Development and validation of health system performance measures for opioid use disorder in British Columbia, Canada

Opioid medication doses among safer supply clients: Current safer supply doses and previous OAT experience

Introduction

Safer opioid supply (SOS) is a harm reduction approach to prescribing pharmaceutical opioids to people at high risk of overdose from the toxic unregulated drug supply. Previous research demonstrates positive health outcomes and reductions in overdose mortality among SOS clients; however few reports describe previous opioid agonist treatment history prior to initiating SOS, or the medication combinations and doses prescribed within SOS programs.

Methods

We used convenience sampling to collect survey data from 95 SOS program clients in London, Canada. We use descriptive statistics to analyze survey data and report on OAT history prior to initiating SOS, including maximum methadone dose. We also report on current SOS medication combinations and doses.

Findings

Previous experience with OAT was common and reported by 87 % of SOS clients. Mean highest dose of methadone ever received was 95 mg (range: 20-200 mg), with close to 40 % reporting doses of ≥ 120 mg. 95 % of SOS clients reported prescriptions for immediate-release tablet hydromorphone; 28 % were receiving hydromorphone monotherapy; 68 % were receiving hydromorphone alongside a long-acting opioid, and 5 % receiving hydromorphone alongside 2 long-acting opioids. Total average milligram morphine equivalent (MME) doses of combination SOS prescriptions (MME 1616) were similar to high dose methadone (120 mg = MME 1440).

Conclusions

Previous high dose OAT experience was common among SOS clients prior to enrollment in the SOS program. Our results may inform the individualization of high dose opioid prescriptions for people with high tolerance due to exposure to unregulated fentanyl.

Case series: Symptom-inhibited fentanyl induction (SIFI) onto treatment-dose opioid agonist therapy in a community setting

BACKGROUND AND OBJECTIVES

Existing opioid agonist therapy (OAT) guidelines are far from sufficient to address rising opioid tolerances and potency of the unregulated opioid market in North America. Inadequate starting doses of OAT are a universally recognized barrier for people who use fentanyl. Our objectives are to present a novel induction protocol called symptom-inhibiting fentanyl induction (SIFI) that uses rapid intravenous fentanyl administration to inhibit symptoms of opioid withdrawal.

METHODS

We describe two cases highlighting the potential clinical utility of SIFI.

RESULTS

This case series demonstrates two safe and successful transitions onto higher-than-standard doses of methadone and slow-release oral morphine harnessing an emerging approach of SIFI in a community clinic setting.

DISCUSSION AND CONCLUSIONS

These results support emerging evidence that SIFI is safe and feasible to meet patients' opioid requirements and facilitate rotation onto OAT. Further studies are needed to increase the generalizability of these findings.

SCIENTIFIC SIGNIFICANCE

Safe transitions onto treatment-dose OAT are of heightened clinical importance at a time when fentanyl and high-potency synthetic opioids are now the norm. SIFI is a novel induction method that could address significant gaps in the currently available OAT options in the fentanyl era.

Quality indicators for substance use disorder care: a scoping review protocol

INTRODUCTION

Substance use disorders (SUDs) are a major public health challenge, affecting millions of individuals globally and contributing to substantial morbidity and mortality. Individuals with SUDs face numerous barriers to accessing high-quality healthcare, leaving vulnerable populations susceptible to the undertreatment of SUDs. Despite the availability of clinical practice guidelines and effective interventions for SUD, there is a notable gap in the implementation and adherence to evidence-based care.Measuring the quality of care (QoC) is a critical initial step toward enhancing the treatment and services provided to individuals with SUDs. While quality indicators (QIs) for SUD care have been established in various regions, including the USA, Canada and the UK, the application of QIs for the routine measurement of QoC for SUDs is not common. Identifying and characterising the areas of low QoC in SUD management can highlight critical targets for quality improvement initiatives. However, QoC measurement in SUD care is complex, with potentially redundant indicators derived from different sources, each with its own definitions, criteria and data requirements. This scoping review aims to explore the range of QIs that are currently available to assess the QoC for individuals with SUDs.

METHODS

The review will follow the Arksey and O'Malley framework and incorporate methods proposed by the Joanna Briggs Institute (JBI) and Levac et al. Reporting will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping review guidelines (PRISMA). Stage 1: the research question will be identified, clarifying the purpose of the scoping review. Stage 2: six academic databases (Cochrane Library, Embase, CINAHL, Medline, APA PsycINFO and Scopus) and grey literature sources will be searched for studies reporting QIs and published from 1990 until 2023. Stage 3: study screening and selection will be completed by two reviewers independently to review titles, abstracts and full texts based on study inclusion criteria. Stage 4: a pilot data charting form has been developed to capture information from each study, including study design, population details, setting, methodology for QI development and reported QIs. Stage 5: data synthesis and consultation will employ thematic analysis and frequency counts to categorise identified QIs within established domains for quality of healthcare. Any discrepancies in data extraction or thematic synthesis will be identified and resolved using a third reviewer when necessary. A consultation exercise using a modified Delphi process will engage experts to prioritise identified QIs, aligning with JBI recommendations for stakeholder involvement in scoping reviews.

PATIENTS AND PUBLIC INVOLVEMENT

Patients and the public will not be directly involved in the design or conduct of this scoping review. However, stakeholder consultation, including individuals with lived experience of SUDs, will be incorporated during the Delphi process to prioritise identified QIs for SUD care.

ETHICS AND DISSEMINATION

Ethics approval is not necessary for stages 1-4 of this scoping review as it will not involve primary data collection. Ethics approval will be obtained from the University of Calgary Health Research Ethics Board prior to the commencement of stakeholder consultation (Stage 5) in January 2025. This scoping review was preregistered on the Open Science Framework. The results of this scoping review will be disseminated through peer-reviewed publications and conference presentations. Findings will be shared with local clinicians through presentations and with the research and clinical community at relevant conferences. This study represents a necessary first step towards establishing routine QoC measurement for SUDs. Results will be used in a stakeholder consensus exercise aimed at identifying key QIs for SUD care in Alberta, Canada, that will guide the future development of continuous QoC measurement using population-based data.

Population perinatal substance use and an environmental scan of health services in British Columbia, Canada

BACKGROUND

Substance use during pregnancy is underreported globally and there is limited data on its prevalence and the availability of supportive services. This study determined population perinatal substance use in British Columbia (BC) by region and examined the availability of clinical and community-based programs.

METHODS

Using linked provincial health administrative data, we conducted a population-based retrospective cohort study including all BC residents accessing care for substance use (alcohol, opioids, stimulants, sedatives, and cannabis) within 12 months of first perinatal care record to delivery during 2016-2021. We also conducted an environmental scan to identify all programs offering perinatal care and substance use treatment/support in BC as of December 2022 and described program components by region.

RESULTS

The population included 12,439 people with perinatal substance use with 13,814 linked livebirths during the study period. The incidence rate of perinatal substance use was nearly eight times higher in rural/remote Northern BC compared to the metropolitan Vancouver Coastal region (1044.2 vs. 131.3 per 100,000 population, respectively). We identified 29 related services (19 wrap-around programs, 8 supportive housing, and only 2 acute care programs). Residents outside of Metro Vancouver accounted for 60 % (N=1745) of people with perinatal substance use; however, these regions represented only 35 % of BC's specialized acute care and supportive housing beds (N=140).

CONCLUSIONS

Expanding supports for perinatal substance use - particularly acute care and supportive housing within more rural/remote regions in BC - will be critical to address geographic inequities in access to perinatal care and improve health outcomes for pregnant people who use substances and their infants.

Estimating effects of time-varying exposures on mortality risk

Administrative databases have become an increasingly popular data source for population-based health research. We explore how mortality risk is associated with some health service utilization process via linked administrative data. A generalized Cox regression model is proposed using a time-dependent stratification variable to summarize lifetime service utilization. Recognizing the service utilization over time as an internal covariate in the survival analysis, conventional likelihood methods are inapplicable. We present an estimating function based procedure for estimating model parameters, and provide a testing procedure for updating the stratification levels. The proposed approach is examined both asymptotically and numerically via simulation. We motivate and illustrate the proposed approach using an on-going program pertaining to opioid agonist treatment (OAT) management for individuals identified with opioid use disorders. Our analysis of the OAT data indicates that the OAT effect on mortality risk decreases in successive OAT attempts, in which two risk classes based on an individual's treatment episode number are established: one with 1-3 OAT episodes, and the other with 4+ OAT episodes.

Impacts of the COVID-19 pandemic on enrollment in medications for opioid use disorder (MOUD) in Vancouver, Canada: An interrupted time series analysis

BACKGROUND

In anticipation of COVID-19 related disruptions to opioid use disorder (OUD) care, new provincial and federal guidance for the management of OUD and risk mitigation guidance (RMG) for prescription of pharmaceutical opioids were introduced in British Columbia, Canada, in March 2020. This study evaluated the combined impacts of the COVID-19 pandemic and counteracting OUD policies on enrollment in medications for OUD (MOUD).

METHODS

Using data from three cohorts of people with presumed OUD in Vancouver, we conducted an interrupted time series analysis to estimate the combined effects impact of the COVID-19 pandemic and counteracting OUD policies on the prevalence of enrollment in MOUD overall, as well as in individual MOUDs (methadone, buprenorphine/naloxone, slow-release oral morphine) between November 2018 and November 2021, controlling for pre-existing trends. In sub-analysis we considered RMG opioids together with MOUD.

RESULTS

We included 760 participants with presumed OUD. In the post-COVID-19 period, MOUD and slow-release oral morphine prevalence rates showed an estimated immediate increase in level (+7.6%, 95% CI: 0.6%, 14.6% and 1.8%, 95% CI: 0.3%, 3.3%, respectively), followed by a decline in the monthly trend (-0.8% per month, 95% CI: -1.4%, -0.2% and -0.2% per month, 95% CI: -0.4, -0.1, respectively). There were no significant changes in the prevalence trends of enrollment in methadone, buprenorphine/naloxone, or when RMG opioids were considered together with MOUD.

CONCLUSIONS

Despite immediate improvements in MOUD enrollment in the post-COVID-19 period, this beneficial trend reversed over time. RMG opioids appeared to have provided additional benefits to sustain retention in OUD care.

Validation and endorsement of health system performance measures for opioid use disorder in British Columbia, Canada: A Delphi panel study

Background

Limited data exists on the performance of the healthcare system in opioid use disorder (OUD). We evaluated the face validity and potential risks of a set of health system performance measures for OUD collaboratively with clinicians, policymakers and people with lived experience of opioid use (PWLE) in the interest of establishing an endorsed set of measures for public reporting.

Methods

Through a two-stage Delphi-panel approach, a panel of clinical and policy experts validated and considered 102 previously constructed OUD performance measures for endorsement using information on measurement construction, sensitivity analyses, quality of evidence, predictive validity, and feedback from local PWLE. We collected quantitative and qualitative survey responses from 49 clinicians and policymakers, and 11 PWLE. We conducted inductive and deductive thematic analysis to present qualitative responses.

Results

A total of 37 measures of 102 were strongly endorsed (9/13 cascade of care, 2/27 clinical guideline compliance, 17/44 healthcare integration, and 9/18 healthcare utilization measures). Thematic analysis of responses revealed several themes regarding measurement validity, unintended consequences, and key contextual considerations. Overall, measures related to the cascade of care (excluding opioid agonist treatment dose tapering) received strong endorsements. PWLE highlighted barriers to accessing treatment, undignified aspects of treatment, and lack of a full continuum of care as their concerns.

Conclusion

We defined 37 endorsed health system performance measures for OUD and presented a range of perspectives on their validity and use. These measures provide critical considerations for health system improvement in the care of people with OUD.