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Marathon Family Health Team (FHT) has developed and implemented the HARMS (High-yield Approach to Risk Mitigation and Safety) Program to improve opioid prescribing practices for patients with chronic non-cancer pain.

The HARMS Program has received various awards including the Association of Family Health Teams of Ontario (AFHTO) Bright Light Award for the category Why Hasn’t This Expanded: Scalable Pilot Programs and the College of Family Physicians of Canada Team Williams Award for Information Technology Innovation.

Health Quality Ontario had a chance to catch up with Dr. Ryan Patchett-Marble to learn about the development, implementation and evaluation of the HARMS Program and how other FHTs can adopt this work.

How did the HARMS Program first come about?

The Marathon FHT is located in Northern Ontario where opioid use disorder is more prevalent compared to other parts of the province. In 2014-15, the FHT created a chronic pain and addictions committee to develop an opioid prescribing program. We formalized the ideas from that program and in the process founded the HARMS Program.

Pictured is the Marathon Family Health Team (MFHT) Chronic Pain and Addictions (CPA) Committee. The CPA committee was involved with the initial creation of the MFHT Opioid Prescribing Program in 2014, which would later become the HARMS Program. Left to right: Shelley Heavens, Michele Lajeunesse, Dr. Ryan Patchett-Marble, Elana Armitage, Dr. Nancy Fitch and Dr. Megen Brunskill. Missing from photo, Trixie Dykstra and Margaret Cousins.

What does the HARMS Program entail?

The HARMS Program applies proven risk mitigation strategies from the addictions literature to chronic pain patients being prescribed opioids.

The HARMS Program has various components including:

Risk stratification

Every patient prescribed opioids has some level of addiction risk. This risk is assessed and stratified into categories of low to high risk. Patients are monitored based on their level of risk and this level is adjusted dynamically as patients are monitored over time.

Urine drug testing (UDT)

All patients taking opioids are subject to urine drug testing (UDT), the frequency of which is determined by an individual’s level of addiction risk. Low risk patients are randomly selected to provide UDT at ~10% per month, moderate risk patients at ~20% per month, and high risk patients at ~50% per month. "Structured" (very high risk) patients have regular UDT, typically between one to two weeks and also random testing.

Figure 1: Visual depicting opioid addiction risk levels and related UDT frequency

START-IT software tool

START-IT is a national award-winning software tool that facilitates uptake of UDT by automating the process. The clinic staff conducting the UDT use a tablet to administer START-IT. START-IT then collects self-reports directly from patients about prescribed opioids, as well as drugs and medications not prescribed. The patient then provides a urine sample and the results of the immunoassay are entered into START-IT. The algorithms then interpret the results automatically and explain the results within the limitations of the test.

This information is then automatically entered into the patient’s electronic medical record (EMR). START-IT collects data securely which can be combined with data from provincial databases (ICES) to evaluate the HARMS Program.

Risk stratification, UDT and the START-IT software all work together to provide efficient and effective opioid prescribing and monitoring.

What have been the results so far?

Ministry of Health and Long-Term Care statistics show that the number of opioids dispensed by our FHT’s family physicians has decreased by 58% and the number of new opioid prescriptions has decreased by 29%. There are also 20 to 30 patients receiving treatment for addiction now; there were none prior to the HARMS Program.

The risk stratification and UDT is shown to be effective in closely monitoring opioid use and has made a significant impact on dispensing practices, new prescriptions and addiction treatment.

Were patients reluctant to take part in the program?

At first, some patients saw UDT as a punitive measure and it was difficult to track and log the treatment agreements that all patients need to sign. We ensured that all patients knew that UDT is being universally implemented and that we don’t prescribe opioids without it. It is meant to keep patients safe and decrease their risk of opioid addiction. UDT ensures opioids are taken as prescribed and allows our physicians to identify if there are other medications being taken that may interact poorly or are inappropriate with opioids.

We used posters in the clinic and public information sessions to provide education to patients before and during the roll out of the program. With the next version of START-IT software, we will be able to provide a treatment agreement that patients can sign electronically, to decrease the paperwork.

Do you have information for other FHTs who want to adopt this program?

Our HARMS website provides details on how to adopt the program as well as learning modules to illustrate key principles when using UDT in primary care for patients taking opioids. A detailed overview of the HARMS Program, UDT, and the START-IT software is also available on the website.

We are working on developing education materials for patients, physicians/prescribers and clinical administration staff to further facilitate adoption.

Need help supporting your patients in managing their pain? Visit the Ontario Pain Management Resources for a coordinated program of tools from partner organizations across the province.