Deep Vein Thromboses in Injecting Drug Users: Meanings, Bodily Experiences, and Stigma.

Deep vein thromboses (DVTs) are common sequelae of injecting drugs into the groin. We explored meanings and experiences of DVTs in a group of 19 patients from the North East of England with a DVT and in treatment for opioid use. We report three themes: (a) DVT meaning making, (b) embodied experience, and (c) Stigma. Patients attributed DVTs to groin injecting, though thought other factors were also partially responsible. Medication performed both treatment and preventive functions. The most pertinent worry was amputation. Patients recognized stopping injecting as important, but it did not necessarily occur. Stigma resulted in delayed admission to hospital and feelings of isolation; support groups might alleviate the latter. Although groin injecting was undertaken partly to avoid the censure of being a drug user, ironically, a DVT led to long-standing stigmata that were discrediting signs of that exact status.

Contraceptive use and pregnancy outcomes among opioid drug-using women: a retrospective cohort study.

OBJECTIVE: The contraceptive needs of illicit opioid users differ from non-drug users but are poorly understood. The aim of this study was to describe contraceptive use and pregnancy outcomes in opioid-using women, and to examine their association with a range of risk factors. METHOD: This retrospective cohort study used UK general practice records, Treatment Outcomes Profile and National Drug Treatment Monitoring System data, and a nested data validation exercise. A cohort of 376 women aged 20-61 years were in active treatment for opioid addiction in October 2010 at two specialised primary care practices in North-East England. Outcomes were age-adjusted prevalence estimates for contraceptive use and pregnancy outcomes in users of illicit opioids. The association between lifestyle-related risk factors and contraception was explored. RESULTS: Drug-using women made lower use of planned (non-condom) contraception (24% vs 50%, p<0.001), had more frequent pregnancy terminations (0.46 vs. 0.025, p = 0.004) and higher annual incidence of chlamydia (1.1% vs. 0.33%, p<0.001), when compared with age-matched population data. Specifically, there was low use of oral contraceptives (4% vs. 25%, p<0.001), IUCD (1% vs. 6%, p<0.001), and sterilisation (7% vs. 6%, p = 0.053), but higher rates of injectable contraceptives (6% vs. 3%, p = 0.003). A total of 64% of children aged <16 years born to this group did not live with their mother. No individual risk factor (such as sex-working) significantly explained the lower use or type of non-condom contraception. CONCLUSIONS: This is the first study to describe planned contraceptive use among drug-users, as well as the association with a range of risk factors and pregnancy outcomes. The low uptake of planned contraception, set against high rates of terminations and sexually transmitted disease demonstrates the urgent clinical need to improve contraceptive services, informed by qualitative work to explore the values and beliefs influencing low contraceptive uptake.

Heroin users' experiences of depression: a qualitative study.

BACKGROUND: Heroin users represent a challenging group of patients for GPs, with a high morbidity including a high prevalence of depression. Compared to other groups, management of 'depression' in heroin users is likely to require different approaches. Aim. To examine heroin users' beliefs about connections between depressive symptoms and drug taking. DESIGN: Qualitative. SETTING: Primary care. METHODS: A total of 17 semi-structured interviews were conducted with patients receiving opioid substitution therapy and antidepressants. One focus group of service users was also interviewed. RESULTS: A wide range of thoughts and emotions were described as 'depression'. Adverse childhood events were viewed as both the cause of depression and as simultaneously placing the individual in social circles where drug use was common. Drug taking was thought to lead to depression through resultant adverse social consequences, though illicit drug use was also regarded as an understandable way to cope with depression. Examples of stigma from taking drugs were commonly described and thought a cause of depression; in contrast, stigmatizing effects of depression were not apparent. The participants often felt isolated. Beliefs about how antidepressants worked incorporated ideas about blocking out thoughts, stopping thoughts racing and keeping emotions level. Self-management techniques for treating depression were rarely described. CONCLUSIONS: Heroin users' experiences of depression-including ideas about causation, how symptoms are felt and experienced and treatment strategies-are overwhelmingly framed by the context of drug taking.

Deep vein thromboses in users of opioid drugs: incidence, prevalence, and risk factors.

BACKGROUND: Users of illicit opioids are at increased risk of hospital admission for deep vein thromboses (DVTs); however, the community prevalence, risk factors, and complications of DVTs in this group are poorly understood. AIM: This study aimed to describe the prevalence of previous DVT for users of opioids in primary care; provide age- and sex-adjusted annual incidence rates of DVT; and explore factors associated with DVT, concordance with subsequent treatment, and complications. DESIGN: A retrospective analysis of DVT prevalence and incidence, and analysis of risk factors for DVT using Poisson regression of incidence rates. METHOD: A review of 734 patients in treatment for opioid addiction, who were registered to a single, specialised primary care practice in Middlesbrough, England. RESULTS: The prevalence of previous DVT in users of opioids was 13.9% (95% confidence interval [CI] = 11.5 to 16.6) with an annual incidence rate of 3.2% (95% CI = 2.6 to 3.7). The incidence rate increased with age and for female users; an exploration of risk factors suggests that rising age, female sex, sex-worker status, and intravenous delivery all independently increase the risk of DVT. Concordance with treatment appeared reasonable and, compared with DVT in groups of people who do not use drugs, there was no evidence of increased risk of pulmonary embolism. Participants with previous DVT reported lower health and wellbeing scores. CONCLUSION: Primary care providers should be aware of the considerably increased risk of DVT and its sequelae in users of intravenous drugs. Evidence for effective primary care prevention and the effective management of DVT complications is lacking; until this emerges, vigilance on the part of clinicians may help to minimise harm.

Primary care summary of the British Thoracic Society Guideline on the management of non-cystic fibrosis bronchiectasis.

The British Thoracic Society (BTS) has recently published a guideline for the management of non-cystic fibrosis (non-CF) bronchiectasis in children and adults. This paper summarises the key recommendations applicable to the primary care setting. The key points are: • Think of the diagnosis of bronchiectasis in adults and children who present with a chronic productive cough or unexplained haemoptysis, and in children with asthma which responds poorly to treatment; • High resolution computed tomography (HRCT) scanning is needed to confirm the diagnosis • Sputum culture should be obtained at the start of an exacerbation prior to initiating treatment with antibiotics; Treatment should be started whilst awaiting the sputum result and should be continued for 14 days; • Patients with bronchiectasis have significant morbidity. Management in primary care is aimed at improving morbidity, and includes; patient education, treatment and monitoring, as well as appropriate referral to secondary care including assessment for long term antibiotics.

GPs' explanatory models for irritable bowel syndrome: a mismatch with patient models?

BACKGROUND: Inconsistencies in doctors' views about causes and treatment of irritable bowel syndrome (IBS) lead to frustration for doctors and in doctor-patient interactions. Diagnosis by GPs does not correspond well to established diagnostic criteria. OBJECTIVE: To understand GPs' explanatory models (EMs) and management strategies for IBS. METHODS: Qualitative, semi-structured interviews with 30 GPs (15 from the UK and 15 from The Netherlands). RESULTS: Diagnosing IBS in primary care is a complex process, involving symptoms, tests, history and risk calculation. GPs were uncertain about the aetiology of IBS, but often viewed it as a consequence of disordered bowel activity in response to stress, which was viewed as a function of people's responses to their environment. GPs tend to diagnose IBS by exclusion, rather than with formal diagnostic criteria. They endeavoured to present the IBS diagnosis to their patients in a way that they would accept, fearing that many would not be satisfied with a diagnosis that had no apparent physical cause. GPs focused on managing symptoms and reassuring patients. Many GPs felt that patients needed to take the responsibility for managing their IBS and for minimizing its impact on their daily lives. However, the GPs had limited awareness of the extent to which IBS affected their patients' daily lives. CONCLUSIONS: GPs' diagnostic procedures and EMs for IBS are at odds with patient expectations and current guidelines. Shared discussion of what patients believe to be triggers for symptoms, ways of coping with symptoms and the role of medication may be helpful.

Patients' explanatory models for irritable bowel syndrome: symptoms and treatment more important than explaining aetiology.

BACKGROUND: Irritable bowel syndrome (IBS) is a common condition associated with no certain organic cause, though diet and stress are widely implicated. The condition is frustrating for both sufferers and doctors, and there are problems in diagnosing and treating the condition. Eliciting explanatory models (EMs) is a useful tool for understanding how individuals relate to their illnesses and their expectations for treatment, particularly for illnesses with uncertain aetiology like IBS. OBJECTIVES: To understand the EMs, experiences and expectations for management of patients with IBS. METHODS: Qualitative, semi-structured interviews were conducted with 51 primary care patients (31 in the UK, 20 in The Netherlands) meeting the Rome II diagnostic criteria for IBS. RESULTS: Although IBS often had a significant dampening effect on daily life, IBS patients made great efforts not to allow the condition to take over their lives. Triggers of symptoms were more important to patients than understanding the underlying aetiology of IBS. Diet and stress were both recognized as important triggers, but views about which foods were problematic and the extent to which stress was modifiable were inconsistent. Diagnosis and treatment were often a confusing and frustrating process, and patients often expected more diagnostic tests than they were offered before receiving a diagnosis of IBS. However, the often poor outcome of medical interventions does not, in general, appear to have a negative impact on the patient-doctor relationship. CONCLUSIONS: Clinicians should be aware of the extensive impact of IBS on sufferers' daily life and the frustration that results from repeatedly trying treatments with little effect. Clearly explaining the guidelines for diagnosing IBS and the range of treatment options may help patients to make sense of the diagnostic and treatment processes. The personal EM should be addressed during the consultation with the IBS patient, ensuring that any successive medical interventions match with the patients' disease perception.

How patients with depressive symptoms view their condition: a qualitative study.

BACKGROUND: Depressive symptoms are common in primary care, yet considerable professional controversy exists about appropriate management including the effectiveness of treatments. In addition, avoiding prescribing antidepressants at least initially is recommended. Views of patients themselves should therefore be particularly important in agreeing management strategies. OBJECTIVE: To examine lay beliefs about depressive symptoms in primary care. METHOD: A total of 23 semi-structured interviews were conducted with patients scoring positively for depression on the Hospital Anxiety and Depression Score in a primary care setting. RESULTS: Differentiating 'depression' from understandable reactions to adversity was difficult for patients. The wide range of consequences discussed included adverse effects on others, difficulties coping with feeling out of control and loss of self-identity. Negative images of depression, such as depression being a 20th century phenomenon, were pervasive. Views about medication varied. Various management strategies described included strategies of detachment, engagement in activities and 'blotting out' symptoms. CONCLUSIONS: Patients' views about depressive symptoms are significantly different from conventional medical views. A 'disease management approach' fits uncomfortably with patients' experiences. Acknowledging feelings of loss of control and loss of self-identity in consultations may be useful. The wide employment of techniques patients use to control their disorders, such as support from others, engagement in activities and working at relationships, may be useful to encourage in consultations as alternatives to the use of antidepressant medication.

General Practitioners with special clinical interests: a qualitative study of the views of doctors, health managers and patients.

BACKGROUND: The difficulties with under-provision of doctors mean that alternative ways of providing services need to be developed. In the UK, some primary care doctors are now providing services traditionally only obtained through secondary care. The views of health care professionals, as well as patients, about these new services are currently unexplored. OBJECTIVES: To study the views of a variety of doctors, health managers and patients concerning the development of General Practitioners with special clinical interests. DESIGN: Qualitative using semi-structured audio-taped interviews. PARTICIPANTS: Health Service Managers, General Practice Registrars (GPRs), General Practitioners (GPs) with no special clinical interest, GPs with special clinical interests (GPSCIs), consultants (from specialties with and without GPSCIs) and patients who had attended a GPSCI clinic. SETTING: The North East of England. RESULTS: A range of positive benefits was identified for GPs with special clinical interests including enhanced job satisfaction and possibly increased recruitment and retention for general practice. They were expected to decrease hospital specialty waiting times and may address previously unmet needs. Patients appreciated the requirement of appropriate professional skill mixes for less serious conditions. Personal aspects of care were important for patients. Outcome measures appeared poorly defined. Negative aspects identified included a deskilling of the general pool of GPs and an increase in workload by treating previously untreated conditions. A variety of challenges in establishing these services (in particular proactive development of GPSCIs in areas of need, accreditation and governance) were uncovered and some potential solutions discussed. CONCLUSIONS: The impact of GPs with special clinical interests has not been studied in any detail, and measures of success for these schemes, where they exist, may fail to address the wide range of potential positive and negative effects. Their cost effectiveness has been questioned, and yet in the future more of these types of schemes seem likely. GPs with special interests may be part of an increasingly flexible career structure that sees GPs and secondary care doctors and consultants having much more interchangeable career paths. Patients' views on the services were generally positive.

The '2-week rule' for suspected breast carcinoma: a qualitative study of the views of patients and professionals.

BACKGROUND: The '2-week rule' for the referral of patients with potential cancers is an important but controversial development. AIMS: To investigate the 2-week rule for women with breast problems from the perspective of the patients and of healthcare professionals. DESIGN OF STUDY: Qualitative study using semi-structured interviews. SETTING: Patients referred to two breast care units and professionals from primary and secondary care in Teesside and Hartlepool. METHOD: Semi-structured interviews with a purposive sample of 12 patients referred under the 2-week rule and 20 professionals. RESULTS: All women experienced considerable worries in the time leading up to diagnosis. This affected relationships with others, and they used selective telling to help maintain control over their own anxiety and prevent anxiety in others. They were not aware of the 2-week rule as a new initiative, but wanted quick referral to assure them that they did not have cancer. Patients felt they needed more information about breast symptoms and the referral process. Comments about communication with professionals, both good and poor, were frequent in their accounts, which contrasted with the absence of such concerns in the accounts of the professionals. The professionals thought that the 2-week rule was advantageous in reducing anxiety, but thought that disadvantages included longer waits for patients referred outside the rule and increased pressure on hospital services. Cultural changes, including increased patient assertiveness and 'breast awareness', were considered important contextual factors. General practitioners (GPs) were concerned about missing diagnoses in patients statistically unlikely to have carcinomas. CONCLUSION: Differences in emphasis were apparent, with patients wanting to be assured that they did not have cancer, specialists concerned both about increased workload and the impact on patients with cancers, and GPs anxious about missing diagnoses. The 2-week rule compromises professional autonomy, which partially accounts for the anger directed against it. There is a need for patients to have more information, and they place great value on good communication. All patient responders experienced significant distress while waiting to be seen.

The 2-week rule for patients with suspected breast cancer: what can be learnt by analysing policy documents?

The '2-week rule', introduced in the UK during 1999, represents a significant organisational change for referral of patients with suspected breast cancer. From an analysis of policy documents, a mixture of influences and agendas from different interest groups are apparent in the current working of the policy. These include political/modernisation agendas with a variety of aims including: reducing variation in care, efficient administration, reassuring patients, improving public confidence, earlier referral and lowering the threshold for referral to improve mortality figures. Specialist agendas, exemplified by the guidelines for referral under the policy but apparent in preceding specialist literature, represent an attempt to modify the working of the policy to ensure that high proportions of those women referred have breast cancer. The agendas of these interest groups are in conflict and have implications for the future development of this particular policy. Similar considerations are likely to apply more widely to other controversial health policy developments. It may be of value to identify the agendas of the groups responsible for the introduction of such policies, as well as the agendas of groups with influence on how the policy is actually implemented, and assess the areas of conflict.

The prescribing and follow-up of domiciliary oxygen--whose responsibility? A survey of prescribing from primary care.

Domiciliary oxygen is expensive and is frequently used outside the prescribing guidelines, which include the need for blood oxygen measures, a hospital-based facility. Ongoing prescriptions are generally provided by general practitioners (GPs). A survey in the north-east of England found that the origin of the initial prescription was often obscure and that there was no record of the responsible clinician or of structured follow-up for the majority of patients. Many patients received oxygen outside the prescribing guidelines. There is a need for better organised, conjoint follow-up of patients on domiciliary oxygen.