No reference to these issues was included in any induction programme. No employment contracts encouraged doctors in North Scotland to register with a GP. Primary care services for resident doctors were not identified. No confirmation was in place at recruitment to remind doctors not to prescribe for themselves and not to prescribe for colleagues, except following a formal clinical consultation.
Whilst clear arrangements via Grampian Health Board for out of area referrals were in place, these arrangements were not widely publicized and were not known to the profession generally. No local directory of services or resources was published. Whilst the three Medical Directors and the Director of Public Health each had an accepted role as the recipient of concerns about doctors' performances and all four met together periodically, it was not clear to the profession locally that this was the case. That group also had disciplinary responsibilities, which may have made it less likely that concerned individuals would call for clarification of what to do next.
Individual doctors were in doubt about who to contact if they were concerned.
In turn, it seemed likely that these services could promote the use of a local contact point if one was established. Enquiries made by Medical Council on Alcoholism advisers revealed limited implementation of the conclusions from this national report. Such strategies will include a requirement for health services to provide alcohol services, a component of which should be dedicated to the special requirements of clinical staff. NHS changes including the establishment of Acute Service and Primary Care Trusts and the refinement of health authority and university roles promote an expectation of full co-operation and collaboration between agencies.
Online Alcohol And Drug Misuse A Handbook For Students And Health Professionals 2008
An opportunity now arises to promote local coordination to deal with alcohol and other drug misuse in doctors, and if these issues are addressed, then isolated practice, idiosyncratic approaches, and the progressive failure to recognize detrimental performance, are all likely to be diminished. In considering a local mechanism to enable anyone to express concern about a doctor's performance, recognizing that the concern could be linked to the possible misuse of alcohol and other drugs, it was agreed that the local Postgraduate Medical Society, which is linked to the Students' Medical Association, would support the establishment of a telephone contact point.
The line will be serviced by a group of experienced doctors nominated by the Society and augmented by the lay involvement of a non-executive director of the Health Board. The doctors will have a knowledge of all local workplace policies and all clinical resources local, out of area, and national. The group will facilitate appropriate intervention, once the nature and validity of any enquiry is established. It is intended to audit the number of contacts and conclusions about how concerns were validated to clarify whether early intervention was achieved. The utility of the arrangement will be tested and outcome statistics will be shared with the Health Board, Trust Boards, Postgraduate Medical Education Committee, and Curriculum Committee in the first instance.
It seems likely that this local group, whose membership will reflect a range of specialties, will also act as a facilitator of further developments. The intention is to provide a confidential, informal, effective mechanism for anyone to express concern about themselves or their colleagues. Further discussion is needed to ensure that concepts relating to the misuse of alcohol and other drugs by doctors become an integral part of student education, medical training, continuing medical education, and professional development through incorporation into the medical student curriculum and all induction programmes relating to medical staff.
Further national consideration may be needed to identify a mechanism for funding retraining and to ensure that a doctor's awareness of the identification and management of substance misuse in the profession becomes a component of the registration process with the Specialist Training Authority and any future revalidation procedure. Oxford University Press is a department of the University of Oxford.
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HMSO, London. Irvine, D. In Problem Doctors , Lens, P. IOS Press, Amsterdam.
Medical Council on Alcoholism a Annual Report pp. Medical Council on Alcoholism, London.
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Three of the included studies employed experimental evaluations that allow for inferences to be made about the effectiveness of these interventions [ 14 , 16 , 21 , 23 ]. The remaining studies were observational, non-controlled, or focused on describing the intervention without an evaluation of effectiveness. As per the eligibility criteria for this review, all studies included examination of feasibility and process outputs. Therefore, it is not possible to make inferences on effectiveness, but these studies provide important insights into challenges in implementation of these interventions that may inform substance misuse programming and intervention research in the future.
The EPIS framework organizes implementation factors into those existing in the inner or outer context Fig. At the intersection of the inner and outer contexts lies the fit of the intervention within the organization and system. More specifically, this refers to the agreement between the roles, structure, values, and authority of the intervention, organization, and system [ 28 , 29 ].
In contrast to previous substance use interventions that have used this framework to develop an implementation and evaluation strategy [ 30 ], we used the EPIS framework to classify implementation challenges that were reported after an intervention had been implemented. Challenges for implementation of substance use treatment and prevention services in conflict-affected populations. We adapted the Exploration, Preparation, Implementation and Sustainment EPIS framework developed by Aarons and colleagues to describe challenges for implementing substance use treatment and prevention interventions in conflict-affected populations into those existing within the inner and outer context [ 29 ].
Challenges related to the service environment, inter-organizational environment, and lack of consumer advocacy were identified in the outer context. Inner context implementation challenges relating to characteristics of the program or implementing organization included absorptive capacity and competing priorities.
Lack of innovation-values fit of substance use services within the system and organization manifested through multiple forms of stigma. In the outer context, we identified implementation challenges existing across EPIS phases. These challenges related to the service environment, inter-organizational environment, and consumer advocacy and support.
Barriers pertaining to the service environment were primarily related to the sociopolitical context in post-conflict settings and included low political will to prioritize or provide resources to support substance misuse services as well as the criminalization and stigma toward illicit substance use and misuse. These challenges were often compounded in conflict-affected settings by frequent and unpredictable government turnover, which resulted in changes to resource allocation, regulations, and support for services [ 21 ].
One example of the impact that changes in governance can cause is the case of the Russian annexation of Crimea in , which was followed by a ban on opioid agonist treatment by the Russian government, thus leaving people who were on medication-assisted treatment without access to care [ 31 , 32 ].
Similarly, the possibility of legal or livelihood consequences, particularly in refugee camp settings where policies prohibiting alcohol or other drug use may have implications for access to humanitarian aid e. Another outer context challenge relating to the service environment is the role of other stakeholders, such as the alcohol industry.
Qualitative interviews with policymakers, humanitarian aid workers, and other local stakeholders revealed that licit substance industries may capitalize on post-conflict environments where governments may weakly regulate or enforce the marketing and distribution of alcohol or the drugs, which is likely to increase access and use of substances [ 33 , 34 ]. In our review, there were several examples of situations where institutional biases toward substance use i. Structural stigma may also be a driver of low prioritization, acceptance, or adoption of substance use services by a variety of organizations and stakeholders.
For individuals with substance use problems, structural stigma may present in the form of negative attitudes held by representatives of medical and other institutions that exclude these individuals from accessing the same level or quality of care [ 35 ]. For example, public transportation drivers reportedly prohibited people who were known to inject drugs from riding buses or other modes of transportation used to travel to harm reduction centers in Afghanistan.
Furthermore, clients who walk to health care facilities reported being harassed by police, which similarly made it difficult to access harm reduction services [ 20 ]. There is a need for advocacy promoting the provision of substance misuse prevention and treatment services for populations affected by conflict directed toward governments, humanitarian agencies, and policymakers that are responsible for allocating resources and determining health system priorities in the aftermath of a conflict or other emergency.
Only one study included in this review described advocacy efforts as part of their implementation strategy but did not specify whether consumers were involved in these activities [ 27 ]. Recommended strategies for increasing the visibility of alcohol and other drug misuse as a priority in conflict-affected populations include increasing awareness regarding the harmful effects of substance misuse, sharing information and expertise on the topic, and improving the quality of data documenting substance misuse and related consequences in conflict-affected populations [ 33 ].
Barriers residing within the inner context were related to intra-organizational factors, primarily those that dealt with human and material resource capacity as well as competing priorities that affected the scope of services provided within the organization. In our review, we identified factors relating to absorptive capacity that challenged implementation of substance use interventions in conflict-affected populations including human and material resource limitations and limited knowledge of evidence-based interventions.
Resource limitations in low- and middle-income contexts are often exacerbated in conflict and post-conflict settings where pre-existing facilities, services, and other resources may become inaccessible or seriously limited, forcing remaining providers to operate within critically resource-constrained circumstances [ 36 , 37 ]. Additionally, when services are provided within the context of research or humanitarian funding, the sustainability of programming may be threatened when resources are no longer available after external humanitarian agencies leave and the responsibility to support these programs is transferred to other stakeholders e.
Loss of human resources due to attrition of providers and other personnel in humanitarian settings further reduces access to services for people with substance use problems [ 38 ]. Lack of specialized providers is a common challenge for mental health programs more broadly in low-income and humanitarian settings [ 39 , 40 ]. Growing evidence suggests that the capacity of lay health workers to provide mental health, including substance misuse, interventions is sufficient and serves as a cost-effective strategy to alleviate the unmet need for care due to the shortage of specialty health providers in many low-income settings [ 41 ].
Although the teacher trainings were reportedly successful, the study investigators cite the process of identifying and adequately training the trainers to be a challenge [ 21 ], and previous researchers have noted the importance of ensuring trainers themselves have sufficient time to practice newly learned skills, before becoming trainers [ 42 ].
Building capacity of intervention providers, particularly non-specialized providers without prior training, often requires high levels of monitoring and supervision that may be impractical for long-term, real-world program implementation, particularly when challenged by language and cultural barriers [ 14 , 23 ].