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
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How many of you had a flu this winter? Anyone took antibiotics for that? But some people can’t take them because they are allergic. Now, imagine someone suffering from pain, being prescribed opioids and having a negative reaction to them. What if this reaction was addiction to opioids? What if we could measure the risk for addiction the same way we can measure allergy to antibiotics? This article describes why opioid addiction is not an allergy to opioids and that we should not think about it that way, nor try to measure it using opioid risk tools.
We wanted to find out whether we can tell which adult will go into opioid addiction when prescribed opioids for pain. Why? Prescription opioid addiction can have devastating consequences but it is not clear how to identify patients with pain among whom prescription opioids can be safely prescribed.
The Journal of the American Medical Association – JAMA Network Open – commissioned us to do a very special kind of review that is called Diagnostic Accuracy Review. For this study, we chose only the best studies. To illustrate diagnostic performance, data from higher quality studies were extracted and used to calculate likelihood ratios (LR). What are likelihood ratios? Likelihood Ratios bigger than 1 increase the probability of a disease. Likelihood ratio of 1 equals roughly zero increase. Likelihood of 2 equals just about 15% increase.
Opioid Risk Tools
The opioid risk screening tools that are in widespread use are based on low quality studies and are not helpful in identifying patients at higher risk. Among them, the pain medication questionnaire had likelihood ratio of 2.6 (slight increase in likelihood, about 15%). Some risk factors were found in a single high quality study:
A history of opioid or non-opioid use disorder, a mental health diagnosis and concomitant prescription of certain psychiatric medications may increase the risk of prescription opioid addiction.
However, only the absence of a mood disorder appeared useful for identifying lower risk patients (and assessment tools incorporating combinations of patient characteristics and risk factors were not useful).
There are few valid ways to identify patients who can be safely prescribed opioid analgesics. Given the lack of good tools and the mounting evidence that opioids are not effective for chronic pain, such as the recent JAMA trial called Space, prescribers should be aware of tools’ limitations when prescribing opioids for pain. Opioid addiction is not an allergic reaction. Don’t try to measure risk for it and whether it’s safe to prescribe. De-implement opioid risk tools!
|Reference: Klimas, J., Gorfinkel, L., Fairbairn, N., Amato, L., Ahamad, K., Nolan, S., Simel, D., Wood, E. (2019) Strategies to identify patient risks of prescription opioid addiction when initiating opioids for pain: A Systematic review. JAMA Network Open. 2(5):e193365. Doi: 10.1001/jamanetworkopen.2019.3365|
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Which student learns best with hospital teams fighting opioid crisis? Understanding how students learn is perhaps the most important way to improve addiction training.
In a new article published by the Substance Abuse journal, we report findings suggesting that the completion of an elective with a hospital-based Addiction Medicine Consult Team appeared to improve knowledge of medical students more than of other types of students. Read more below or listen to the podcast.
Firstly, we found that both emerging and established physicians appear to be responsive to this type of training. Secondly, the learner self-assessment can provide valuable feedback to the consultants. Then, consultants can focus more on the students who learn less.
Keep fighting opioid crisis through training
The study sample was drawn from medical students, residents and physicians who took part in a month-long rotation with a hospital-based addiction medicine consult team in Vancouver, Canada. The addiction rotation includes full-time clinical training involving intake assessment and treatment planning. And referrals to community agencies and starting people on evidence-based medications for substance use disorders. The students take part in didactic lectures, bedside teaching, journal clubs and some prepare papers for submission to peer-reviewed journals. Each year, about 80 learners go through the program. Furthermore, learners rate their knowledge before and after the training.
At the end, all learners reported increased knowledge. One group, however, learned more than the others – the medical students. This two-year study confirms that a structured clinical training program can lead to an increased knowledge on addiction and that medical students benefit from it the most.
For more info read the full article at:
Gorfinkel, L., Klimas, J., Ahamad, K., Mead, A., McLean, M., Fairgrieve, C., Nolan, S., Small, W., Cullen, W., Wood, E., Fairbairn, N. (2019) In-hospital training in addiction medicine: A mixed methods study of health care provider benefits and differences. Substance Abuse (Published online Jan 28) doi: 10.1080/08897077.2018.1561596
If interested, you can also read: What can hospital teams teach medical students about addiction to help curb the opioid overdose epidemic?
Or visit a post that talks about this research as it was presented at the Canadian Society for Addiction Medicine link here