New approach to opioids goes provincewide

When Dr. Hakique Virani thinks of the lives changed by opioid treatment, among the many that come to his mind is a professional truck driver who nearly lost everything to addiction.

The man had occasionally used drugs and it progressed to the point he was using street heroin multiple times a day. He had to sell several trucks from his fleet because of the money he was spending on street opioids, and he eventually lost his home.

Unable to work, his family relationships estranged, and very sick with opioid withdrawal, he went to an emergency department. The physician screened him for opioid use disorder (OUD), started him on buprenorphine, a medication that helps reduce cravings and withdrawals, and referred him for a next-day followup appointment at the Metro City Medical Clinic in Edmonton to begin treatment. It changed his life.

“He’s doing well now,” says Hakique, the clinic’s medical director and a public health and addiction medicine specialist in the University of Alberta’s Faculty of Medicine & Dentistry. “He’s parenting his kids, he’s back driving long-haul truck. He has good flexibility with respect to his treatment. He’s even visited the country his family is from for the first time in years.”

Hakique has been a public health advocate for addiction treatment and harm reduction for about 15 years. He believes the program, designed to help patients who arrive in emergency departments get started on treatment immediately, is an important tool to address Alberta’s opioid crisis.

“It is definitely making a difference,” says Stacey Brewster, acting program manager for emergency at the Grey Nuns Community Hospital. “They’re given a chance to make a different choice.”

Grey Nuns was one of three hospitals across the province to pilot the program a year ago, and due to its success, it’s now being rolled out to all 103 emergency departments and six urgent care centres in Alberta. It enables emergency physicians and staff to screen patients for OUD, start them on buprenorphine immediately and refer them for a followup appointment at a treatment clinic the next day. Hakique says the emergency department is an effective place to engage those patients.

“One of the greatest predictors of a fatal overdose is a previous non-fatal overdose, and those often present to emergency departments.”

The program was created in the spring of 2018, led by the Alberta Health Services Emergency Strategic Clinical Network (ECSN). Ken Scott, senior project manager, says emergency departments have traditionally focused on managing the symptoms or reversing an overdose.

“But actually, the underlying condition is a chronic one, and it’s opioid use disorder, which requires different treatment strategies that are more long-term.”

The program is already active in about half of the province’s emergency departments, including Banff Mineral Springs Hospital, Bonnyville Health Centre and St. Mary’s Hospital in Camrose. Ken says the clinical network team hopes to have all sites using the program within a year.

The results so far are encouraging. Of the patients who were referred to a clinic, 47 per cent attended their first appointment. One psychiatrist at Grey Nuns who specializes in addiction expected it to be closer to 10 per cent.

“That’s way better than we ever thought. It’s one in two patients,” says Ken. “And remarkably, that’s been sustained from the first three pilot sites up until today.”

They’re also tracking how many patients stay on the path to recovery and are still filling their prescription for buprenorphine 30, 60, 90 and 120 days later. Thirty days after their ED visit, 58 per cent of patients who went to their first followup appointment are still filling their prescription.

“It gives you a good feeling that even if you help just one person, that’s one person whose life has been changed for the better and they can do things and have a life that maybe they couldn’t have had before,” says Nicole Oman, clinical nurse educator at Grey Nuns.

Grey Nuns emergency department staff are seeing an increasing number of addiction-related cases. In 2018, 3.5 per cent of visits were addiction related, compared with 3.3 per cent the year before. Staff see about one overdose a day. About one in five patients with an opioid-related presentation has been initiated on the program, which is what the clinical network team expected based on their research. In the first 12 months of the buprenorphine program, there were 69 prescriptions given, each tablet representing a potentially life-saving intervention.

“If anyone looks at that as a glass half empty, they may not fully appreciate how difficult it can be to live with opioid use disorder and to get to a clinic, to follow through on treatment. It’s a lot to ask for these people,” says Ken. “And the fact that we’re transitioning from acute to community care at that success rate is really good.”

The approach is also working well in rural areas, thanks to a partnership with the Virtual Opioid Dependency Program. It refers patients for followup treatment provided through phone call, text or telemedicine. The physician then faxes the prescription to a nearby pharmacy for pickup. This approach is helpful for patients who are screened at a rural ED or those who initially go to an urban hospital but then decide to move closer to their support network in a rural community.

“The treatments for opioid use disorder that improve survival and function are the same, whether you live in a big city or in a small one,” says Hakique. “The most important thing is the journey between asking for help and getting it has to be short. When they present, the dots should connect in as straight a line as possible with as little distance in between.”