British Columbia is rolling out a provincewide initiative modelled after a successful HIV/AIDS strategy aimed at retaining people with opioid-use disorder in treatment.
It will see teams of physicians, nurses, counsellors, peers and others regularly following up with people receiving opioid agonist therapies (OAT) such as methadone and buprenorphine-naloxone (Suboxone). Failing to refill a prescription, for example, might mean a follow-up phone call or a visit at home.
“Opioid agonist therapies actually can decrease mortality by about 80 per cent – so actually save lives,” said Rolando Barrios, senior medical director at the BC Centre for Excellence in HIV/AIDS (BC-CfE). “So the question for us is how we scale up that treatment and how we support people on the treatment so they benefit from the effects of that medication."
The BC-CfE and Vancouver Coastal Health partnered to create the Best Practices in Oral Opioid AgoniSt Therapy (BOOST) Collaborative, launching it as a pilot project in the fall of 2017. Seventeen clinical teams worked with about 1,100 clients in the city of Vancouver.
On Thursday, Dr. Barrios shared preliminary findings from the pilot project when announcing the BOOST Collaborative’s provincewide launch: After 90 days, the number of people retained in treatment increased from three out of 10 to seven out of 10. The expectation is that continued retention and support will lead to a reduction in overdose events and deaths, Dr. Barrios said.
He added that the program will require no additional funding or resources, only a reallocation of existing resources, to implement.
The BOOST Collaborative strategy is built on lessons learned from a successful BC-CfE program launched in 2010 called Seek and Treat for Optimal Prevention of HIV/AIDS, or STOP HIV/AIDS, of which Dr. Barrios was director.
That program entailed actively seeking out untreated HIV-positive people through widespread testing and providing them with highly active antiretroviral therapy, which has been shown to virtually eliminate progression of the virus to AIDS and greatly reduce the likelihood of HIV transmission. With both, more time in treatment is associated with better outcomes.
At their core, both the BOOST Collaborative and STOP HIV/AIDS strategies are about meeting people where they are at, recognizing that those with serious illnesses and addictions may have trouble following daily regimens and making medical appointments.
Patricia Daly, chief medical health officer and vice-president of public health at Vancouver Coastal Health, said the BOOST Collaborative is about improving quality of care, particularly with marginalized populations.
“It really needs a public-health approach, which is what we’re doing with BOOST: creating that public-health approach so that we can identify and support people in the community, not just wait for them to come in your door for their scheduled appointment,” she said. “If they don’t come, we need to go and find them and engage them in care.”
Continued treatment would still hinge on the consent of the patient.
Research has shown that people with opioid disorder who are on appropriate doses of OAT are less likely to use illicit drugs and more likely to remain in treatment. However, provincial data show just over half (55 per cent) of those on methadone achieve an optimal dose, which takes time, and that only 42 per cent of those who start methadone are still in treatment six months later. That figure drops to 32 per cent one year later.
Julio Montaner, executive director and physician-in-chief at the BC-CfE, recalled his father, a tuberculosis specialist in Buenos Aires having taken a similar approach with tuberculosis. Research from decades ago showed that tuberculosis could be treated and cured if patients adhered to a regimen over a period of one or two years, Dr. Montaner said.
“The problem, my father used to say, is that politically, it was very attractive to talk about it, but very boring to actually do it. So people tended to lose focus and lose interest,” Dr. Montaner said. “What we’re saying here is that we need to do this in the long-haul. The TB campaigns worked, if you maintained the effort.
“We can do this. It requires good old boring work.”