Building capacity for a CHC response to Ontario's Opioid Crisis

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1 Building capacity for a CHC response to Ontario's Opioid Crisis Rob Boyd Oasis Program Director Luc Cormier, RN, MScN Community Health Nurse Sandy Hill Community Health

2 CFPC Conflict of Interest Presenter Disclosure Presenters: Rob Boyd & Luc Cormier Relationships to commercial interests: Grants/Research Support: None Speakers Bureau/Honoraria: None Consulting Fees: None Other: None

3 Learning objectives 1) Learn basic pharmacological and physiological properties of methadone and buprenorphinenaloxone in order to understand their use in managing opioid use disorder; 2) Gain a better understanding of the various models of care for opioid replacement treatment currently being used in a CHC; 3) Explore the benefits and challenges of integrating addiction medicine within existing primary care settings such as CHCs.

4 What does your organization need to consider increasing your role in treating Opioid Use Disorder?

5 Oasis Program Oasis provides harm reduction based primary health care and social services to people at risk of HIV/AIDS and hepatitis C who experience barriers to accessing care due to overwhelming addiction to street drugs and cooccuring mental illness. Image: Art piece made by peers

6 Primary health care services The Drop-In Housing First Program Case Management Opioid Substitution Therapy Health Promotion Needle and Crack Pipe Distribution Program Support Groups Addictions and Mental Health Counseling Community Development

7 Is this problem common worldwide?

8 Opioid Crisis: Scope of the Problem Narcotics Monitoring System: April to Sept million dispensing events 5.1 million different patients different prescribers Opioid Agonist Treatment 2014/2015 MMT / Suboxone /

9 Substance use disorder in Canada Approximately 21.6% of Canadians aged 15 and over will meet the criteria for a substance use disorder in their lifetime. Alcohol 18.6% Cannabis 6.8% Others 4%

10 Opioid Use Disorder in Ontario

11 Opioid related deaths, by drug 1 in 170 deaths related to opioid use 1 in 8 among young adults aged 25-34

12 Opioid Overdoses Number of Opioid toxicity Deaths by Drug in Ontario Office of the Chief Coroner and Ontario Forensic Pathology Service Year Codeine Fentanyl Heroin Hydromorph Methadone Morphine Oxycodone

13 Case Study Case Scenario develop a treatment plan based on your current knowledge (issues/barriers/facilitators) Small groups discussion Details of case study to come

14 Goals of SUD treatment Treatment retention Reducing harm caused by substances Reduction in severity and frequency of substance use Management of concurrent psychiatric and medical conditions

15 Goals of SUD treatment Improving all areas of life affected by SUD (employment, interpersonal relationships, interface with the law/criminal justice system) Improving all levels of adaptive functioning Preventing relapse to substance use

16 Principles of treatment Treatment must be culturally-sensitive taking into consideration special populations including and pregnant women, ethnic minorities, individuals who identify as LGBTQ Recovery is conceptualized as a process rather than an event and is individualized for and defined by each client Treatment should include pharmacology, mutually agreed upon treatment goals, education, and interdisciplinary care

17 Continuum of Substance Use Treatment Concurrent disorders Chronic Non Use Abstinence Managed Use Problematic Use Complex Addiction Annual Screening of substance use and mental health Screen, brief intervene, treat and refer, biopsychosocial, Addiction medicine Low threshold medical, pragmatic support, SIS

18 Pharmacotherapy for opioid use disorder Opioid agonists Opioid antagonists Symptomatic treatment of withdrawals Opioid agonists are generally use for moderate to severe presentations of OUD. Often referred to as opioid substitution therapy (OST) or opioid agonist treatment (OAT) Buprenorphine-naloxone and methadone (MTD: requires a special license). Opioid antagonists block the opioid receptors and their effect. Symptomatic treatment with clonidine, acetaminophen, ibuprofen, dimenhydrinate, loperamide, trazodone.

19 Differences between opioid agonists and opioid antagonists Opioid agonists Suppress craving and withdrawal symptoms, and block the acute effects of other opioids Full or partial opioid agonist Opioid antagonists Block effects of other opioids from current or future use Used in overdose situations (naloxone) or as maintenance (naltrexone)

20 Pharmacology of Methadone Methadone (full opioid agonist) Long-acting Binds to and occupies mu-opioid receptors Prevents withdrawal symptoms and reduces craving for opioids Reduces euphoric effects of subsequent opioid use

21 Pharmacology of Methadone Benefits of treatment Increases retention in care Reduces illicit opioid use Associated with reduced spread of HIV infection Reduced criminal behaviour Reduces overall mortality rate Challenges Higher risk of substance misuse and overdose Requires special exemption for Rx Stigma associated with methadone

22 Pharmacology of buprenorphine-naloxone Buprenorphine- naloxone or Suboxone (partial opioid agonist) Ceiling effect due to partial activity (less likely to cause overdose) Binds very tightly to receptors, displaces other opioids (may precipitate withdrawal) Co-formulation with naloxone (opioid antagonist) taken sublingually low bioavailability of naloxone via this route

23 Pharmacology of buprenorphine-naloxone Benefits of treatment Increases retention in care Reduces illicit opioid use (more than methadone) Significantly less risk for lethal overdose (6x lower risk profile) Can be prescribed by primary care physicians Challenges Must be in moderate to severe withdrawal

24 What s the difference between opioid agonist treatment and using drugs? Opportunity for stabilization Ability to focus on other aspects of their life Lessens severity of problematic behaviours associated with OUD

25 Models of care for OST Fee-for-service Bare bones Rapid Access Clinic

26 Fee-for-service Model Billing through OHIP (visits and urine drug screens) Requires health card 330 physicians for patients ~154 patients per physician 72% fewer than 300 patients Very little primary care or psychosocial supports 50% MMT patients are with high volume practices

27 Remuneration through hourly salary Ideal for clients who don t have health cards Low threshold (carries, UDS) Bare Bones Model

28 Bup-nx/Suboxone only Does not require exemption Can be effectively managed in primary care practice Still need competency to prescribe Still need to address psychosocial issues

29 Rapid Access Clinic Model Interested individuals with opioid- or alcohol-related ED visits are referred to RAAM clinic and seen within 7 days Stabilization & transfer to primary care for ongoing management ED-initiated treatment is more effective than conventional approaches

30 Potential Models Primary Care Providers at CHCs begin prescribing suboxone or methadone. CHCs invite FFS OAT prescribers on site and offer integrated primary care and psychosocial support CHCs create formal agreements with stand alone FFS practices to provide primary care and psychosocial support.

31 OAT is best prescribed within an integrated primary care clinic with access to psychosocial supports What would need to happen for your agency to expand services to include Opioid Agonist Therapy in the next 6 months?

32 What information would be helpful to you in considering the possibility of expanding services to include OMT? Knowledge of scope of the problem in my community Access to training for PCPs New resources to operate Understanding on how funding models work/others currently work

33 Questions? Comments? Rob Boyd Director Oasis Program Sandy Hill CHC Luc Cormier Community Health Nurse Sandy Hill CHC

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