Agreement to Amend the Canada-Alberta Emergency Treatment Fund Bilateral Agreement

BETWEEN:

HER MAJESTY THE QUEEN IN RIGHT OF CANADA (hereinafter referred to as "Canada" or "Government of Canada") as represented by the Minister of Health (herein referred to as "the federal Minister")

- and -

HER MAJESTY THE QUEEN IN RIGHT OF ALBERTA (hereinafter referred to as "Alberta" or "Government of Alberta") as represented by the Minister of Health herein referred to as "the Alberta Minister")

REFERRED to collectively as the "Parties"

PREAMBLE

WHEREAS, Canada and Alberta made the Canada-Alberta Emergency Treatment Fund Bilateral Agreement to be effective March 14, 2019 to augment treatment services through one-time funding in response to the opioid crisis;

WHEREAS, the Government of Alberta has declared its intent to revise the Alberta Action Plan under the Canada-Alberta Emergency Treatment Fund Bilateral Agreement in a manner consistent with the Agreement and in accordance with section 9 of the Agreement;

WHEREAS, Canada has agreed with the revisions to the Alberta Action Plan;

NOW THEREFORE, Canada and Alberta agree to amend the Canada-Alberta Emergency Treatment Fund Bilateral Agreement as follows:

1.1 The Canada-Alberta Emergency Treatment Fund Bilateral Agreement is amended:

(a) In section 2.1.1 by inserting the following immediately after subsection (b):

"(c) Increasing access to psychosocial supports in opioid dependency treatment clinics

(d) Enhancing access to treatment and addiction services in emergency departments.";

(b) to replace all of Annex 1, the Alberta Action Plan, with the revised Alberta Action Plan at Annex 1 of this Amending Agreement.

1.2 In all other respects, the Canada-Alberta Emergency Treatment Fund Bilateral Agreement shall remain unchanged.

1.3 This Amending Agreement shall be read together with the Canada-Alberta Emergency Treatment Fund Bilateral Agreement and takes effect as if its provisions were part of the Canada-Alberta Emergency Treatment Fund Bilateral Agreement.

1.4 This Amending Agreement comes into force once it has been signed by both Parties.

1.5 This Agreement may be executed in counterparts, in which case (i) the counterparts together shall constitute one agreement, and (ii) communication of execution by fax transmission or emailed in PDF shall constitute good delivery.

SIGNED on behalf of Canada by the Minister of Health at Ottawa this 13 day of October, 2020.

The Honourable Patricia Hajdu, Minister of Health

SIGNED on behalf of Alberta by the Minister of Health at Edmonton this 29 day of July, 2020.

The Honourable Tyler Shandro, Minister of Health

Approved pursuant to the Government Organization Act: Intergovernmental Relations, Executive Council. Date: August 6, 2020

Annex 1 - Revised Alberta Action Plan

Overview of the opioid crisis and treatment in Alberta

The unprecedented rise in opioid related harms and deaths in Alberta continues to be a public health crisis. Despite the ongoing efforts, on average in the first nine months of 2019, two individuals died every day in Alberta as a result of an apparent accidental opioid poisoning (overdose). This trend is a continuation from 2018, where 789 Albertans died from an apparent accidental opioid poisoning (overdose).

Since 2015, the Government of Alberta and other entities in Alberta have taken a number of actions to respond to the opioid crisis. The Government of Alberta is prioritizing improved access to addiction and mental health care for all Albertans. Alberta recognizes and supports the provision of a comprehensive continuum of care for individuals and families impacted by the opioid crisis, including treatment and recovery supports, prevention and health promotion, and harm reduction.

To support Albertans with problematic substance use, specifically opioid use disorder, the Government of Alberta has taken many actions related to treatment. These interventions include, but are not limited to:

• Increasing public funding of addiction treatment beds;
• Increasing access to opioid dependency programming by expanding existing, and opening new, opioid dependency programs;
• Piloting an enhanced Addiction Recovery and Community Health (ARCH) program in Edmonton and Calgary;
• Establishing new programming such as:
  • initiating opioid agonist therapy (OAT) treatment for people with opioid use disorder in emergency departments;
  • injectable OAT programs in Edmonton and Calgary; and
  • a virtual opioid dependency program.
• Increasing access to supports and training for primary care providers to offer appropriate treatment, medication and care to patients and families affected by the opioid crisis; and
• Including OAT initiation and maintenance (i.e., buprenorphine/naloxone) in the scope of practice for nurse practitioners.

As the opioid crisis continues, Alberta is exploring opportunities to augment its response by: establishing, building upon or enhancing existing treatment approaches; encouraging further implementation of innovative treatment solutions; and/or recognizing the importance of broader strategies to support access to treatment services by enhancing health care providers' knowledge of best practices. For this purpose, the Government of Alberta will invest funds from the Emergency Treatment Fund (ETF) to enhance treatment initiatives to respond to the opioid crisis in Alberta. ETF investments, cost matched by Alberta in accordance with the terms of the Canada-Alberta ETF Bilateral Agreement, will support increased access to treatment services and expand existing treatment approaches in Alberta.

Expanding coverage of opioid agonist therapy medication

Opioid agonist therapy (OAT), which involves the provision of medications like buprenorphine/naloxone (e.g., Suboxone) or methadone, is a mainstay for opioid use disorder treatment. OAT medications are prescribed to be taken on a daily basis like many other medications. However, unlike many medications, OAT prescriptions are often dispensed on a daily basis, and are therefore subject to additional costs. Data has indicated that approximately 30 per cent of Albertans with opioid use disorder experience financial barriers to treatment, including paying out-of-pocket for OAT medications and associated costs.

Alberta has been working to increase accessibility of opioid use disorder treatment across the province. With the support of the ETF, Alberta will implement a program to help alleviate the financial burden related to OAT medications and associated costs. This will be done by providing coverage of up to four months' costs associated with specified OAT medications for individuals in Alberta with opioid use disorder who do not currently have coverage through a supplementary health benefit plan and who are initiating OAT treatment until they are covered under a Government of Alberta supplementary health benefit plan.

ETF funding will be used to enhance this programming. This investment is anticipated to increase the number of individuals in Alberta with opioid use disorder accessing OAT, and facilitate transitions between OAT initiation and maintenance settings.

Increasing access to psychosocial supports in opioid dependency treatment clinics

The Canadian Research Initiative in Substance Misuse National Guideline for the Clinical Management of Opioid Use Disorder (2019) suggests that psychosocial treatment interventions and supports should be routinely offered to individuals accessing OAT. The Canadian Centre on Substance Use and Addiction Best Practices across the Continuum of Care for the Treatment of Opioid Use Disorder (2018) recommends that at a minimum, psychosocial needs assessment, supportive counselling, links to existing family supports and referrals to community services, should be provided to individuals seeking treatment. Currently, Alberta Health Services (AHS), the Regional Health Authority for the Province, operates 10 opioid dependency treatment clinics across the province. Currently, these clinics provide OAT and variable levels of psychosocial supports, depending on available staff.
Alberta, leveraging funding from the ETF, will enable all AHS opioid dependency treatment clinics to provide a consistent standard of psychosocial supports, and move towards providing an augmented, provincial approach to psychosocial supports for Albertans with opioid use disorder. This includes having increased and equitable access to a staffing complement that includes a variety of the following professionals: addiction counsellors, social workers, peer support workers, psychologists, and mental health therapists in the AHS opioid dependency treatment clinics. These supports, provided by funds from the ETF and Alberta, will help more people move towards achieving their recovery goals.

Expanding accessibility to OAT in provincial correctional facilities; facilitate transitions to community settings

AHS provides care, treatment and support in provincial correctional and remand facilities, including OAT maintenance and related addiction treatment. In 2017, British Columbia stated that approximately one-third of incarcerated individuals participate in programming to receive OAT in their provincial correctional settings. Likewise, data available from the United States estimates that 23% of individuals within the correctional system meet criteria for opioid use disorder. This indicates that, based on the population of Alberta's adult provincial correctional system, approximately 7,000 people per year could benefit from OAT. To support the proportion of individuals entering Alberta's provincial correctional facilities who present with opioid use disorder, AHS implemented a pilot program to three adult correctional facilities to initiate high-risk patients on OAT.

Funds from the ETF will be used to expand and enhance OAT initiation and maintenance for individuals who present with opioid use disorder in Alberta adult provincial correctional and remand facilities.

This includes:

• Expanding the OAT initiation pilot program to all provincial correctional and remand adult facilities;
• Enhancing provision of OAT maintenance for individuals in provincial correctional and remand adult facilities; and
• Enhancing the connection to opioid treatment as individuals are transitioned to community settings.

ETF Funds will enhance both an existing treatment approach and access to treatment services in Alberta. This programming will allow for a larger proportion of individuals with opioid use disorder to access OAT within Alberta's provincial correctional facilities. This project will leverage the AHS Virtual Opioid Dependency Program to support the transitions of individuals initiated and maintained on OAT in this project to community OAT providers and other wrap around supports.

Enhancing access to treatment and addiction services in emergency departments

As part of the response to the opioid crisis, Alberta piloted two in-hospital teams, in Calgary and Edmonton, to intervene with patients in the acute care, inpatient environment. The Addiction Recovery and Community Health (ARCH) teams worked in two AHS hospitals to provide patient centered, comprehensive, trauma informed care to individuals who have high-risk substance use and health conditions related to social inequities.

The pilot involved embedding ARCH teams into two emergency departments to improve identification of patients at risk of substance related harms (including death by opioid poisoning), increase initiation into treatment and provide additional resources to these departments that have seen a significant increase in the number of individuals presenting with opioid use disorder. Given that individuals with problematic substance use who are admitted into acute care tend to have higher motivation for treatment, the ARCH Teams provided the following services:

• Immediate initiation of OAT and transition to community providers;
• Comprehensive, evidence-based addiction management, including treatment recommendations for complicated intoxication and withdrawal;
• Psychosocial supports, such as identification and referral for associated mental health conditions; social stabilization (e.g., housing and income support); and health promotion activities (e.g., immunizations and screening for sexually transmitted or blood-borne infections).

This pilot was funded for a two-year trial period, beginning in 2018 with funds set to expire March 31, 2020. Given the initial success of the pilot, funds from the ETF will be used to continue the availability of ARCH Teams for three additional years. Continuing this programing will support client health outcomes and emergency department capacity. In addition, following an evaluation of this model funded by Alberta Health, ETF funding will enhance access to this innovative model of opioid treatment and addiction services by:

• Supporting ARCH teams to assess the applicability of this model as a key component of the continuum of care for Albertans with problematic substance use (including opioid use disorder); and
• Developing training and protocols to enhance healthcare providers' knowledge of best practices and scaling up this innovative model of care for potential expansion to other settings (e.g. rural hospitals).

Expenditure Plan

Table 1 - ETF Funds Expenditure Plan by initiative

Initiative	2019/20	2020/21	2021/22	2022/23	Total
Expanding coverage of opioid agonist therapy (OAT) medication	0	$980,000	$1,060,000	$1,420,000	$3,460,000
Increasing access to psychosocial supports in opioid dependency treatment clinics	0	$297,376	$297,375	$297,375	$892,126
Expanding accessibility to OAT in provincial correctional facilities; facilitate transitions to community OAT services	0	$2,000,000	$2,000,000	$2,000,000	$6,000,000
Enhancing access to treatment and addiction services in emergency departments	0	$4,631,922	$4,631,922	$4,631,922	$13,895,766
					$24,247,892

Table 2 - Alberta cost-matching initiatives*

Initiative	Fiscal Year	Alberta Funding (in millions)
Expansion of Opioid Dependency Clinics	2016/17	8.9
OAT medications	2016/17	11.1
Alberta Health Services' injectable OAT program	2017/18	4.0
	Total	24.0

*This list is not an exhaustive compilation of initiatives undertaken by the Government of Alberta regarding treatment services for opioid use disorder. This list refers only to select initiatives funded or to be funded by Alberta, for the purposes of the Canada-Alberta ETF Bilateral Agreement.