Sex and gender  are important determinants of health and influence the physiological and psychosocial aspects of many health conditions, including substance use disorders. Several clear trends regarding gender and opioid use have been identified, related to harms from opioid use, risk factors, and access to services.  One is that opioid poisonings, ...

The evidence supporting psychosocial interventions is often mixed, which may be due to inconsistency in the delivery of the intervention and methodological limitations of studies examining psychosocial interventions. Available meta-analyses and clinical trials examining the effectiveness of psychosocial interventions for treating OUD do not deviate ...

Important Notice Regarding BC Pharmacare Coverage   Buprenorphine/naloxone, extended-release subcutaneous buprenorphine (Sublocade), commercially available methadone  (Methadose and Metadol-D), and slow-release oral morphine (24-hour formulation; brand name Kadian) are all fully covered as regular benefits for those enrolled in PharmaCare Plan C (In...

The recommendations in this guideline should be considered applicable and relevant to the general adult patient population; however, there are additional considerations when working with specific patient populations. This section provides strategies for working with the following patient populations: Indigenous peoples, 2S/LGBTQQIA+ populations, and...

Opioids produce feelings of euphoria and general well-being and have been used throughout history to treat pain and a variety of different ailments.2 In the 21st century, opioids are available as regulated, pharmaceutical medications and in unregulated non-medical forms (e.g., heroin), which have become increasingly adulterated with highly potent op...

As is the standard of care for any complex or chronic medical condition, clinicians should provide health management to patients with OUD. By definition, health management includes, but is not limited to: providing non-judgmental support and advice; assessing motivation and exploring barriers to change; developing and regularly reviewing a treatment...

A3.4 Slow-release Oral Morphine-specific Guidance Slow-release oral morphine (SROM; brand name Kadian) is a long-acting, 24-hour formulation of oral morphine available in BC to treat opioid use disorder. Like methadone, SROM does not have a ceiling effect, requiring a similar level of monitoring during initiation to ensure patient safety. In the abs...

This section provides a review of evidence pertaining to non-pharmacological interventions for patients with OUD. In this context, psychosocial interventions include: Psychosocial treatment options for substance use disorders (e.g., contingency management, cognitive behavioural therapy) Bed-based treatment and supportive recovery programs ...

Take-home naloxone refers to naloxone that is administered outside of a health care setting by non-health care professionals (e.g., people who use drugs, friends, family members) who have received training to administer naloxone in the event of an opioid overdose. Findings from a 2018 systematic review indicate that take-home naloxone is effective i...

Broadly defined, harm reduction refers to policies, programs, and practices that aim to reduce the adverse health, social, and economic consequences of licit and unregulated substance use. In BC, established harm reduction initiatives include safer consumption and safer sex supplies distribution programs, take-home naloxone, drug checking, overdose ...

A Note on Terminology: The source material reviewed in this section uses several different terms to describe the Indigenous Peoples in what is presently known as Canada, some of which are legal terms directly tied to the Canadian constitution and various acts (e.g., Section 35 of the Constitution Act, 1982; the Indian Act, R.S.C. 1985). This termino...

Housing is an important determinant of health that has been linked to a variety of poor health outcomes. Research indicates that living situations such as homelessness and marginal housing (e.g., single-room occupancy housing) are associated with a higher prevalence of chronic and infectious diseases and poorer overall mental and physical health. Es...

All patients who screen positive for opioid use disorder should then be administered a diagnostic interview using the DSM-5 Clinical Diagnostic Criteria for Opioid Use Disorder to confirm the diagnosis and assess the severity of OUD.  According to studies to date, the DSM-5-TR criteria have substantial test-retest reliability in establishing the pre...

This guideline uses the term “family” to encompass all relationships that are important to the patient, which may include romantic partners, close friends, and other people of significance who may or may not be legally recognized as family. Family members can have an important role as partners in an individual patient’s care, and should be included ...

Based on a review of evidence supporting the safety and efficacy of OAT medications, this guideline recommends the following: Recommendation 1. Offer of OAT to all patients with OUD Adults with opioid use disorder should be offered opioid agonist treatment as the standard of care. Quality of Evidence: High Strength of Recommendation: STRONG Remarks:...

A1.1 Funding  Guideline development activities were entirely supported by funding provided by the BC Ministry of Mental Health and Addictions and the BC Ministry of Health to the BCCSU.  No support was received from the pharmaceutical industry or associated stakeholders for guideline development. A1.2 Committee Membership The first edition of the BC...

Abundant evidence has demonstrated that historic and present-day colonialism has disrupted the health and well-being of Indigenous peoples in Canada. Decades of federal policies with the sole purpose of eradicating Indigenous identities, families, communities, culture, and traditional ways of life have resulted in intergenerational trauma, racism, a...

Assessment of functional outcomes is increasingly recognized as an important component in patient care. Unlike screening, assessment of functional outcomes can occur on an ongoing basis in order to identify any changes in a patient’s symptoms or functioning during treatment. Functional outcomes can encompass different concepts, including health-rela...

Harm reduction has been defined as “policies, programmes and practices that aim to minimise negative health, social and legal impacts associated with drug use, drug policies and drug laws. Harm reduction […] focuses on positive change and on working with people without judgement, coercion, discrimination, or requiring that they stop using drugs as a...

The continuum of care for OUD includes care planning and services oriented towards recovery and self-defined wellness. This guideline suggests adoption of the United States-based SAMHSA’s Working Definition of Recovery75 as an overarching framework and for the purpose of developing patient-centred, recovery-oriented treatment plans: “A process of ch...

Individuals with OUD have high rates of emergency department (ED) utilization.155-157 These high rates of utilization suggest that ED visits may be an opportunity to engage individuals in evidence-based OUD care and promote harm reduction. A small but growing body of evidence suggests that ED-based initiation of OAT increases engagement and retentio...

Retention in OAT is associated with substantial reduction in all-cause and overdose mortality,111 whereas abundant observational evidence has associated discontinuation of OAT medications with high rates of return to unregulated opioid use275,276 and subsequent drug toxicity death.111,277,278 In reference to these findings, national and internationa...

The distribution of sterile injection equipment to people who inject drugs via needle and syringe programs has been widely implemented across a number of countries in an effort to prevent HIV and hepatitis C infections, reduce needle sharing and re-use, and decrease the number of discarded needles and syringes in communities.  Sterile injection equi...

Based on the available evidence base for opioid antagonist treatment options, this guideline makes the following recommendations: Recommendation 8. Oral naltrexone Oral naltrexone is not a recommended treatment for adults with opioid use disorder. However, it may be offered to individuals who have declined or discontinued OAT and would prefer non-op...

  A3.1 General Guidance All prescribers wishing to provide the full scope of OAT to patients in BC are required to complete the Provincial Opioid Addiction Treatment Program (POATSP) and a clinical preceptorship in order to have full prescribing privileges.1  The POATSP online course offers two dedicated training pathways for potential OAT prescribe...

A3.5 Transitioning Between OAT Medications Transitioning between OAT medications may be appropriate for a number of reasons including: No change from pre-treatment levels of non-prescribed opioid use Increased or re-initiated use of non-prescribed opioids while on OAT in order to manage opioid cravings or withdrawal symptoms Continued, increased, or...

Individuals subject to provincial or federal workplace-related legislation or who are otherwise limited in their treatment options due to the requirements of their jobs (e.g., regulated health care professionals, pilots) may not have access to the full continuum of care for OUD (i.e., OAT) if they wish to remain active in their position. Clinicians ...

There are no systematic reviews or meta-analyses considering the impacts of bed-based programs (also called residential or inpatient treatment) or supportive recovery treatment programs for individuals with opioid use disorder. The overall dearth of evidence does not mean that bed-based treatment is ineffective, but rather that the intervention has ...

Recommendation 12. Psychosocial treatment interventions and supports  Psychosocial treatment interventions and supports should be routinely offered to adults with opioid use disorder, in conjunction with pharmacological treatment. Quality of Evidence: Moderate Strength of Recommendation: STRONG As a standard of care, patients should be offered acces...

A brief overview of methods used to conduct the structured review of the literature, develop recommendations for clinical practice, and assess quality of evidence and strength for each recommendation can be found in Appendix 1.  ...

A3.3 Methadone-specific Guidance A3.3.i Assessment Methadone-specific contraindications Hypersensitivity to methadone hydrochloride Currently taking monoamine oxidase inhibitors (MAOIs) or use within past 14 days  Severe respiratory compromise or obstructive disease      Caution If pre-existing risk of prolonged QT interval (e.g., cardiac hypertroph...

Drug checking refers to a service in which street-obtained drugs are chemically analyzed and information regarding their contents is shared with the person using the drug checking service. Drug checking can be conducted using multiple technologies either at an on-site location or at a laboratory where samples are dropped off or shipped for analysis....

Recommendation 13. Harm reduction Conversations about safer drug use, take-home naloxone programs, and referral to other harm reduction services should be routinely offered as part of standard care for individuals with opioid use disorder. Quality of Evidence: Moderate Strength of Recommendation: STRONG Remarks: A growing body of research has shown ...

Take-home dosing (carries) of OAT may increase motivation to participate in opioid agonist treatment, improve treatment retention, facilitate virtual care, and enhance quality of life by increasing patient autonomy and flexibility and decreasing treatment burden. Carries also decrease costs related to daily witnessed ingestion. However, these benefi...

The SOWS612 is a self-administered scale for grading opioid withdrawal symptoms. It contains 16 symptoms, the intensity of which the patient rates on a scale of 0 (not at all) to 4 (extremely), and takes less than 10 minutes to complete. Patient Instructions: Please score each of the 16 items below according to how you feel right now. Circle one num...

  Recommendation Quality of evidence Strength of recommendation Relevant evidence review sections  Pharmacological Treatment 1 Adults with opioid use disorder should be offered opioid agonist treatment as the standard of care. High Strong Section 3.2  Section 3.2.ix (Remarks) 2 Prescribers should work with each patient to determine which of the foll...

On April 14, 2016, the Provincial Health Officer declared a public health emergency under the Public Health Act, following an unprecedented increase in overdose-related harms due to an unpredictable, highly toxic unregulated drug supply. In response to this emergency, the Ministry of Health and the BC Centre on Substance Use (BCCSU) prioritized the ...

Supervised consumption sites, which include supervised injection and inhalation sites, provide sterile supplies and a safe, hygienic space for PWUD to consume previously obtained unregulated drugs under the observation of health care providers or other trained staff.372 While supervised consumption sites had long operated without the approval of the...

The lack of tailored, age-appropriate approaches to and options for substance use care have consistently been cited as barriers to engaging youth in treatment.428,429 Strategies that primary care clinicians and care teams can use to improve retention and engagement in care in youth include: emphasizing confidentiality within and across services; inc...

Treatment retention Data regarding comparative treatment retention among the 3 oral OAT medications is mixed. For example, a 2021 meta-analysis (N=10 RCTs, 3 observational studies; n=5,065) found that retention rates—both length of time retained in study and presence on final day of study—are generally equal for fixed-dose oral OAT with methadone an...

Approximately 14% of British Columbians live in rural areas of the province.446 Notably, 30.3% of Indigenous people in BC live in rural areas and another 40.1% of Indigenous people live on-reserve.447  While data on the prevalence of OUD in rural and remote populations is lacking, 2015–2016 data from BC’s Provincial Overdose Cohort indicates a non-f...

Like tapering off opioids with methadone, an opioid agonist taper involving buprenorphine/naloxone appears to reduce the severity of withdrawal symptoms, but most patients still relapse to opioid use if a strategy involving only withdrawal management is employed. For instance, participants in the Prescription Opioid Addiction Treatment Study demonst...

Research has shown that members of communities that face racism are disproportionately affected by the harms associated with substance use, including criminal justice involvement, morbidity, and mortality.59 This disparity in health and social outcomes can be directly attributed to institutional racism.59-61 For example, although available evidence ...

Patient-centred care is about meaningful partnership between the patient and provider. It takes into account the unique needs and preferences of each patient, and aims to and empower patients as experts in their own care.19 Patient-centred care encompasses a variety of approaches that attempt to account for power imbalances and experiences of margin...

Social determinants of health can be understood as “the broad range of personal, social, economic, and environmental factors that determine individual and population health.”31 At a population level, this can be understood as the quantity and quality of resources a society makes available to all of its members, which include, but are not limited to:...

Given that withdrawal management alone is not recommended, it is the consensus of the committee that, in cases where it is preferred, most individuals with opioid use disorder should be offered community-based, outpatient withdrawal management as opposed to rapid inpatient withdrawal management. This is consistent with the American Society of Addict...

All patients should be screened routinely (i.e., at least annually) for substance use. Introducing substance use screening tools in a non-judgmental, conversational manner can foster trust and, in turn, improve the accuracy of self-report. Seeking the patient’s consent and providing context prior to asking screening questions may also aid in buildin...

Naltrexone is an opioid receptor antagonist that blocks the euphoric effects of opioids at adequate doses.282 Potential benefits of naltrexone include ease of administration, lack of induced tolerance during long-term treatment, and lack of potential for dependence or non-medical use.283 However, as an opioid antagonist, naltrexone fully blocks the ...

A number of standardized screening instruments are available that have been validated in a range of clinical care settings for opioid and substance use disorders, including the 2-item Screen of Drug Use, Rapid Opioid Dependence Screen (RODS), Severity of Dependence Scale (SDS), Cutdown, Annoyed, Guilt, Eye-opener Adapted to Include Drugs (CAGE-AID),...

Withdrawal management alone is not an effective treatment for opioid use disorder, and offering this as a standalone option to patients is neither sufficient nor appropriate. As will be reviewed in detail below, rates of dropout and relapse to opioid use are high, regardless of treatment modality used.298-300 Furthermore, the risks of serious harms,...

As with any chronic condition, individuals with opioid use disorder should receive comprehensive and continuing care. This should include ongoing review and assessment of the following: Adequacy of dosage Any emerging side effects and drug–drug interactions Patient’s treatment goals  Physical and mental health Need for, and access to, harm reduction...

In response to the ongoing overdose crisis, novel approaches have been piloted to reduce harms related to the use of unregulated opioids for individuals in care who have not benefited from traditional OAT approaches.  In July 2021, the Ministry of Mental Health and Addictions, Ministry of Health, and Office of the Provincial Health Officer released ...

Specific guidance for the treatment of OUD in correctional settings is outside the scope of this guideline. However, health care providers should be aware of the importance of maintaining care for patients who transition in and out of correctional settings. The following general principles should guide care for people transitioning in or out of corr...

This section outlines several overarching principles of care, which apply to all recommendations and clinical care guidance offered in this guideline and, more broadly, to establishing positive partnerships with patients and families experiencing opioid-related harms. The principles of care are intended to serve as a general framework to support cli...

Tapering off opioids with methadone appears to reduce the severity of withdrawal symptoms; however, the majority of patients still relapse to opioid use if a strategy involving only withdrawal management is employed.308 For example, clinical trials report relapse rates ranging from 53.1–66.7% at 1 month, and 61.1–89.2% at 6 months post-methadone tap...

While this guideline is intended to be applicable to all adults age 18 and above, there are unique considerations for older adults (age 65 and above). For specific guidance on prevention, screening, assessment, and treatment of OUD in older adults, as well as an overview of the issues unique to this population, please refer to the Canadian Coalition...

Peer support in the provision of OUD care may include peer navigators and peer support workers in OAT programs as well as peer-based support groups, such as Narcotics Anonymous, SMART Recovery, and LifeRing. Peer support workers The evidence on peer support workers is limited; however, “Nothing About Us Without Us”: Greater, Meaningful Involvement o...

This document aims to update BC’s first provincial guideline for the treatment of OUD, published in 2017. The original provincial guideline was the first of its kind to recommend buprenorphine/naloxone as first-line treatment for OUD, slow-release oral morphine as an alternative treatment option for opioid use disorder, and include harm reduction se...

The continuum of care for OUD includes evidence-based pharmacotherapies, psychosocial supports and interventions, and recovery support services. Individuals with OUD may need or want to try multiple approaches of varying intensity along this continuum of care, as their needs, circumstances, and goals change, in order to reduce harm, improve health a...

Disclaimer for Health Care Providers The recommendations in this guideline represent the view of the provincial guideline committee, arrived at after careful consideration of the available scientific evidence and external expert peer review. When exercising clinical judgment in the treatment of opioid use disorder, health care professionals are expe...

Slow-release oral morphine  (SROM) is widely used for pain management, but there is also a growing evidence base for its use as an OAT medication. In Canada, slow-release oral morphine for treatment of OUD has been eligible for coverage under Health Canada’s Non-Insured Health Benefits (NIHB) program since November 2014 (now Plan W in BC), and as a ...

In the context of opioid use, research has shown that the prevalence of OUD is significantly higher among individuals who have been diagnosed with post-traumatic stress disorder66 and that those who have been diagnosed with concurrent post-traumatic stress disorder and OUD experience a greater severity of OUD compared to those who have been diagnose...

Compared to placebo, alpha2-adrenergic agonists (e.g., clonidine, lofexidine, guanfacine, tizanidine) have been found to be effective for reducing the severity of opioid withdrawal symptoms and increasing the probability of completing withdrawal management; however, the majority of patients will relapse to opioid use if only a withdrawal management ...

Urine drug testing (UDT) at indicated intervals is the standard of care in OAT programs and can be used to assess adherence to treatment, validate self-reported use of opioids or other substances, detect use of other substances which may affect safety (e.g., benzodiazepines), and evaluate treatment response and outcomes (e.g., abstinence from heroin...

Buprenorphine is a partial opioid agonist available as both a monoproduct and a combined formulation of buprenorphine and naloxone. The naloxone component in the buprenorphine/naloxone formulation is added to deter diversion, injection use and insufflation. Due to almost complete first-pass metabolism and low sublingual availability, naloxone admini...

A substantial body of evidence has shown methadone to be significantly more effective than non-pharmacological outpatient treatment approaches in terms of treatment retention and suppression of heroin use.164  In terms of treatment retention, a 2022 systematic review and metanalysis (N=79) of randomized controlled trials found that methadone was mar...

A3.2 Buprenorphine-specific Guidance A3.2.i Buprenorphine/naloxone-specific Contraindications Allergy to buprenorphine, naloxone, or any other components of the drug product    A3.2.ii Buprenorphine/naloxone Pharmacology Buprenorphine is a partial agonist at the mu-opioid receptor and an antagonist at the kappa-opioid receptor Naloxone, which is an ...

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Given the significant pharmacologic and pharmacokinetic differences among OAT medications, practice standards for take-home dosing have been informed by each medication’s safety profile based on the best available data. Overall, methadone has been represented in significantly more overdose deaths than buprenorphine,120,173,174 which has led to diffe...

Individuals with opioid use disorder may face a number of barriers to initiation of, and retention in, oral OAT, including inadequate management of opioid cravings and withdrawal symptoms despite appropriate OAT dose adjustments; adverse events associated with oral OAT; contraindications to one or more oral OAT medications; insufficient improvements...

Psychosocial treatment interventions appear to be beneficial adjuncts to opioid withdrawal management.320 When offered in addition to pharmacologically-supported withdrawal management (e.g., opioid agonist taper), psychosocial treatment interventions such as contingency management and psychotherapeutic counselling may be effective in improving treat...

Given the high rates of hospitalization among individuals with OUD, inpatient settings present a significant opportunity to engage individuals in evidence-based OUD care and promote harm reduction.  However, as summarized below, there is currently a limited body of research evaluating OAT initiation in inpatient settings.  Two RCTs published in 2014...

Specific guidance for the treatment of OUD in pregnant individuals is outside the scope of this guideline. See the BCCSU, Ministry of Health, and Ministry of Mental Health and Addiction’s Treatment of Opioid Use Disorder During Pregnancy—Guideline Supplement .439 Care providers can access the Rapid Access to Consultative Expertise (RACE) line or 24/...

For each item, circle the number that best describes the patient’s signs of symptoms. Rate based the apparent relationship to opiate withdrawal. For example, if heart rate is increased because the patient was jogging just prior to assessment, the increased pulse rate would not add to the score. Table 31. Clinical Opiate Withdrawal Scale (COWS)611 Sc...

Extended-release naltrexone via monthly intramuscular injection may promote improved treatment adherence in comparison to oral naltrexone.282 Several randomized controlled trials have found that injectable naltrexone is superior to placebo in terms of improved retention in treatment, increased abstinence rates, and decreased opioid cravings.288-290 ...

As detailed below, this guideline recommends against withdrawal management alone. For patients who expressly wish to pursue withdrawal management, slow outpatient opioid agonist tapers should be considered, followed by long-term psychosocial OUD treatment for relapse prevention. Recommendations 10. Withdrawal management alone Withdrawal management a...

A. A problematic pattern of opioid use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period: Opioids are often taken in larger amounts or over a longer period than was intended. There is a persistent desire or unsuccessful efforts to cut down or control opioid us...

Land Acknowledgement The British Columbia Centre on Substance Use would like to respectfully acknowledge that the land on which we work is the unceded territory of the Coast Salish Peoples, including the traditional territories of xʷməθkwəy̓əm (Musqueam), Sḵwx̱wú7mesh (Squamish), and səl̓ílwətaɬ (Tsleil-Waututh) Nations. We recognize that the ongoin...