Buprenorphine/naloxone initiation and referral as a quality improvement intervention for patients who live with opioid use disorder: quantitative evaluation of provincial spread to 107 rural and urban Alberta emergency departments.

OBJECTIVES: Opioid use disorder is a major public health concern that accounts for a high number of potential years of life lost. Buprenorphine/naloxone is a recommended treatment for opioid use disorder that can be started in the emergency department (ED). We developed an ED-based program to initiate buprenorphine/naloxone for eligible patients who live with opioid use disorder, and to provide unscheduled, next-day follow-up referrals to an opioid use disorder treatment clinic (in person or virtual) for continuing patient care throughout Alberta. METHODS: In this quality improvement initiative, we supported local ED teams to offer buprenorphine/naloxone to eligible patients presenting to the ED with suspected opioid use disorder and refer these patients for follow-up care. Process, outcome, and balancing measures were evaluated over the first 2 years of the initiative (May 15, 2018-May 15, 2020). RESULTS: The program was implemented at 107 sites across Alberta during our evaluation period. Buprenorphine/naloxone initiations in the ED increased post-intervention at most sites with baseline data available (11 of 13), and most patients (67%) continued to fill an opioid agonist prescription at 180 days post-ED visit. Of the 572 referrals recorded at clinics, 271 (47%) attended their first follow-up visit. Safety events were reported in ten initiations and were all categorized as no harm to minimal harm. CONCLUSIONS: A standardized provincial approach to initiating buprenorphine/naloxone in the ED for patients living with opioid use disorder was spread to 107 sites with dedicated program support staff and adjustment to local contexts. Similar quality improvement approaches may benefit other jurisdictions.

ABSTRAIT: OBJECTIFS: Le trouble lié à la consommation d'opioïdes est une préoccupation majeure en santé publique qui explique le nombre élevé d'années potentielles de vie perdues. La buprénorphine/naloxone est un traitement recommandé pour le trouble lié à l'utilisation d'opioïdes qui peut être commencé au service des urgences (SU). Nous avons mis au point un programme axé sur les urgences pour commencer la buprénorphine/naloxone pour les patients éligibles qui vivent avec un trouble lié à l'utilisation d'opioïdes, et pour fournir suivis des cas référés le jour suivant vers une clinique de soins des troubles liés à l'utilisation d'opioïdes (sur place ou virtuelle) pour les soins continus aux patients partout en Alberta. MéTHODES: Dans le cadre de cette initiative d'amélioration de la qualité, nous avons aidé les équipes locales de SU à offrir la buprénorphine/naloxone aux patients admissibles qui se présentent à la SU avec un trouble présumé de consommation d'opioïdes et à les diriger vers des soins de suivi. Le processus, les résultats et les mesures d'équilibre ont été évalués au cours des deux premières années de l'initiative (du 15 mai 2018 au 15 mai 2020). RéSULTATS: Le programme a été mis en œuvre dans 107 sites en Alberta pendant notre période d'évaluation. Les initiations à la buprénorphine/naloxone à l'urgence ont augmenté après l'intervention dans la plus grande partie de sites pour lesquels des données de référence étaient disponibles (11 sur 13), et la plupart des patients (67 %) ont continué de remplir une ordonnance d'agonistes opioïdes 180 jours après la visite à l'urgence. Sur les 572 renvois enregistrés aux cliniques, 271 (47 %) ont assisté à leur première visite de suivi. Des événements liés à la sécurité ont été signalés dans 10 initiatives et ont tous été classés comme n'ayant causé aucun conséquences à des conséquences minimes. CONCLUSIONS: Une approche provinciale standardisé de lancement de la buprénorphine/naloxone à l'urgence pour les patients atteints d'un trouble lié à la consommation d'opioïdes a été diffusée à 107 sites à l'aide de soutien aux programmes spécialisé et des ajustements aux contextes locaux. Des approches semblables d'amélioration de la qualité pourraient profiter à d'autres juridictions.

The Alberta Neonatal Abstinence Syndrome Mother-Baby Care ImprovEmeNT (NASCENT) program: protocol for a stepped wedge cluster randomized trial of a hospital-level Neonatal Abstinence Syndrome rooming-in intervention.

BACKGROUND: Neonatal Abstinence Syndrome (NAS), a problem common in newborns exposed to substances in-utero, is an emerging health concern. In traditional models of care, infants with NAS are routinely separated from their mothers and admitted to the Neonatal Intensive Care Unit (NICU) with long, expensive length of stay (LOS). Research shows a rooming-in approach (keeping mothers and infants together in hospital) with referral support is a safe and effective model of care in managing NAS. The model's key components are facilitating 24-h care by mothers on post-partum or pediatric units with support for breastfeeding, transition home, and access to Opioid Dependency Programs (ODP). This study will implement the rooming-in approach at eight hospitals across one Canadian Province; support practice and culture shift; identify and test the essential elements for effective implementation; and assess the implementation's impact/outcomes. METHODS: A stepped wedge cluster randomized trial will be used to evaluate the implementation of an evidence-based rooming-in approach in the postpartum period for infants born to mothers who report opioid use during pregnancy. Baseline data will be collected and compared to post-implementation data. Six-month assessment of maternal and child health and an economic evaluation of cost savings will be conducted. Additionally, barriers and facilitators of the rooming-in model of care within the unique context of each site and across sites will be explored pre-, during, and post-implementation using theory-informed surveys, interviews, and focus groups with care teams and parents. A formative evaluation will examine the complex contextual factors and conditions that influence readiness and sustainability and inform the design of tailored interventions to facilitate capacity building for effective implementation. DISCUSSION: The primary expected outcome is reduced NICU LOS. Secondary expected outcomes include decreased rates of pharmacological management of NAS and child apprehension, increased maternal ODP participation, and improved 6-month outcomes for mothers and infants. Moreover, the NASCENT program will generate the detailed, multi-site evidence needed to accelerate the uptake, scale, and spread of this evidence-based intervention throughout Alberta, leading to more appropriate and effective care and use of healthcare resources. TRIAL REGISTRATION: ClinicalTrials.gov, NCT0522662. Registered February 4th, 2022.

Virtual opioid agonist treatment: Alberta's virtual opioid dependency program and outcomes.

BACKGROUND: Virtually delivered healthcare (telehealth, telemedicine) has the potential to reduce gaps in access to opioid agonist therapy (OAT). Barriers to accessing OAT such as lack of transportation, in-person induction requirements, employment demands and limited childcare options reduce treatment opportunities for clients. A completely virtual model of care has been developed in Alberta, Canada. This paper introduces the unique virtual clinic model and describes outcomes from that model. METHODS: A retrospective chart review was conducted using datasets within existing electronic health records and databases from Alberta's Virtual Opioid Dependency Program (VODP). Outcome data were extracted at admission to ongoing care by Case Management within the VODP and at 3, 6 and 12 months for the duration of treatment. Utilization trends over three years were analyzed, including admissions, discharges and active client information. Data regarding clinical outcomes for clients engaged in ongoing care with the VODP were aggregated for analysis over four time periods, including treatment retention rates at 6 and 12 months. RESULTS: A total of 440 client records were included in the study sample. Descriptive analysis showed rapid growth in utilization over three fiscal years. Despite rapid growth in utilization, median wait days for treatment decreased from 6 to 0 days with the initiation of a Same Day Start service to support low barrier immediate access to treatment. Treatment retention rates for clients in ongoing care were comparable to published reports, with 90% of the study sample remaining in treatment over 6 months, and 58% showing retention over 12 months. Clients reported high levels of satisfaction (90%) and outcomes reflected reductions in drug use and overdose as well as improved social functioning. CONCLUSIONS: The VODP model demonstrated high levels of client satisfaction, rapid growth in utilization and positive preliminary clinical outcomes. Entirely virtual delivery of opioid agonist therapy is a promising option to facilitate access to evidence based treatment for opioid use disorder (OUD) in the context of a fentanyl overdose crisis, particularly for individuals living in rural or underserved areas.