Doctrine Update 4-16 3 ATP 3-01.8, Techniques for Combined Arms for Air Defense, provides guidance to combined arms commanders on how to defend against air defense threats. Its focus is to assist in understanding the possible air and
Report CopyRight/DMCA Form For : Methadone Treatment And Services Advisory Committee Final
LETTER FROM THE CO CHAIR, On behalf of my colleagues on the Methadone Treatment and Services Advisory Committee we are. pleased to submit this report of final key recommendations to the Minister of Health and Long Term. We have done our best under the challenging time constraints given to bring the concerns of a variety. of stakeholders to the table understanding that the existing issues with the current system of opioid. agonist therapy and services in Ontario are multi faceted incredibly complex and impact each. stakeholder differently Recognizing this the conversations hosted by the Advisory Committee and the. topics of in depth discussion focused on putting patients at the centre of care plans to ensure that they. receive the appropriate treatments and supports they desperately require. It is our hope that through the implementation of these recommendations treatment and quality of life. for those facing opioid use disorders will be greatly improved. The recommendations included in this report are based on the best available evidence and the diverse. expertise of the Advisory Committee members, Thank you for the opportunity to provide advice on this important issue. Dr Meldon Kahan, Co Chair Methadone Treatment and Services Advisory Committee. TABLE OF CONTENTS,Acknowledgements 3,Executive Summary 3. List of Recommendations 4,INTRODUCTION 9,Current Methadone Practices 10. Advisory Committee 11,Mandate 11,Composition 12,Process 12. Background Presentations 12,Patient Engagement Considerations 13. Statement of Principles and Values 13,RECOMMENDATIONS 15. Pharmacology 15,Standards of Practice 18,Health Care Delivery 23. Indigenous People and Communities 30,Pregnant Post Natal 32. Physician Incentives Funding 33,Harm Reduction Overdose Prevention 34. Social Determinants of Health 36,Educational Supports 37. Technology 41,Research 42,APPENDICES 43,Appendix 1 Member Biographies 43. Appendix 2 Glossary of Terms 49,Appendix 3 Notes 51. Acknowledgements, Over the course of our time limited Advisory Committee work we heard many diverse views and. perspectives on the necessary changes that are required to improve the way that opioid agonist therapy. is currently delivered in Ontario We observed a tremendous generosity of knowledge and a willingness. to engage understand diverse perspectives and find common ground on contentious issues. The process of generating the following recommendations was a highly collaborative and rich. experience We would especially like to thank the secretariat provided to us by the Ontario Ministry of. Health and Long Term Care Ministry This team of individuals worked long hours evenings and. weekends to coordinate research strategize and keep us to deadline. The Advisory Committee wishes to thank those who presented and provided valuable feedback for a. full list see pages 12 and 13 These unique perspectives were integral to informing the final. recommendations found in this report Specifically the Advisory Committee would like to thank Ontario. Regional Chief Isadore Day Wiindawtegowinini for speaking to the Advisory Committee about the. importance of appropriately addressing the unique needs of Indigenous people and communities. We would also like to thank Dr Carol Strike for sharing the viewpoints of people with lived experience. Dr Strike provided the invaluable results of her research on a comprehensive study on patient. involvement with opioid agonist therapy programs in Ontario Her work grounded the conversations. ensuring that quality care and access to essential treatments and services lie at the heart of the. recommendations,Executive Summary, The system of prescribing opioids and treating Opioid Use Disorder OUD in Ontario needs to be. transformed Canada is the largest per capita consumer of prescription opioids in the world and now the. additional threat of illicit opioids is causing further harm to our communities and our families Of all the. provinces and territories Ontario has the highest rates of opioid prescription and rates of addiction and. overdose deaths continue to increase 1, Deaths from opioid overdoses have hit crisis proportions but access to addiction treatment and long. term management with Opioid Agonist Therapy OAT remains limited especially in remote and rural. areas and uneven in terms of quality, While the College of Physicians and Surgeons of Ontario CPSO has standards and guidelines in place to. guide the delivery of methadone maintenance treatment MMT a significant minority of methadone. clinics insist on imposing burdensome requirements such as weekly clinic visits that are not required by. the standards and guidelines Twice weekly urine drug screenings can severely restrict a patient s ability. to conduct daily living activities such as their ability to work travel and participate in social activities. There are many physicians and other health care providers across the province dedicated to caring for. patients with OUD but too many systemic barriers and inappropriate incentives remain in the way of. quality patient centred care, Developmental and bio psychosocial determinants of health play a significant role in OUDs and. contribute to the variety of services required to support patient centred care There are treatment. options that can save lives However in order to be effective treatment needs to be accessible. available and consider the individual needs of a person s full health care requirements. The recommendations of this Advisory Committee intend to transform how OUDs are managed and. how patients are treated It rests on a model of inclusiveness where patients are treated for all of their. health care needs and receive accessible services quality supervision and holistic health care. The members of the Advisory Committee recognize that improving the treatment pathway for OUD will. not be sufficient on its own Important upstream improvements need to be made to ensure that opioids. are appropriately prescribed and monitored from when patients first seek treatment for acute and. chronic pain as well as expansion of harm reduction initiatives to reduce injury and death from opioid. overdose As a result some of the recommendations provided by the Advisory Committee go beyond. the scope of OUD treatment and services,List of Recommendations. PHARMACOLOGY, Recommendation 1 Providers should present benefits side effects and risks of opioid agonist. therapy buprenorphine naloxone and methadone to all patients with an. opioid use disorder Given its better safety profile and accessibility in Ontario. providers should recommend buprenorphine naloxone as the first line. medication for most patients The selection of medication should be a shared. decision making process with the patient making the final choice about their. Recommendation 2 The Ministry of Health and Long Term Care should facilitate moving. buprenorphine naloxone combinations from Limited Use status to a General. Benefit on the Ontario Drug Benefit Formulary, Recommendation 3 The Ministry of Health and Long Term Care support amendments to. provincial regulations that would enable nurse practitioners with appropriate. training to prescribe and administer buprenorphine naloxone and. methadone for opioid use disorder,STANDARDS OF PRACTICE. Recommendation 4 Health Quality Ontario with the participation of regulatory colleges and. professional organizations as appropriate should develop clear Quality. Standards and guidelines for opioid use disorder including opioid agonist. therapy by the end of 2017, Recommendation 5 Health Quality Ontario in collaboration with the Ministry of Health and Long. Term Care College of Physicians and Surgeons of Ontario CPSO and other. professional organizations and regulators as appropriate should develop. standards on opioid prescribing The CPSO and other professional. organizations should provide appropriate oversight to ensure adherence to. these guidelines The CPSO should focus its regulatory oversight on all. opioids not just methadone,HEALTH CARE DELIVERY, Recommendation 6 The Ministry of Health and Long Term Care should allocate funding to. develop rapid access treatment clinics services for those seeking immediate. help for opioid use disorder, In addition to medical treatment clinics services must include and provide. access to a broad range of health care services and supports including mental. health and addictions counselling and have plans protocols and timelines in. place for transferring stable patients to appropriate care for ongoing. management, Recommendation 7 The Ministry of Health and Long Term Care and Local Health Integration. Networks should ensure that models pathways and funding support Health. Service Providers to develop appropriate transition plans tailored to the. specialized needs of the patient to support continuity of care. Recommendation 8 The Ministry of Health and Long Term Care and Local Health Integration. Networks should prioritize opioid agonist therapy patients for attachment to. primary care particularly those models associated with interprofessional. primary care teams Family Health Teams and Community Health Centres. should be contractually obligated to accept a specific number of patients who. have a diagnosis of opioid dependence per year and provide opioid agonist. Recommendation 9 Opioid agonist therapy and addiction treatment with the appropriate. regulatory oversight should be fully integrated into the usual breadth of. primary care services Until such integration can be achieved opioid agonist. therapy prescribers and focused clinics should be required to try to attach. patients to primary care providers and engage in regular bilateral ongoing. communications opioid agonist therapy prescribers and focused clinics. should integrate the full scope of mental health and addiction services into. their practice, Recommendation 10 The Ministry of Health and Long Term Care should ensure all health care. providers who regularly prescribe opioids should be provided with. assessment and feedback reports on their opioid prescribing. Recommendation 11 The Ministry of Health and Long Term Care should work with service. providers in both public and private institutions where opioid agonist therapy. patients reside e g residential treatment programs long term care homes. hospitals corrections facilities to ensure that, a patients on opioid agonist therapy are able to continue treatment in. an uninterrupted fashion when admitted and, b they provide rapid access to opioid agonist therapy when clinically. indicated or if requested by the patient at any point during their. The Ministry of Health and Long Term Care should provide assistance in. implementing these policies as requested, Recommendation 12 Youth should have access to services specific to their developmental needs. Buprenorphine naloxone should be the first line opioid agonist therapy and. should be the only treatment for youth that live in or travel frequently to. communities where methadone is not available in particular First Nations. communities Opioid agonist therapy clinicians and clinic staff should have. access to education and connection to other supports as needed in providing. youth specific services, Recommendation 13 The Ministry of Health and Long Term Care should support a pilot for a youth. specific opioid agonist therapy addiction treatment program that will. measure treatment outcomes of opioid substitution therapy including. optimal support for tapering down and off of opioid agonist therapy. INDIGENOUS PEOPLE AND COMMUNITIES, Recommendation 14 The Ministry of Health and Long Term Care in collaboration with Health. Canada First Nations leadership and Indigenous partners should allocate. sustainable funding for Prescription Drug Abuse programs that are based in. community land and culture The programs should include treatment with. buprenorphine naloxone as well as addictions recovery and relapse. prevention counselling, Recommendation 15 The Ministry of Health and Long Term Care the College of Physicians and. Surgeons of Ontario and other regulatory and professional regulatory bodies. should encourage all opioid agonist therapy providers to support transition. from methadone to buprenorphine naloxone when clinically or. geographically indicated for First Nations patients and other patients. Recommendation 16 The Ministry of Health and Long Term Care in collaboration with Indigenous. partners and Health Canada should provide funding for training and. programs that support recovery from Intergenerational Historical Trauma. and Post Traumatic Stress Disorder Funding should provide support for. wellness retreats for Chief and Council leadership. training of Prescription Drug Abuse program workers in Trauma. Informed Care and, culturally appropriate aftercare programs that support individual. family and community healing from Post Traumatic Stress Disorder. and Historical Trauma Transmission,PREGNANT POST NATAL. Recommendation 17 The Ministry of Health and Long Term Care should provide additional. supports to pregnant and post natal women with opioid use disorder through. the removal of barriers to treatment access support for breast feeding and. nutritional supplements child care and improved training and education on. substance use disorders for,child protection workers. child protection services lawyers and,judges and jury members. Recommendation 18 Buprenorphine should be prescribed to pregnant women who live in or travel. to communities where methadone is not available especially First Nations. women Opioid agonist therapy should be consistently maintained during. pregnancy labour and post natal care,PHYSICIAN INCENTIVES FUNDING. Recommendation 19 The Ministry of Health and Long Term Care should work with the Ontario. Medical Association and Local Health Integration Networks to support the. variety of service models that meet patients individual physical and mental. health needs This should include consideration around alternative physician. remuneration structures in order to ensure high quality care is provided in all. settings including in high volume clinics,HARM REDUCTION OVERDOSE PREVENTION. Recommendation 20 The Ministry of Health and Long Term Care should quickly follow through on. its commitment to ensure naloxone is broadly and immediately available to. all those who can benefit from it, Recommendation 21 The Ministry of Health and Long Term Care should revise coverage of opioids. under the Ontario Drug Benefit Formulary to, place limits on reimbursement of high total daily doses of opioids. delist unnecessarily high dose formulations of potent opioids. Recommendation 22 The Ministry of Health and Long Term Care should support and fund. evidence based practice to include harm reduction programming including. but not limited to access to safer injecting and smoking supplies and. supervised drug consumption,SOCIAL DETERMINANTS OF HEALTH. Recommendation 23 The provincial government should allocate funding to promote and support a. range of supportive housing including the Housing First approach for people. with opioid use disorder,EDUCATIONAL SUPPORTS, Recommendation 24 The Ministry of Health and Long Term Care should work with appropriate. regulatory colleges professional associations and organizations and. educational institutions to develop curriculum updates and align educational. initiatives and standards on safe opioid prescribing by Ontario s physicians. and nurse practitioners and safe opioid dispensing by nurses and. pharmacists, Recommendation 25 The Ministry of Health and Long Term Care should mandate hospitals and. interprofessional primary care clinics including Family Health Teams. Community Health Centres and Aboriginal Health Access Centres to develop. programs to support the initiation of opioid agonist therapy in patients. presenting with opioid overdose or opioid use disorder based on best. practice treatment guidelines, Recommendation 26 The Ministry of Health and Long Term Care should provide sustainable. funding to expand existing programs such as the Medical Mentoring in. Addiction and Pain Network and establish new programs if necessary to. facilitate long distance clinical support and mentorship programs to assist in. the safe prescribing and dispensing of opioids and in the management of. opioid use disorders, Recommendation 27 The Ministry of Health and Long Term Care should develop in collaboration. with other organizations e g Health Quality Ontario Centre for Addiction. and Mental Health a comprehensive education package including patient. rights and standardized patient information package for patients who are. currently receiving opioids for pain management and considering and or. beginning opioid agonist therapy This education package should be. developed in consultation with physicians with training in the treatment of. opioid use disorder and pain pain management specialists in medical ethics. pharmacists and people with lived experience with opioid use disorder. TECHNOLOGY, Recommendation 28 The Ministry of Health and Long Term Care should champion the use of. electronic tools for the documentation of care plans and capturing and. sharing of health information This will avoid duplication promote file sharing. between care providers and improve patient experience transitioning. through the system, Recommendation 29 The Ministry of Health and Long Term Care should develop information. systems that proactively identify providers with potentially dangerous opioid. prescribing practices The Ministry of Health and Long Term Care and the. College of Physicians and Surgeons of Ontario should work together to. address dangerous prescribing practices All clinicians should have access to. the Narcotics Monitoring System, Recommendation 30 The Ministry of Health and Long Term Care should invest in research on the. opioid crisis and opioid addiction treatment to address questions that impact. clinical practice community based services and supports and public policy. INTRODUCTION, Canada is now the highest per capita consumer of opioids in the world 2 and Ontario has the highest. rate of prescription opioid use in the country 3 Approximately one of every 170 deaths in Ontario is now. related to opioid use 4 Among young adults aged 25 to 34 one of every eight deaths is related to. opioids making it the leading cause of death among young adults in Ontario 5. Years of liberal prescribing practices have inappropriately exposed a broad range of people to potent. opioids for all types of pain management This has caused a dramatic increase in rates of prescription. opioid addiction and has also created a large market for the diversion of licit opioids and the influx of. illicit variations Opioids are often illicitly used as a form of self medication for physical pain and. untreated mental health conditions Social determinants of health for example the lasting effects of. intergenerational trauma in many Indigenous communities have made already marginalized. individuals and communities vulnerable to the risks of opioid addiction and overdose. The current opioid crisis is having devastating consequences on individuals families and entire. communities across the province as the prevalence of addiction and the incidence of injuries and. deaths associated with opioids have increased dramatically in recent years 6 7. Opioid Agonist Therapy OAT refers to the long term treatment of opioid addiction with methadone or. buprenorphine naloxone also known as Suboxone or from this point forward in the report. buprenorphine two long acting opioids which relieve opioid withdrawal symptoms and reduce drug. cravings for up to 24 hours Both medications have a slow onset of action so they do not cause. intoxication or euphoria when taken at the appropriate dose. OAT typically has three components frequent dispensing of these medications under the observation of. a pharmacist including supervised on site consumption with the gradual introduction of short term. take home doses ongoing monitoring of substance use with urine drug screens and office visits and the. provision of counselling and medical care Numerous controlled trials and long term cohort studies have. demonstrated that OAT is the most effective long term strategy for reducing illicit opioid use retaining. patients in treatment preventing overdose and restoring function However some patients are. successfully able to taper and discontinue the maintenance prescriptions with significant support from. their treatment providers and community based services. Opioid Use Disorder OUD is a complex health issue that requires holistic patient centred care that is. often not available or accessible when and where patients need it most Currently the most common. treatment is methadone maintenance treatment MMT provided in stand alone fee for service clinics. academic centres Community Health Centres CHCs and community clinics Some of these clinics in. addition to their appointments require patients to attend the clinic weekly to provide a urine drug. screen and receive a prescription from the physician regardless of the state of recovery achieved by the. patient These time consuming obligatory visits limit patients autonomy and interfere with their ability. to participate in work travel enjoy time with friends and family and other activities of daily living. The work of this Advisory Committee builds on the foundational work of the 2007 Methadone. Maintenance Treatment Practices Task Force and reflects issues that have emerged since then such as. a dramatic increase in opioid overdose fatalities The Advisory Committee considered several aspects of. OUD treatment access to OAT safety and appropriateness of the medications used in OAT impact of. OAT on quality of life and treatment retention provision of primary care and mental health care and. specific treatment needs of youth pregnant women and Indigenous populations. The Advisory Committee also considered strategies to reduce rates of overdose and addiction through. provision of take home naloxone and promotion of safe opioid prescribing practices. Current Methadone Practices, In Ontario Ontario Health Insurance Plan OHIP funded stand alone clinics often referred to as. methadone clinics provide the large majority of OAT. Since methadone became more available as an addiction treatment option in 1996 methadone. maintenance has been a very effective treatment modality associated with marked reductions in illicit. opioid use improved mood and function and, decreased health care utilization and mortality The CPSO was asked by the Ministry to operate a. However reform is needed to better meet the methadone program in Ontario with the goal of increasing. the availability of prescribers in Ontario as there was. needs of all patients with OUD A number of limited access at the time The College established a. serious systematic issues are severely impairing Methadone Committee in by law in 1999 to provide. treatment access and quality These include oversight and undertook to do the following. i Ensure there were programs in place to, Exemption from the Federal provide educational training for physicians. Government Physicians are required to before they prescribe methadone. ii Facilitate the development of MMT, obtain an exemption from the Federal guidelines and standards with key Ontario. Controlled Drugs and Substances Act addiction experts on the safe management. facilitated through the CPSO to of opioid dependence. iii Develop a rigorous program to assess, prescribe methadone This stipulation methadone prescribing physicians to. effectively deters many primary care ensure they are practicing safely and. effectively and, physicians from prescribing methadone iv Decide whether to issue refuse to issue or. in their family practices withdraw a permit for a physician to. administer prescribe or otherwise furnish,Lack of access to OAT clinics There is. methadone for the management of opioid,concern that there are insufficient dependence. numbers of clinics to meet patient, The involvement of the CSPO has increased access for. needs Over 40 000 patients are patients while supporting physicians e g through help. currently on methadone maintenance with acquiring an exemption to prescribe methadone. from the federal government guidelines to help with safe. treatment yet many communities have,provision of MMT an annual conference practice. limited or no access to OAT especially feedback education through the practice assessment. Northern rural and remote, communities Access to treatment is extremely limited for Indigenous people and communities. In addition stigma and discrimination further reduces access for some groups more than others. e g language barriers and ethnic minorities, Lack of access to comprehensive care in stand alone fee for service clinics Many of these. clinics provide little more than urine drug screening and methadone prescribing and dispensing. leaving patients without access to primary care mental health and addiction screening brief. intervention or counselling and management of acute and chronic illnesses. Variation in the quality of clinical services Some clinics require frequent attendance for urine. drug screening and a brief office visit regardless of the state of recovery demonstrated by the. patient This is wasteful and can be harmful to patients recovery as attendance can be. inconvenient and at times very challenging particularly for those in rural and geographically. isolated areas, Lack of access to other treatment options such as naltrexone and abstinence based treatment. Advisory Committee, The Ministry of Health and Long Term Care Ministry established the Methadone Treatment and. Services Advisory Committee with a mandate to, review current jurisdictional best practices against more recent evidence and new expert. reports and, provide evidence based tangible targeted recommendations for both the short and long. term on implementation of OUD treatment that integrates primary care and connects patients. to primary health care supports and community services. Objectives to be addressed by these recommendations include. enhanced care pathways for patients that integrates methadone treatment into primary care. identification of appropriate alternative treatment options buprenorphine. enhanced clinical support and training about opioid prescribing and addiction for health care. providers and their patients with emphasis on addictions and mental health support and. improved treatment and supports in high risk areas Northern rural and remote communities. particularly for Indigenous people and communities. The expert advice of the Advisory Committee members was sought to ensure the proposed province. wide plan considers the best evidence from both population health and systems based perspectives. Composition, The Advisory Committee members hold a variety of positions related to addictions and opioid use and. bring a range of professional expertise on key issues pertaining to the opioid crisis The Advisory. Committee was chaired by Dr Meldon Kahan Medical Director Substance Use Service at Women s. College Hospital and includes the following members see Appendix 1 for full biographies. Dr Philip Berger Dr Mike Franklyn Dr Ken Lee,Mr Rob Boyd Ms Tara Gomes Dr Bernard Le Foll. Dr Claudette Chase Dr Doris Grinspun Ms Sabrina Merali. Dr Sharon Cirone Mr Wade Hillier Dr Peter Selby, Dr Robert Cooper Ms Carol Hopkins Dr Sheryl Spithoff. Ms Gail Czukar Ms Mae Katt,Dr Irfan Dhalla Dr Tara Kiran. The Advisory Committee conducted its work from February to May 2016 Thorough discussions led to. the expert recommendations in this report outlining how to design and implement a strategy for the. delivery of OAT that encompasses additional services required to provide quality holistic and patient. centred care, Comprehensive academic research published evidence from the field clinical guidelines and best. practices from other jurisdictions supported the Advisory Committee members unique viewpoints. advice and cumulative experience driving the process and the development of their key. recommendations, This report outlines recommendations to improve the current system of service delivery for patients. faced with OUD and to provide them with the best possible care and quality of life creating an OAT. system that truly puts patients first, The majority of the advice and recommendations in this report were achieved by consensus. Background Presentations, The Advisory Committee received background presentations from the following. A panel of community services providers on their experience providing community based OAT. and wrap around supports The panel was comprised of Penny Marrett Executive Director. Addiction Services York Region Dennis Long Executive Director Breakaway Services in Toronto. Robin Griller Executive Director St Michael s Homes Toronto and Nancy Black Director St. Joseph s Care Group Thunder Bay, Ministry of Community Safety and Correctional Services on the challenges faced in corrections. facilities, Ministry of Health and Long Term Care on the status and forward plans for the Comprehensive. Drug Profile Repository, Wade Hillier from the CPSO and Advisory Committee member on CPSO guidelines for. methadone treatment programs, Tara Gomes Advisory Committee member and Principal Investigator at the Ontario Drug Policy. Research Network on emerging research on opioid agonist therapy options. Dr Carol Strike a health services researcher with the Dalla Lana School of Public Health at the. University of Toronto on people s lived experience with receiving OAT. Ontario Regional Chief Isadore Day Wiindawtegowinini on the experience of Indigenous people. Patient Engagement Considerations, Transformational change which puts the person at the centre of the care plan requires input from. patients themselves The Advisory Committee took Dr Carol Strike s excellent work on patient. experience within the opioid agonist system in Ontario into consideration throughout the development. of the report However the Advisory Committee recognizes that more patient engagement is required. In Recommendation 4 the Advisory Committee is proposing that Health Quality Ontario HQO engage a. diverse patient population as they develop a Quality Standard for the treatment of OUD This will ensure. that the patient s needs are fully considered when developing specific guidelines for service standards. and treatment options as well as implementation, Given that HQO has significant expertise in safe and meaningful patient engagement processes and will. be developing the Quality Standard the Advisory Committee feels as though patient engagement would. have a greater overall impact on service delivery during this stage of the work. Statement of Principles and Values, A key component of the Advisory Committee s mandate was to consider the patient as being at the. center of a transformed system As a result in developing the recommendations the Advisory. Committee relied on the guiding principles from the Ministry of Health and Long Term Care s Patients. First Action Plan for Health Care, Focusing on the person not solely on the addiction. Providing care that is coordinated and integrated so a patient can get the right care from the. right providers, Helping patients understand how the system works and where to access care so they can find. the care they need when and where they need it, Making decisions that are informed by patients and ensuring patient engagement in affecting. system change, Considering the impacts of long term treatment on daily living. Being more transparent in health care so Ontarians can make informed choices 8.
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