Posts by Jano Klimas about community, collaboration, charity and social welfare.
Posts by Jano Klimas about community, collaboration, charity and social welfare.
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.
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.
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.
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:
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.
(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;
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.
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.
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.
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, 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
Celebrating 30 years of CSAM-SMCA in Vancouver, BC, the conference focused on: Crisis, Controversy & Change. What is the role of education in tackling the overdose crisis?
Three speakers at the education session on Friday offered several potential solutions.
(1:30) Who Learns the Most about Addictions in Hospitals? A Mixed Methods Study.
Jan Klimas (representing a co-author team: Gorfinkel, L., Ahamad, K., Mead, A., McLean, M., Fairgrieve, C., Nolan, S., Small, W., Cullen, W., Wood, E., and Nadia Fairbairn), summarised the results of a 2-year evaluation of the addiction medicine consult team in the St Paul’s hospital, Vancouver, British Columbia. Learners, such as medical students, completed web surveys before and after their clinical placements with the team. A purposeful sample participated in post-elective interviews. Results of this research study will soon appear in a paper accepted for publication in the Substance Abuse journal.
(1:45) Addiction Medicine Mentorship: Capacity Building Through Relationship Building.
Kate Hardy (Manager) and Sarah Clarke (Sarah Clarke) from the Metaphi mentoring project spoke about the role of primary care providers in the treatment of substance use disorders. The length of the treatment is more important than the intensity. Patients prefer to be treated in primary care. Integrating mental health with physical health services creates better outcomes. Primary care has greater capacity for treatment. But many providers are not willing to take over the care of persons with SUD. Medical mentoring of primary care providers by specialists. There’s no wrong door to access the addictions treatment. Mentorship, such the one provided via Hardy’s and Clarke’s project – metaphi – must be easy and convenient, sufficiently incentivized. Check out the project website www.metaphi.ca.
(2:00) The ABC’s of Addiction Fellowship Programs in Canada.
Melanie Willows (introducing her co-author team: Anees Bahji, Annabel Mead, Nikki Bozinoff, Ron Lim, Lydia Vezina, Ronald Fraser & Kim Corace) and a group of fellowship directors facilitated a session, which was sponsored by the CSAM education committee, about the Canadian fellowships in addiction medicine and offered recommendations for the future of the training programmes in Canada. In addition to the fellowship directors, the talk started with a lived experience of someone who has been accepted to the fellowship but who has not started the fellowship. A recent fellowship alumna concluded the group presentation.
If you enjoyed reading about this year’s CSAM 2018 conference, you can read about the CSAM 2015 here
With the end of the Thursdays Writing Collective coming soon in April 2018, I’ve decided to re-post my earlier blog from 2016 about this unique collective.
During each session, we spend half the time writing in response to prompts and the other half, especially before group performances, workshopping pieces and instructing fellow writers about time, place, format, and so on. However, I quickly found out that the collective is so much more than a writing group. It’s a true creative hub. Published authors visit frequently. Kate Braid, the poet, and her friend, Clyde Reed, a jazz musician, came to read us their poetry and improvised with a double bass on the spot. Clyde allowed us to read our own pieces while he played his mesmerising bass to accompany our words.
At most meetings, we share books and poems by authors we revere and it always serves to be an enlightening experience. For example, we discussed the Devil in Deerskins, by Katherine Swarthile, whose work is among the earliest published mementos on the first nations’ themes. Katherine Swarthile, the daughter of Anahareao, actually visited us. Her environmental message to the group gave further impetus and context to her book, which we all read in anticipation of her visit.
We also receive regular invitations to read poetry at spoken word events around town, including the Verses Festival and the Vancouver Poetry Slam. The Vancouver Co-op radio offered us spots on their poetry show Wax Poetix. Pamela Post, a journalist from the CBC national radio show, The Current, visited several times. She recorded hours of readings, including a story by one of our own, Henry Doyle, that documented our premiere concerts at University of British Columbia School of Music and the first encounter of Henry with composer Lucas Oickle.
Over time, I began to understand what it was that I couldn’t find anywhere else when I was searching for a writing group. The Collective acts as a single soul. My previous writing groups were wonderful places of exploration and were right for me at the time, but we rarely got together outside of class. This made it feel more like a language course where people mind their own business and go about their lives. However, Thursday’s Collective is a community. We chat during breaks, nibbling at fruit and veggies. The volunteers work hard in the background and keep us informed on new developments. Thanks to fees from the paid classes, they are able to do unpaid classes for people in shelters, prisons, or treatment centres. The members of the Collective have input into the decisions about the performances that we take part in, cash for readers, and choice of projects. Democratic votes about these decisions follow after group discussions. If someone read at a recent event, another writer is encouraged to read next. It reminds me of one of those artist collectives one might read about from the past, where creatives managed their own promotions and shared the same building, using it for studios and shows.
We are like a band with a leader who sets the tone, direction, and vision. Elee Kralji Gardiner—writer and editor—was this leader until 2016. Elee was our facilitator, manager, and director. Elee unified the Collective at the meetings and did a tremendous amount of work in the background, outside the meetings, to help us grow our work and allow the collective to thrive. With Elee at the helm, every year, the Collective also publishes an anthology. Last year’s (2014) theme was Music and Art Song.
In the history of music, Art Song played an important role. Loosely defined as a musicalized poem, typically performed by a singer and a piano, this form of music combines the work of a poet, composer, singer, and pianist into a stand-alone artistic statement. UBC graduate composers have set eleven of our poems to music, and their fellow student singers and pianists performed them at two April premieres in the UBC Roy Barnett Hall and St James Anglican Church at Cordova Street. The poets introduced their work and read the text before each performance.
We launched the “Voice to Voice” – our art song anthology – at the end of June 2015 in the Lost & Found Café. The book contained not only art songs, but also poems, stories, songs, and memoirs by our writers. An Indiegogo campaign funded the book and others supported it in many ways, including the Canada Council for the Arts, UBC School of Music, Peter Wall Centre, Instruments of Change, Carnegie Community Centre and SFU’s Writer’s Studio. Dwayne Woloshyn painted the book cover praised in the Keremeos Review magazine.
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Thank you all Thursday-ers.
Have you ever heard of compound 1080? No? I’m not surprised. Illegal in most countries, this poison (sodium monofluoroacetate) is used to kill wolves in Canada. Read more about a recent visit to the Northern Lights wolf centre near Golden, BC, that opened my eyes to the cruel practices of money and politics – the usual suspects from the war on drugs.
Caribou’s population in Western Canada is dwindling. Some Canadian provinces, like Alberta and British Columbia, have put in place aggressive measures to save Caribou.
Wolves are Caribou’s natural predators. To kill them seems logical in the fight for the Caribou’s survival. But only if we forget that Wolves are keystone species. “A keystone in anarch’s crown secures the other stones in place. Keystone species play the samerole in many ecological communities by maintaining the structure and integrityof the community.” This means that their killing will kick-start a chain reaction, leading to extinction not only of Caribou, but also other species and desolation of the land. The Yellowstone example is a worthwhile lesson: when the park eradicated the thriving predators, the antelopes overcrowded and nearly destroyed the grasslands. Predators have been reintroduced successfully.
“The recovery of the gray wolf after its eradication from Yellowstone National Park, almost ninety years ago, demonstrates how crucial keystone species are to the long-term sustainability of the ecosystems they inhabit.”
Drugs have predictable effects on people – the higher the dose, the more toxic they are. This is different from the addictive potential. Even the most dangerous of drugs – like heroin or cocaine – are used by millions of people relatively without problems and without addiction. Nobody becomes addicted after one dose. This means that we have been lied to about drugs and their effects.
Meanwhile, Canadian’s officials keep laying poisoned baits that will be eaten not only by the wolves, but by all other carnivore, such as, foxes, ravens, etc. The 24-hour delay of the poison kills not only the alpha-female, but her cubs too. When she comes back from the hunt, feeds them the food from her stomach, all of them will die. Seems effective. How come that this strategy won’t save the Caribou?
Our strategy to solve the drug problem has been based on the lies about drugs’ effects. The war on drugs was declared as the most powerful strategy to eliminate them. Research has shown that it doesn’t work. Instead, wrong people are put to jail when the drug laws are enforced selectively. What’s needed is often viewed as bad by the general public. Clean needles, safe injecting rooms and prescribed heroin are seen as helpful to maintaining harmful behaviour of people with addiction. The opposite is truth. They save lives. Because it’s the public opinion, and not the science, that wins elections, politicians will selectively use to please the public and ignore the science in solving the drug problem. Too bad for people who use drugs, but who cares about them anyway?
Not only are wolves the keystone species, they also are not the reason for Caribou’s sudden decline. Who’s to blame? Firstly, it’s the oil and fracking industry. By taking the land where the old-growth forest hosts Caribou, the industry is pushing them out of their natural habitat. Secondly, Caribou thrives in old-growth forest only. It takes 80-100 years for the forest to grow back again. Finally, they’ll die before they could return back.
Most likely, the Caribou will disappear from Canadian’s landscape. People will say that they were destined to die. We have done everything we could. We even killed the wolves. Similarly, many people who use illicit drugs will die or go to prison. People will say that they lacked motivation or were beyond help. We have done everything we could to help them. We banned the drugs and enforced the law.
“We need wolves to have a future; we need the to have water, air and biodiversity.” But they need your help and your voice. Vote! Contact the politicians and ask them about environmental issues. Likewise, people will continue to use drugs in future. We need an open and science-informed discussion about drugs.
Inspired about parallels between animal and addiction research? Read my blog about killer whales and researchers here.
Disclaimer: the organisations and individuals named in this article have not seen or reviewed this article. The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of any agency mentioned.