Thursday, November 21, 2013

Translating Evidence into Best Outcomes in Addiction Medicine - Dr. Robert Ali (Australia)

(These are my rough notes. I share them in hope of showing the depth and breadth of material presented. I apologize for any errors. For greater clarity I would hope you would go to the source - W. Hay)

Managing Addiction through Evidence Based Medical and Psychosocial Interventions
15th Annual International Society of Addiction Medicine 
Telecom Malaysia Convention Centre
Kuala Lumpur, Malaysia

IMG 1614

These are my rough notes of an excellent presentation by one of the leaders in the field, educator  and  consultant to WHO  

Dr. Ali began his presentation showing a man with a crystal methamphetamine addiction . He was chained to a tree in his village.  He’d been a threat to his wife and neighbours and the community didn’t know what to do.

Dr. Ali was invited as part of the WHO to Cambodia and Vietnam.  They were there initially to assess boot camp compulsory treatments which didn’t work.  

Rational for Evidence Based Practice
-would improve quality of care
-facilitate consistency - so you could predict
-increase effectiveness and cost effectiveness
-improve accountability - (we work within systems of professional accountability and community accountability to people we treat and the politicians)

Significant national and international efforts:
UK NICE guidelines
USA NIDAs CTNs (clinical trial networks)

Guideline formulation
4 component
-who is the patient
-what is the intervention
-compared to what
-what is the outcome of interest (how important is it?)
(I live in a relatively resource rich environment but this is not necessarily accessible in other venues)
(As a researcher, I’m interested in treatment retention, but politicians see treatment retention as negative - they see it as keeping more people in treatment and more cost, and as failure)

What is quality of evidence
-clinicians weight up benefits and downsides of alternative strategies
-decisions should be influenced by the best estimate of likely outcome AND the confidence in that estimate (we trust peer review journals) 
-failure to do so risks
--supporting things with poor evidence (eg “I woke up cured from heroin addiction “ woman’s journal - gave story of a rapid detox of an individual 3 months  - politicians don’t read medical journals - they read what others read - they thought this was wonderful , a ‘cure’, and quick and cheap - made them question all the other treatments which we put forward.)
--failing to recognise high quality evidence -(growth in evidence is astonishing, new information all the time, real risk we’re going to miss the pearls).

Determinants of quality
RCT’s start high - radomized control trials - we respect them but in our field we often don’t have these available
Observational - these are lower - but they are important because they are what we get 

What can lower quality oin RCT’s
-Study limitations - concealment, intention to treat, blinding, loss to follow up, early stopping  - these should be addressed
-Inconsistency - variability in results, variation in size of effect, overlap in confience intervals, statistical significance of heterogeneity
-Indirectness of evidence - differences in patients, interventions, comparators, outcomes
- other consideratins - imprcise or sparse data, publication bias
(Not all RCT’s are equal)

What can raise quality in observational studies
-large effect size
-clear dose response relationship
-all plausible biases are considered

Factors that influence strength of recommendations
-quality of evidence
-balance between desired and undesired effects
-uncertainty or variability in values and preferences
-whether the intervention is a wise use of resources

In some countries we have one treatment and we do that because we don’t have resources and we don’t have evidence to compell changes in a different direction

Other things that matter
-prevalence of the condition
(eg when methamphetamine began as problem many didn’t know who to spell it - now it’s a major problem)
-equity - treatment should improve all of their lives not just the drug addiction

Systematic reviews can inform decision making and policy

GRADE group
-(Grading of Recommendations Assessment, Development and Evaluation)
--commenced 2000
-found no standarizzed way of presenting information 

GRADE Uptake now used by
Cochrane Collaboration
Upt date
Clinical evidence


GRADE Quality of Evidence
High - considerable confidence in estimate of effect
very low - any estimate of effect is very unceratin

In Cochrane
-Forest Plot of Comparions - a way of making sense of many studies 
eg Buprenorphine versus clonidince
  • showed benefit for inpatients and outpatients
  • many studies done aren’t statistically significant
Forest plot  Buprenorphine versus morphine 
-benefits of one over the other not statistically significant
-more likely to complete withdrawal if you take buprenorphine than morphine but not statistically significant
-attempt to show clinician whether or not evidence is worth listening too

Recognise the business of clinicians
  • National Pharmacotherapy Policiy
  • took existing 4 documents and combined
  • target audience
  • grading of guidelines using stars
  • 4- body of evidence and can be trusted to guide
  • 3 - 
  • 2-
  • 1 - evidence is weak

Not all statements can be grade
C- reflects consensus
or evidence isn’t available yet

Haynes et al 1996 - evidences of effectiveness

Methadone - 60 mg /day more effective than lower does  work in retention in treatment, reduction in unsanctioned opioid and associated high risk behaviour
4 stars

How to develop workforce
-initial focus on education and training
-emphasis on knowledge and skills
-doesn’t always translate into sustainable practice
-quality can be beyond the individuals control--can be dependent on structural, organization and systemic factors

Followed by AOD internals systems approaches
Train and knowledge and skills are affects by organization structurs systems and culturs, government polics and strategies, work condition and opportunities.
Roche and Pidd 2010

Future: a human services system approach
-greater role clarity betwen special and generalist sector
-greater integration with other sectors 

Client centred care
-need linkage between primary care and specialist, need to recognise addiction as a speciality,  in australia - those with addiction medicine qualifications will be re imbursed on the basis of those specialist qualification -relationship should be no different to any other part of care

Integrated Shared Care - family services, child care services, housing services, financial services, legal services etc.

Evidence based implementation
-if we are to make decisions about implementation stategiest informed by research 
-likely effectivenest of interntions - direction, predicted effect size , relative effectiveness
-likely effect modifiers (context, barriers to change)
-resources need to deliver interventions - we’re not all resource rich and we’re going through resource loss so much do what is effective and matters.  

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