Mal uso y abuso de opioides

Lieke J.A. Hassink-Franke Evelyn M. van W eel-B aum garten Eric W ierda

Maike W.M. Engelen M e ch tild M.L. Beek Hans H.J. Bor

Henk J.M. van den Hoogen Peter L.B.J. Lucassen Chris van Weel

Submitted fo r publication

Presented at:

A b s tra c t

Introduction

In general practice many patients present w ith emotional symptoms. Both patients and physicians desire effective non-pharmacological treatm ents. To study the effectiveness of problem ­ solving tre a tm e n t (PST) delivered by trained general practice (GP) registrars fo r patients w ith emotional symptoms.

Methods

In a controlled clinical trial we compared the effectiveness of PST versus usual care fo r patients w ith emotional symptoms. Dutch GP registrars provided PST or usual care, according to their own preference. Patients were included if they (a) had presented fo r three or more consultations w ith emotional symptoms in the past 6 months; and (b) scored fo u r or more on the 1 2 -ite m General Health Questionnaire. Outcomes at 3 and 9 month follow -up were standard measures of depression, anxiety and quality of life.

Results

T h irty-e ig h t GP registrars provided PST and included 9 8 patients; 4 3 provided usual care and included 1 0 4 patients. PST patients improved significantly more than usual care patients: at 9-m onth follow -up recovery rates fo r som atoform disorder and anxiety were higher in the PST group (OR 6 .5 0 , p = 0 .0 1 respectively OR 1 1 .2 5 , p=0.03). PST patients had improved sig n ifica n tly more on the domains social functioning, role lim itation due to emotional problems and general health perception.

Discussion

Patients w ith emotional symptoms improved sig n ifica n tly more a fte r PST delivered by m otivated GP registrars than a fte r usual care by GP registrars. F urther research, w ith randomization of interested registrars or interested GPs, is needed.

Introduction

In general practice many patients have emotional sym ptom s and/or psychosocial problem s.1-2 M ost patients are treated adequately, but in a

m inority of cases a pattern of recurrent or chronic sym ptom s develops w ith a negative im pact on quality of life3 and frequent consultations.4 This makes diagnosis and tre a tm e n t of emotional sym ptom s an im portant ta sk in general practice. General practicioners (GPs) often prescribe medication, usually benzodiazepines or antidepressants2 but m edication is not always

appropriate. It has im portant side e ffe c ts ,5-6 p atient adherence is low7 and the effectiveness of antidepressants is being disputed.8 A lternative

approaches have to be considered. This looks a ttra c tiv e as m ost patients prefer non-pharmacological tre a tm e n ts.9 Counseling is nearly always part of the tre a tm e n t in general p ra ctice 10 and has the potential to strengthen patients' self-m anagem ent. However, its content often varies and evidence fo r its long­ term effectiveness is w eak.11

Problem-solving tre a tm e n t (PST) m ight be an a ttra ctive option because of its

structured approach w ith a focus on patient-em pow erm ent.12 PST is a brief psychological intervention suitable fo r prim ary care, focusing on how to deal w ith everyday problems. PST is effective in anxiety and depression, especially in major depression,1214and there are indications th a t it is effective fo r unexplained physical sym ptom s15 and in palliative care.16 A recent Cochrane review recommended fu rth e r research on the effectiveness of PST in patients w ith emotional symptoms, irrespective of w hether these fu lfil the criteria fo r DSM -IV disorders.17 Concurrently, GPs and GP registrars have expressed the need fo r an effective psychological tre a tm e n t they can deliver them selves to manage patients w ith emotional sym ptom s.18“ 20 Training GP registrars in PST could meet GPs' need in an early career stage. A pilot study w ith 1 1 GP registrars showed th a t registrars can be trained successfully in PST but the authors recommended fu rth e r investigation w ith a larger sample of registrars and evaluation of p atient outcom es.21 We aimed to study the effectiveness of PST delivered by trained GP registrars

Figure 1 Problem -solving tre a tm e n t (PST)

A brie f psychological tre a tm e n t w ith 7 stages: 1. E xplanation and rationale

2. C la rifica tio n and d e fin ition of the problems 3. E stablishing achievable goals

4. G enerating solutions 5. S electing p re ferred solution 6. Im plem enting solution

fo r patients w ith recurrent or chronic emotional symptoms.

Methods

Design

We compared, in a pragm atic controlled clinical trial, the effectiveness of PST versus usual care fo r patients w ith emotional symptoms. PST and usual care were applied by GP registrars. This design prom otes external validity, which means th a t it increases the applicability of a trial's results to situations other than the trial s itu a tio n .22

S etting

The study took place in a Dutch three-year GP residency programme. From 2 0 0 3 to 2 0 0 5 the residency programme scheduled the participation of all third-year registrars (81) in this study as p a rt of the core programme. Registrars p articipated in tw o groups, PST and 'usual care! Initially, we assigned registrars randomly to PST or usual care. We had to change this selection as registrars who were uncom fortable w ith PST did not include any patients. We allowed the next year group (2 0 0 4 -2 0 0 5 ) to choose the s tra te g y they were m ost com fortable w ith: PST (including training) or usual care. Ethical approval was obtained according to local protocols.

R ecruitm ent and selection crite ria

We asked registrars to recruit adult patients who presented emotional symptoms, during their regular clinical w ork in th e ir training practice (September 2 0 0 3 to April 2 0 0 6 ). We asked each registrar to re cru it 4 -6 patients because, from a logistical perspective, this was regarded as the

maximum feasible number w ithin one year of residency. We defined emotional sym ptom s as sub threshold as well as formal disorders of depressed mood, anxiety or stress, and psychosocial problems. Patients were included in the study, if they (a) had presented emotional sym ptom s during three or more consultations in the past 6 months; and (b) had a score of fo u r or more on the 1 2 -ite m General Health Questionnaire (GHQ-12).23

Exclusion criteria were (a) severe physical disease; (b) severe mental m orbidity (organic psychiatric disorder, substance misuse, active suicidal ideas); (c) current or recent (past year) psychiatric or psychological treatm ent or cognitive behavioural therapy; (d) in su fficie nt m astery of Dutch language. Registrars received support of a research assistant in the selection of suitable patients. All participating patients signed inform ed consent.

Treatm ent and training

PST is a brief psychological treatm ent, derived from cognitive behavioural therapy, teaching patients how to use their own skills to cope w ith everyday life problems in a system atic way. It is assumed th a t sym ptom s reduce if control over problems is (re)gained.12 PST comprises seven stages (Figure 1). The tre a tm e n t consists of four to six consultations over a period of approxim ately 8 -1 2 weeks w ith a duration of no more than 3 0 minutes, except fo r the firs t session which may last 6 0 minutes.

The registrars were trained by experienced PST trainers in a tw o- day course, followed by supervised tre a tm e n t and feedback meetings. Trainers assessed the quality of PST through registrars' PST w ork sheets.

Details about the fe a sib ility of this training programme during residency were published before.24

The exact nature of'usual care'w as retrieved from patient records a fte r the trial. Both tre a tm e n t groups were allowed to prescribe medication.

F ollow-up a n d o u tc o m e s

Primary outcom es were the proportion of patients who rem itted, the reduction of symptoms, and im provem ent of quality of life. We used the Primary Health Questionnaire (PHQ) assessing the presence of five DSM -IV

disorders,25 the Hospital A nxiety

and Depression Scale (HADS)26, the 3 6 -ite m MOS sh o rt form (SF- 3 6 )27 and the 5-dim ension Euroqol measuring quality of life (EQ-5D)28, and the social problem-solving (skills) inventory-revised measuring problem ­ solving skills (SPSI-R)29. Secondary outcom es were: p atient satisfaction (a self developed questionnaire based on the C onsultation S atisfaction Questionnaire30 w ith 9 item s measuring satisfaction w ith the doctor and 7 items measuring satisfaction w ith the treatm ent); number of disa b ility days (TiC-P)31; and health care utilization. Health care utilization data were

Figure2 F lo w ch a rtP S T -tria l

2 0 2 p a tie n ts m et e n try crite ria

1 0 4 patients assigned to receive usual care

I