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A road map out of the opioid crisis

Paul McGary, the director of mental health and addiction services for Lakeridge Health was one of two chairs who coordinated the working group responsible for the Opioid Strategy that is set to guide the decision making and actions of the Central East LHIN over the next two to three years. (Photo by Joel Wittnebel)

By Joel Wittnebel/The Oshawa Express

In the battle against opioids, there are a lot of moving parts.

There are hospitals and addiction services and community health organizations, SIS and RAAM clinics and OPS and enough acronyms to leave anyone baffled.

It also makes the system a confusing one to navigate, and when it comes to opioid addiction, even the smallest barrier can seem insurmountable when it’s the choice between withdrawal and relief.

However, for that reason, as the opioid crisis continues to deepen across the country, killing approximately 4,000 Canadians in 2017, the Central East Local Health Integration Network has recently approved a new Opioid Strategy to guide the decision making and resources toward improving the system for opioid users, while also increasing education and spending in the areas that most need it.

The Central East LHIN covers a wide swath of Ontario that stretches from Scarborough in the west, and Northumberland County in the east, and from Lake Ontario north to Algonquin Park. The area is one of the fastest growing in the province and includes approximately 11 per cent of Ontario’s population with 1.4 million people.

The new strategy is the result of work from a group of stakeholders within the Central East LHIN, brought together by Lakeridge Health and chaired by Dr. Rosana Salvatera and Paul McGary, the director of mental health and addiction services for Lakeridge Health.

On March 28, the strategy was received by the LHIN Board of Directors, who have since directed their staff to come forward with an implementation plan this summer.

The plan includes 21 recommendations, all of which include a number of sub-items to be potentially implemented covering all aspects of the opioid crisis and how to potentially turn the tide, including prevention, treatment, harm reduction and enforcement, the four pillars of the strategy.

“The impact of the opioid crisis crosses every sub-region and every demographic in our LHIN and requires all of us, either as individuals or organizations to work together,” says Louis O’Brien, chair of the Central East LHIN Board of Directors “By building on what we have done to date, hearing from people with lived experience and those who are providing front line care, we will be able to respond in an integrated and coordinated way. On behalf of the Board, I would like to thank the Opioid Strategy Action Group for their leadership in developing the Central East LHIN Opioid Strategy and we look forward to supporting the ongoing implementation of recommendations.”

Those recommendations range in priority level, but for McGary, he sees the plan being relevant and implemented over the next two to three years.

“As this crisis deepens, time is of the essence,” he says. “I would see that this is crucial for immediate attention over the next two to three years, we know the LHIN received it with the same level of urgency, many of the items that we talk about are of no cost, so they can be actioned immediately.”

High priority items include distributing drugs such as naloxone to emergency departments, supporting the implementation of new prescription guidelines, and working to educate those across the spectrum on stigma and trauma in order to better serve those with opioid addiction disorder.

“There are so many moving pieces in this. There are so many contributing factors to how we got to where we are, but then there are even a greater number of strategies out and enablers that if put in place, will help us get on top of this and to start to bend the curve on these metrics that are, right now, really getting out of control,” McGary says.

Along with opioid related deaths, which increased by 30 per cent in Canada between 2016 and 2017, emergency department visits for opioid related overdoses have increased by 53 per cent in the last 10 years.

On top of that, the drugs are getting more dangerous, with 74 per cent of apparent opioid related deaths involving fentanyl, or fentanyl analogues.

So now, the Central East LHIN hopes that its four-pillared approach may help to guide the way in overcoming the ongoing crisis.

Getting the word out

When it comes to opioids and their treatment, education is a key component. It’s something the LHIN has known for some time, getting the word out and stopping addiction before it happens is crucial, however it still forms a large part of the strategy’s recommendations.

“It really is a huge piece,” McGary says. “And some of this work that we find at this important juncture is work that has been important all along and is now of additional significance.”

And while the strategy identifies a number of places to educate, whether that be for drug users or the medical services themselves, and to provide materials that are tailored to these different audiences, McGary says things really boil down to two core aspects.

“One of them is doing, really what I would call anti-stigma education along our frontline health providers to ensure people are welcomed, (and) treated fully respectfully, as any other health condition,” he says, calling the stigmatization of opioid users within the medical field a “pervasive issue.” “That’s work that we have been doing some of, and I think we have learned that we need to do more of it.”

Along with that, McGary says that part of the strategy will work to ensure that care for opioid users is “trauma informed.”

“So many people who have addiction and mental health issues, have experienced trauma in their lives and there are ways we as healthcare providers can make sure that we respect they have experienced trauma and we can work with them in ways that will not cause them further harm and build upon some of their vulnerabilities to ensure that their recovery is successful.”

A large piece of the education component also comes down to limiting the flow of opioids at the source, something the province has attempted to tackle with the release of new prescription guidelines.

In 2017, a report from Health Quality Ontario found that Ontarians had filled more than nine million prescriptions for opioids in 2015-2016, almost double the amount from three years earlier.

Part of the strategy also recommends that the LHIN support the increase in access to pain management consultations across the LHIN to perhaps find alternative means of relief for patients besides opioids.

“It is critical that healthcare providers are aware of alternative pain management therapies shown to be safe and effective in the treatment of acute and chronic pain,” the document reads.

And the education efforts can’t stop there either, McGary says with the strategy recommending efforts to include police and other community stakeholders. The LHIN strategy recommends the creation of a Central East LHIN “Community of Practice” which would be a group bringing together various disciplines in order to exchange knowledge and resources around opioids.

Working with emergency departments

The strategy is also looking to address emergency departments across the Central East LHIN, and not only make it better for opioid users who may go there for help, but also to streamline the process and ensure they get the care they require.

“We often see that people are under-treated for their conditions, so people with chronic addiction issues are not managed very well, most EDs don’t have thorough protocols for what to do with someone who has an opioid use disorder,” McGary explains. “We saw that, and we saw that as an opportunity to create some standards of care.”

And those standards of care, in the medical field, are known as “order sets” and McGary says they are currently in the process of creating four different sets to handle opioid users who arrive at EDs.

In simple terms, the order sets work as a checklist for what to do and what to test when an opioid user arrives at the ED.

“In Central East we had very few of those, in fact, if any for addictions,” McGary says. “We’re working with our peer hospitals so that we’re all going forward and to adopt those new order sets in a consistent way.”

A few of the fundamental items could include providing the person with health education, naloxone kits and giving referrals to RAAM clinics, or provided with certain medications to ensure their withdrawal is appropriately addressed.

“We saw a huge opportunity there in raising the quality of care that people should be entitled to as part of the health conditions they have,” he says.

Access to assistance

A large part of the strategy is also about ensuring that the proper medications and proper treatment options are available and accessible to the people who need it, something that seems like a no-brainer, but in the medical world filled with what the LHIN strategy labels as “fragmented treatment pathways” people can sometimes miss out on the help they need, and with potentially dire consequences.

To prevent that, the strategy recommends a number of measures to increase access across the board, including the creation of an Opioid Outreach Team, enhancing withdrawal management services, and expanding medication-assisted therapy options.

As well, it recommends the implementation of Rapid Access Addictions Medicine (RAAM) clinics,  something Lakeridge had already created and seen early success with.

The two clinics, located at Lakeridge Oshawa and the Pinewood Centre, one of the hospital’s addictions and mental health branches located at 300 Centre Street South, offer short-term addiction treatment and counselling on a walk-in basis.

“Ours has taken off like wildfire,” McGary says, noting the clinic has seen 77 people in the first two months of operations.

“Those are all unique patients, many of them had no previous involvement with Pinewood or any addiction services,” he says. “About half of them are being treated for opioids and half are being treated for alcohol, and they’re being started on meds right on the spot.”

And not only can these RAAM clinics have a big impact on drug users by eliminating any wait time, they can also have a large impact on the number of ED visits.

In Sudbury, where similar RAAM clinics are operating, the hospital saw a 63 per cent reduction in ED visits during the first 90 days of the clinic operating. Similar results were seen in Sarnia as well where a 45 per cent reduction in ED visits was seen after the RAAM clinic’s first 90 days.

McGary says that Lakeridge is guaranteed to see similar results to Sudbury and Sarnia.

“We’re doing not only exactly what they’re doing, but we’re taking it a bit further,” he says.

Moving forward, the plan also looks to address potential long-term strategies to drug and addiction issues, including the advocation for the decriminalization of all drugs for personal use.

“There are some very good public health examples of how changing our focus to substance use as a health condition versus a criminal condition greatly shifts how we think about and approach the issue and ultimately how we resource it as well,” McGary says. “That’s a long-term consideration as we look at different opportunities for treating this health issue that can really make a sustained effect on population health when we take away the criminal aspect and implement instead early intervention strategies, better treatment strategies, and make things more accessible.”

For now, McGary says the strategy will need to be the roadmap for the LHIN’s future planning to battle the opioid crisis, and continue to assist them in navigating people through the complicated healthcare system.

“We have to recognize where people often enter, and then where people will often next normally go, and we have to be the navigators of that with people to help them,” he says. “That will make a huge difference as well.”