New resources to help people with opioid use disorder

published on November 22, 2023

BC clinicians have newly updated clinical guidance to help deliver care for people living with opioid use disorder. The updated provincial Guideline for the Clinical Management of Opioid Use Disorder was published by the BC Centre on Substance Use (BCCSU) today.

The updates provide clinicians with guidance to help people engage and stay on treatment, pursue recovery, and reduce their reliance on unregulated substances. They were developed in response to the ongoing and evolving drug poisoning crisis – in which the unregulated drug supply continues to intensify in toxicity – and reflect the latest in evidence, as well as clinical and patient experiences.

Recommendations in the update include guidance to optimize access to opioid agonist treatments (OAT). For those with opioid use disorder, OAT are evidence-based medications that can, as part of a treatment plan, support an individuals’ recovery and overall health and wellness.

Other key updates include:

• Collaborative decision-making – a shift away from first/second/third-line medications towards a collaborative decision-making approach based on clinical judgement and client goals, circumstances, and preferences
• Updates to OAT dosing, titration, and missed doses – these include modified starting doses, titration protocols, and maximum daily doses that address increased opioid tolerance due to the presence of fentanyl in the unregulated drug supply.
• Take-home dosing protocols – Clinicians will now be able to better cater their requirements for take home dosing for individuals on a case-by-case basis to best meet their needs. This can help balance person-centered care, through increased flexibility and reduced treatment burden, with individual and community safety.
• Inclusion of extended-release buprenorphine – this is a formulation of buprenorphine that is administered monthly via abdominal subcutaneous injection
• Addition of principles of care — meant to guide care for all people with opioid use disorder and include trauma- and violence-informed care, cultural safety and humility, anti-racism, and person-centered care

The new guidance is an update to the 2017 provincial guidelines. Since those guidelines were released, the unregulated drug supply has become increasingly toxic and unpredictable — a trend that has only increased since the pandemic.

Drug checking, along with toxicology reports from the BC Coroners Service, have shown that since 2020 concentrations of fentanyl in the unregulated drug supply have increased dramatically. In addition, adulterants such as benzodiazepines and xylazine have emerged in the drug supply. As a result, responding to overdose events as well as initiating substance use treatment have become increasingly difficult, and helping people reduce their reliance on the unregulated drug supply has become more challenging for clinicians. It’s estimated that there are approximately 100,000 British Columbians with an opioid use disorder.

To optimize access to treatment and care in BC, BCCSU also provides training and education for current and new prescribers, as well as resources and tools to support system navigation for people seeking help.

More than 1,500 clinicians completed have already completed the Provincial Opioid Addiction Treatment Support Program (POATSP) since it was launched by BCCSU in 2017, leading to a nearly 400% increase of OAT prescribers in BC (from under 500 in 2016 to just under 2,000 at the end of 2022).

The full guidelines and supplementary materials, including a brief clinical summary and medication-specific summaries, as well as system navigation resources, are available on the BCCSU website at www.bccsu.ca/opioid-use-disorder/.

Quotes:

Jennifer Whiteside, Minister of Mental Health and Addictions:
“When providing health care for people with substance use issues, we need to meet people where they are at, and ensure that health care providers are equipped to provide support for peoples’ specific needs every step of the way. The updates to the opioid use disorder guidelines gives more tools to clinicians and are an important step to improving treatment for people on their path to wellbeing and to help save more lives.”

Cheyenne Johnson, Executive Director, BC Centre on Substance Use:
“In the context of an increasingly toxic and unpredictable unregulated drug supply, it is critical to ensure British Columbians living with opioid use disorder have access to the best available treatment. These new guidelines build upon knowledge, experience, and the latest science to make that possible. This guidance will give clinicians the tools to help people engage and stay on treatment, pursue recovery, reduce their reliance on unregulated substances, and minimize their risk of toxic drug poisoning.”

Dr. Paxton Bach, addiction medicine physician and co-chair of guideline writing committee:
“As an addiction medicine physician, I know that having up-to-date guidance that I can rely on to support my patients is crucial – especially in the midst of a public health emergency. These new guidelines will ensure that BC clinicians have access to the most current evidence available in order to support collaborative decision-making, to provide the highest level of care possible, and to help our patients achieve their goals.”

Dr. Bonnie Henry, B.C. Provincial Health Officer:
“What we heard from clinicians was the need for these updated guidelines which were first published six years ago and have now been updated to incorporate the many learnings of the past few years. With this updated, evidence-based guidance, clinicians will be better supported to provide people with opioid-use disorder the care that meets them where they are and keeps them engaged in treatment.”

Cynthia Johansen, Registrar & CEO, BC College of Nurses and Midwives (BCCNM):
“BCCNM welcomes these new guidelines, and thanks BCCSU for their partnership and support for nurses who diagnose and treat opioid use disorder. B.C. is fortunate to have a world-class agency like BCCSU dedicated to clinical excellence, best practices, and compassionate leadership. We value BCCSU’s commitment to addressing the overdose crisis and its continued efforts to improve the lives of individuals living with substance use disorder.”

Key facts:

• Opioid Agonist Therapy (OAT) – OAT is an evidence based medical option of medications used to provide relief from withdrawal symptoms and cravings in people with opioid use disorder. OAT is the recommended first-line treatment for opioid use disorder in British Columbia. Types of OAT Medications – Buprenorphine/Naloxone (Suboxone), Sublocade (injectable extended release formulation of Buprenorphine/Naloxone), Methadone, Slow Release Oral Morphine – SROM (Kadian).
• Injectable OAT (iOAT) – iOAT is an evidence-based medication option for people with opioid use disorder. iOAT involves the supervised injection of prescribed hydromorphone, or diacetylmorphine (i.e. medical heroin). Types of iOAT Medications include Hydromorphone (injectable), Diacetylmorphine (injectable), Tablet injectable hydromorphone (TiOAT).