By Joel Wittnebel/The Oshawa Express
After getting approval for a sweeping response plan to address the ongoing opioid crisis in Durham, Lakeridge Health and stakeholders in the Central East Local Health Integration Network (LHIN) have been moving quickly to put in place a number of immediate measures to not only assist the region’s opioid-using population, but in many cases, save their lives. The timing could not be any better.
As Durham enters the warm summer months and the mercury continues to rise, so do emergency department visits related to opioids.
According to data from the Durham Region Health Department, opioid-related visits to Durham EDs in 2017 saw the number triple as the region entered the summer months, increasing from just over 20 in May, to more than 60 in September.
It’s a trend that has not gone unnoticed by Paul McGary, the director of mental health and addictions with Lakeridge Health and one of the heads of the task force responsible for developing the Central East LHIN’s Opioid Strategy.
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, which received board approval in March, 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 McGary.
The new 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.
Since approval, McGary explains they have been hard at work on next steps to move a number of the items forward, the first of which was creating an Implementation Action Group to come up with a plan for bringing the recommendations to fruition. He says it was key to move forward quickly.
“The worst thing you want to do is let something like this sit,” he says. “You don’t want to lose your momentum. I had a working group of (approximately 25) key stakeholders and leaders helping us write this thing and everyone is engaged and you just don’t want to lose that.”
Not only that, the opioid crisis continues to deepen across Ontario and the country, claiming the lives of approximately 4,000 Canadians last year, an increase of 30 per cent from the year before. Along with that, emergency department visits for opioid related overdoses have increased by 53 per cent in the last 10 years.
The Implementation Action Group contains the majority of members who were involved in the strategy’s creation, but McGary explains they have added some new members to assist with the implementation phase along with some additions who have lived-experience with opioids.
As it stands, thanks to a batch of funding from the Ministry of Health to assist with the opioid crisis, the Central East LHIN was able to hit the ground running with several key initiatives to assist with the crisis, some of them even before the Opioid Strategy’s final approval.
Those initiatives included a series of community withdrawal management activities, assisting a trio of community agencies with harm reduction work, and the opening of a Rapid Access Addiction Medicine (RAAM) clinic at Lakeridge Health in Oshawa.
“When we were developing this thing, we already had in Central East, $1.6 million, and so that was how we went ahead and did those three things,” McGary says. “We were able to write this report with lots of great ideas, but at the same time we were already working with partners to get some cash out and start doing stuff, and so that was really good.”
The Lakeridge RAAM clinic opened its doors on Jan. 30, and offers same-day, nearly immediate treatment for those suffering from withdrawal or looking to get assistance with their addictions.
Since the strategy’s approval, similar clinics have been opened in Peterborough and Scarborough and addiction counsellors have been embedded in those facilities to provide immediate assistance.
These clinics have also started to assist the LHIN with getting a better picture of the population their are assisting, which can help inform future treatment decisions, McGary says.
“(We) started to look at some of our valuations and by that, looking at just how many people are coming, where are they coming from, what drugs are they using. So, we have some early data on that,” he says. “Unless you really know who you are client base is, it’s hard to know what treatments to do next.”
Along with that, a number of priority items in the strategy have been implemented to date, including the distribution of naloxone to EDs, and education for stakeholders around new quality standards and prescription guidelines that are aimed at slowing the flow of opioids from various sources.
For McGary, two “game-changing” items have also been put in place over the last three months. One of those items is the usage of suboxone in EDs.
An drug similar to methadone in that it contains an opioid, suboxone, or buprenorphine, is billed as a safer alternative and more accessible.
“You can treat 90 per cent of the opioid (using) population on suboxone, but the best thing about suboxone is you’re not doing urine tests every day, you’re not going to a special pharmacy and it has naloxone built into it,” McGary says. “So now you’re using this opioid to help you avoid withdrawal and it has naloxone, which is the drug-reversing agent, built into it. So it’s super safe and it’s also cheaper.”
Also being offered in EDs is the nasal spray version of naloxone, a life-saving drug that acts as an opioid blocker and can temporarily reverse an overdose, providing critical moments to get someone to a hospital.
The program is funded as part of the Ministry of Health initiatives to battle the opioid crisis. In 2017, the provincial government announced $222 million over three years to help battle the crisis.
“We prioritized this process. We didn’t put this in a typical queue, given the fact that we’re in an opioid crisis, we prioritized this and we fast-tracked this in a responsible way,” McGary says of the naloxone distribution.
“People come and they may have had an overdose, we may just identify that they’re a user, they may be there for some other reason, and just as part of good, health teaching and good harm reduction, we can now say to the person, here’s what we have, here’s how you use it, can we give you one?”
The hospital, as of July 13, is also now offering fentanyl test kits, a tool that can be used to test drugs for the presence of the deadly, super-strong opioid, which in recent years has begun to spring up in other street drugs. Fentanyl is 100 times more potent than morphine, and according to data from the Health Canada in 2017, 74 per cent of apparent opioid related deaths involved fentanyl, or fentanyl analogues.
McGary says these tools, including the test kits and naloxone, are offered to whoever needs them.
“We have pushed the system to make sure that these interventions are low-threshold, no barrier. So a person off the street may have heard that we have naloxone or fentanyl test kits and they can walk into one of our sites, like our community sites, and ask for one of those things and they will be provided that,” he says. “In traditional services and that way this has gone in other communities, those things are reserved for people who are registered clients or registered patients, so we have removed that…We believe that saving lives and preserving health is the most important thing.”
Outside of the hospital, the LHIN has been working to educate stakeholders on new prescription guidelines and quality standards, and hosted an education and training session alongside Health Quality Ontario that was attended by approximately 70 people.
Over the last year, new guidelines for prescribing opioids have started implementation, and while aimed at reducing the availability of the drugs, the drastic changes have sometimes caused issues with some doctors correcting their past prescription habits too quickly and pushing patients into withdrawal.
McGary says they’ve seen it happen here in Durham, and in some cases, it just irresponsible, he says.
“Their need on the one hand to align their practice with new standards and so forth, but are doing it at such a rate that it’s in fact quite damaging to patients and so patients are showing up in our ED or at our RAAM clinics in acute withdrawal because their physicians are either not renewing certain prescriptions or they’re just dropping the doses way too fast.”
Moving forward, the Central East LHIN Opioid Strategy includes a number of long-term recommendations, including the advocation for the decriminalization of all drugs.
With that said, McGary says that Lakeridge is committed to addressing this issue head on.
“This for me, personally and professionally and for Lakeridge Health, this is a mission. We are leading a mission on this and we’re focused and dedicated. We’re surrounded by and aligned with great people and we are dedicated to bending the curve on this.”
KEY PILLARS OF THE CENTRAL EAST PLAN
- Increase public education and improve awareness about the risks and harms associated with opioid use
– Work with Public Health Units, healthcare providers, and ensure public education resources are tailored to different audiences
2 Support healthcare providers system wide, in current best practice prescribing guidelines
– Educate prescribers and physicians
– Create a Central East LHIN “Community of Practice” where various disciplines are able to exchange knowledge and resources
– Employ management tools for prescribing and better identifying signs of dependence
- Improve health information technology to enable best practices in opioid prescribing and substance use care
– Use the Digital Health Drug Repository
- Support increased access to pain management consultation services for health care providers and interventions for patients throughout the Central East LHIN
- Ensure all healthcare providers identify and address personal beliefs that act as barriers to care
– Implement an anti-stigma standard
- Ensure best practices in delivering trauma-informed care by healthcare providers
- Implement Rapid Access Addictions Medicine (RAAM) clinics
“Implementation of RAAM clinics has shown to significantly reduce opioid-related emergency department visits and repeat emergency department visits.”
– Decreased ER visits before and after the first 90 days of RAAM opening, Sudbury saw a 63 per cent decrease, and Sarnia saw 45 per cent
– Opioid Outreach Team
- Support the engagement of primary care providers in evidence-based management of chronic pain and opioid use disorders
- Enhance the role of emergency departments in the identification and standardized treatment of opioid and alcohol use disorders
- Support local implementation of Health Quality Ontario (HQO) standards for the treatment of opioid use disorder
- Increase access and use of buprenorphine/naloxone for opioid use disorder among healthcare providers across the spectrum of care
– Medications are the “gold standards” for treatment for opioid use disorder
– Increasing access to these medications is critical
– Opioids are extemely hard to get off of and the withdrawal is agonizing, many people relapse quickly
- Improve identification and treatment of opioid use during pregnancy and with infants born to mothers who have used opioids during pregnancy
- Enhance withdrawal management services
– Pinewood offers the WMS through a 22 bed location serving approximately 1,900 people annually
– Increase this programming across the board
- Expand medication-assisted therapy options
- Enhance harm reduction and outreach services
– Increase street outreach and in shelters
– Increase number of peer support workers
– Investigate the feasibility of a mobile harm reduction/health unit that would target higher needs communities
– Implement a drug-checking service, or at the least distribute fentanyl test strips
- Develop and implement a specialized peer support training program
- Increase distribution of naloxone
- Support application processes for supervised consumption sites and/or overdose prevention sites
- Foster stronger relationships between enforcement partners and local treatment and harm reduction service providers
– Promote Good Samaritan Law
– Provide naloxone to all front line officers
- Adopt a standardized approach to substance use and support efforts to decriminalize the possession of all drugs for personal use
- Increase access to treatment for people involved in the criminal justice system