Concurrent alcohol dependence poses a significant burden to health and wellbeing of people with e... more Concurrent alcohol dependence poses a significant burden to health and wellbeing of people with established opioid dependence. Although previous research indicates that both genetic and environmental risk factors contribute to the development of drug or alcohol dependence, the role of genetic determinants in development of concurrent alcohol and opioid dependence has not been scrutinised. To search for genetic pre-determinants of concurrent alcohol and opioid dependence, electronic literature searches were completed using MEDLINE (PubMed) and EBSCO (Academic Search Complete) databases. Reference lists of included studies were also searched. In this discussion paper, we provide an overview of the genes (n=33) which are associated with the opioid, serotonergic, dopaminergic, GABA-ergic, cannabinoid, and metabolic systems for each dependency (i.e., alcohol or opioid) separately. The current evidence base is inconclusive regarding an exclusively genetic pre-determinant of concurrent alc...
Purpose“Integrated care” (IC) is an approach to health and social care delivery that aims to prev... more Purpose“Integrated care” (IC) is an approach to health and social care delivery that aims to prevent problems arising from fragmented care systems. The collective content of the IC literature, whilst valuable, has become extensive and wide-ranging to such a degree that knowing what is most important in IC is a challenge. This study aims to address this issue.Design/methodology/approachA scoping review was conducted using Arksey and O'Malley's framework to determine IC priority areas.FindingsTwenty-one papers relevant to the research question were identified. These included studies from many geographical regions, encompassing several study designs and a range of populations and sample sizes. The findings identified four priority areas that should be considered when designing and implementing IC models: (1) communication, (2) coordination, collaboration and cooperation (CCC), (3) responsibility and accountability and (4) a population approach. Multiple elements were identified...
Background: Identifying and treating problem alcohol use among people who also use illicit drugs ... more Background: Identifying and treating problem alcohol use among people who also use illicit drugs is a challenge. Primary care is well placed to address this challenge but there are several barriers which may prevent this occurring. The objective of this study was to determine if a complex intervention designed to support screening and brief intervention for problem alcohol use among people receiving opioid agonist treatment is feasible and acceptable to healthcare providers and their patients in a primary care setting. Methods: A randomised, controlled, pre-and-post design measured feasibility and acceptability of alcohol screening based on recruitment and retention rates among patients and practices. Efficacy was measured by screening and brief intervention rates and the proportion of patients with problem alcohol use. Results: Of 149 practices that were invited, 19 (12.8 %) agreed to participate. At follow up, 13 (81.3 %) practices with 81 (62.8 %) patients were retained. Alcohol screening rates in the intervention group were higher at follow up than in the control group (53 % versus 26 %) as were brief intervention rates (47 % versus 19 %). Four (18 %) people reduced their problem drinking (measured by AUDIT-C), compared to two (7 %) in the control group. Conclusions: Alcohol screening among people receiving opioid agonist treatment in primary care seems feasible. A definitive trial is needed. Such a trial would require over sampling and greater support for participating practices to allow for challenges in recruitment of patients and practices.
Objective: We sought to establish the views of general practitioners about detecting and managing... more Objective: We sought to establish the views of general practitioners about detecting and managing patients with a first episode of schizophrenia in Ireland.Method: Twenty per cent of GPs were invited to participate in a cross-sectional postal survey.Results: Sixty-two per cent (n = 261) participated. Almost all (99.2%) see at least one case of suspected first episode schizophrenia annually. The most commonly (80.7%) encountered symptom is ‘bizarre behaviour’. Many (47.7%) rarely or never prescribe antipsychotics to patients whom they suspect have a first episode of schizophrenia. However, 80.6% of GPs reported that they ‘always’ refer this group of patients to psychiatric services. Over half (57.8%) advised patients with schizophrenia to continue medication for less than a year. A large number of respondents reported that it is difficult to obtain a rapid psychiatric assessment.Conclusions: GPs want more information about identifying early psychosis, a closer liaison with psychiatri...
Dublin has an estimated 13,460 opiate drug users. The role of general practice in providing care ... more Dublin has an estimated 13,460 opiate drug users. The role of general practice in providing care for this group has increased over the last four years. A Central Methadone Treatment List (CMTL) registers all clients currently on treatment. To obtain a social, demographic and drug using profile of opiate users attending general practitioners (GPs) for methadone maintenance. A cross sectional survey of opiate users attending general practice for methadone maintenance in the Dublin area in early 1999. Data was collected on 571 clients (62% of total number attending general practice), of whom 97% had used heroin in the past and 12% had never injected. Although clients had been receiving methadone maintenance in general practice for a mean of 14 months, 16% were still using heroin, of whom 31% were still injecting. The mean age of first drug use was 15.5 years and of first injecting was 19.4 years. Younger clients are starting both to use drugs and inject drugs at an earlier age. Record ...
The British journal of general practice : the journal of the Royal College of General Practitioners, 2000
Heroin overdose is responsible for significant mortality. It has not previously been highlighted ... more Heroin overdose is responsible for significant mortality. It has not previously been highlighted as an important prevention or care issue for general practitioners (GPs) involved in the management of drug misuse. To examine the prevalence and experience of heroin overdose in a population of drug users attending a general practice. A questionnaire-based interview of drug users attending a general practice in Dublin, Ireland. Twenty-four (73% of estimated total) drug users were interviewed. Although 17 (71%) were on recognised methadone treatment programmes, 10 (42%) were still injecting heroin. A total of 23 (96%) had witnessed an overdose, with 10 (42%) having been victims of overdose themselves. Twenty-two (92%) knew a victim of fatal overdose, with four (17%) having been present at a fatal overdose. The interviews revealed high levels of activity associated with overdose and poor use of preventive measures. The issue of prevention and management of overdose should become a priorit...
Purpose: This paper describes the development and process evaluation of an educational interventi... more Purpose: This paper describes the development and process evaluation of an educational intervention, designed to help general practitioners (GPs) identify and manage problem alcohol use among problem drug users. Methodology: The educational session was developed as part of a complex intervention which was informed by the Medical Research Council framework for complex interventions. A Cochrane review and a modified Delphi-facilitated consensus process formed the theoretical phase of the development. The modelling phase involved qualitative interviews with professionals and patients. The training's learning outcomes included alcohol screening and delivery of brief psychosocial interventions and this was facilitated by demonstration of clinical guidelines, presentation, video, group discussion and/or role play. Findings: Participants (N=17) from three general practices and local medical school participated in four workshops. They perceived the training as most helpful in improving their ability to perform alcohol screening. Most useful components of the session were the presentation, handout and group discussion with participants appreciating the opportunity to share their ideas with peers. Value: Training primary healthcare professionals in alcohol screening and brief psychosocial interventions among problem drug users appears feasible. Along with the educational workshops, the implementation strategies should utilise multi-level interventions to support these activities among GPs.
Alcohol use is an important issue among problem drug users. Although screening and brief interven... more Alcohol use is an important issue among problem drug users. Although screening and brief intervention (SBI) are effective in reducing problem alcohol use in primary care, no research has examined this issue among problem drug users. The objective of this study is to determine if a complex intervention including SBI for problem alcohol use among problem drug users is feasible and acceptable in practice. This study also aims to evaluate the effectiveness of the intervention in reducing the proportion of patients with problem alcohol use. Psychosocial intervention for alcohol use among problem drug users (PINTA) is a pilot feasibility study of a complex intervention comprising SBI for problem alcohol use among problem drug users with cluster randomization at the level of general practice, integrated qualitative process evaluation, and involving general practices in two socioeconomically deprived regions. Practices (N=16) will be eligible to participate if they are registered to prescri...
GPs, as healthcare professionals with whom young people commonly interact, have a central role in... more GPs, as healthcare professionals with whom young people commonly interact, have a central role in early intervention for mental health problems. However, successfully fulfilling this role is a challenge, and this is especially in deprived urban areas. To inform a complex intervention to support GPs in this important role, we aim to identify the key areas in which general practice can help address youth mental health and strategies to enhance implementation. We conducted a modified Delphi study which involved establishing an expert panel involving key stakeholders/service providers at two deprived urban areas. The group reviewed emerging literature on the topic at a series of meetings and consensus was facilitated by iterative surveys. We identified 20 individual roles in which GPs could help address youth mental health, across five domains: (1) prevention, health promotion and access, (2) assessment and identification, (3) treatment strategies, (4) interaction with other agencies/re...
Aim: To explore and describe the experience of mental health and addiction for young people livin... more Aim: To explore and describe the experience of mental health and addiction for young people living in urban deprived areas in Ireland. Method: Semi-structured qualitative interviews were conducted with 20 young adults attending health and social care agencies in two deprived urban areas, and analysed using thematic analysis. Results: Five main themes were identified: experiencing symptoms, symptom progression, delay accessing help, loss of control/crisis point, and consequences of mental health and substance use issues. As young people delayed help, symptoms disrupted normal life progression and they found themselves unable to engage in everyday activities. Living in deprivation made it harder to avoid developing problems: many had added stressors, less familial support and early exposure to violence, addiction and bereavement. Conclusion: Young people in urban deprived areas are vulnerable to mental health and addiction issues. Early identification is necessary to halt this progression to improve their chances of achieving their potential.
To determine the effectiveness of psychosocial interventions targeting problem alcohol use versus... more To determine the effectiveness of psychosocial interventions targeting problem alcohol use versus other treatments in illicit drug users.
Cochrane database of systematic reviews (Online), Jan 14, 2012
Problem alcohol use is common among illicit drug users and is associated with adverse health outc... more Problem alcohol use is common among illicit drug users and is associated with adverse health outcomes. It is also an important factor in poor prognosis among drug users with hepatitis C virus (HCV) as it impacts on progression to hepatic cirrhosis or opiate overdose in opioid users.
Background Hepatitis C is a common infection among people who attend GPs for methadone maintenanc... more Background Hepatitis C is a common infection among people who attend GPs for methadone maintenance treatment. Aim To determine the views of GPs towards clinical guidelines for the management of hepatitis C among current or former injecting drug users in advance of their implementation. Methods A purposive sample of 14 GPs (10% of the total prescribing methadone at the time the guidelines were developed) was invited to review a pre-publication draft of the guidelines and interviewed regarding content, presentation, perceived barriers to implementation and suggested interventions to facilitate effective implementation of the guidelines. Results GPs indicated the guidelines were useful but suggested aspects of presentation should be clarified. Organisational issues were identified as the principal barriers to effective implementation, with the provision of additional nursing support the principal intervention suggested to facilitate implementation. Conclusions Interviewing intended recipients may be an important step in ensuring clinical practice guidelines are effectively implemented.
BACKGROUND: Problem alcohol use is common among problem drug users (PDU) and associated with adve... more BACKGROUND: Problem alcohol use is common among problem drug users (PDU) and associated with adverse health outcomes. Primary care has an important role in the overall stepped approach to alcohol treatment, especially screening and brief intervention (SBI). AIM: To discuss three themes that emerged from an exploration of the literature on SBI for problem alcohol use in drug users attending primary care. METHODS: Material for this discussion paper was gathered from three biomedical databases (PubMed, PsycINFO and Cochrane library), conference proceedings and online resources of professional organisations or national health agencies. RESULTS: Themes discussed in this paper are: (a) the potential of primary care for delivery of alcohol SBIs to PDUs, (b) screening methods and (c) application of brief interventions to PDUs. CONCLUSIONS: Although SBI improves health outcomes associated with problem alcohol use in the general population, further research is needed among high-risk patient g...
Concurrent alcohol dependence poses a significant burden to health and wellbeing of people with e... more Concurrent alcohol dependence poses a significant burden to health and wellbeing of people with established opioid dependence. Although previous research indicates that both genetic and environmental risk factors contribute to the development of drug or alcohol dependence, the role of genetic determinants in development of concurrent alcohol and opioid dependence has not been scrutinised. To search for genetic pre-determinants of concurrent alcohol and opioid dependence, electronic literature searches were completed using MEDLINE (PubMed) and EBSCO (Academic Search Complete) databases. Reference lists of included studies were also searched. In this discussion paper, we provide an overview of the genes (n=33) which are associated with the opioid, serotonergic, dopaminergic, GABA-ergic, cannabinoid, and metabolic systems for each dependency (i.e., alcohol or opioid) separately. The current evidence base is inconclusive regarding an exclusively genetic pre-determinant of concurrent alc...
Purpose“Integrated care” (IC) is an approach to health and social care delivery that aims to prev... more Purpose“Integrated care” (IC) is an approach to health and social care delivery that aims to prevent problems arising from fragmented care systems. The collective content of the IC literature, whilst valuable, has become extensive and wide-ranging to such a degree that knowing what is most important in IC is a challenge. This study aims to address this issue.Design/methodology/approachA scoping review was conducted using Arksey and O'Malley's framework to determine IC priority areas.FindingsTwenty-one papers relevant to the research question were identified. These included studies from many geographical regions, encompassing several study designs and a range of populations and sample sizes. The findings identified four priority areas that should be considered when designing and implementing IC models: (1) communication, (2) coordination, collaboration and cooperation (CCC), (3) responsibility and accountability and (4) a population approach. Multiple elements were identified...
Background: Identifying and treating problem alcohol use among people who also use illicit drugs ... more Background: Identifying and treating problem alcohol use among people who also use illicit drugs is a challenge. Primary care is well placed to address this challenge but there are several barriers which may prevent this occurring. The objective of this study was to determine if a complex intervention designed to support screening and brief intervention for problem alcohol use among people receiving opioid agonist treatment is feasible and acceptable to healthcare providers and their patients in a primary care setting. Methods: A randomised, controlled, pre-and-post design measured feasibility and acceptability of alcohol screening based on recruitment and retention rates among patients and practices. Efficacy was measured by screening and brief intervention rates and the proportion of patients with problem alcohol use. Results: Of 149 practices that were invited, 19 (12.8 %) agreed to participate. At follow up, 13 (81.3 %) practices with 81 (62.8 %) patients were retained. Alcohol screening rates in the intervention group were higher at follow up than in the control group (53 % versus 26 %) as were brief intervention rates (47 % versus 19 %). Four (18 %) people reduced their problem drinking (measured by AUDIT-C), compared to two (7 %) in the control group. Conclusions: Alcohol screening among people receiving opioid agonist treatment in primary care seems feasible. A definitive trial is needed. Such a trial would require over sampling and greater support for participating practices to allow for challenges in recruitment of patients and practices.
Objective: We sought to establish the views of general practitioners about detecting and managing... more Objective: We sought to establish the views of general practitioners about detecting and managing patients with a first episode of schizophrenia in Ireland.Method: Twenty per cent of GPs were invited to participate in a cross-sectional postal survey.Results: Sixty-two per cent (n = 261) participated. Almost all (99.2%) see at least one case of suspected first episode schizophrenia annually. The most commonly (80.7%) encountered symptom is ‘bizarre behaviour’. Many (47.7%) rarely or never prescribe antipsychotics to patients whom they suspect have a first episode of schizophrenia. However, 80.6% of GPs reported that they ‘always’ refer this group of patients to psychiatric services. Over half (57.8%) advised patients with schizophrenia to continue medication for less than a year. A large number of respondents reported that it is difficult to obtain a rapid psychiatric assessment.Conclusions: GPs want more information about identifying early psychosis, a closer liaison with psychiatri...
Dublin has an estimated 13,460 opiate drug users. The role of general practice in providing care ... more Dublin has an estimated 13,460 opiate drug users. The role of general practice in providing care for this group has increased over the last four years. A Central Methadone Treatment List (CMTL) registers all clients currently on treatment. To obtain a social, demographic and drug using profile of opiate users attending general practitioners (GPs) for methadone maintenance. A cross sectional survey of opiate users attending general practice for methadone maintenance in the Dublin area in early 1999. Data was collected on 571 clients (62% of total number attending general practice), of whom 97% had used heroin in the past and 12% had never injected. Although clients had been receiving methadone maintenance in general practice for a mean of 14 months, 16% were still using heroin, of whom 31% were still injecting. The mean age of first drug use was 15.5 years and of first injecting was 19.4 years. Younger clients are starting both to use drugs and inject drugs at an earlier age. Record ...
The British journal of general practice : the journal of the Royal College of General Practitioners, 2000
Heroin overdose is responsible for significant mortality. It has not previously been highlighted ... more Heroin overdose is responsible for significant mortality. It has not previously been highlighted as an important prevention or care issue for general practitioners (GPs) involved in the management of drug misuse. To examine the prevalence and experience of heroin overdose in a population of drug users attending a general practice. A questionnaire-based interview of drug users attending a general practice in Dublin, Ireland. Twenty-four (73% of estimated total) drug users were interviewed. Although 17 (71%) were on recognised methadone treatment programmes, 10 (42%) were still injecting heroin. A total of 23 (96%) had witnessed an overdose, with 10 (42%) having been victims of overdose themselves. Twenty-two (92%) knew a victim of fatal overdose, with four (17%) having been present at a fatal overdose. The interviews revealed high levels of activity associated with overdose and poor use of preventive measures. The issue of prevention and management of overdose should become a priorit...
Purpose: This paper describes the development and process evaluation of an educational interventi... more Purpose: This paper describes the development and process evaluation of an educational intervention, designed to help general practitioners (GPs) identify and manage problem alcohol use among problem drug users. Methodology: The educational session was developed as part of a complex intervention which was informed by the Medical Research Council framework for complex interventions. A Cochrane review and a modified Delphi-facilitated consensus process formed the theoretical phase of the development. The modelling phase involved qualitative interviews with professionals and patients. The training's learning outcomes included alcohol screening and delivery of brief psychosocial interventions and this was facilitated by demonstration of clinical guidelines, presentation, video, group discussion and/or role play. Findings: Participants (N=17) from three general practices and local medical school participated in four workshops. They perceived the training as most helpful in improving their ability to perform alcohol screening. Most useful components of the session were the presentation, handout and group discussion with participants appreciating the opportunity to share their ideas with peers. Value: Training primary healthcare professionals in alcohol screening and brief psychosocial interventions among problem drug users appears feasible. Along with the educational workshops, the implementation strategies should utilise multi-level interventions to support these activities among GPs.
Alcohol use is an important issue among problem drug users. Although screening and brief interven... more Alcohol use is an important issue among problem drug users. Although screening and brief intervention (SBI) are effective in reducing problem alcohol use in primary care, no research has examined this issue among problem drug users. The objective of this study is to determine if a complex intervention including SBI for problem alcohol use among problem drug users is feasible and acceptable in practice. This study also aims to evaluate the effectiveness of the intervention in reducing the proportion of patients with problem alcohol use. Psychosocial intervention for alcohol use among problem drug users (PINTA) is a pilot feasibility study of a complex intervention comprising SBI for problem alcohol use among problem drug users with cluster randomization at the level of general practice, integrated qualitative process evaluation, and involving general practices in two socioeconomically deprived regions. Practices (N=16) will be eligible to participate if they are registered to prescri...
GPs, as healthcare professionals with whom young people commonly interact, have a central role in... more GPs, as healthcare professionals with whom young people commonly interact, have a central role in early intervention for mental health problems. However, successfully fulfilling this role is a challenge, and this is especially in deprived urban areas. To inform a complex intervention to support GPs in this important role, we aim to identify the key areas in which general practice can help address youth mental health and strategies to enhance implementation. We conducted a modified Delphi study which involved establishing an expert panel involving key stakeholders/service providers at two deprived urban areas. The group reviewed emerging literature on the topic at a series of meetings and consensus was facilitated by iterative surveys. We identified 20 individual roles in which GPs could help address youth mental health, across five domains: (1) prevention, health promotion and access, (2) assessment and identification, (3) treatment strategies, (4) interaction with other agencies/re...
Aim: To explore and describe the experience of mental health and addiction for young people livin... more Aim: To explore and describe the experience of mental health and addiction for young people living in urban deprived areas in Ireland. Method: Semi-structured qualitative interviews were conducted with 20 young adults attending health and social care agencies in two deprived urban areas, and analysed using thematic analysis. Results: Five main themes were identified: experiencing symptoms, symptom progression, delay accessing help, loss of control/crisis point, and consequences of mental health and substance use issues. As young people delayed help, symptoms disrupted normal life progression and they found themselves unable to engage in everyday activities. Living in deprivation made it harder to avoid developing problems: many had added stressors, less familial support and early exposure to violence, addiction and bereavement. Conclusion: Young people in urban deprived areas are vulnerable to mental health and addiction issues. Early identification is necessary to halt this progression to improve their chances of achieving their potential.
To determine the effectiveness of psychosocial interventions targeting problem alcohol use versus... more To determine the effectiveness of psychosocial interventions targeting problem alcohol use versus other treatments in illicit drug users.
Cochrane database of systematic reviews (Online), Jan 14, 2012
Problem alcohol use is common among illicit drug users and is associated with adverse health outc... more Problem alcohol use is common among illicit drug users and is associated with adverse health outcomes. It is also an important factor in poor prognosis among drug users with hepatitis C virus (HCV) as it impacts on progression to hepatic cirrhosis or opiate overdose in opioid users.
Background Hepatitis C is a common infection among people who attend GPs for methadone maintenanc... more Background Hepatitis C is a common infection among people who attend GPs for methadone maintenance treatment. Aim To determine the views of GPs towards clinical guidelines for the management of hepatitis C among current or former injecting drug users in advance of their implementation. Methods A purposive sample of 14 GPs (10% of the total prescribing methadone at the time the guidelines were developed) was invited to review a pre-publication draft of the guidelines and interviewed regarding content, presentation, perceived barriers to implementation and suggested interventions to facilitate effective implementation of the guidelines. Results GPs indicated the guidelines were useful but suggested aspects of presentation should be clarified. Organisational issues were identified as the principal barriers to effective implementation, with the provision of additional nursing support the principal intervention suggested to facilitate implementation. Conclusions Interviewing intended recipients may be an important step in ensuring clinical practice guidelines are effectively implemented.
BACKGROUND: Problem alcohol use is common among problem drug users (PDU) and associated with adve... more BACKGROUND: Problem alcohol use is common among problem drug users (PDU) and associated with adverse health outcomes. Primary care has an important role in the overall stepped approach to alcohol treatment, especially screening and brief intervention (SBI). AIM: To discuss three themes that emerged from an exploration of the literature on SBI for problem alcohol use in drug users attending primary care. METHODS: Material for this discussion paper was gathered from three biomedical databases (PubMed, PsycINFO and Cochrane library), conference proceedings and online resources of professional organisations or national health agencies. RESULTS: Themes discussed in this paper are: (a) the potential of primary care for delivery of alcohol SBIs to PDUs, (b) screening methods and (c) application of brief interventions to PDUs. CONCLUSIONS: Although SBI improves health outcomes associated with problem alcohol use in the general population, further research is needed among high-risk patient g...
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Papers by Walter Cullen