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Rapid step in battling opioid crisis

Lakeridge clinics helping in crisis

Officials at Lakeridge Health in Oshawa say that the opening of two Rapid Access Addiction Medicine (RAAM) clinics has been key in the region’s battle against the opioid crisis.

By Joel Wittnebel/The Oshawa Express

In the battle against the opioid crisis, there is no stronger tool than timing.

“Timing is everything, this is not a population wanting to wait for a week or a month for something,” says Paul McGary, the director of mental health and addiction services at Lakeridge Health. “The opioid using population is very challenging to engage in treatment and so literally every hour, every day, counts significantly, because the level of motivation is very fluid.”

Unfortunately, in recent years, it would appear many health agencies are still struggling with getting the timing right, and being available to open their doors to treatment when a users needs it most.

According to numbers from Statistics Canada, in 2017, there were nearly 4,000 opioid-related deaths in Canada, an increase of 34 per cent from the previous year. The increase of drugs laced with fentanyl and other deadly additives playing a large role in the increasing death-toll, with 72 per cent of deaths involving fentanyl or fentanyl analogues, a 55 per cent increase in such cases from the year before.

This troubling trend is also being seen in Ontario, where opioid related deaths have increased from 726 in 2016, to 1,125 in 2017.

“Provincially, there were very few programs that were medically treating addictions very well, and we weren’t doing it very well in Durham either,” says McGary.

That was, until the start of 2018.

If timing is issue, then the Rapid Access Addiction Medicine (RAAM) Clinic is the cure.

The “rapid” in the title is not simply a turn of phrase, but the crux of an entire healthcare model that aims at giving treatment to addicts of opioids or alcohol in the fastest possible way.

For McGary, when Lakeridge opened its pair of RAAM clinics in January, there was an immediate impact.

“This filled an enormous gap in the system,” McGary says.

And the numbers back him up.

Since the opening on Jan. 30, the clinics, which are open for a couple hours each day four days a week, they have seen 221 patients come through the doors, many of them coming back multiple times totalling 659 visits. In July alone, the RAAM clinics saw 48 new patients. On top of that, if asked, 97 per cent of those who used the clinics care would recommend the process to a fellow user.

Not only that, but McGary says that the clinics have opened the doors for members of the using population, who have never sought treatment before.

“We’ve found people who before were out there and they didn’t know where to go or where to turn,” he says.

The satisfaction for users can be given almost instantly, with nurse practitioners on staff who can provide immediate care to ease cravings, and start a treatment plan that can start users on a path to eliminating their dependency, whether that’s opioids or alcohol. And the numbers are split, with 41 per cent of patients arriving at the RAAM clinic with opioid related addictions and 44 per cent with alcohol addictions.

For Helen Manohararaj, a nurse practitioner at Lakeridge Health’s RAAM clinics, the clinics could not have opened at a better time.

“The crisis was basically overpowering, even the speed at which we were able to cope,” she says. “So this was kind of a good way of reaching out to the community, but also capturing most of the vulnerable population that needed the service right away.”

McGary says having nurse practitioners on staff at the clinics, expands the services they are able to offer in a big way. Nurse practitioners are required to obtain a master’s degree and generally bring specialized work experience above the level of registered practical nurses (RPNs) or registered nurses (RNs). Most significantly, they are able to offer prescriptions to users for medicines to treat harsh cravings.

“It’s invaluable because nurse practitioners bring a unique skill set,” McGary says. “We’d be more limited, trying to operate a clinic like this without nurse practitioners.”

Along with treatment options, the RAAMs can provide valuable tools for the using population including naloxone kits, a vital tool in saving lives in the event of an overdose, and fentanyl test kits, which can be used to test whether certain drugs are laced with the deadly additive.

The RAAM clinic model is a fairly new tool in the battle against the opioid crisis.

Originating from research completed by Women’s College Hospital, the RAAM model is now in a number of places in Ontario, including GTA locations like Markham, Richmond Hill, Newmarket and Toronto, along with a number of northern locations in Sudbury, Thunder Bay and Sault Ste. Marie.

In Ontario, Lakeridge Health can be partially credited for putting the RAAM model on the province’s radar.

In August of 2017, McGary and Lakeridge made a recommendation to the Central East Local Health Integration Network (LHIN), on ways to use recent funding from the province to battle the opioid crisis. That recommendation included funding to start up RAAM clinics across the LHIN.

“We put RAAM clinics at the very top of the list. It wasn’t on the ministry’s radar as far as we knew,” McGary says.

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 RAAM clinics also form a large part of the LHIN’s opioid strategy, which was spearheaded by McGary and Dr. Rosana Salvatera and approved in March.

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.

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.

According to McGary, there are a number of benefits to being able to offer treatment readily for those struggling with opioid and alcohol addiction.

On top of the speed making things much more accessible for the population, McGary says the locations in Oshawa are also playing a big part in the RAAM clinics early success.

With locations at Lakeridge Health Oshawa (open Monday and Thursday, 9 to 11 a.m.) and the Pinewood Centre (open Tuesday and Friday 9 to 11 a.m.), the spots flank Oshawa’s downtown and other high needs areas.

Pinewood in particular benefits first from being recognized already in the community for its role as an addiction and mental health services centre, but as a community treatment centre, it can make it easier for people to walk in the doors.

“Community settings are simply more accessible. You can walk in right off the street and you’re inside the building within seconds,” McGary says. “We have a nice setting in the hospital, we’ve made it right off the south entrance…and it’s very accessible as well, but there’s something different about walking into a hospital and how it makes you feel, versus walking into a community setting and how it makes you feel.”

“Helen has seen a lot of people who are in very rough shape, who are really struggling, so for them, the environment makes a huge difference, I think,” he adds.

However, that doesn’t mean the model has been without its early hiccups.

For Manohararaj, the number of repeat visits by patients can be trying, especially when the model is designed to try and direct them elsewhere after initial treatment.

“The model of RAAM is that once they’re started on treatment and they’re stabilized, that we pass them back to their primary care provider to continue maintenance,” she says. “The model was never designed to keep them.”

With that said, this model can only succeed if there are a sufficient number of general practitioners in the area who can take on such patients. According to information from the Journal of General Practice, Canada has one of the lowest patient to doctor ratio of 34 countries rated in the Organization for Economic Cooperation and Development.

“I’m finding that, to me, is a big barrier,” Manohararaj says.

During recent discussions on the implementation of the Central East LHIN’s Opioid Strategy, it’s clear that expansion is in the cards for the RAAM model.

Along with the locations in Durham, RAAMs are also located in Peterborough and Scarborough within Central East.

For the 2018-2019 year, there is $150,000 budgeted for the RAAM program, that number is set to double for 2019-2020.

“Do I see more opportunity in Durham? Yes. Where that would be, I’m not exactly certain,” McGary says. “We would want to look at the data.”

And while the numbers continue to paint a disturbing picture of the opioid crisis across Canada, McGary is sure of one thing when it comes to the RAAM clinics.

“There is certainly a need,” he says.