Providing holistic end-of-life care for people with a history of problem substance use: a mixed methods cohort study of interdisciplinary service provision and integrated care.

Harmful use of illicit drugs and/or alcohol is linked to life-limiting illness and complex health and social care needs, but people who use substances and have complex needs do not receive timely palliative care and fail to achieve quality standards for a good death. They and their families often require support from multiple health and social care services which are shown to be poorly integrated and fail to deliver interdisciplinary care. This study aimed to identify the existing barriers and facilitators within and between services in providing this population with a good death. Using a mixed methods approach of survey, focus groups and semi-structured interviews, we explored the perspectives of practitioner and management staff across a range of health and social disciplines and organisations in one combined authority in a large city in the north west of England. Our findings indicate that practitioners want to provide better care for this client group, but face structural, organisational and professional boundary barriers to delivering integrated and shared care. Differences in philosophy of care, piecemeal commissioning and funding of services, and regulatory frameworks for different services, lead to poor and inequitable access to health and social care services. Ways forward for improving care are suggested as bespoke hostel-based accommodation for palliative care for this client group, and specialist link workers who can transcend professional and organisational boundaries to support co-ordination of services and support. We conclude that it is no longer adequate to call for more training, better communication and improved joint working. Complex care at the end of life requires creative and cohesive systemic responses that enable multi-disciplinary practitioners to provide the care they wish to give and enables individuals using substances to get the respect and quality service they deserve.

Postoperative decline in renal function after rectal resection and all-cause mortality: a retrospective cohort study.

AIM: Fluid loss, dehydration and resultant kidney injury are common when a diverting ileostomy is formed during rectal cancer surgery, the consequences of which are unknown. The aim of this retrospective single-site cohort study is to evaluate the impact of sustained postoperative renal dysfunction after rectal resection on long-term renal impairment and survival. METHOD: All patients with rectal adenocarcinoma undergoing resection between January 2003 and March 2017 were included, with follow-up to June 2020. The primary outcome was impact on long-term mortality attributed to a 25% or greater drop in estimated glomerular filtration rate (eGFR) following rectal resection. Secondary outcomes were the long-term effect on renal function resulting from the same drop in eGFR and the effect on long-term mortality and renal function of a 50% drop in eGFR. We also calculated the effect on mortality of a 1% drop in eGFR. RESULTS: A total of 1159 patients were identified. Postoperative reductions in eGFR of 25% and 50% were associated with long-term overall mortality with adjusted hazard ratios of 1.84 (1.22-2.77) (p = 0.004) and 2.88 (1.45-5.71) (p = 0.002). The median survival of these groups was 86.0 (64.0-108.0) months and 53.3 (7.8-98.8) months compared with 144.5 (128.1-160.9) months for controls. Long-term effects on renal function were demonstrated, with those who sustained a >25% drop in renal function having a 38.8% mean decline in eGFR at 10 years compared with 10.2% in controls. CONCLUSION: Persistent postoperative declines in renal function may be linked to long-term mortality. Further research is needed to assess causal relationships and prevention.

Principles, tools and techniques for brief behaviour change interventions.

Nurses are well placed to deliver brief opportunistic health promotion interventions during routine encounters with patients. Brief interventions have been shown to be effective in prompting behaviour change among people who engage in harmful drinking or substance misuse. Nurses can use their communication, relationship-building and partnership-working skills to support people to consider behaviour change. This article explains the concepts that underlie brief behaviour change interventions, which include motivational interviewing and the transtheoretical model of behaviour change. The article also describes practical tools and techniques that nurses can use to deliver such interventions.

Psychosocial health in adolescent unmarried motherhood in rural Uganda: Implications for community-based collaborative mental health education, and empowerment strategies in the prevention of depression and suicide.

Teenage pregnancy rates in Uganda are among the highest in sub-Saharan Africa. Child marriage is often the result of unmarried teenage pregnancy and is recognised by Uganda's government as a form of sexual violence and an outcome of inequality. However, unmarried motherhood incurs stigma and shame within traditionally living rural communities. Using co-produced Open Space and ethnographic methods, we examined the psychosocial impact of unmarried motherhood on girls and their communities, and explored problem-solving with key local stakeholders. Findings indicate that girls experience extreme stress, social exclusion and rejection by their families, and experience bereavement from school expulsion and the loss of their career aspirations. Depressive symptoms and suicidal behaviour are reportedly not uncommon among this population group. Community and family efforts to promote marriage for these mothers to avoid social stigma increased the mothers' feelings of depression, whereas mothers who became independent appeared to fare better psychologically. Community members and local stakeholders demonstrated a willingness to act locally to reduce the negative impacts of unmarried motherhood but lacked knowledge and support resources. Our findings indicate that mental health promotion for teenage mothers is likely to be better served through empowerment strategies rather than marriage and, in a context of poor mental health service access, there is a substantial role for community mobilisation and the promotion of self-help strategies to support teenage mothers. This study raises important points regarding different community understandings of depression and indicates collaboration between professionals and communities for a values-based approach.

Trends in Mortality From Novel Psychoactive Substances as "Legal Highs": Gender Differences in Manner of Death and Implications for Risk Differences for Women.

Introduction: This study aimed to examine drug-related deaths in the UK in which novel psychoactive substances (NPS) are an implicated substance, and to focus on female deaths in comparison with male deaths. While male overdoses dominate epidemiological statistics, there is an increase in female drug-related deaths and a narrowing of the gap between gender mortality rates which is to date unexplained. Method: This study analyzed data from the National Programme for Substance Abuse Deaths (NPSAD) database that records drug-related deaths in the UK from coronial records. A dataset was constructed using parameters to capture all drug-related cases during the period 2007-2017 when NPS were legal and highly available in the UK, in order to capture deaths recorded among both regular and occasional drug users, and to include all cases recorded during that period regardless of NPS status in order to make comparisons. The final dataset comprised 10,159 cases, with 456 NPS-related deaths. Data for NPS and non-NPS were compared, and comparisons were made between cohorts by gender. The dataset also includes coronial narrative notes which allowed a qualitative analysis of NPS female deaths to add contextual explanation. Results: The proportion of male NPS deaths is significantly higher than that for female NPS deaths but does not reflect the generalized difference between male and female drug-related mortality of this period studied. Demographic and outcome data by gender difference were significant for all drug-related deaths, but not for NPS-only deaths, indicating a greater homogeneity among NPS deaths by gender. Older women using NPS were more likely to have methadone or diazepam as another drug implicated and have established histories of drug misuse. Conclusion: Where NPS have been used, differences in drug death profiles are less likely to be accounted for by gender than other demographic or behavioral differences more typically found in opiate deaths. The social and health problems of older women may be key characteristics that differentiate female deaths from male deaths. These findings also support evidence of increasing uptake of NPS among older established drug users that adds further risk to polydrug use.

'I'm getting the balls to say no': Trajectories in long-term recovery from problem substance use.

This study uses individualisation theory to explore identity transition in substance misuse recovery. Identity narratives gained over 4 years from co-produced video/audio interview and video diary accounts were co-productively collected and analysed using framework analysis. Results indicate a trend towards individualistic and agentic identity as recovery trajectories progress over time. Within-case analysis demonstrates agentic growth for most participants, from early-stage gratitude and reliance on support groups to self-determination and independent decision-making. This early work exploring longer-term recovery adds to the current recovery and social identity discussion and provides evidence of identity growth in longer-term stages of recovery.

Does perception of drug-related harm change with age? A cross-sectional online survey of young and older people.

OBJECTIVES: To investigate how young and older people perceive the harms associated with legal and illegal drugs. DESIGN: Cross-sectional study: adults aged 18-24 years versus 45+ completed an online survey ranking the perceived harms associated with 11 drugs on 16 drug-related harm criteria. SETTING: Online survey. PARTICIPANTS: 184 participants aged 18-24 years (113 female: mean age 21: SD 1.3) and 91 participants aged 45+ (51 female: mean age 60: SD 8.5). MAIN OUTCOME MEASURES: 'Perception of drug-related harms': This was measured using a rating scale ranging from 1 (no risk of harm) to 4 (high risk of harm). Participants were also asked about sources which informed their perception on drug-related harms as well as their own personal self-reported drug experiences. RESULTS: Of the illegal drugs, heroin, methamphetamine and cocaine were rated as the most harmful and cannabis was rated as the least harmful. Alcohol and tobacco were also rated as less harmful. The results showed that perceptions of drug-related harms were inconsistent with current knowledge from research on drugs. Furthermore, perceptions on drug harms were more conservative in the 45+ group for a number of illegal drugs and tobacco. However, the 45+ age group did not perceive alcohol as any more harmful than the younger group. CONCLUSIONS: This survey demonstrates that the greatest misperception was in relation to alcohol-related harms which did not change with age. In order to minimise harms, this misperception needs to be addressed through education and policies that legislate drug use.

Exploring the characteristics of effective communicators in healthcare.

Nurses require effective communication and interpersonal skills to provide optimal care, and to ensure that patients and their families and carers have a positive experience of receiving care. The new Nursing and Midwifery Council standards of proficiency for registered nurses, and for nurse education and training, published in May 2018, recognise that future nurses will be practising in increasingly complex roles and environments. This article identifies the essential communication skills that will be required by nurses in the future, summarising the characteristics of a modern nurse communicator. It also suggests various approaches that nurses can use to develop their communication skills.

Gallstone Ileus Caused by Cholecystocolonic Fistula and Gallstone Impaction in the Sigmoid Colon: Review of the Literature and Novel Surgical Treatment with Trephine Loop Colostomy.

Gallstone ileus is an uncommon cause of intestinal obstruction and occurs following the formation of a cholecystoenteric fistula, permitting passage of gallstones into the gastrointestinal tract. Impaction of a gallstone in the sigmoid colon is rare and is usually at sites of previous colonic disease. Definitive management can be challenging due to the advanced age and co-morbidity usually seen in this group of patients. We describe a patient successfully managed with on-table endoscopy and, under local anaesthetic, the formation of a left iliac fossa trephine loop colostomy, permitting an enterolithotomy to deliver the stone whilst accommodating for severe pre-existing distal sigmoid diverticular disease. A review of the literature identified various endoscopic and surgical treatments that, depending on local expertise and patient characteristics, can be considered on a case-by-case basis. We advocate the management described in this case for patients presenting with large bowel obstruction due to gallstone ileus, with a background of diverticular disease and who are not fit for general anaesthetic or formal bowel resection, as an alternative to medical palliation alone.

The utility and impact of information communication technology (ICT) for pre-registration nurse education: A narrative synthesis systematic review.

OBJECTIVES: To evaluate and summarise the utility and impact of information communication technology (ICT) in enhancing student performance and the learning environment in pre-registration nursing. DESIGN: A systematic review of empirical research across a range of themes in ICT health-related education. DATA SOURCES: Science Direct, Cinahl, AMED, MEDLINE, PubMed, ASSIA, OVID and OVID SP (2008-2014). Further date parameters were imposed by theme. REVIEW METHODS: Evidence was reviewed by narrative synthesis, adopting Caldwell's appraisal framework and CASP for qualitative methods. Selection and inclusion was grounded in the PICOS structure, with language requirements (English), and further parameters were guided by theme appropriateness. RESULTS: Fifty studies were selected for review across six domains: reusable learning objects, media, audience response systems, e-portfolios, computer-based assessment and faculty adoption of e-learning. Educational ICT was found to be non-inferior to traditional teaching, while offering benefits to teaching and learning efficiency. Where support is in place, ICT improves the learning environment for staff and students, but human and environmental barriers need to be addressed. CONCLUSION: This review illuminates more advantages for ICT in nurse training than previously. The key advantage of flexibility is supported, though with little evidence for effect on depth of learning.

Poles apart: does the export of mental health expertise from the Global North to the Global South represent a neutral relocation of knowledge and practice?

The World Health Organization's Mental Health Action Plan 2013-2020 identifies actions for all member states to alleviate the global burden of mental ill health, including an obligation for mental healthcare to be delivered in a 'culturally appropriate' manner. In this article we argue that such a requirement is problematic, not least because such pronouncements remain framed by the normative prepositions of Western medical and psychological practice and their associated ethical, legal and institutional standpoints. As such, when striving to export Western mental health expertise, different paradigms for evidence will be necessary to deliver locally meaningful interventions to low and middle income countries. Our discussion highlights a number of philosophical concerns regarding methodologies for future research practice, including those relating to representation and exclusion in the guise of epistemic injury, presumptive methodologies arising from Western notions of selfhood, and related ethical issues.

The recovery model and complex health needs: what health psychology can learn from mental health and substance misuse service provision.

This article reviews key arguments around evidence-based practice and outlines the methodological demands for effective adoption of recovery model principles. The recovery model is outlined and demonstrated as compatible with current needs in substance misuse service provision. However, the concepts of evidence-based practice and the recovery model are currently incompatible unless the current value system of evidence-based practice changes to accommodate the methodologies demanded by the recovery model. It is suggested that critical health psychology has an important role to play in widening the scope of evidence-based practice to better accommodate complex social health needs.

A systems approach to care pathways into in-patient alcohol detoxification: outcomes from a retrospective study.

This paper describes the effects of the adoption of a systems approach to alcohol service delivery by four previously separate organisations in Manchester, UK that commenced in 1997. The study examined a database of 5542 admissions for in-patient detoxification between 1995 and 2003, which permitted the analysis of changes occurring in the composition of the client group after the adoption of the new model. Findings suggest that working with the systems approach resulted in more effective targeting of people with higher levels of alcohol dependency towards in-patient detoxification. Females and people in stable housing also benefited from increased access in the new system. Increases in planned discharges were observed across all demographic variables, although alcohol-dependent males without stable accommodation found it more difficult to access in-patient detoxification after the new model was introduced. We conclude that in comparison to a loose network of services a co-ordinated and managed service system can improve targeting for in-patient detoxification for most people with severe alcohol dependence but may not do so for all who need access.

Antidepressant-related deaths and antidepressant prescriptions in England and Wales, 1998-2000.

BACKGROUND: Deaths from antidepressants continue to account for a substantial proportion of drug-related deaths. AIMS: To investigate the relative toxicity of the major classes of antidepressant drugs, with the specific objective of assessing this in relation to the cause of death; and to analyse the deaths where there were multiple mentions of antidepressant drugs or other psychoactive drugs with antidepressants. METHOD: Mortality data were collected from the National Programme of Substance Abuse Deaths, and antidepressant prescription data were collected. RESULTS: Most deaths from antidepressant drugs were suicides (80%). Tricyclic antidepressants (TCAs) accounted for more drug mentions than did other antidepressant drugs (12 per million prescriptions). Selective serotonin reuptake inhibitors (SSRIs) were associated with a significantly lower risk of toxicity, but 93% of deaths from SSRIs occurred in combination with other drugs, especially TCAs (24.5%). In 'combination' deaths patients were significantly more likely to have had a history of drug misuse. CONCLUSIONS: The efficacy and safety of augmentation therapy with TCAs in SSRI-resistant patients should be monitored carefully, and patients prescribed antidepressants should be screened for drug use/misuse.

Cause and manner of death in drug-related fatality: an analysis of drug-related deaths recorded by coroners in England and Wales in 2000.

This study investigated causes and manner of drug-related fatalities recorded in 2000 in the United Kingdom, measuring the 'masked' manner of death in cases typically recorded as overdose. A retrospective cohort study was used of 1037 cases of accidental drug-related fatalities reported by coroners in England and Wales to the National Programme of Substance Abuse Deaths. Whilst 802 cases were identified as direct acute overdose, representing 77% of the total accidental deaths, 23% of 'overdose' fatalities were caused by asphyxiation (7%), drug-related medical conditions (7%), non-drug-related conditions (4%), traumatic accidents (3%) and infections (2%). Younger people show higher risk of overdose and asphyxiation; older people show higher risk from pre-existing medical conditions. This study not only confirmed the high risk of overdose associated with heroin and polydrug use, but it also identified other high fatality risk factors for heroin/morphine users such as contracting an acute infection leading to septicaemia or endocarditis, or contracting a chronic infection such as HIV, HBV or HCV. In contrast, stimulants particularly featured in traumatic accidents, with amphetamine use most associated with cardio-vascular fatality. These findings highlight the 'masked' manner of death in cases commonly recorded as overdose and demonstrate the need for a more-detailed and systematic method of recording drug-related deaths in order to inform drug education and harm reduction strategies.