Addressing missed opportunities for opioid agonist therapy

Amidst an enduring crisis that has tragically taken the lives of thousands, Dr. Tina Hu, principal investigator of the recently published study titled Initiation of opioid agonist therapy (OAT) after hospital visits for opioid poisonings in Ontario, sought to investigate the rates of administration of a life-saving treatment recommended by national guidelines. The findings were unsettling, revealing that, despite a rising death toll, only one in 18 individuals received essential treatment within a critical seven-day window. In 2022 alone, Canada recorded 7,328 deaths resulting from opioid overdoses.

At the time of the study, Dr. Hu was a hospitalist at William Osler Health System (Osler), a centre of excellence for hospital-based mental health and substance abuse disorders. Having previously worked on a project focusing on the effectiveness of a program initiating opioid agonist treatments in the Emergency Department, she was left with an important question: “Just how frequently is opioid agonist treatment initiated?” With this in mind, Dr. Hu and a team of researchers began to look at these patterns by conducting a retrospective data analysis using administrative health care and demographic data. “Given the pervasiveness of the opioid crisis and the increasing opioid-related deaths across all demographics, I felt we needed a better understanding of treatment initiation overall, but especially in the seven days post overdose.”

The seven days after an overdose is a critical window, representing the period with the highest mortality risk for patients. During this timeframe, treatment is key to reducing cravings, preventing withdrawal symptoms, and aid patients in stabilizing. “Previous research underscores that patients are more likely to continue treatment if OAT is initiated in the emergency department, as opposed to just getting a referral for outpatient treatment alone,” Dr. Hu stated.

As well, in 2018, a Canadian opioid use disorder (OUD) guideline strongly recommended buprenorphine–naloxone as the preferred first-line treatment. The team of researchers then set out to evaluate the impact of this guideline on whether the treatment was administered. After reviewing 20,702 records of hospital visits for opioid toxicity, they were able to demonstrate that even though OAT is a proven and effective treatment for managing addiction, capable of reducing both morbidity and mortality, the guideline did not improve the rates of administration. Over seven years of the guideline in place, this rate only rose from 1.7% in 2013 to 5.6% in 2020.

Another narrative also emerged from the data, that of disparities in treatment showing that older patients, patients with mental health diagnoses, or patients that were low income, were less likely to get care. “Opioid use disorder is a medical condition influenced by various factors beyond an individual’s control and it carries a heavy burden of stigma, impacting their quality of life and creating barriers to treatment access,” says Hu. “We must shift our view of addiction and treat it like any other medical condition. We need to encourage open discussions with healthcare providers about treatments and reflect on our own clinical practices. We also need to take each opportunity we have to offer treatment, so more patients can receive the care they need.”

In order to increase the rates of initiation of OAT and help to alleviate the crisis, Hu advocates for broad action, not just for improved individual health but also to impact the health care system at a wider level. “To improve the outcomes for patients we could streamline referral pathways, initiate training and educational programs and establish protocols in emergency departments and hospital wards.”

Dr. Hu also recommends comprehensive harm reduction strategies that go beyond medications for patients; including education, ensuring opioid overdose reversal medications are available widely, and supporting the prevention of infectious diseases. “The root causes of an individual’s addiction must be explored in order to support people towards recovery. We can also help patients navigate through the health care system and to receive other aid such as with counseling and income supports.”

The study findings serve as a call to action for timely intervention, urging health care providers to act fast in helping to combat the opioid crisis and save lives. “Together, we can contribute to a collective understanding that informs patient care and furthers population health initiatives,” Hu says. The urgency of this message, underscored by escalating opioid-related deaths, emphasizes the critical importance of seizing every available opportunity for life-saving treatment for individuals struggling with overdose and addiction.

Research paper summary: Addressing missed opportunities in OAT initiation

Canadian OUD management guideline

In 2018, a Canadian OUD guideline strongly recommended buprenorphine–naloxone as the preferred first-line treatment for OUD. This study evaluates OAT initiation rates after a hospital encounter for opioid toxicity in Ontario and whether the 2018 Canadian OUD management guideline was associated with increased initiation rates.

A public health crisis in Ontario

• 286% increase of Opioid-related emergency department visits in Ontario between 2016 and 2021.
• 26,690 opioid-related deaths in Canada between 2016 and 2021.

Study details

The study looked at:

• 20,702 records of emergency department or hospital admissions for opioid toxicity analyzed.
• Seven years of data collected between January 1, 2013, and March 31, 2020.
• Seven days following discharge studied, a critical period for recovery. Studies have shown the mortality risk to be highest in the days immediately after an overdose, this is the period when timely OAT initiation and care are essential.

Assessing OAT guideline impact

The study observed only a gradual increase in OAT initiation rates showing that the guideline had no significant impact in the 7-days after an opioid toxicity event overall (1.7% in 2013 to 5.6% in 2020).

Key findings

Despite an increasing prevalence of opioid-related hospital visits, only 4.1% initiated OAT within 7 days of discharge.

When was treatment given

If treatment was given, 36.1% were initiated on discharge day or the day following, 48.1% were initiated on days 2–5, and 15.9% on days six or seven.

Barriers to care

Disparities in prescribing found in:

• Older patients
• Patients with mental health diagnoses
• Patients that were low income

Recommendations

Information and training to help physicians feel ready to prescribe OAT:

• Formal training
• Knowledge sharing and resources
• Strengthen local protocols and referral networks

Conclusion

Despite an increasing prevalence of opioid-related hospital visits, there were low OAT initiation rates between 2013 and 2020. This leads to the conclusion that efforts to initiate OAT in acute care settings need to improve, address barriers to prescribing and seize opportunities during hospital encounters to enhance patient outcomes in those with OUD.

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