Impact of changes to the delivery of opioid agonist treatment, introduced during the COVID-19 pandemic, on treatment access and dropout in Ireland: An interrupted time series analysis.

BACKGROUND: Following the emergence of COVID-19, Ireland introduced national contingency guidelines to ensure rapid and uninterrupted access to opioid agonist treatment (OAT). This study aims to assess the impact of changes introduced to the delivery of OAT on the number of people accessing treatment and treatment dropout. METHODS: The study conducted interrupted time series analyses, with separate segmented regression models (March 2019-February 2020) vs (April 2020-March 2021), for (A) total number of people accessing OAT, (B) the number initiating treatment, and (C) the number dropping out of treatment, using data from the National OAT treatment register. The study examined immediate (change in level or intercept: ß2) and long-term impacts (change in slope; i.e., the difference between the slope before and after the intervention: ß3). We performed total and stratified analyses by gender, age group (<40/≥40 years), and OAT drug (methadone or buprenorphine). RESULTS: A total of 10,251 people accessed OAT in Ireland in March 2019 (2 % buprenorphine, n = 178), increasing to 11,441 (4 % buprenorphine, n = 471) in March 2021. The study observed an immediate (ß2 = 504.3, p < 0.001) and continued (ß3 = 31.9, p < 0.001) increase of people accessing treatment following the introduction of the OAT contingency guidelines. In contrast, observed changes in level and slope were not significant for treatment initiation or dropout. The study did find, however, a modest reduction in dropout among those receiving buprenorphine (ß3 = -0.6, p = 0.036). CONCLUSIONS: Changes introduced to the delivery of OAT, under the COVID-19 contingency guidelines, are associated with increased access to OAT in Ireland, with no evidence of increase in treatment dropout. Whether these effects will be maintained over time remains to be seen.

Psychosocial interventions for alcohol use among problem drug users: protocol for a feasibility study in primary care.

BACKGROUND: 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. OBJECTIVE: 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. METHODS: 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 prescribe methadone and/or at least 10 patients of the practice are currently receiving addiction treatment. Patient must meet the following inclusion criteria to participate in this study: 18 years of age or older, receiving addiction treatment/care (eg, methadone), or known to be a problem drug user. This study is based on a complex intervention supporting SBI for problem alcohol use among problem drug users (experimental group) compared to an "assessment-only" control group. Control practices will be provided with a delayed intervention after follow-up. Primary outcomes of the study are feasibility and acceptability of the intervention to patients and practitioners. Secondary outcome includes the effectiveness of the intervention on care process (documented rates of SBI) and outcome (proportion of patients with problem alcohol use at the follow-up). A stratified random sampling method will be used to select general practices based on the level of training for providing addiction-related care and geographical area. In this study, general practitioners and practice staff, researchers, and trainers will not be blinded to treatment, but patients and remote randomizers will be unaware of the treatment. RESULTS: This study is ongoing and a protocol system is being developed for the study. This study may inform future research among the high-risk population of problem drug users by providing initial indications as to whether psychosocial interventions for problem alcohol use are feasible, acceptable, and also effective among problem drug users attending primary care. CONCLUSIONS: This is the first study to examine the feasibility and acceptability of complex intervention in primary care to enhance alcohol SBI among problem drug users. Results of this study will inform future research among this high-risk population and guide policy and service development locally and internationally.

The advanced paramedic internship: an important clinical learning opportunity.

INTRODUCTION: Ireland introduced paramedic services to its ambulance services in 2005 and an accredited training programme has begun to train candidates. The training programme is 11 months long and includes distance learning, taught and internship phases. The internship involves six weeks of supervised paramedic practice in the setting of a rapid response vehicle crewed by two candidates, principally in urban and suburban settings. Internationally, little information has been published on the educational opportunities or impact of paramedic training and particularly on the clinical practice components of that training. METHODS: A detailed audit was carried out of clinical care activity completed by the initial 30 candidates to undertake the internship. Data were collected on patient descriptors, types of clinical problem, basic and advanced interventions undertaken and the Clinical Practice Guideline-Advanced (CPG-A) under which the advanced intervention was undertaken. Data were compiled using SPSS V11. RESULTS: Thirty candidates completed the 6-week internship, caring for a total of 1237 patients, of whom 46.3% had an advanced intervention. Intravenous cannulation was the most common advanced procedure undertaken, in one fifth of all patients seen. Twenty-two candidates inserted a total of 42 tracheal tubes or laryngeal mask airways and 55 cardiac arrests were managed. Smaller numbers of glycaemic, epilepsy and fluid resuscitation cases were dealt with. DISCUSSION: Well supervised clinical training facilitates the transition from student to autonomous practitioner. Candidates in this programme accomplished a range of clinical assessments, decisions and interventions with the support of a senior supervisor, but in a situation where they carried responsibility for safe practice.

Impossible laryngeal intubation in an infant with Fraser syndrome.

Congenital webbing of the vocal cords is rare, and is usually incompatible with life. We report a case of an infant with Fraser syndrome who required a surgical airway because of a severe stenosis of her airway secondary to a glottic web. The decision process leading to tracheostomy in this neonate is described. The pertinent features of Fraser syndrome in relation to airway management are discussed.