Effect of THNPs on Heroin OD Mortality | Methodology

Effect of THNPs on Heroin OD Mortality MethodologyChapter 2. Methods2.1 universeThis chapter contains a precise interpretation of the process used to hunt and judge the express for this systematic literature review. The inquisition was carried out during August and September 2014. An in-depth description of how evidence and re chase unattached related to the PICO question were generated, will be discussed. As mentioned in the previous chapter, the aim of this dissertation is to determine the effect of THNPs to diacetylmorphine users, on heroin OD mortality.The analysing process of the PICO question, whether THNPs reduces the incidence of bleak heroin OD deaths, will be amplified through a description of the actual hunt strategy, and the methods used to appraise the retrieved studies. Through specific criteria, a systematic approach was applied in obtaining and selecting the relevant literature. Identified keywords used for the chase sentence structurees will be presented, together with the databases used for the retrieval of evidence, and the number of hits produced from separately database. Search sentence structure is the relationship of a sequence of words used in a search strategy. A discussion of the inclusion and expulsion criteria trammel for this systematic review (SR) will follow, together with the methods of appraisal chosen to evaluate the studies.2.2 Keywords and databases usedPICO Element explanationKeywordsPopulationHeroin injection users in the communityheroin users, injection drug users, drug users, opioid usersInterventionTake-home naloxone program pull in naloxone program, naloxone diffusion program,ComparisonNo comparisonOutcomeReduced incidence of fatal heroin OD deathsOD reversal, OD prevention, opioid OD prevention, heroin OD prevention, harm reductionAccording to Timmins and McCabe (2005) the cornerstone of an effective search strategy is the use of proper keywords. A number of keywords were formulated from the PICO quest ion parts, and from the feeler search of the literature. These were master(prenominal)ly identified from titles and keywords used in articles found from the preliminary search. sidestep 2.1 below, shows the keywords used in relation to each PICO element. slacken 2.1 Keywords developed to discern the PICO frameworkThe main electronic systematic search with the search sentence structurees explained further on in this chapter was carried out using assorted databases accessed from the Hybrid Disc overy (HyDi) available from the online library at the University of Malta. Relevant databases were found on HyDi by choosing the category Health Sciences and sub-category Nursing since the separate sub-category is Midwifery which is unrelated. Six databases were used to conduct a search for the literature. These were Academic Search Complete, Cumulative Index to Nursing and Allied Health CINAHL Plus with Full Text, Cochrane Central Register of Controlled Trials, and Cochrane Database of SRs via EBSCO host search engine together with Medline via ProQuest search engine, and Science Direct. In addition to these databases Google Scholar was also utilised, hardly the search phrase structurees combinations could not be used since the search engine does not have an advanced search strategy, and the search resulted in large thousands of articles. Therefore simple keywords alone were used to search for some(prenominal) other relevant studies, or to obtain full text versions which be not available in other databases. forces and boundarys of each database are describe below in table 2.2.DatabaseStrengthLimitationAcademic Search CompleteDaily updatesProvides full text journalsAvailable only from EBSCO hostCINAHL Plus with Full TextWeekly updates everywhere 950 journalsCovers references and abstracts from 1982 onwardsAvailable only from EBSCO hostside and American language biasCochrane LibraryCochrane Central Register of Controlled TrialsCochrane Database of SRsResear ch analyzed using fiducial methodsLarge source of literatureUp-to-dateComplete text reviewsLimited by restrictionsMedlineRecords indexed with Medical Subject Heading (MeSH)Provides a large source of look sciences evidence need by health professionalsLimited by restrictionsScience DirectProvides full text from Elsevier Science journalsProvides full text articlesLimited by restrictionsGoogle ScholarFree access web based search engineLarge amount of results due to lack of an advanced search strategy Table 2.2 Databases strengths Limitations2.3 Inclusion and Exclusion CriteriaFor readers to assess reliability and validity of a SR they have to be provided with a set of inclusion and exclusion criteria (Cronin, Ryan, Coughlan, 2007). Furthermore, Torgerson (2003) suggests that a set of inclusion and exclusion criteria are important so that throughout the search, only the articles that will answer the PICO question are extracted while others are eliminated.During the preliminary search it was noted that literature about the subject lacks randomized controlled trials (RCTs), meta-analysis, and SRs. As shown in figure 2.1, these study designs are found at the top of the hierarchy of evidence as described by Aslam et.al (2012). Hence, all types of study designs were part of the inclusion criteria. Sibbald Roland (1998) said that clinical trials are known to be a gold ensample to perform good evidence based practice and although they were in the inclusion criteria, the results were negative since up-to date no RCTs have taken place. Although this is a major limitation for this literature review, one must keep in mind that currently, the first and largest RCT is macrocosmness carried out as described in chapter 1.Source type selected in all databases was Academic Journals since books, newspaper articles, and magazines are not of strong evidence for evidence based healthcare because sometimes they do not have any type of study design, and may be narrative. Each sea rch was limited to English language literature only. Studies that administered intranasal (IN) naloxone were excluded since this method is an off-label method (Doe-Simkins, Walley, Epstein, Moyer, 2009), and in an RCT by Kelly et al. (2005) it was found that IM naloxone was clinically more effective than IN naloxone (6 minutes vs 8 minutes). Table 2.3 and table 2.4 below describe further in detail the inclusion and exclusion criteria respectively.Figure 2.1 The Hierarchy of Evidence Pyramid (adapted from Aslam et al. 2012, p.3) Table 2.3 Inclusion CriteriaInclusion CriteriaRationaleLiterature had to be in English languageNot possible to translate to EnglishStudies published from 1980s till September 2014Studies about THN commenced in the 90s, and so all studies are obtained (Darke Hall, 1997)Involving heroin injection drug users preceding(prenominal) 18 years of ageSince the population are adults injecting heroin, and in all studies found, drug users were of 18 years and aboveInv olving THNPSince this review concerns the outcome of THNPExperimental studies including RCTs, reviews, observational studies including cohort studies and longitudinal studiesTo include all study designs and to not eliminate valuable literatureStudy needed to have an outcome of survival rates or OD reversals associated to THNPIf outcomes were different, studies would not answer the PICO questionExclusion CriteriaRationaleStudies researching attitudes, views and opinions of health care practitioners providing THN and other stakeholders much(prenominal) as policeOutcome of studies unrelated to PICO questionStudies about experiences of fatal OD victims where naloxone was not provided to heroin users as a preventive greenback of fatal ODStudies had to have THNP studied as a preventive measure rather than other measuresDevelopment of instrument tools for THNP evaluationThese instruments do not answer the PICO questionUsers of prescription opiates including methadoneSince population is s pecifically heroin injection drug usersStudies including HIV, AIDS, buprenorphine, methadone, and supervising injecting facilities as a main topicFor the event that THNP is the main subject and intervention of this SRStudies were intra nasal naloxone was usedNaloxone nasal spray is not yet approved or licenced anywhere in the worldStudies where naloxone was not administered by any of the participantsThe outcome was not attributed directly to naloxone administrationStudies not published in EnglishNot possible to translate to English Table 2.4 Exclusion Criteria2.4 Search StrategyThe keywords mentioned in table 2.1 were developed so that each PICO element has its own search syntax as identified by Bettany-Saltikov, (2012). The use of search syntaxes has assisted in narrowing the search to the most relevant studies to the PICO question. Table 2.5 below, shows the search syntax used for each PICO item.PICO elementSearch syntax numberSearch syntaxPopulationSearch syntax 1heroin users O R injection drug users OR drug users OR opioid usersInterventionSearch syntax 2take-home naloxone program OR naloxone distribution programOutcomeSearch syntax 3overdose reversal OR overdose prevention OR opioid overdose prevention OR heroin overdose prevention OR harm reduction OR overdose mortalityTable 2.5 Search syntaxesSearch syntaxes were combined as described herePopulation (syntax 1) AND Intervention (syntax 2)Population (syntax 1) AND Outcome (syntax 3)Intervention (syntax 2) AND Outcome (syntax 3)Boolean logic operator OR was used to combine each keyword of each PICO element syntax, while the operator AND was used to combine the PICO elements together as described above.In all search fields of the databases used except Google Scholar, In All Text was selected for all searches. In Google Scholar the keywords searched independently were take-home naloxone and naloxone distribution. These keywords were searched in titles only, since when searched for anywhere in the article th e results were over 50,000 with most of them irrelevant to the dissertation.As shown in table 2.6 below, the defined search resulted in 2,260 articles. After the titles were evaluated whether they fit with the inclusion and exclusion criteria mentioned previously, and removing duplicate articles the search results were decreased to 160 articles by reading through the titles. The abstracts of these 160 articles were read and consequently 25 articles were noted to be directly related to the PICO question addressed in this dissertation, as they all met the inclusion criteria. One of the 25 articles which is a study by Lenton Hargreaves (2000) was not available online for free. The author, Professor Lenton was contacted via e-mail. Fortunately there was an immediate response, and the article was provided for free. However, afterward reading these 25 articles, 15 were eliminated because they had one or more of the exclusion criteria fit. The remaining 10 articles were identified and h ad fit all of the inclusion and exclusion criteria and were chosen for the critical appraisal of this systematic literature review. Furthermore the search was enhanced by looking up at all the reference lists of the lowest articles chosen for critical appraisal, but no new studies were found. Identified studies for critical appraisal are the following Strang et al. (2008), Piper et al. (2008), Tobin, Sherman, Beilenson, Welsh, Latkin (2009), Enteen et al. (2010), Wagner et al. (2010), Bennett, Bell, Tomedi, Hulsey, Kral (2011), Bennett Holloway (2012), Lankenau et al. (2013), Banjo (2014), and Clark, Wilder, Winstanley (2014). In addition to the electronic search, a hand search was done within the University of Malta library which did not produce any results. Table 2.6 below presents the number of hits obtained from each of the databases above and the different search syntaxes combination.DatabaseKeywordsNumber of hitsAcademic Search Completesearch syntax 1 AND search syntax 22 74search syntax 1 AND search syntax 3272search syntax 2 AND search syntax 355CINAHL Plus with Full Textsearch syntax 1 AND search syntax 27search syntax 1 AND search syntax 3114search syntax 2 AND search syntax 310Cochrane Central Register of Controlled Trialssearch syntax 1 AND search syntax 20search syntax 1 AND search syntax 30search syntax 2 AND search syntax 30Cochrane Database of SRssearch syntax 1 AND search syntax 20search syntax 1 AND search syntax 31search syntax 2 AND search syntax 30Medlinesearch syntax 1 AND search syntax 231search syntax 1 AND search syntax 3228search syntax 2 AND search syntax 328Science Directsearch syntax 1 AND search syntax 2532search syntax 1 AND search syntax 3485search syntax 2 AND search syntax 3145Google Scholartake-home naloxone, naloxone distribution78Total number of literature found = 2,260 Table 2.6 Number of articles found from each search2.5 Refining of the research questionAfter determination the relevant literature to the original PIC O question, and considering properly the population being studied, the research question was duly handsome since this systematic literature review will be based on the impact of THNP effect on heroin OD deaths amongst heroin injection drug users. Initial PICO question wasDo naloxone take-home programs provided to drug users in the community reduce the incidence of fatal opioid OD?The question was refined toDo naloxone take-home programs reduce the incidence of fatal heroin OD amongst heroin injection users?The refining of the PICO question was essential since some of the literature concerned prescription opioid users or general drug users, but the reviewers main interest is heroin injection users.2.6 Methods of AppraisalAfter identifying the relevant studies and refining the PICO question, the next step for this dissertation was to critically appraise the literature. This will be covered in chapter 3. Critical appraisal is the evaluation of strength and quality of research studies in order to deliver evidence-based clinical decisions and after determining the worthiness of different studies through the use of different critical appraisal tools, multiple research findings can be synthesized together to develop evidence-based-practice (LoBiondo-Woods Haber, 2013). Furthermore, Burls (2009) argues that studies being biased can result in false outcomes and conclusions, because they are not composed of an acceptable quality. A bias is an orderly deviation of the results occurring from the way that a study is led, investigated or reported. In light of this, critical appraisal tools were developed to help researchers in identifying valid and reliable studies. Specific critical appraisal tools in the form of checklists are used to analyse different study designs. Commonly used appraisal tools areCritical Appraisal Skills Programme (CASP)Scottish intercollegiate Guidelines Network (SIGN)Centre for Evidence Based Mental Health (CEBMH)Critically Appraise Topic (CAT)Aft er studying and considering all of the above methods of appraisal, together with other appraisal tools, it was decided that the CASP appraisal tools are to be used for critically appraising the identified studies relevant to the PICO question. The reason for choosing the CASP appraisal tools is because it is clear, concise, and easy to understand. CASP offers different checklists entrance for different research designs where one can critically evaluate research through a set of questions and helps in determining the quality of the literature being appraised. At this phase, the studies were also rated and arranged according to the hierarchy of evidence adopted from Aslam (2012) as shown in figure 2.1.2.7 ConclusionIn conclusion, the studys main objective is to determine whether THNPs reduces the mortality rate of heroin OD. Several keywords were identified from the PICO question elements, and from preliminary search results. These keywords were systematically searched in different d atabases using different search syntaxes combinations. A set of inclusion and exclusion criteria were then set up in order to get to the studies relevant to the PICO question. PICO question was then refined and then it was decided to use the CASP appraisal tools for evaluating the relevant studies which will be discussed in the next chapter.Words 1763