem drug use in general hospital settings............................................................... 19 1.1.2.1 Prevalence………………………………………. 19 1.1.2.2 Presentation of unhealthy alcohol users and problem drug users…………………………….. 20 1.1.2.3 The role and impact of healthcare workers….. 22 1.1.2.4 Screening, assessment and intervention.……. 23 1.1.2.5 Implementation challenges……………………. 25 1.2 The ARiAS programme…………………………………………….. 27 1.3 Aim……………………………………………………………………. 28 1.4 Objectives……………………………………………………………. 28 1.5 Thesis structure……………………………………………………... 30 2. Summary of methods……………………………………………………… 31 2.1 Systematic review and meta-regression methods………………. 31 2.2 The Delphi method………………………………………………….. 33 3. Screening…………………………………………………………………… 35 3.1 Screening for unhealthy alcohol use……………………………… 35 3.2 Screening for problem drug use…………………………………… 36 - 3 - 3.2.1 Paper 1………………………………………………………. 37 3.2.1.1 What does this study contribute to the body of knowledge?...................................................... 39 3.3 Implications of research findings to policy and practice………… 40 3.4 Implications for future research……………………………………. 42 4. Assessment………………………………………………………………… 44 4.1 Assessment for unhealthy alcohol use and problem drug use… 44 4.1.1 Paper 2………………………………………………………. 44 4.1.1.1 What does this study contribute to the body of knowledge?...................................................... 45 4.2 Implications of research findings to policy and practice………… 46 4.3 Implications for future research……………………………………. 46 5. Intervention…………………………………………………………………. 48 5.1 Interventions for unhealthy alcohol use and problem drug use... 48 5.1.1 Paper 3………………………………………………………. 50 5.1.1.1 What does this study contribute to the body of knowledge?...................................................... 51 5.1.2 Paper 4………………………………………………………. 52 5.1.2.1 What does this study contribute to the body of knowledge?...................................................... 53 5.2 How can the effectiveness of brief interventions in general hospital settings be enhanced?................................................... 54 5.2.1 Paper 5………………………………………………………. 55 5.2.1.1 What does this study contribute to the body of knowledge?...................................................... 55 5.3 Implications of research findings to policy and practice………… 56 5.4 Implications for future research……………………………………. 57 6. Implementation of interventions in general hospital settings…………. 61 6.1 Addressing implementation challenges…………………………... 61 6.1.1 Paper 6………………………………………………………. 62 - 4 - 6.2 Study’s contribution to the body of knowledge and implications for policy, practice and future research…………………………… 62 7. Final remarks and recommendations……………………………………. 64 7.1 Policy and practice recommendations……………………………. 64 7.2 Research recommendations………………………………………. 65 7.3 How the portfolio of work informed phase 2 of ARiAS…………. 67 Appendix 1: Papers 1 to 6……………………………………………………… 70 Definitions………………………………………………………………………... 147 Glossary………………………………………………………………………….. 149 References………………………………………………………………………. 150 - 5 - List of tables Table 1: List of papers included as part of the thesis………………………… 14 Table 2: Mapping of objectives onto the aim with regards to type of substance use and the three key stages………………………………………. 29 Table 3: Mapping of papers onto objectives…………………………………… 29 - 6 - List of boxes Box 1: Summary of main findings from Paper 1……………………………… 38 Box 2: Summary of main findings from Paper 2……………………………… 45 Box 3: Summary of main findings from Paper 3……………………………… 51 Box 4: Summary of main findings from Paper 4……………………………… 53 Box 5: Summary of main findings from Paper 5……………………………… 55 Box 6: Summary of main findings from Paper 6……………………………… 62 Box 7: Main research recommendations……………………………………… 66 - 7 - List of figures Figure 1: Model of alcohol consumption, mediating variables, and short- term and long-term consequences…………………………………………. 17 Figure 2: Interrelationships between stages of screening, assessment and intervention……………………………………………………………………….. 25 Figure 3: An illustration of how the presented body of work informed the ADAPTA pilot trial………………………………………………………………... 68 - 8 - Acknowledgements I would like to dedicate this thesis to my husband Stanley, son Anesu and daughter Farirai who inspire me and make me smile every day. I would like to say thank you to my parents Enisia and Norman Ngoni Mdege for your hard work, sacrifice and support throughout my education. To my sisters Netsayi and Norita, thank you for your encouragement. I am deeply thankful to Professor Christine Godfrey for initiating this endeavour, and to my advisor Mr Charlie Lloyd who has been very supportive, helpful, encouraging, thoughtful and wise in his guidance throughout this enterprise. Thanks also to Professor Jim McCambridge and Dr Jude Watson for their invaluable input and advice on the integrative chapter. To Paul Toner I say thank you for advice and spending time proof reading my work. I would like to thank my co-authors for making this collection of papers possible; and the ARiAS research team, a team of esteemed researchers whom I worked alongside with. A very sincere thank you also goes to the ARiAS management group. Finally I would like to thank the NIHR for funding this work through the Collaborations for Leadership in Applied Health Research and Care for York, Leeds and Bradford. - 9 - Author’s declaration This thesis is based on a collection of six papers listed below. While all the papers are co-authored with others, I made significant individual contribution to each of them. Details of these contributions are provided below, signed by myself and one of the major contributory co-author for each paper. 1. Mdege, N.D., and Lang, J., on behalf of the ARIAS Research Group. (2001). Screening instruments for detecting illicit drug use/abuse that could be useful in general hospital wards: a systematic review. Addictive Behaviors, 36(12), 1111–1119. Contribution of the candidate: I was involved in the conception of the research question and study design; and conducted the literature search. I was also involved in instrument and study selection and data extraction. I conducted the data analysis, synthesis and interpretation, and prepared the manuscript including subsequent revisions. ________________________ ______________________ Noreen D. Mdege Jennifer Sweetman (nee Lang) 2. Sweetman, J., Raistrick, D., Mdege, N.D., and Crosby, H. (2013). A systematic review of substance misuse assessment packages. Drug and Alcohol Review, 32(4), 347-355. Contribution of the candidate: I was involved in the conception of the research question and study design; and was responsible for conducting the literature search. I was also involved in instrument and study selection; data