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
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
The HARMS Program applies proven risk mitigation strategies
from the addictions literature to chronic pain patients being prescribed
The HARMS Program has various components including:
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.
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
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
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
We are working on developing education materials for
patients, physicians/prescribers and clinical administration staff to further
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