Provincial guidelines for injectable opioid treatments released

published on October 11, 2017

The BC Centre on Substance Use (BCCSU) has released the province’s first-ever guidelines for prescribing of injectable treatments for opioid addiction.

The new guidelines provide recommendations for how injectable opioid agonist treatments can be introduced into clinical practice in order to prevent premature death from overdose and other imminent harms associated with ongoing injection drug use, while also engaging individuals in addiction treatment who have been otherwise unable to access or have not benefited from other forms of treatment.

The guidelines – which consider hydromorphone and prescription heroin (also known as diacetylmorphine) with a focus on the former due to current regulatory challenges to accessing prescription heroin – represent a critical step to expanding access to injectable treatments for opioid addiction.

“In the midst of an epidemic of opioid overdoses, we need to give people who are struggling with addiction as many treatment options as we can so we can reduce the tragic number of deaths in communities across our province,” said Judy Darcy, Minister of Mental Health and Addictions. “Expanding access to additional treatments for opioid addiction like hydromorphone will help provide a wider range of supports for people with addiction across the continuum of care, from harm reduction through to recovery.”

In June 2017, the BCCSU introduced new provincial guidelines for treating opioid addiction. However, not all individuals benefit from those recommended first and second-line treatments – such as buprenorphine/naloxone and methadone – for a variety of reasons, including side effects, intolerance, inadequate reduction in craving, and ongoing drug-related harms. Those individuals face significant risks, including fatal overdose due in large part to the proliferation of fentanyl and other synthetic analogues into the illicit drug supply.

“There is an urgent need to respond to the ever-increasing toxicity of the drug supply that is fueling the epidemic of overdoses,” said Dr. Seonaid Nolan, an addiction medicine physician at St. Paul’s Hospital and clinician researcher at BCCSU who was a member of the guideline development committee. “The available evidence demonstrates that oral and psychosocial treatments currently accessible are effective for most people with an opioid use disorder, but not all. Injectable treatments have proven to be effective for those other individuals, and they represent a safe alternative to the incredibly dangerous illicit market many turn to when other treatments don’t work.”

The guidelines provide recommendations for three potential models of care: comprehensive and dedicated supervised injectable opioid agonist treatment program in which clients can access a full complement of care in one setting; an integrated or embedded supervised injectable opioid agonist treatment program for clients in a less intensive setting within pre-established services; as well as an emerging model, a pharmacy-based supervised injectable opioid agonist treatment program allowing for improved access to care in communities where other, more intensive models may not be appropriate or feasible.

“How injectable treatment looks will depend on what the community context calls for,” said Cheyenne Johnson, Director of Clinical Activities and Development at the BCCSU. “That means ensuring that all stakeholders – from clinical care providers to people who use drugs to family members to recovery experts – have a voice and are appropriately consulted. Like all medical interventions, treatment needs to be provided along a continuum, with the treatment matched to individual patient needs.”

The BCCSU assembled an expert interdisciplinary committee composed of over 40 individuals, including representation from each regional Health Authority, the Provincial Health Services Authority, people who use drugs, and the BC Ministry of Health, to develop this guidance document. Key health systems partners, community and family advocacy groups, and international experts also reviewed the document.

The guidelines are grounded in the extensive international and Canadian research, including the NAOMI and SALOME studies conducted at Providence Health Care’s Crosstown Clinic, showing that hydromorphone and prescription heroin are both effective treatments for opioid addiction, providing both stability and health benefits to those who have not benefited with traditional oral treatments.

Health Canada recently lifted restrictions on the import of diacetylmorphine and other drugs to address overdoses, however, barriers to implementing access to this treatment still remain, including cost, challenges around production, and additional regulations required for prescribers. Hydromorphone has been found to be as effective as prescription heroin in both treatment outcomes and retention and comparatively inexpensive without the barriers to implementation.

The guidelines are the first of their kind in North America. In addition to the new guidance document for injectable opioid agonist treatment, the BCCSU has also developed guidelines for the clinical management of opioid use disorder and operating supervised consumption services.

• The full version of the injectable opioid agonist treatment guidance document can be found here.
• The executive summary can be found here.
• FAQs can be found here.

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About the BC Centre on Substance Use
The BC Centre on Substance Use (BCCSU) is a provincially networked organization with a mandate to develop, help implement, and evaluate evidence-based approaches to substance use. Located at St. Paul’s Hospital in Vancouver with researchers based at the University of British Columbia and Simon Fraser University, the BCCSU aims to build upon the success of its partner organization, the BC Centre for Excellence in HIV/AIDS, by improving the integration of best practices and care across the continuum of responses to substance use through the collaborative development of policies, guidelines, and standards. With the support of the province of BC, BCCSU aims to transform substance use policies, programs, and services by translating research into education and care guidance, thereby serving and improving the health of all British Columbians.

For additional information or to schedule an interview, please contact:
Kevin Hollett, BCCSU
778-918-1537
[email protected]