Module 2: Continuum of Care and Available Resources – Topic H Recognize the multifactorial nature of opioid use, and the subsequent need for interprofessional and intersectoral collaboration throughout the continuum of care.

Learning Objectives

By the end of this topic, the student should be able to:

• Identify the diverse reasons that individuals use opioids.
• Understand the interprofessional needs of opioid users.
• Understand the roles of social workers, nurses, and pharmacists.
• Explain the difference between intersectionality and intersectoral collaboration.
• Explain the importance of opioid stewardship from an interprofessional perspective.
• Describe the role of intersectoral collaboration in addressing individual and community needs around opioid use.

Key Concepts

• There are several reasons individuals use opioids and these may be medical or non-medical.
• The primary medical use of opioids is to treat pain, with secondary medical uses including treatment of severe cough and diarrhea, and as part of palliative care, among others.
• Non-medical uses include recreational use (taken for enjoyment), management of withdrawal symptoms, and many uses relating to pain, including mental pain and anguish.
• Promoting safer opioid use is not confined to any one profession. Physicians, dentists, nurse practitioners, pharmacists, nurses, social workers, and many other professions have important roles to play with respect to opioid use and opioid stewardship.
• Interprofessional collaboration is crucial not only for the person using opioids but also for their families, supports, and communities.
• Municipal, regional, provincial, territorial, and national intersectoral drug and opioid strategies are a mechanism for bridging intersectoral needs for opioids, including the opioid crisis.
• Both intersectional and intersectoral processes are important to ensuring a comprehensive approach to care.
• To optimize health outcomes, team-based health care approaches that facilitate interprofessional collaboration are being recognized as effective interventions in opioid use management.

Reasons for Opioid Use

Opioids are used primarily for their analgesic (pain-relieving) effects for moderate to severe acute pain from a variety of causes.

• Less commonly, opioids are used to suppress severe coughs (e.g., dextromethorphan) and to treat diarrhea (e.g., loperamide).
• Opioids are also used in combination with other drugs in anaesthesia.

Opioids are frequently used to treat chronic cancer pain. Opioids are also used in opioid replacement therapy in the form of buprenorphine or methadone.

• Alternatives to opioids, such as antidepressants and anticonvulsants, are preferred for chronic nerve pain.

The use of opioids for reasons other than the treatment of pain as managed by a prescriber is sometimes called non-medical use; however, this description is misleading.

• Prescription and unregulated opioids can be used recreationally—for pleasure.
• Opioids can also be used for self-medication of physical pain, emotional pain, and trauma, or to avoid symptoms of opioid withdrawal.
  • Although these are medical reasons, when used outside the medical system, they are sometimes called non-medical use.
  • In this way, opioids are used as a coping mechanism against psychological or emotional pain and distress such as feelings resulting from trauma.
  • As an example, Canadian research has shown that up to 90 percent of women in treatment for substance use have experienced trauma (Jean Tweed Centre, 2013).
  • In many cases, a combination of recreational and self-medication reasons may contribute to ongoing opioid use.

Opioid users have complex, interprofessional needs. In order to understand these needs, we will explore the role of several professions when it comes to opioid users.

Opioids and the Role of the Social Worker

Almost every social worker who is involved in clinical or community work will engage with a person experiencing a substance use disorder or a family that has a member who is.

• Social workers represent one of the largest providers of professional substance use and mental health services, partly because of the holistic perspective in which they practise in schools, public and private health care clinics, hospitals, child welfare agencies, counselling agencies, addiction rehabilitation centres, detoxification centres, and social justice and advocacy locations, in addition to local, provincial, territorial, and federal levels of policy.
• Social workers receive education and training within a context of professional and ethical responsibility to both the individual and the community. This results in social workers having a broad perspective to bring to an interdisciplinary team when working in the field of opioid use.
• Social workers approach addiction not just from a clinical perspective but from a holistic, anti-oppressive orientation and so they consider the individual in relation to their environment, along with the structural factors that contribute to the use and misuse of drugs.
• A social worker’s learning experience is based on educational training and practicum placement. Social workers apply a person-in-environment perspective, enabling them to identify the biopsychosocial factors that influence the well-being of clients and families.
• Expertise in interviewing skills and the ability to establish a trusting therapeutic relationship with the individual allows the social worker to collect valuable information that can be shared (with consent) with the interprofessional team.

Roles of the Social Worker

Listed below are some of the positions social workers are involved in related to opioid use practice.

Clinical Social Workers and Opioid Assessment

Depending upon the setting, a social worker may screen an individual for opioid use and/or assess the individual.

• Clinical social work focuses on the individual and those identified as being within their circle of care, such as a partner or children.
• Clinical social work may also focus only on the partner and other family members as addiction impacts them in specific ways apart from the person experiencing addiction.
• As treatment for addiction is interdisciplinary and involves other health and social service professionals, the social worker may assume the role of a case manager or discharge planner (if the individual is hospitalized).
• The role may also include connecting the individual with supports within the community specific to their needs, which may include housing, employment, social services, peer supports, food security, and transportation, among others.
• Navigating the system with the client is particularly critical in substance abuse treatment to ensure adequate recovery and minimize relapse for people with opioid use disorder.
• Because of the high prevalence of trauma and violence associated with opioid use, social workers adopt a trauma-informed approach.

Opioids and the Role of the Nurse

The following are recommendations by CASN for registered nurses and nurse practitioners on how to address the opioid crisis in Canada (CASN, 2017).

1. Optimize assessment skills related to substance use and misuse.
   • Establish whether opioids are being used.
   • Explore why opioids are being used.
   • Assess the risk of substance misuse.
   • Identify indicators of substance use and misuse.
   • Identify signs and symptoms of withdrawal.
   • Improve medication reconciliation.
2. Educate individual clients, families, and the public regarding substance use and misuse.
   • Provide appropriate information to clients who are prescribed opioids.
   • Provide discharge information to postsurgical clients prescribed opioids post-surgery.
   • Provide counselling, information, and support to families of persons abusing substances.
   • Provide education programs to populations at risk for abusing prescribed or illicit substances (e.g., students in schools).
3. Optimize pain management skills.
   • Provide evidence-based knowledge related to pain and pain management to clients with acute or chronic pain.
   • Apply knowledge related to pharmacological and non-pharmacological approaches to promote comfort and pain relief.
4. Support palliative and end of life (PEOL) clients’ and families’ use of opioids to control pain.
   • Teach and support the clients and families in appropriate opioid use to control pain.
   • Teach and support the PEOL family in safe disposal of narcotics in the home following client’s death.
5. Encourage best practices in harm reduction strategies.
   • Promote harm reduction practices associated with routes of use, substances used, and social use practices.
   • Possess knowledge and skills to support safe injections.
6. Refer clients to community resources.
   • Identify the need for community resources related to substance misuse.
7. Respond to overdose.
   • Recognize overdose.
   • Provide emergency assistance.
8. Adopt a trauma-informed approach.
   • Apply an understanding of the role of trauma in substance misuse.
9. Destigmatize addiction.
   • Address stigma related to substance misuse.
10. Collaborate interprofessionally and intersectorally to address the crisis.
    • Apply an understanding of the roles of other professionals related to substance use and misuse.
    • Work with other professionals to prevent or address substance misuse.

Opioids and the Role of the Pharmacist

The primary roles of the pharmacists with respect to opioids are drug dispensing, client care, and opioid stewardship.

Community pharmacists are the gatekeepers of prescription opioids. They interact with the client and/or caregiver on a regular basis, are easy to access, and are the resource for over-the-counter medication inquiries. Pharmacists address the opioid crisis in Canada by doing the following:

• Seek out or update their knowledge of best practices in pain management and opioid use.
• Provide an unbiased overview of the risks and benefits of chronic opioid therapy to the clients and other health and social service professionals.
• Encourage clients to use only one pharmacy for all their prescriptions, especially the chronic opioid prescriptions.
• Work as a part of an interdisciplinary team to improve pain management.

Pharmacists are in an ideal position to monitor for adverse events and client progress. Pharmacists must ensure that opioid prescriptions are appropriate and dispense the correct product. In addition, pharmacists can:

• Offer the client a private area to talk in, ideally in advance or when filling the prescription.
• Review client’s medications for drug interactions, assess the effect of concurrent metabolism inhibitors/inducers, and advise on dosing adjustments as needed.
• Provide feedback to the prescriber if any problems arise (any potential aberrant drug-related behaviours, or if clients are receiving opioids from other prescribers or pharmacies).

Pharmacists must communicate with clients about opioid use to maximize benefits and minimize the risk of adverse effects, including the possibility of tolerance, dependence, and addiction. They are in a position to:

• Influence and support positive client behaviours (support clients in abiding by the treatment agreement).
• Monitor for efficacy, adverse events, adherence, and aberrant drug-related behaviours.
• Encourage pharmacy staff to observe for questionable client behaviours, demeanour, or any symptoms of prescription opioid abuse or any substance use disorder.

Since 2016, pharmacists have also been directly engaged with harm reduction, dispensing naloxone to medical and non-medical opioid users and their supports. They may also have more time to dedicate to client education and follow-up. Pharmacists also maintain the dispensing records for opioids (as well as other medications).

Interprofessional Collaboration as Part of the Continuum of Care

To optimize health outcomes, team-based health care approaches that facilitate interprofessional collaboration are being recognized as effective interventions for opioid misuse and treatment.

Randomized control trials have shown improved client outcomes when the interprofessional team members collaborate in multi-modal care planning with the individual and their family. Referred to as collaborative care (CC), this model of care involves a number of health professionals working with a person who uses drugs to comprehensively address issues related with opioid use.

• Normally, the collaborative care team consists of a medical professional, a case manager (ideally someone who can offer help with medication), and a mental health specialist.
• It is based on the chronic care model, which integrates behavioural health into primary care.

Evidence suggests that by using the collaborative care approach, treatment outcomes can be significantly improved.

• Watkins et al. (2017) carried out a randomized controlled trial of 377 clients to assess the impact of a collaborative care versus usual primary care.
  • Individuals who received collaborative care reported abstaining from opioids 6 months longer after treatment compared to the control group.

Comprehensive addiction evaluation and individualized treatment plans should be supported over usual primary care. Treatment can include behavioural therapy (such as addiction treatment counselling, cognitive behavioural therapy, or motivational interviewing), medications, cultural interventions, or a combination of approaches.

• The specific type of treatment or combination of treatments will depend on the individual’s needs.
• A combination of approaches appears to be more effective than a single approach because each type of treatment works on a different aspect of addiction.
• People who use drugs often suffer from other health problems, as well as occupational, legal, family, and social problems that should be addressed simultaneously.

In the United States, different professions are implementing initiatives that can help to address the opioid crisis. These initiatives are outlined below.

Regis University Rueckert-Hartman College for Health Professions (RHCHP). Represented opioid panel health care professions and associated professional association opioid initiatives.

Adapted from Brooks et al. (2017)

What Does Intersectoral Collaboration Mean?

Described as both a tool and a process, intersectoral collaboration is defined as

“A recognized relationship between part or parts of the health sector with part or parts of another sector which has been formed to take action on an issue to achieve health outcomes ... in a way that is more effective, efficient or sustainable than could be achieved by the health sector acting alone”

• Because issues relating to opioid use span multiple sectors, including medicine, health, well-being, housing, employment, personal and family supports, and law enforcement, and different systems (local, municipal, provincial, territorial, and federal), it is imperative for individuals and agencies within each sector to know and understand the roles each play, to work together, and to avoid conflicting messages and actions.
• Intersectoral collaboration is now recognized as an essential part of comprehensive strategies to address these issues and health disparities (Danaher, 2011).
• Many regions and municipalities work to align and engage sector cooperation with the establishment of drug task forces or drug strategies.
• One of the first drug strategies in Canada was established in Vancouver in 2000. This strategy, like many others, uses a four-pillar approach:
  • prevention
  • treatment
  • enforcement
  • harm reduction
• Many regions and municipalities have developed drug strategies tailored to the needs of a particular community, designed to guide improvements in services and approaches to substance use.
  • For example, since 2015, many of these have developed opioid-specific task forces to address the opioid crisis. The following case examples make explicit the intersectoral model in practice.

Case Examples

Opioid Stewardship

Stewardship is defined as the responsible management of resources (Saskatchewan Health Authority, 2020). Interventions should be responsible in ensuring the appropriate use of opioids.

Opioid stewardship is described as coordinated interventions designed to improve, monitor, and evaluate the use of opioids to support and protect human health (ISMP Canada, 2020).

• An opioid stewardship program, like Saskatchewan Health Authority’s Opioid Stewardship Program supports health and social service providers and clients using evidence-based education on the appropriate prescribing of opioids and non-pharmaceutical interventions.
• Stewardship can be done through promoting peer-to-peer engagement between pharmacists and physicians to comply with opioid prescribing guidelines.
• For an example of government action on the topic, see Ontario Moving Quickly to Expand Life-Saving Overdose Prevention Programs.

Stop and Think

Now that you have reviewed this content, consider the following:

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References