Within the arsenal of interventions is buprenorphine, a synthetic opioid that is among the recommended standards of care for people with untreated opioid disorder. However, despite evidence of its efficacy in both mitigating overdose and managing opioid use disorder and opioid addiction, uptake of buprenorphine in emergency departments (ED) widely across hospitals has been limited.

Dr. Kalocsai, alongside a team of scientists, clinicians – including Dr. Nikki Bozinoff, an associate scientist and physician at the Centre for Addiction and Mental Health (CAMH) and Dr. Dominick Shelton, an emergency physician at Sunnybrook – librarians and people with lived experience of opioid use, recently led a scoping review to find out why.

The findings, published this month in The Lancet Regional Health, point to a health system that is grappling with the intricacies of structural and social barriers that contribute to a worsening opioid crisis, but also an opportunity to enhance teaching and education for clinicians who work with people who use drugs through what Dr. Kalocsai calls structural competency training.

“We found that some of the barriers that limit uptake is the failure to recognize and address structural stigma, poorly equipped services to manage patients’ medical and psychosocial complexity, and difficulties adapting to the increasingly toxic drug supply,” Dr. Kalocsai says.

As an education scientist, she adds, “this research shows where there are opportunities to educate clinicians to better serve marginalized communities and think about the structures of power, health disparities and equity.”

Dr. Kalocsai explains the significance of the findings of this scoping review, and the ways that they can contribute to a body of knowledge around the opioid toxicity crisis.

What do people need to know about the social and structural barriers that exist in addressing opioid use and overdose?

We know that the overdose crisis has disproportionately affected racialized and marginalized people, but the research on buprenorphine initiation in the ED rarely reports on patient characteristics that can contribute to marginalization. In that sense, much of the existing research actually fails to consider how intersecting structural barriers influence the inequitable access to buprenorphine in the ED. Most of the articles, for example, refer to stigma as a barrier, but usually define stigma as a negative attitude rooted in the individual, without diving deeper into how it might be structurally embedded through laws, policies, norms and processes at the level of the organization and society.

What is structural competency training, and how could it help support health care providers’ decision-making in the ED?

Structural competency training is education that enables people to recognize and respond to various social and structural factors – such as racism, colonialism, sexism, heteronormativity, houselessness and poverty – that people who use opioids often navigate, and which produce persistent health disparities and marginalization.

When it comes to buprenorphine initiation, what we’ve seen in the literature is a lack of comfort with buprenorphine and substance use care generally in the ED, and consequently increasing biomedical buprenorphine training as a solution. But the research also suggests that biomedical training is insufficient in and of itself to bring about behaviour change among health care providers. We recommend including structural competency training – in addition to training on motivational interviewing, harm reduction approaches co-created with patients, as well as ongoing provider supports such as mentorship, communities of practice and just-in-time training – so health care providers can recognize the social and structural factors that impact the opioid crisis.

An as education scientist, what can you tell us about the role that this kind of research can play in fostering health care providers’ ability to recognize and respond to different systemic barriers?

I hope our findings will lead to changes in how health professions are trained to provide care for people with opioid use challenges and support the optimization of ED-based buprenorphine and opioid-agonist treatment initiation as both a treatment and harm reduction strategy. I also hope that the study will contribute to increased coordination of implementation efforts, and a shift to equitable and inclusive opioid agonist therapy initiation pathways across Canada and the United States.

What message do you have for front-line clinicians who are treating patients in the ED affected by substance use and overdose?

Our results point to innovations that deliver high-quality care: multi-disciplinary addiction consult teams, low-barrier harm reduction-informed services that support transition to outpatient care, and adaptations to introducing buprenorphine that address the toxicity of the drug supply. Taken together, these changes could lead to the normalization of opioid use disorder care in the ED and a shift in understanding opioid use disorder as a condition is amenable to treatment in the ED.

Education science is a niche area of health research, and this study is especially unique. Can you tell me about that, and what the added value is of this research?

This is the first comprehensive review of the complex web of factors that facilitate and challenge the implementation of buprenorphine initiation in the ED. We wedded two research frameworks — the Consolidated Framework for Implementation Research (CFIR), which is a popular implementation science framework, and critical theory to understand how relations and structures of power undergird buprenorphine implementation in the ED. Our analysis also sheds light to the limits of CFIR, which does not easily lend itself to the examination of power. It suggests that by adapting CFIR to incorporate a critical lens, for example, an intersectional approach could help us understand how structures of power and oppression influence the inequitable access to the implementation of buprenorphine in the ED.

The post Behind the Research: The role of education science in the opioid crisis appeared first on Your Health Matters.

Part of the problem, Herriot says, is med schools don’t focus enough attention on these topics, particularly addiction. 

Do you think trainees – medical and others – are given the tools for treating patients with addictions and other mental health issues? 


Read the whole post here.


Check out the Sunnybrook Media Mental Health Playlist – lots of great videos featuring our staff, patients and their families, and highlighting the latest research.

The post Mental Health Issues: Are trainees taught enough? appeared first on Your Health Matters.