Opioid Use Disorder (Opioid Addiction)

Care for People 16 Years of Age and Older

Click below to see a list of brief quality statements and scroll down for more information.

Quality Statements in Brief

Quality standards are sets of concise statements designed to help health care professionals easily and quickly know what care to provide, based on the best evidence.

See below for the quality statements and click for more detail.

Quality Statement 1: Identifying and Diagnosing Opioid Use Disorder
People at risk of opioid use disorder are asked about their opioid use and are further assessed as appropriate.

Quality Statement 2: Comprehensive Assessment and Collaborative Care Plan
People diagnosed with or identified as having opioid use disorder have a comprehensive assessment and a care plan developed in collaboration with their care providers.

Quality Statement 3: Addressing Physical Health, Mental Health, Additional Addiction Treatment Needs, and Social Needs
People with opioid use disorder have integrated, concurrent, culturally safe management of their physical health, mental health, additional addiction treatment needs, and social needs.

Quality Statement 4: Information to Participate in Care
People with opioid use disorder are provided with information to enable them to participate in their care. If their family is involved, they are also provided with this information.

Quality Statement 5: Opioid Agonist Therapy as First-Line Treatment
People with opioid use disorder are informed that treatment that includes opioid agonist therapy is safer and more effective than treatments that do not include opioid agonist therapy.

Quality Statement 6: Access to Opioid Agonist Therapy
People diagnosed with or identified as having opioid use disorder have access to opioid agonist therapy as soon as possible, within a maximum of 3 days.

Quality Statement 7: Treatment of Opioid Withdrawal Symptoms
People with opioid use disorder who are in moderate or severe withdrawal from opioids are offered relief of their symptoms with buprenorphine/naloxone within 2 hours.

Quality Statement 8: Access to Take-Home Naloxone and to Overdose Education
People with opioid use disorder and their families have immediate access to take-home naloxone and to overdose education.

Quality Statement 9: Tapering Off of Opioid Agonist Therapy
People who have achieved sustained stability on opioid agonist therapy who wish to taper off are supported in a collaborative slow taper if clinically appropriate.

Quality Statement 10: Concurrent Mental Health Disorders
People with opioid use disorder who also have a mental health disorder are offered concurrent treatment for their mental health disorder.

Quality Statement 11: Harm Reduction
People who use opioids have same-day access to harm reduction services. A comprehensive harm reduction approach includes education, safe supplies, infectious disease testing, vaccinations, appropriate referrals, and supervised consumption services.

Resources Quality Statements Advisory Committee About

Summary

This quality standard addresses care for people 16 years of age and older (including those who are pregnant) who have or are suspected of having opioid use disorder. The scope of this quality standard applies to all services and care settings, including long-term care homes, mental health settings, remote nursing stations, and correctional facilities, in all geographic regions of the province.

Please refer to Health Quality Ontario’s Opioid Prescribing for Chronic Pain quality standard and Opioid Prescribing for Acute Pain quality standard for detailed quality statements related to these topics.

Scope of This Quality Standard

This quality standard focuses on care for people 16 years of age and older (including those who are pregnant) who have or are suspected of having opioid use disorder. The scope of the standard covers all services and settings, including nursing homes, mental health settings, remote nursing stations, and correctional facilities, in all geographic regions of the province.

While the scope of this quality standard includes adolescents aged 16 and 17 years and people who are pregnant, it should be noted that the statements in this standard are based on guidelines whose evidence is derived primarily from studies conducted on adult (aged 18 years and older), nonpregnant populations with moderate to severe opioid use disorder. Health Quality Ontario’s Opioid Use Disorder Quality Standard Advisory Committee members agreed that the guidance in this quality standard is also relevant and applicable to people with opioid use disorder who are 16 and 17 years of age and to people who are pregnant. However, care providers should take into account that specialized skills and expertise may be required when providing treatment for special populations, including youth with opioid use disorder, those who use opioids intermittently or on a nondaily basis, and those with opioid use disorder who are pregnant. If treatment of these or other special populations is beyond a care provider’s expertise, the provider should consult or work with a care provider with appropriate expertise.

This quality standard includes 11 quality statements and 1 emerging practice statement addressing areas identified by Health Quality Ontario’s Opioid Use Disorder Quality Standard Advisory Committee as having high potential for improving the quality of care in Ontario for people with opioid use disorder.

Terminology Used in This Quality Standard

In this quality standard, “family” refers to family members, friends, or supportive people not necessarily related to the person with opioid use disorder. The person with opioid use disorder must give appropriate consent to share personal information, including medical information, with their family.

The term “care provider” is used to acknowledge the wide variety of providers that can be involved in the care of people with opioid use disorder. The term includes both regulated health care professionals, such as nurses, nurse practitioners, occupational therapists, pharmacists, physicians, physiotherapists, psychologists, social workers, and speech-language pathologists, and unregulated health care providers, such as peer support workers and volunteer providers. Our choice to use “care provider” does not diminish or negate other terms that a person may prefer.

“Opioid use disorder” is defined as “a problematic pattern of opioid use leading to clinically significant impairment or distress, occurring within a 12-month period.” The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) describes 11 symptoms of opioid use disorder.

The term “diagnosis” refers to the use of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) by physicians, psychologists, or nurse practitioners to determine if someone has opioid use disorder. Formal diagnosis is a requirement for initiating opioid agonist therapy; however, formal diagnosis is not, and should not be, a requirement to access other services. People often seek help for an addiction on the basis of self-identification, or a need for care may be identified by a care provider who administers assessments but who cannot formally diagnose a substance use disorder. Therefore, this quality standard uses the term “identified” to refer to situations in which a person has been assessed as having suspected opioid use disorder but has not received a formal diagnosis.

“Opioid agonist therapy” is defined as the provision of an opioid agonist (typically a long-acting formulation) as part of a treatment program. Opioid agonist therapy eliminates the cycle of intoxication and withdrawal, reduces opioid cravings, and blocks the effect of other opioids. People with opioid use disorder who are stabilized on opioid agonist therapy are considered to be in recovery and typically experience a significant improvement in health and social function. They would have uncomfortable symptoms if they were suddenly to discontinue opioid agonist therapy, but they are no longer considered to have an active substance use disorder. In Ontario, opioid agonist therapy must be prescribed by a physician or nurse practitioner.

Why This Quality Standard Is Needed

People with opioid use disorder have a mortality rate more than 10 times that of the general population. Fatal overdoses are a significant cause of mortality for people with opioid use disorder, and the rate of fatal overdoses has been rising rapidly in Ontario. According to statistics from the Office of the Chief Coroner for Ontario, the rate of opioid overdose–related deaths increased by 285% between 1991 and 2015. Opioids have become one of the leading causes of death among younger adults in Ontario: In 2010, nearly 1 in every 8 deaths among 25- to 34-year-olds was related to opioid use. Opioids also disproportionately affect those involved with the justice system: 1 in every 10 drug overdose deaths in adults occurs within 1 year of release from a correctional facility. In addition to the high risk of overdose, people with opioid use disorder are also at higher risk for death from a variety of other causes, including cardiovascular conditions and infectious diseases.

There are many opportunities to improve health outcomes and the quality of care for Ontarians with opioid use disorder. Many people with opioid use disorder report being unable to access the care they need. There are also regional variations in the availability of opioid agonist therapy—the first-line treatment for opioid use disorder—with significantly less provision in rural and remote locations than in urban centres. Some treatment facilities also prohibit the use of this evidence-based therapy: Roughly 1 in 4 residential addiction treatment programs in Ontario do not allow people to take opioid agonist therapy while participating in their programs (ConnexOntario.ca, May 2017).

Even when people are able to access opioid agonist therapy in Ontario, they do not always receive evidence-based care for other health needs. For example, people receiving methadone therapy in Ontario are significantly less likely to be screened for cervical, breast, and colorectal cancer, and those with diabetes are less likely to receive diabetes monitoring than the general population.

There is an urgent need to address the opioid crisis in Ontario, and a crucial part of achieving this goal is addressing gaps in the quality of care for people with opioid use disorder across the province. Based on evidence and expert consensus, the 11 quality statements that make up this quality standard provide guidance on high-quality care for opioid use disorder, with accompanying indicators to help care providers and organizations monitor and improve the quality of care they provide.

In addition to this quality standard, Health Quality Ontario has developed two further quality standards related to opioids: Opioid Prescribing for Acute Pain and Opioid Prescribing for Chronic Pain.

Principles Underpinning This Quality Standard

This quality standard is underpinned by the principles of respect and equity.

People with opioid use disorder should receive services that are respectful of their rights and dignity and that promote shared decision-making. They should be given the same care and be treated with the same degree of respect and privacy as any other person.

People with opioid use disorder should be provided services that are respectful of their gender, sexual orientation, socioeconomic status, housing, age, background (including self-identified cultural, linguistic, ethnic, and religious backgrounds), and disability. Equitable access to the health system also includes access to culturally safe care. Language, a basic tool for communication, is an essential part of safe care and needs to be considered throughout a person’s health care journey. For example, in predominantly Anglophone settings, services should be actively offered in French and other languages.

Care providers should be aware of the historical context of the lives of Canada’s Indigenous peoples and be sensitive to the impacts of intergenerational trauma and the physical, mental, emotional, and social harms experienced by Indigenous people, families, and communities.

Although not completely understood, addiction appears to be associated with psychological and social factors, particularly adverse childhood experiences such as neglect and abuse.

Care for people with opioid use disorder should be guided by a trauma-informed approach. With this approach, it is not necessary for the person to disclose their trauma; rather, this approach acknowledges how common trauma is among people who use substances and seeks to connect those interested in treatment with appropriate trauma services.

People with opioid use disorder benefit from care provided by a care provider or care team with the knowledge, skill, and judgment to provide evidence-based treatment for opioid use disorder while also receiving care that addresses all of their primary health care needs.

A high-quality health system is one that provides appropriate access, experience, and outcomes for everyone in Ontario no matter where they live, what they have, or who they are.

How Success Can Be Measured

The Opioid Use Disorder Quality Standard Advisory Committee identified a small number of overarching goals for this quality standard. These have been mapped to indicators that may be used to assess quality of care provincially and locally.

How Success Can Be Measured Provincially

Rate of opioid-related deaths
Urgent hospital use:

Rate of opioid-related emergency department visits
Rate of opioid-related hospital admissions

Percentage of primary care providers (family physicians and primary care nurse practitioners) who have prescribed opioid agonist therapy in the last year
Percentage of community pharmacies providing opioid agonist therapy services in the past year

How Success Can Be Measured Locally

You may want to assess the quality of care you provide to people with opioid use disorder. You may also want to monitor your own quality improvement efforts. It may be possible to do this using your own clinical records, or you might need to collect additional data. We recommend the following list of potential indicators, some of which cannot be measured provincially using currently available data sources:

Percentage of people receiving treatment for opioid use disorder who reported improved quality of life
Percentage of people receiving treatment for opioid use disorder who reported improved functional outcomes, including the following:

Return to work and/or work retention
Social functioning
Physical functioning

12-month treatment retention rate for people treated for opioid use disorder

In addition, each quality statement within this quality standard is accompanied by one or more indicators. These indicators are intended to guide the measurement of quality improvement efforts related to the implementation of the statement.

What Does It Mean for Patients and Caregivers?

I lost my beautiful son, Pete, to an accidental overdose in 2001. He was only 25 years old. Pete struggled with chronic pain and mental health issues. His doctor prescribed opioids to help manage the pain and his addiction evolved from there.

For the past 18 years, I have been in recovery from addiction, mental health issues, and childhood trauma, and I also struggle with chronic pain. I advocated for my son but felt completely discouraged by a system that could not bridge the complexity of our needs. Stigma, cyclical family breakdown, lack of safe and affordable housing, poverty, abuse, and trauma—these are only some of the issues people with opioid use disorder [OUD] endure.

That word, “bridge,” comes to mind when I think about what this quality standard means to me. It standardizes care while nurturing patient-directed care and empowering caregivers. It connects medical care with holistic recovery processes. It spans clinical and community environments. It meets people where they are at in their journey, at all ages and stages, and navigates those differences. It is a bridge between system transformation and treatment transformation.

- Betty-Lou Kristy, Lived Experience Advisor Panel Member, Opioid Use Disorder Quality Standard Advisory Committee

What Does It Mean for Providers?

I hope this quality standard will help all care providers, not just those in the addiction treatment sector, realize that there are many interventions that lead to improved health and quality of life for those with opioid use disorder (OUD). I hope the standard will assist providers in relaying evidence-based, accurate information to patients with OUD, and I hope it will spur rapid access to effective interventions. This is particularly important in rural and remote areas of Ontario where treatment for OUD is not always available. For these communities, creative and timely efforts are required to ensure equitable access to treatment.

Many of those who use substances have experienced significant psychological trauma, particularly abuse and neglect in childhood, yet they frequently face stigma and discrimination when they interact with the health care system. And so, perhaps most importantly, I hope this standard will ensure that providers and the people around them treat those with OUD with the same respect and care they give to any other patient.

- Sheryl Spithoff, Co-Chair, Opioid Use Disorder Quality Standard Advisory Committee

Timeline for This Quality Standard

This quality standard was completed in March 2018.

For more information, contact QualityStandards@HQOntario.ca.

Evidence to Improve Care