Drug overdoses due to illicit drugs in British Columbia have been challenging health and social systems across the province and dominating news headlines. In 2016, the B.C. Provincial Medical Health Officer declared a public health emergency in response to the dramatic increase in opioid-related overdose deaths. Despite the public health emergency declaration and new services, the number of opioid-related overdose deaths continues to be far above historical averages. The year 2018 opened with 125 people dying of a suspected illicit drug overdose in B.C. in January. This number is up from December 2017 by 25%.
Current data shows that only 3,500 individuals accessing care through Vancouver Coastal Health (VCH) clinics are on a therapeutic dose of Methadone or Suboxone, also called oral opioid agonist therapy (oOAT). However, approximately 9,000 clients are estimated to have an opioid use disorder and could benefit from the treatment. This means there are approximately 4,000 individuals who are not currently receiving oOAT, despite the evidence showing it could help curb opioid cravings and reduce risk of overdose. Further, the use of slow release oral morphine is indicated for roughly 5% of people with opioid use disorder, yet only approximately 0.5% of people are receiving this treatment.
The BOOST Collaborative aims to close these gaps, engaging and retaining more individuals with opioid use disorder into care. BOOST is the Best-practice in Oral Opioid agoniSt Therapy (BOOST) Collaborative, an initiative aiming for quality improvement in order to expand the reach, quality and effectiveness of oral opioid agonist therapy. Currently, BOOST is only being implemented with the Vancouver region. The initiative was developed and implemented by the BC-CfE in partnership with VCH.
A growing range of scientific and research evidence demonstrates that a significant proportion of individuals with opioid use disorder will respond to treatment with methadone or Suboxone. Opioid use disorder can be defined as a strong desire to use opioids, an increased tolerance to opioids, or experiencing withdrawal symptoms when not using opioids. Treatment success has been shown to be linked to shorter time to treatment from diagnosis and longer duration of treatment.
To learn more, we checked in with Laura Beamish, BC-CfE Quality Improvement Coordinator who has been highly involved with the launch of the BOOST Collaborative.
BC-CfE: How is the BOOST Collaborative working overall: Is it meeting the objectives you had hoped it would?
Laura Beamish, BC-CfE: Quality Improvement Coordinator: We are now entering our sixth month of the BOOST Collaborative and are very excited to see the progress made to date. One of the essential elements for successful quality improvement Collaboratives is identifying your population of focus-or the folks you are trying to improve care for. In our case, this means clients with opioid use disorder accessing services in Vancouver at clinics within VCH. This process involved working with teams to standardize clinical data entry, meaning the information collected to describe clients’ needs. This is the first step in easily and efficiently identifying clients with opioid use disorder within the electronic medical record.
The standardization process involves an incredible amount of work on the part of our frontline clinicians. As a result of these efforts so far, a greater number of individual records have been included in the system with an accurate diagnosis code: from around 600 clients to well over 3,000 in just five months. We continue to work with teams on standardizing their clinical data entry. Going forward, we hope to be able to share outcome measures based on interventions and care provided to clients, for example more precise information on metrics such as optimal dosing and retention.
We are also really pleased to see how far some teams have come in developing their quality improvement knowledge and skills. They have also come up with innovative approaches to applying this knowledge!
BC-CfE: Have you encountered any unanticipated barriers?
LB: In quality improvement we like to think of barriers as system opportunities. Implementing this project has allowed us to systematically identify common opportunities for improvement within the clinic teams, as well as across the health care system as a whole. This includes things like better linkages to local pharmacies and improved communication across programs.
BC-CfE: How do you feel about the results so far?
LB: I am excited to see the progress to date. While standardizing clinical data entry may not seem like a big step, it is critical to allow us to measure the hard work of our team as they evaluate changes implemented through BOOST. So far, this work has allowed physicians and allied health professionals to draw on the full capabilities of Profile EMR, which is the electronic clinical documentation system used by VCH. There have also been intangible and immeasurable positive results, such as relationship building and informal information sharing between providers. These are part of a hugely important piece to improving services across all of VCH programs.
BC-CfE: Are there any surprises?
LB: In my role as Quality Improvement Coordinator, I travel around the city (by bike) visiting all of our teams for one-on-one coaching. What continues to amaze me is the amount of compassion and care each and every one of the frontline staff brings to their daily work and to the BOOST Collaborative.
BC-CfE: Are you seeing a decent level of buy-in from all those involved?
LB: Yes, I would say that all of the teams involved believe in the value of this work and are excited. Where there was some hesitation, we shared information on exactly how the Collaborative is frontline-driven work to identify and close gaps in care. This helped to dispel any negative sentiments or myths about the program and allowed teams to feel ownership over the work. As teams continue to do this work and become more comfortable with quality improvement processes, they are becoming more innovative and excited to try different ideas.
BC-CfE: When will you be able to say this is in approach that will save lives?
LB: This is a difficult question to answer. If we can support improved retention on opioid agonist therapies, we can reduce the risk of overdose death for individuals who are at risk. It should be noted that currently BOOST is only capturing a segment of those being directly affected by the overdose crisis.
BC-CfE: To follow on your last answer, is BOOST being extended and why?
LB: Yes, a decision was made that a six-month extension of the BOOST Collaborative would allow us to make a maximum impact. The timing of BOOST paralleled to some degree the implementation of VCH’s Second Generation Strategy to form a new model of care in the Downtown East Side. Given the level of work needed to standardize clinical data entry and other adjustments taking shape, it was decided additional time would better allow all teams to become skilled with quality improvement methodology. The acquired learning can then be applied to other chronic illnesses such as hepatitis C or psychosis.
It is also possible that BOOST will expand to other communities and health authorities across B.C., bringing its potential benefits to a greater population of individuals.