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:
Frequent drug tests in addiction treatment have become a common practice despite proven benefits of such testing. When do tests become the end instead of the means to health and wellness?
In a previous post, I have explained how there was no agreement on the frequency of drug testing in Canada. Not until March 2018, when the British Columbia Centre on Substance use released the National guidelines for opioid use disorder. This article looks at the scientific evidence (or the lack of it) for frequent drug testing in addiction treatment. Read more or watch podcast below:
What is the study about?
We wanted to find out whether frequent urine drug tests correspond with better outcomes of treatment with opioid agonists such as methadone or buprenorphine.
How we did the study ?
We looked at the scientific literature from 1995 up until the end of 2017.
Then, we wanted to see how often the screening should be done while in the opiod agonist treatment. In the study, we included people of any gender, age or ethnicity.
Frequent drug tests lack evidence
We found only one higher quality studies with patients from USA
The study compared weekly and monthly urine drug testing with take-home doses of opioid agonists
Our review identified an urgent gap in research evidence underpinning an area of clinical importance and that is routinely reported by patients as an area of concern
Why is the study important?
Opioid use disorder is a chronic condition impacting the reward, motivation and memory pathways of the brain (ASAM, 2017).
Opioid agonist therapy is a first-line treatment for opioid use disorder.
The frequency and role of urine drug screening in opioid agonist treatment has received little research attention.
Although prior evidence suggests that testing frequency reflects philosophy and practice context, rather than differences in patient characteristics or clinical need, frequent urine testing remains under-researched.
Finally, the editorial of the Canadian Journal of Addiction featured this study as important for bringing additional management aspects for consideration:
McEachern J, Adye-White L, Priest KC, Moss E, Gorfinkel L, Wood E, Cullen W, Klimas J: Lacking evidence for the association between frequent urine drug screening and health outcomes of persons on opioid agonist therapy. International Journal of Drug Policy 2019, 64:30-33.
Updating Cochrane systematic reviews makes them most useful and fresh for readers. We updated our review on concurrent alcohol and drug problems again.
Which new studies we found?
We found seven studies that examined 825 people with drug problems. Six of the studies were funded by the National Institutes for Health or by the Health Research Board; one study did not report its funding source.
One study focused on the way people think and act versus an approach based on Alcoholics Anonymous. It aimed to motivate the person to develop a desire to stop using drugs or alcohol.
Three studies looked at a counselling style for helping people to explore and resolve doubts about changing their behaviour (group, individual and intensive formats). Their controls were education, or less intensive counselling, or assessment-only.
Two Irish studies and one Swiss study looked at practices that aimed to identify an alcohol problem and motivate the person to do something about it versus usual treatment.
This study has been made into a podcast available at Cochrane.org news item at https://www.cochrane.org/news/podcast-which-talking-therapies-work-people-who-use-drugs-and-also-have-alcohol-problems
and a Network news item https://mhn.cochrane.org/news/podcast-which-talking-therapies-work-people-who-use-drugs-and-also-have-alcohol-problems Listen to the podcast below:
Updating Cochrane Review – Key results
The Swiss and Irish studies were directly compared. They took place in general practices (one trial) or methadone clinics (two trials). They included 170 participants with a mean age of 37 years. All participants had positive alcohol screening test upon entry to the trial. At the end, the scores between groups were similar (average difference in scores: -0.6, 1.7 and -2, respectively).
One study found that a brief motivational intervention led to a reduction of alcohol use (by seven or more days in the past month at 6 months).
It remains uncertain whether talking therapies affect drinking and drug-using in people who have problems with both alcohol and other drugs. We lack high quality studies.
Cited cochrane review: Klimas J, Fairgrieve C, Tobin H, Field C-A, O’Gorman CSM, Glynn LG, Keenan E, Saunders J, Bury G, Dunne C, Cullen W. Psychosocial interventions to reduce alcohol consumption in concurrent problem alcohol and illicit drug users. Cochrane Database of Systematic Reviews 2018, Issue 11
Read a summary of the previous version of this review here
Clinicians commonly use urine drug tests to detect or validate self-reported drug use, particularly when beginning and maintaining opioid agonist therapy (for example buprenorphine or methadone). Until now, there has been no clinical consensus on urine drug testing frequency in Canada.
National guidelines for opioid use disorder released: Canadian consensus on urine drug testing frequency
Vancouver, B.C. [March 5, 2018] — “A first of its kind Canadian guideline setting out best practices for treating people with opioid addiction has been released today. The national guideline was based on provincial guidelines developed by the BC Centre on Substance Use (BCCSU) and implemented in British Columbia last year.” This guideline has been federalized and published in the Canadian Medical Association Journal. Health care professionals should follow the new guidelines.
Large Variation in Provincial Guidelines for Urine Drug Tests during Opioid Agonist Treatment
Before the new guidelines, each province had their own guidelines for treating opioid addiction. At that time, there was no summary of the published clinical practice guidelines for urine drug tests in Canada. Also, no one measured the consistency with which different provinces suggested administering drug screening. In June 2017, the American Society of Addiction Medicine released the national consensus document for appropriate use of drug testing.
Therefore, we looked at all policies and guidelines for Urine drug screening in Canada, examining the published clinical practice guidelines for each Canadian province and extracting all relevant data in March 2017. Our recent provincial guideline and policy scan found that urine drug screening frequency recommendations vary greatly among Provinces for persons receiving opioid agonist therapy for opioid addiction.
To read the whole story, please visit the journal website www.canadianjournalofaddiction.org or lookup the paper using the following citation:
Moss, E., McEachern, J., Adye-White, L., Priest, K., Gorfinkel, L., Wood, E., Cullen, W., Klimas, J. (2018) Large Variation in Provincial Guidelines for Urine Drug Screening during Opioid Agonist Treatment in Canada. Canadian Journal of Addiction, 9(2):6-9
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