Tackling opioid use disorder on the frontlines
“Evidence-based treatment can improve the lives of those living with an opioid use disorder”
…so begins a report prepared by the Canadian Centre on Substance Use and Addiction (CCSA) last year documenting the many best practices in use across the country to manage a condition inexorably linked to the explosion of opioid-related deaths.
The Public Health Agency of Canada estimated 10,300 Canadians died from opioid-related causes between January 2016 and September 2018. More than 100 Ontarians are dying of an opioid overdose each month, and the crisis is not yet slowing. It is clear that we have an evidence-based consensus that more can and should be done to support those working on the front-lines of our health care system—family physician offices, nurse practitioner led clinics, and emergency departments, for example.
In its report, the CCSA report references the quality standard on opioid use disorder developed by Health Quality Ontario, to help clinicians and patients recognize what quality care looks like in managing opioid use disorder. The standard highlights actions that clinicians can take to improve diagnosis, treatment, the management of withdrawal symptoms, and harm reduction.
The national overview also notes that almost all jurisdictions, including Ontario, are working to improve family physician and nurse practitioner knowledge of appropriate opioid prescribing. For example, a consortium of partners including Ontario’s six medical schools is offering a series of online courses for primary care physicians and nurse practitioners to help patients with opioid use disorder and to treat them appropriately. Other Ontario programs are focused specifically on the devastating impact this problem has had on Indigenous communities.
Yet more can be done to equip front-line health care providers to identify opioid use disorder and guide people to appropriate interventions.
For example, nurses and physicians in emergency departments need to have buprenorphine/naloxone available so they can offer it to patients who are suffering withdrawal from opioids, as well as to patients who would like to initiate long-term opioid agonist therapy. They also need ready access to naloxone and education materials they can give patients to take home.
Emergency physicians, primary care physicians and nurses also need easy access to addiction specialists. The CCSA report mentioned above notes that Ontario has established clinics to provide rapid access to addiction treatment. These clinics now exist across the province (thanks to help from Health Quality Ontario and others) and allow for simple and quick referrals from primary care and emergency departments. Specialists at these clinics can also mentor the patient’s family physician in the patient’s ongoing treatment.
And lastly, family physicians and nurse practitioners providing primary care benefit from mentorship or support when they first start prescribing opioid agonist therapy (e.g., methadone or buprenorphine) to patients with opioid use disorder. Further steps could be taken to support them including:
- Ensuring that medical students, resident physicians and nurse practitioners students learn how to identify and care for patients with opioid use disorder - particularly for emerging clinicians who will work in primary care and emergency department settings. This should be a core competency like the ability to manage diabetes and its complications.
- Providing supports for primary care teams and community health centres (which are especially well suited to manage patients with opioid use disorder). Programs could focus on creating a community of practice within a care team or community health centre by training pharmacists, social workers, peer support workers, family physicians, nurses and nurse practitioners together. These services should also be made available to the patients of family physicians who practice outside these team-based models.
- And building more awareness of the compensation available to family physicians who provide opioid use disorder treatment. Many family physicians remain unaware that there are billing codes for family physicians who care for people with addictions, allowing them extra time to provide treatment and support.
The challenge the opioid crisis presents is a big one and requires a multifaceted solution, including addressing underlying societal issues and the social determinants of health. Meanwhile, the health care system and those who work in it have their parts to play to tackle opioid use disorder on the frontlines and more is needed to equip them.
Dr. Sheryl Spithoff is a family physician and addictions physician in Toronto and Dr. Irfan Dhalla is VP, Evidence Development and Standards, Health Quality Standards.