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Society of Rural Physicians of Canada 26TH ANNUAL RURAL AND REMOTE MEDICINE COURSE
ST. JOHN'S NEWFOUNDLAND AND LABRADOR APRIL 12 - 14, 2018
• 250
Dr. Sandra Allison • PRINCE GEORGE • BC
A VIEW INTO THE OPIOID CRISIS IN RURAL BC An overview of the opioid overdose crisis in Northern BC, characteristics unique to the north, and response activities to address the crisis. 1. Recognize the current status of the opioid crisis in Northern BC. 2.Identify characteristics specific to rural, remote and northern settings. 3. Identify actions that can be taken in rural, remote and northern settings to address the opioid overdose crisis.
4/26/2018
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A view into the Opioid Crisis in Rural BC
Dr. Sandra Allison, MPH CCFP FRCPC DABPM
Chief Medical Health Officer, Northern Health
(Acting) Chair, Rural, Remote, and Northern Public Health Network
President, Public Health Physicians of Canada
Northern Health Eating Disorders GP/Locum GP
1
Conflict of Interest
• I have no pharmaceutical (or other) industry conflicts to disclose.
• I work for a regional health authority.
• As a public health and preventive medicine specialist my interest is in preventing disease, injury, and death, prolonging life and improving quality of life through health promotion and protection.
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4/26/2018
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Objectives
• Understand the current status of the opioid crisis in Northern BC and characteristics and drivers.
• Identify actions that can be taken in rural, remote and northern settings to address the opioid overdose crisis.
3
Northern HealthGeography and Population
620 000 km2
54 First NationsOver 80 FN Communities GEOGRAPHY30 Municipalities3 HSDAs/ 17 LHAs288 000 people18% Status First Nations POPULATIONRegional Birth Cohort - 3400 childrenSchool DistrictsRCMP DistrictsRegional Districts and PARTNERSRegional Hospital Districts 4
4/26/2018
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Epidemiological updateAmbulance – ER ‐ deaths
More illicit drug deaths in BC than any other unnatural cause of death
6
4/26/2018
4
Lower rate of death in NH vs. rest of BC, but still much higher than in the past
0
5
10
15
20
25
30
35
40
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
2013 2014 2015 2016 2017
Dea
ths
per
100,
000
peop
le p
er y
ear
Quarter (calendar year)
BC
NH
Illicit drug overdose death rate, NH vs BC, 2013-2017
7
8
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Overdose fatality rates by First Nations Status, by RHA, Jan 2015‐Jul 2016
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Risk factors
• Demographic• Age 20‐59
• Male
• First Nations (most ODs occur in urban settings)
• Drug use pattern/context• Opioid use disorder, not on OAT
• Polysubstance use
• Using alone in a private residence
• Interruption and relapse (post‐detox or incarceration)
• Comorbidities• Mental health issues
• Chronic pain
• Social factors• Unemployment or construction trade employment
• Unstable housing
• Social isolation
• Disengagement from health care services
• History of trauma
10
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Key drivers• Pain
• Psychological and physical
• Often rooted in childhood trauma
• Stigma• Alienates and isolates people who use drugs
• Hampers political will to implement solutions
• Poorly addressed risk factors• Substance use disorder, mental health, chronic pain
• Inappropriate initiation and discontinuation of opioid prescriptions
• Social determinants of health• Poverty, homelessness, isolation, violence, discrimination, racism
• Unpredictable dosing with black market opioids • More potent substances as a consequence of prohibition (new!)
11
Analyses for response planning
• Most had prescription for LT opioids in the past, some had no Rx in past 5 y
• Most did not have an active Rx at time of OD
• Most pts had past prescriptions for psychotropic agents
• Most had no history of medications for treatment for SUD
• Pain related diagnoses WERE NOT more common amongst those who OD
• Most pts were highly engaged with the health system prior to OD, some had no contact at all. (16%)
• Seek to connect to SU treatment prior to OD
• Of those brought to ED, many left AMA
• Consider Harm reduction in facilities• Addressing subjective symptoms of pain and withdrawal
• Reduce actual and perceived stigma
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Crisis ResponseIn Rural, Remote, and Northern Settings
Provincial Overdose Emergency Response Centre (OERC)
On December 1, 2017, the Ministry of Mental Health and Addictions launched the new Overdose
Emergency Response Centre
Purpose
• The emergency centre will have a strong focus on measures to prevent overdoses and provide life‐saving supports that are:
• on‐the‐ground
• locally driven and delivered
• action‐oriented
• rapidly implemented
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Refreshed Provincial Opioid Crisis response“Comprehensive Suite of Services”
Essential Health Sector Actions
Naloxone and overdose response training
Overdose prevention and supervised consumption services
Drug checking
Acute OD case management
Treatment services
Surveillance
Essential Actions for Supportive Environments
Social stabilization - income, housing, supportive relationships
Peer employment and engagement
Cultural safety
Addressing stigma, discrimination, and human rights
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NH Opioid Crisis Response
• Regional Response Team • Monthly internal meetings
• Meet with provincial OERC once monthly
• 2 Community Action Teams• Funding flowing through CAI
• PG and FSJ
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NH Opioid Emergency Response Operational Model
Central FNHA
Regional FNHA
Local FNHA
• Health Directors
• Community Engagement Coordinator
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Provincial/Regional
• CMHO
• MHSU Lead
HSDA
• MHOs
• Specialized Services Dir
Local
• HSA, CSM, PHRN
Detailed Operational Plan Implementation
Align current status and efforts to support provincial reporting and funding structures
Respond to community needs and readiness
Drug CheckingOverdose prevention and SCS
Includes NaloxoneTreatment interventions and supports
including surgeHospital and ER department services
Pain ManagementProfessional Education
Data Analysis
Stipulate Precision across the Region
Stimulate Resonance at the Community
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Indigenous Peer Journey Map
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BC First Nations Health Authority Overdose/Opioid Response
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1. Prevent people who overdose from dying
Expanding Take‐Home Naloxone Training
2. Keep people safer when using
Peer (people who use drugs) Engagement, Coordination & Navigation
3. Create an accessible range of treatment options
Increasing access to Opioid Agonist Therapy (OAT) in rural & remote contexts
Integrated First Nations Addictions Care Coordinator
Intensive Case Management
Clinical Pharmacy Services through Telehealth4. Support people on their healing journey
Unlocking the Gates‐Peer Corrections Mentoring Program
Indigenous Harm Reduction Grant
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By the Numbers ‐ Distribution of Take Home Naloxone kitsNH, Jan 2015‐Sep 2017
15 20 27 45
192 220123
1268
608
1372
809
0
200
400
600
800
1000
1200
1400
1600
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3
2015 2016 2017
THN kits
Quarter (calendar year)
Shipped toNH sites
Dispensedto clients
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ONE OD deathPrevented per
10 kits distributed
Naloxone Distribution and Training
• Large geography – difficult to provide face to face training• Developed online curriculum in Learning Hub for Naloxone training
• High staff turnover – difficult to keep staff trained• Part of (lengthy) required site specific training as part of scope of role, ER, Community health nursing
• Staff shortages – hard to prioritize this training over other more critical functions
• Ensure backups where possible
• Variable overdose rates and perspectives on the crisis – it is hard to be in a crisis for 2 years
• Continued messaging and updates to ensure top of mind
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23
Supervised Consumption and Overdose Prevention• Proposed models designed on urban experience
• Continue to modify (rural‐proof) the models to meet rural needs
• Process for SCS approval is lengthy and iterative, resource intense• Continue with Overdose Prevention Sites as per Ministerial Order
• Bricks and mortar development is not feasible in large rural, under resourced communities
• Advocate for SC Services as a standard of care to be provided by health care providers
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Drug Checking
• Provision of colorimetric strips for detection of fentanyl requires basic training for interpretation
• Staff onsite provide the education
• Spread to other sites requires development of Learning Hub training materials
• FTIR spectrometry detection at selected high volume sites
• Expensive technology impractical when low volumes
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Acute OD Risk Case Management
• Develop Standardized approach to: Responding to an overdose presentation in Emergency Rooms
Responding to an overdose presentation by BCAS including follow‐up
/ Offer education on Take home Naloxone
Rapid Initiation of OAT in emergent settings as appropriate
Routine follow‐up by Mental Health/Substance Use clinicians
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By the numbers ‐ Consumption of OAT by RHA, Jan 2010‐Aug 2016
Interior
FraserVCH
VIHA
Northern
0
5
10
15
20
25
30
35
40
45
Morphine Equivalent (m
g) per Cap
ita
27
Treatment Interventions and Supports
• Identify and address the gaps and barriers to service
• Strengthen leadership in Addictions Medicine• Regional Leadership in place
• Sub‐regional nodes in development
• Improve spectrum of services through program planning• Address the full scope of addictions care from detox, treatment, maintenance
• Ensure adequate providers in place, skill up NPs for suboxone
• Increasing access to OAT through• Developing strong collaboration with primary care
• Design processes for provider supports
• Virtual care where needed, local providers preferred28
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Pain Management
• Northern Health’s Chronic Pain Strategy treats chronic pain as a chronic disease with most patients’ needs being met at the community and primary care levels.
• The Strategy proposes building capacity in the lowest levels of care and so as to reserve access to higher levels of care only for cases where it is deemed appropriate when appropriate.
29
Data Analysis – Surveillance
• Reliable information based on complete reporting is crucial in helping NH appropriately direct attention to communities with higher number of overdoses.
• Data will be used to inform decisions and actions to direct care and services
• Includes Epidemiologist and Outcomes Analyst
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Social stabilization ‐ income, housing, supportive relationships
• Community Action Team initiative through the Ministry of Mental Health and Addictions, OERC and partners
• Identify the underlying social drivers of the crisis
• Bring the appropriate partners and influencers together
• Encourage action by partners to address the drivers
31
Peer employment and engagement
• Ensure interventions meet the needs of the population served
• Engage peers in planning and implementing activities to address the crisis
• Value the effort of peers through appropriate remuneration
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Cultural Safety
• Ongoing investment in cultural safety training of staff in community and facility
• Exploration of Trauma informed care for emergency room staff
33
Addressing stigma, discrimination, and human rights
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Professional Education and Training
This is a cornerstone to the overdose prevention and response efforts. NH wants to ensure that there is:
• Increased access to staff with competency in substance use treatment
• Increase in peer engagement in planning and service delivery for substance use treatment
• Decrease in discrimination for people who use substances
• Increase in harm reduction supply distribution and education
• Funding to support new Clinical Education Resource positions and to support Anti‐Stigma Campaigns
35
Refreshed Provincial Opioid Crisis response“Comprehensive Suite of Services”
Essential Health Sector Actions
Naloxone and overdose response training
Overdose prevention and supervised consumption services
Drug checking
Acute OD case management
Treatment services
Surveillance
Essential Actions for Supportive Environments
Social stabilization - income, housing, supportive relationships
Peer employment and engagement
Cultural safety
Addressing stigma, discrimination, and human rights
36
Addresses the Emergency Addresses Drivers
4/26/2018
19
Lastly, the impact of Poverty, Inequality and Distress
37
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20
39
40
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Objectives
• Understand the current status of the opioid crisis in Northern BC and characteristics and drivers.
• Identify actions that can be taken in rural, remote and northern settings to address the opioid overdose crisis.
41
Thank you!!
T’oyaxsim nisim(Gitxsan)
Slahja(Nadleh Whut’en)
Musi(Nak’azdli DakalhYekooche)
T’ooyaksiy nisim(Nisga’a)
’
Háw’aa(Haida)
Meduh(Tahltan)
Gunałchéesh(Tlingit)
Mussi‐cho(Kaska Dena)
Snay Kahl Ya(Wet’suwet’en)
Snachailya(Carrier)
T’oyaxsut ‘nüün(Gitxaala, Gitga’at)
WuujoAasanalaa(Beaver)
Kinanâskomitin(Cree)
42