Research paper
Outcomes of Ottawa, Canada's Managed Opioid Program (MOP) where supervised injectable hydromorphone was paired with assisted housing

https://doi.org/10.1016/j.drugpo.2021.103400Get rights and content

Highlights

  • The managed opioid program paired injectable hydromorphone with housing.

  • 77% of the participants remained in treatment at one-year.

  • 58% had no overdoses and at one-year 45% stopped non-prescribed opioid use.

  • 42% reconnected with estranged family and 31% started a vocational program.

  • Future studies that pair housing with injectable opioid agonist treatment are needed.

Abstract

Background

The Ottawa Inner City Health's Managed Opioid Program is the first, to our knowledge, to pair injectable opioid agonist hydromorphone treatment with assisted housing for people experiencing homelessness with severe opioid use disorder (OUD) and injection drug use. We aimed to describe this program and evaluate retention, health, and social wellbeing outcomes.

Methods

We retrospectively assessed the first cohort of clients enrolled in the Managed Opioid Program between August 2017–2018. The primary outcome was retention at 12 months. Secondary outcomes included injectable and oral opioid dose titration, non-prescribed opioid use, overdoses, connection with behavioural health services, and social well-being. Descriptive statistics were used to summarize baseline demographics and secondary outcomes. Actuarial survival analysis was used to assess retention among participants.

Results

The study sample included 26 participants: median age was 36 years, 14 were female, 22 were White, eight had alcohol use disorders, 25 had stimulant use disorders, and all had a history of concurrent psychiatric illness. Retention at 12 months was 77% (95% CI 62–95). Throughout the first-year participants’ opioid treatment doses increased. The median daily dose of injectable hydromorphone was 36 mg [17–54 mg] and 156 mg [108–188 mg] at enrollment and one year respectively. The median daily dose of oral opioid treatment was 120-milligram morphine equivalents [83–180 mg morphine equivalents] and 330-milligram morphine equivalents [285–428 mg morphine equivalents] at enrollment and one year respectively. Over half had no overdoses and there were no deaths among participants who remained enrolled. At one year, 45% stopped non-prescribed opioid use, 96% connected to behavioral health services, 73% reconnected with estranged families, and 31% started work or vocational programs.

Conclusion

Individuals with severe OUD engaged in injectable hydromorphone treatment and housing showed high retention in care and substantive improvements in patient-centered health and social well-being outcomes.

Introduction

In 2018, globally there were 0.5 million deaths attributable to substance use, of which more than 70% were related to opioid use (World Health Organization, 2018). Since 2013 opioid-related overdose deaths have increased across North America secondary to the growing presence of illicitly manufactured fentanyl in the drug market (Centers for Disease Control & Prevention, 2020; Public Health Agency of Canada, 2021). In Canada in 2020, there were 6214 apparent opioid-related deaths (approximately 17 deaths per day), the majority of which (5148 deaths) occurred during the height of the COVID-19 pandemic (April to December 2020), representing an 89% increase from the same period in 2019 (Public Health Agency of Canada, 2021). Medications for opioid use disorder (MOUD), including methadone, buprenorphine, and slow-release oral morphine are associated with reduced overdose morbidity (Beck et al., 2014; Mattick, Breen, Kimber, & Davoli, 2009, 2014) and mortality (Sordo et al., 2017) for individuals with opioid use disorder (OUD). However, not all people with OUD seek and/or tolerate MOUD (Degenhardt et al., 2011), and long-term retention in care remains challenging despite best delivery practices (Fairbairn et al., 2019).

The Study to Assess Longer-term Opioid Medication Effectiveness (SALOME), compared supervised injectable hydromorphone to injectable heroin for people with OUD who had previously been on either methadone, buprenorphine, and/or slow-release oral morphine, and continued non-prescribed opioid use. SALOME found that hydromorphone was non-inferior to diacetylmorphine and both treatments were associated with high retention rates (>75%), reductions in street opioid use (from daily to a few days per month), and reductions in illegal activities (Oviedo-Joekes et al., 2016, 2017). In May 2019 Health Canada approved injectable hydromorphone for use as a treatment for severe OUD in adults. New national Injectable Opioid Agonist Treatment Guidelines supported expanded access to injectable opioid agonist treatment in Canada (Fairbairn et al., 2019).

Like other cities across Canada, there has been increasing morbidity and mortality secondary to the overdose epidemic in Ottawa. Between 2014–2015 the rate of drug overdose deaths increased by 32% in Ottawa, driven primarily by fentanyl (Ottawa Public Health, 2020). In 2017 in response to this growing public health crisis Ottawa Inner City Health, a community-based organization that provides health care, shelter, and social services to Ottawa's homeless community, established a pilot injectable hydromorphone treatment program (Fig. 1). Whereas injectable hydromorphone treatment programs have modestly expanded across Canada and globally, longitudinal data evaluating outcomes are limited (Eydt et al., 2021). Additionally, the Ottawa Inner City Health injectable opioid agonist treatment program, known as the Managed Opioid Program (MOP), is the first, to our knowledge, to pair injectable hydromorphone treatment with assisted housing.

In this study, we aimed to describe the Ottawa Inner-City Health's MOP and retrospectively evaluate retention at 12 months post-enrollment among the first MOP cohort. Secondarily, we aimed to describe the injectable hydromorphone and oral opioid titration trajectories and the changes in illicit substance use and overdose rates over time. We also described human immunodeficiency virus (HIV) prevention with post-exposure prophylaxis and antiretroviral treatment, hepatitis c virus (HCV) treatment, connection to behavioural health services, and the attainment of wellness milestones, including reconnecting with family or entering a vocational training program among MOP participants.

Section snippets

Study setting and program description

We assessed the first cohort of participants accepted into the MOP, in which supervised injectable hydromorphone was paired with assisted housing. The MOP was established in response to the overdose crises in Ottawa (Fig. 1) in collaboration with a community-based harm reduction organization and regional health authority (see Appendix 1 for complete program description and pictures of the facility). Eligible participants for the MOP included people with severe OUD who: had tried at least one of

Results

Twenty-six participants were included in the study sample (Fig. 2). At least one participant was excluded given they did remain in treatment for 14 days. MOP Staff noted that there may have been others who were offered MOP enrollment and/or received one or two doses of intravenous hydromorphone but did not remain engaged in treatment. Anecdotally, staff report that people with active criminal legal involvement, severe untreated psychiatric illness, and severe stimulant use disorders were less

Discussion

This evaluation of a program that integrated housing and injectable hydromorphone treatment for people with severe OUD demonstrated substantive improvements in the health and social well-being of participants. We observed that retention was high and illicit opioid use, but not stimulant use, decreased throughout the program with almost half of participants abstaining from illicit-opioids at 12-months. Among those retained in the MOP, over half had no overdose events, a significant reduction

Conclusion

In this retrospective study of the first cohort of Ottawa Inner City Health's MOP, we observed that the combination of injectable opioid agonist treatment with housing was an effective strategy to retain people with severe OUD in treatment. The MOP was established in response to an overdose crisis and is an example of how novel OUD treatment programs can be piloted during public health emergencies. Future studies that pair housing and other wrap-around services are needed to see if the MOP

Source of funding

Miriam Harris is supported by the Research in Addiction Medicine Fellowship (NIDA-R25DA033211-Samet) and the International Collaborative Addiction Medicine Research Fellowship (NIDA R25-DA037756-Fairbairn). Seonaid Nolan is supported by the Michael Smith Foundation for Health Research and UBC's Steven Diamond Professorship in Addiction Care Innovation. Nadia Fairbairn is supported by a Michael Smith Foundation for Health Research/St. Paul's Foundation Scholar Award and the Philip Owen

Declarations of Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgements

We acknowledge that the land where we work, live, teach, learn, and gather, is the traditional territory of Indigenous Peoples. Ottawa, the Anishnaabeg nation and Boston the Massachusett and their neighbors, the Wampanoag and Nipmuc Peoples, who have stewarded these lands for hundreds of generations, and continue to do so today.

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