Although opioid agonist treatment is effective in treating opioid use disorders, retention in such treatment is suboptimal in part due to quality of care issues. A new initiative sought to boost treatment of opioid use disorders so that people stay there longer. This article describes how teams did in a structured quality improvement initiative in Vancouver, Canada.
Best Practice Oral Opioid Agonist Therapy Collaborative
The Best-practice in Oral Opioid agoniSt Therapy – or the BOOST – was a 24-month Breakthrough Series Collaborative which is a model of the Institute for Healthcare Improvement.
It was the first program of its kind in Canada and was among the latest efforts to turn the tide on the opioid crisis. It aimed to improve care for people living with opioid use disorder in Vancouver by implementing, measuring and sharing best practices.
We looked at electronic medical record (EMR) chart data to find patients with a documented diagnosis of opioid addiction. For those who had this diagnosis, or who were suspected of having opioid addiction, we looked at their age, gender and housing information.
What did the BOOST change?
17 health care teams participated in this study. They were caring for a total of 4301 patients with a documented diagnosis of opioid addiction. The mean age of patients was 43, with 64% identifying as male, 35% female and 1% trans or non-binary. The majority of patients lived in the Vancouver region (76%) and half of them had Most Responsible Provider – MRP. While typically referring to a physician, this may include a nurse practitioner or other healthcare professional.
The implementation scores showed that the majority of (59%) teams made some improvement throughout the Collaborative.
Why is quality improvement important?
Descriptive data from the evaluation of this initiative illustrates its success. Most participants with an active prescription stayed in care. As such, this evidence supports the use of quality improvement to close gaps in opioid care processes and treatment outcomes. Finally, this system-level approach has been spread across British Columbia, and other jurisdictions facing similar overdose crises can use it too.
Find more info about the collaborative online here: http://stophivaids.ca/STOP/wp-content/uploads/post/BOOST-Collaborative-Change-Package.pdf).
Citation: Beamish, L., Sagorin, Z., Stanley, C., English, K., Garelnabi, R., Cousineau, D., Barrios, R., Klimas, J. (2019) Implementation of a regional quality improvement collaborative to improve care of people living with opioid use disorder in a Canadian setting. BMC Health Services Research (2019) 19:663 https://doi.org/10.1186/s12913-019-4472-8
If you enjoyed reading this post, you may also wish to read about comparison of Canadian and United States opioid agonist therapy policies:
Canada and the United States (U.S.) face an opioid use disorder and opioid overdose epidemic.
The most effective OUD treatment is opioid agonist therapy (OAT). It means buprenorphine (with and without naloxone) and methadone. Although federal approval for OAT occurred decades ago, in both countries, access to and use of OAT is low. Restrictive policies and complex regulations contribute to limited treatment access.
We did a non-systematic literature scan and reviewed all available policy documents. We studied and compared treatment policies and practice at the federal level in Canada vs. United States. And also at the local level in British Columbia (B.C.) vs. Oregon.
There are differences and similarities between federal and local OAT policies. This applies to access to treatment. In Canada, treatment policy control has shifted from federal to provincial authorities. But in the U.S., federal authorities maintain primary control of treatment regulations. Local OAT health insurance coverage policies differed between B.C. and Oregon. While B.C. had 5 treatment options, Oregon had only 2 OAT options with some limitations.
Relaxation of special federal regulatory policies
The Canadian and U.S. federal OAT policies differ. So do the local OAT access and coverage policies in B.C. and Oregon. And it’s also because of the relaxation of special federal OAT regulatory controls in Canada. Our paper also highlights the complicating contributions and likely policy solutions. For example, the prescription regime and drug control regime within the drug policy sub-domain. Or, the constitutional rights within the broader policy domain.
U.S. policy makers and health officials could consider adopting Canada’s regulatory policy approach to expand treatment access.
Better access mitigates the harms of the ongoing opioid overdose epidemic.
Reference: Priest, K. C., Gorfinkel, L., Klimas, J., Jones, A. A., Fairbairn, N., & McCarty, D. (2019). Comparing Canadian and United States opioid agonist therapy policies. Int J Drug Policy. doi:10.1016/j.drugpo.2019.01.020
If you enjoyed reading this article, you may also enjoy reading about the role of treatment monitoring via drug testing:
What are the training needs of newly trained professionals working in addiction medicine around the world? Do they get enough and appropriate training to treat people who live with addictions? A new study protocol plans to answer these questions. (more…)
What is the smartest scale for asking clinicians about their training needs?
In a new article published by the Journal of Substance Abuse Treatment, we report findings from a study that looked at a new scale, the training needs assessment. Read more or watch podcast below:
|QUICK FACT: Addiction Medicine (AM) rarely uses Training Need Assessments (TNA).|
How we did the study?
We did a cross-sectional study in four countries (Indonesia, Ireland, Lithuania and the Netherlands). 483 health professionals working in addiction care completed AM-TNA. To assess the factor structure, we used explorative factor analysis. Reliability was tested using Cronbach’s Alpha, ANOVA determined the discriminative validity.
What has the scale found?
- Tailored training of health professionals is one of the elements to narrow the “scientific knowledge-addiction treatment” gap. Addiction Medicine (AM) rarely uses Training Need Assessments (TNA). The AM-TNA scale is a reliable, valid instrument to measure addiction medicine training needs. The AM-TNA helps to determine the profile of future addiction specialist.
The Training Need Assessment is a reliable, valid instrument to measure addiction medicine training needs.
Why is the scale important?
The AM-TNA proved reliable and valid. Additionally, the AM training needs in the non-clinical domain appeared positively related to the overall level of AM proficiency. Furthermore, researchers should study whether the AM-TNA can also measure changes in AM competencies over time and compare different health professionals. Finally, the AM-TNA assists tailoring training to national, individual and group addiction priorities.
|Reference: Pinxten, W.J.L. et al. (2019) Excellent reliability and validity of the Addiction Medicine Training Need Assessment Scale across four countries. Journal of Substance Abuse Treatment , Volume 99 , 61 – 66|
For more info read the full article in the Journal of Substance Abuse Treatment 99 (2019) 61–66 https://doi.org/10.1016/j.jsat.2019.01.009
Read more about this topic in a post from 2017: What are the core skills of an addiction expert?
You can also read a related post from 2015: International Society of Addiction Medicine | Congress #isam2015
Is drug court meeting the need of the most vulnerable people who use drugs? What is the drug court judge’s hardest decision? What is social detox? How voluntary is drug court treatment?
November 8th, The Association for Multidisciplinary Education and Research in Substance use and Addiction (AMERSA) met for 42nd time in San Francisco, CA. These, and other questions, pondered five AMERSA speakers at the Thursday’s Interdisciplinary panel session.
Meeting the Need: Collaborative Justice and Treatment.
(Interdisciplinary panel, Thursday, November 8th, 2018, 10:15 – 11:45 am)
The panel was presented by:
Judge Eric Fleming, JD – San Francisco Collaborative Courts
Lisa Lightman, MA – Collaborative Courts, San Francisco Superior Court;
Angelica Almeida, PhD – San Francisco Department of Public Health;
Linda Wu, MSW, LCSW – San Francisco Department of Public Health;
Charles Houston – San Francisco Department of Public Health;
Drug Court Judge’s hardest choice.
Judge Eric Fleming, JD
The court calls people who have addictions participants, not defendants. Among others, the key role is to listen as a judge and to show respect. The hardest decision is to decide who’s going to be terminated; terminating very young people is the hardest. Some people have been fighting addiction for 20 years, but not making enough progress. This raises a question: What is enough progress?
It is one of the most important courts in San Francisco, they devoted a chief to it – not just someone pushing them through the system. The court takes high risk clients, those who haven’t done well in previous programs, facing significant punishment.
They understand that there are layers to the individuals, case can be dismissed if it’s the first case, but not the fourth case. If anything happens the system can send them to jail, but it doesn’t; instead, they talk to them and they listen – give them numerous chances. Relapse is considered as part of the process – if judge understands that, it’s good for the client.
The graduation is pretty awesome, it wasn’t easy for anyone. The judge oversees the ceremony, starts with positive remarks, and then problems. I’m proud of you as a judge, I hope you learned from me, because I learned from you. The judge concluded with a story about a young female user, 22-year old, that he had to terminate, before the termination, he made a couple of phonecalls to make sure that she had a place to go when he terminated her.
Where does transitional youth belong?
Angelica Almeida, PhD – San Francisco Department of Public Health
Some of the core functions of the drug court system are: (1) Making sure that the services were coordinated, mental health and addiction behavioral health. (2) Trying to keep people in the least restrictive settings by intervening early.
Sometimes, it is a challenge of being a harm reduction city but working in a court that is historically abstinence based. The drug court is offering outpatient and intensive outpatient services. Also, low threshold services – medication assisted treatment.
Harm reduction principles are really what brings people to treatment; not judging them also makes a big difference. Thinking about how they work with transitional age youth, which don’t quite fit to children or adult services, is still evolving. System made to work with adults, really older adults. The transitional age youth drops out of services too much. Next step after residential treatment is always the hard piece.
Sobriety doesn’t take a certain number of days.
Linda Wu, MSW, LCSW.
Drug court treatment center has now become a civil service organisation. It is Co-located with community justice and violence intervention programs. It utilizes onsite urinalysis testing, all observed. Four levels of treatment graduation, graduation rate is 20% but 6 months of sobriety required, also housing and income or training – “you can’t be sober if that’s all you’re working on.” After graduation the case manager can help them even after the case is over, because they are part of dept of public health. Clients making significance progress towards recovery despite ongoing use, finding housing or using less harmful drugs such as cannabis. To be able to offer some choices (voluntary program) is really important and confidence-building.
Challenges of drug courts are many. Clients look at the treatment in terms of their sentence – sometimes, they ask how many days I have to serve? Sobriety doesn’t take a certain number of days.
There is a continuous discussion between harm reduction versus abstinence; it’s challenging at times to find the balance between client centered treatment and also making recommendations to the court. One of the ways they make recommendations to the court is through the UA (commitment, process).
Staff is sometimes feeling pressured to become enforcers because they need to write the court notes for court. It’s very different than writing clinical reports. Clinical note is very different from court note. That takes away the awareness from the what am I (staff) doing – to what are you (client) doing. Lack of community resources in a resource-rich city because lack of space (beds) and big stigma of working in drug services.
When change came over him
Charles Houston – public health.
Mr Houston, once a drug court participant – now working for the city and county, as a family liaison – spoke about how important drug court is. He was running (there was a warrant), but then change came over him. He called the court himself. They asked him, do you want to try it – drug court? Judge reviewed monthly progress, fostered accountability. They showed him a different way, the strengths that he had, the ability to make change.
While drug courts benefit certain groups of persons who use drugs, the jury is still out there when judging their overall effectiveness and organisation. Yes, treatment is voluntary but court mandated – the other option is jail.
AMERSA – what’s in the name?
AMERSA, formerly known as the association for medical education and research in substance abuse was recently renamed. Now it is The Association for Multidisciplinary Education and Research in Substance use and Addiction. The association’s mission is to improve health and well-being through interdisciplinary leadership in substance use education, research, clinical care and policy. Text taken from www.amersa.org
If you enjoyed reading about this year’s conference, you may like to read my notes from the previous years:
39th meeting in Washington, DC, November 5th, 2015
38th meeting in San Francisco, CA, November 4th, 2014