Assisting young people aged 12-25 years to cease e-cigarette use in general practice.

BACKGROUND: Increasing numbers of young people (adolescents aged 12-17 years and young adults aged 18-25 years) are using e-cigarettes. Although the extent of the health effects is currently unknown, young people are at risk of developing nicotine dependence and, as a result, find it difficult to cease use of e-cigarettes. They might seek help from their general practitioner (GP) to do so. OBJECTIVE: This article summarises the available evidence for e-cigarette cessation in young people and suggests a rational approach to assist GPs seeing young people seeking help for e-cigarette cessation. DISCUSSION: There is limited evidence to support best treatment options for e-cigarette cessation in young people. An approach based on the experience from tobacco cessation in adults and adapted for young people might assist. Management that supports family and school engagement, with behavioural interventions, nicotine replacement therapy, other pharmacological interventions and ongoing review as appropriate for the young person's age and developmental milestones, might help successful e-cigarette cessation.

'Why do we have to be the gatekeepers?' Australian general practitioners' knowledge, attitudes and prescribing intentions on e-cigarettes as a smoking cessation aid.

BACKGROUND: A significant policy change impacting the availability of nicotine for use in electronic cigarettes (e-cigarettes) in Australia took effect from October 1, 2021. This change meant that nicotine containing liquids for use with e-cigarettes would only be available by prescription from a medical practitioner as part of a smoking cessation plan. This study aimed to explore general practitioners (GPs) perceptions about the role of e-cigarettes, and understand factors informing their intentions to prescribe e-cigarettes as part of a smoking cessation plan. METHODS: In-depth semi-structured interviews were conducted with thirteen GPs. Purposeful sampling was used to recruit participants. Interviews were audio recorded and transcribed verbatim. Thematic analysis was used to classify, describe and report themes in the data. QSR NVivo was used to aid coding, thematic analysis and retrieval of quotes. RESULTS: Participants had diverse views on recommending and prescribing e-cigarettes as smoking cessation aids to patients. Some participants were willing to prescribe e-cigarettes to patients if other methods of smoking cessation had not worked but there were concerns, and uncertainty, about the safety and efficacy of e-cigarettes for smoking cessation. There was poor understanding of the current policy and legislation about e-cigarettes in Australia. Mostly the participants in this sample did not feel confident or comfortable to prescribe, or have discussions about e-cigarettes with patients. CONCLUSION: The participants of this study held diverse attitudes on recommending and prescribing e-cigarettes for smoking cessation. Clarity in guidelines and consumer product information are required to enable GPs to provide consistent and accurate advice to patients that wish to use e-cigarettes as a smoking cessation aid.

Diagnosing and managing patients with chronic pain who develop prescription opioid use disorder: A scoping review of general practitioners' experience.

BACKGROUND AND OBJECTIVES: Prescription opioid use disorder (pOUD) is an important sequela of long-term prescribed opioids for chronic pain. General practitioners (GPs) may not systematically diagnose or manage this; however, it is unclear why. METHOD: This scoping review searched multiple databases to assess GPs' experience diagnosing and managing patients prescribed opioids for chronic pain who have developed pOUD. RESULTS: The 19 included articles report high levels of GP concern regarding opioid diversion, inappropriate use, abuse, misuse, diversion, dependence and addiction. Confidence screening and detecting pOUD is mixed, and few screen systematically. The most common response is declining to prescribe rather than diagnosing and managing pOUD. DISCUSSION: GPs experience high levels of conflict when considering potential pOUD in their patients with chronic pain prescribed opioids. Their experiences diagnosing and managing pOUD are not fully understood. Further theory-based research may help to understand this and assist future policy directions, programs and research priorities.

Retention rates with monthly depot buprenorphine in general practice in Melbourne, Australia.

BACKGROUND AND OBJECTIVES: Opioid dependence is an important public health issue with high rates of relapse. This study, conducted in a suburban Australian general practice, reports treatment retention for patients on long-acting depot buprenorphine injections. METHOD: Patients were offered monthly buprenorphine depot from 11 December 2019 to 31 July 2020; data collection ceased on 30 November 2020. Overall retention at 168 days was estimated, and retention when discontinuation was defined as >2 or >4 weeks' delay between injections (2/4 WTD). RESULTS: For 126 patients treated (mean age: 40.2 years [range: 20-65 years], 32% women, 98% with history of heroin dependence), the overall retention rate was 62% (53% and 40% using 2WTD and 4WTD definitions of discontinuation). Eleven patients returned to previous treatment; 10 patients with planned discontinuations were censored. DISCUSSION: Depot buprenorphine supported more than half of patients to remain in treatment, while allowing some flexibility in dose interval. Predictive power is limited by the small sample and observational design.

What do general practitioners want from specialist alcohol and other drug services? A qualitative study of New South Wales metropolitan general practitioners.

INTRODUCTION: Alcohol and other drug (AOD) use is common in Australia with significant health and community impacts. General practitioners (GP) often see people with AOD use; however, there is little research to understand how specialist AOD services could assist GPs in the management of patients with AOD issues. METHODS: Thirty-five GPs working in general practice in a metropolitan area in Sydney in New South Wales, Australia, participated in one of three focus groups. The groups were recorded, transcribed and thematically analysed. RESULTS: The five themes raised by participants were: GP personal agency and interest in AOD issues; GP education and training gaps; improving pathways between GP and specialist AOD services; easier access to AOD specialist advice; and improving access to collaborative care for patients with complex AOD presentations. Participants requested education on screening, assessing, managing AOD issues, focused on alcohol, stimulants and high-risk prescription medicines. They suggested better referral processes, discharge summaries and care planning for complex presentations. Participants wanted easy access to specialist advice and suggested collaborative care assisted by experienced AOD liaison nurses. DISCUSSION AND CONCLUSIONS: Australia has several existing programs; online referral pathways and specialist phone advice, that address some of the issues raised. Unfortunately, many participants were not aware of these. GP education must be supported by multiple processes, including durable referral pathways, ready access to local specialist advice, clear communication (including patient attendance and a treatment plan), care planning and written summaries.

Managing opioid withdrawal precipitated by buprenorphine with buprenorphine.

Buprenorphine is a partial opioid agonist commonly used to treat opioid dependence. The pharmacology of buprenorphine increases the risk of a precipitated opioid withdrawal when commencing patients on buprenorphine treatment, particularly when transferring from long acting opioids (e.g. methadone). There is little documented experience regarding the management of precipitated withdrawal. In our case, a patient developed a significant precipitated opioid withdrawal following buprenorphine administration, and was able to be successfully treated in hospital with further buprenorphine. This demonstrates that rapid increases in buprenorphine dose can be used as an effective treatment for buprenorphine-induced precipitated opioid withdrawal. The use of buprenorphine to manage withdrawal then allows the individual to continue on this highly effective treatment.

How stigmatising language affects people in Australia who use tobacco, alcohol and other drugs.

BACKGROUND: Use of tobacco, alcohol and other drugs (TAOD) is common in Australia and can cause high morbidity and mortality. It is not uncommon for people who use TAOD to experience stigma when accessing healthcare, including general practice. Stigma communicated through words can affect people seeking help and undertaking treatment for their health issues. The language that clinicians use is an important factor that perpetuates stigma. OBJECTIVE: The aim of this article is to describe how spoken and written language can create stigma and how this affects a person's experience of care, which in turn can adversely affect health outcomes. DISCUSSION: Language matters, and this article suggests that clinicians consider how the language they use might affect the people they see. The use of person-centred language and specific language rather than labels may assist conversations and improve outcomes.