Appendix F. List of modifiable prognostic factors. Table F1: Modifiable prognostic factors evalua... more Appendix F. List of modifiable prognostic factors. Table F1: Modifiable prognostic factors evaluated by included reviews. (DOCX 14 kb)
There has been a large increase in the number of prescriptions for opioid drugs in the United Kin... more There has been a large increase in the number of prescriptions for opioid drugs in the United Kingdom over the last 20 years or more and the prescribing of opioids in high doses continues to increase. Much opioid prescribing is for chronic non-cancer pain (CNCP) despite serious doubts about the long-term effectiveness of opioids for this indication. Clinical experience is that there are increasing numbers of patients who are on high dosages of opioid drugs over sustained periods which provide limited or no pain relief while having significant negative effects on functioning and quality of life. The aim of this article is to bring readers’ attention to some clinical observations of the CNCP population with high doses and to describe an intervention to reduce these doses. Many of these patients have no clinical features of addiction; we suggest that those who show little or no substance misuse behaviours are best understood as a distinct clinical population who have different treatment needs. In order to understand and treat these patients, a model is required which, rather than seeing the problem as lying solely with the patient, focuses on the interaction between the individual and his or her environment and seeks a change in what the patient does every day, rather than a simple, and largely unattainable, goal of symptom elimination. The clinician authors worked together to develop an intervention based upon approaches taken from both pain management and psychiatric practice. A detailed description of this rapid opioid reduction intervention (RORI) is provided along with some preliminary outcome data.
Aims/BackgroundSocial determinants of health (SDOH) are social factors that have a causal role in... more Aims/BackgroundSocial determinants of health (SDOH) are social factors that have a causal role in ill health and have an adverse effect on health outcomes. SDOH are part of the UK medical student curriculum but mainly discusses epidemiologically. There are few educational approaches that aim to incorporate an understanding of SDOH into the experiential and competency-based elements of undergraduate medical education. Prisoners are a population who experience high levels of stigma, social adversity and health disadvantage. Clinical attachments in prison may teach students about the impact of SDOH in a vivid and memorable way. Aims: We aim to explore changes in medical students' knowledge/attitude towards SDOH during and after psychiatry placements at HMP-Berwyn prison.MethodsAll year four medical students on psychiatry placement in North East Wales during 2021–2022 participated. In each of the six placement cohorts, one student did their psychiatry placement in prison. All the ot...
Background The classification of mental disorders used to be based only on people seen by hospita... more Background The classification of mental disorders used to be based only on people seen by hospital psychiatrists. In fact, most people with a mental disorder were, and are, not seen by psychiatrists because of decisions made prior to psychiatric consultation. The first description of this ‘pathway’ to care and its levels and filters was published by Goldberg and Huxley in 1980. Aims To conduct a review of papers relevant to the application of the Goldberg–Huxley model in the 21st century. Method Systematic review (PROSPERO registration CRD42021270603) of the pathway to psychiatric care in the 21st century. The review concentrates on community surveys and passage through the first filter (consultation in primary care or its equivalent). Ten databases were searched for papers meeting the defined inclusion criteria published between 2000 and 2019 and completed on 15 February 2020. Results In total, 1824 papers were retrieved, 137 screened fully and 31 included in this review. The resul...
BackgroundPrescribing of opioid medication has increased over the past 20 years. Most occurs in p... more BackgroundPrescribing of opioid medication has increased over the past 20 years. Most occurs in primary care for chronic pain. There is little evidence that these drugs are effective for this indication. There are concerns about the continuing prescribing of opioids, particularly in the long term and at high doses.AimTo explore GPs’ experiences of prescribing opioids, problems encountered, and factors militating against good prescribing practice.Design & settingQualitative interviews with GPs who prescribe opioids in primary care in North East Wales.MethodSemi-structured interviews with 20 GPs were transcribed and subjected to thematic analysis utilising the framework approach.ResultsParticipating GPs identified a range of problems associated with prescribed opioids. They were concerned about limited effectiveness of the drugs and what they perceived as addiction resulting from their use. They identified healthcare system factors that were obstacles to good prescribing practice such...
BackgroundThere are concerns about continuing increases in the number of patients prescribed long... more BackgroundThere are concerns about continuing increases in the number of patients prescribed long-term opioids and the prescribing of 'strong' opioids for chronic pain. Little is known about patients who are prescribed these long-term, high-dose drugs.AimTo understand patterns of opioid prescribing that lead to long-term, high-dose use.Design & settingA mixed-method study of the opioid prescription histories of patients using high doses in a North Wales GP practice.MethodAll patients on high-dose opioids during the census week were identified. Summary graphs of the prescription histories were prepared. Qualitative analysis was conducted individually by four researchers. A workshop was held to arrive at a consensus about common features and to inform further quantitative analysis.ResultsA quarter of high-dose regimens were initiated outside the practice, either in a different primary care practice or in secondary care. The majority of the remaining patients showed a pattern o...
AimsBackground: Although social determinants of health (SDOH) are to some extent incorporated wit... more AimsBackground: Although social determinants of health (SDOH) are to some extent incorporated within preclinical medical education, little validated educational methodology exists to provide guidance on how to integrate teaching about SDOH within the competency-based training of medical students’ clinical years. This is potentially important. The COVID-19 pandemic has highlighted the importance of SDOH, and social determinants have become topical, with increasing discussion in journals about equity, inequality, and sustainability. Sir Michael Marmot's 2020 review has highlighted these issues. Consequently, the evaluation of medical students’ experience of prison placements is an interesting area to investigate. This will help us to explore their understanding of SDOH, and implications of gained knowledge for their future practice. Aims: This study explores changes in year four psychological medicine students’ knowledge and attitude towards SDOH during prison placements.MethodsA ...
Appendix F. List of modifiable prognostic factors. Table F1: Modifiable prognostic factors evalua... more Appendix F. List of modifiable prognostic factors. Table F1: Modifiable prognostic factors evaluated by included reviews. (DOCX 14 kb)
There has been a large increase in the number of prescriptions for opioid drugs in the United Kin... more There has been a large increase in the number of prescriptions for opioid drugs in the United Kingdom over the last 20 years or more and the prescribing of opioids in high doses continues to increase. Much opioid prescribing is for chronic non-cancer pain (CNCP) despite serious doubts about the long-term effectiveness of opioids for this indication. Clinical experience is that there are increasing numbers of patients who are on high dosages of opioid drugs over sustained periods which provide limited or no pain relief while having significant negative effects on functioning and quality of life. The aim of this article is to bring readers’ attention to some clinical observations of the CNCP population with high doses and to describe an intervention to reduce these doses. Many of these patients have no clinical features of addiction; we suggest that those who show little or no substance misuse behaviours are best understood as a distinct clinical population who have different treatment needs. In order to understand and treat these patients, a model is required which, rather than seeing the problem as lying solely with the patient, focuses on the interaction between the individual and his or her environment and seeks a change in what the patient does every day, rather than a simple, and largely unattainable, goal of symptom elimination. The clinician authors worked together to develop an intervention based upon approaches taken from both pain management and psychiatric practice. A detailed description of this rapid opioid reduction intervention (RORI) is provided along with some preliminary outcome data.
Aims/BackgroundSocial determinants of health (SDOH) are social factors that have a causal role in... more Aims/BackgroundSocial determinants of health (SDOH) are social factors that have a causal role in ill health and have an adverse effect on health outcomes. SDOH are part of the UK medical student curriculum but mainly discusses epidemiologically. There are few educational approaches that aim to incorporate an understanding of SDOH into the experiential and competency-based elements of undergraduate medical education. Prisoners are a population who experience high levels of stigma, social adversity and health disadvantage. Clinical attachments in prison may teach students about the impact of SDOH in a vivid and memorable way. Aims: We aim to explore changes in medical students' knowledge/attitude towards SDOH during and after psychiatry placements at HMP-Berwyn prison.MethodsAll year four medical students on psychiatry placement in North East Wales during 2021–2022 participated. In each of the six placement cohorts, one student did their psychiatry placement in prison. All the ot...
Background The classification of mental disorders used to be based only on people seen by hospita... more Background The classification of mental disorders used to be based only on people seen by hospital psychiatrists. In fact, most people with a mental disorder were, and are, not seen by psychiatrists because of decisions made prior to psychiatric consultation. The first description of this ‘pathway’ to care and its levels and filters was published by Goldberg and Huxley in 1980. Aims To conduct a review of papers relevant to the application of the Goldberg–Huxley model in the 21st century. Method Systematic review (PROSPERO registration CRD42021270603) of the pathway to psychiatric care in the 21st century. The review concentrates on community surveys and passage through the first filter (consultation in primary care or its equivalent). Ten databases were searched for papers meeting the defined inclusion criteria published between 2000 and 2019 and completed on 15 February 2020. Results In total, 1824 papers were retrieved, 137 screened fully and 31 included in this review. The resul...
BackgroundPrescribing of opioid medication has increased over the past 20 years. Most occurs in p... more BackgroundPrescribing of opioid medication has increased over the past 20 years. Most occurs in primary care for chronic pain. There is little evidence that these drugs are effective for this indication. There are concerns about the continuing prescribing of opioids, particularly in the long term and at high doses.AimTo explore GPs’ experiences of prescribing opioids, problems encountered, and factors militating against good prescribing practice.Design & settingQualitative interviews with GPs who prescribe opioids in primary care in North East Wales.MethodSemi-structured interviews with 20 GPs were transcribed and subjected to thematic analysis utilising the framework approach.ResultsParticipating GPs identified a range of problems associated with prescribed opioids. They were concerned about limited effectiveness of the drugs and what they perceived as addiction resulting from their use. They identified healthcare system factors that were obstacles to good prescribing practice such...
BackgroundThere are concerns about continuing increases in the number of patients prescribed long... more BackgroundThere are concerns about continuing increases in the number of patients prescribed long-term opioids and the prescribing of 'strong' opioids for chronic pain. Little is known about patients who are prescribed these long-term, high-dose drugs.AimTo understand patterns of opioid prescribing that lead to long-term, high-dose use.Design & settingA mixed-method study of the opioid prescription histories of patients using high doses in a North Wales GP practice.MethodAll patients on high-dose opioids during the census week were identified. Summary graphs of the prescription histories were prepared. Qualitative analysis was conducted individually by four researchers. A workshop was held to arrive at a consensus about common features and to inform further quantitative analysis.ResultsA quarter of high-dose regimens were initiated outside the practice, either in a different primary care practice or in secondary care. The majority of the remaining patients showed a pattern o...
AimsBackground: Although social determinants of health (SDOH) are to some extent incorporated wit... more AimsBackground: Although social determinants of health (SDOH) are to some extent incorporated within preclinical medical education, little validated educational methodology exists to provide guidance on how to integrate teaching about SDOH within the competency-based training of medical students’ clinical years. This is potentially important. The COVID-19 pandemic has highlighted the importance of SDOH, and social determinants have become topical, with increasing discussion in journals about equity, inequality, and sustainability. Sir Michael Marmot's 2020 review has highlighted these issues. Consequently, the evaluation of medical students’ experience of prison placements is an interesting area to investigate. This will help us to explore their understanding of SDOH, and implications of gained knowledge for their future practice. Aims: This study explores changes in year four psychological medicine students’ knowledge and attitude towards SDOH during prison placements.MethodsA ...
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