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 prescribers: 1) the Physicians and Nurse Practitioners’ Education and Training Pathway, and 2) the Registered Nurses and Registered Psychiatric Nurses’ Education and Training Pathway. Allied health professionals are also encouraged to complete POATSP, or access specific modules as needed for information and support in providing high quality, evidence-based care to patients on OAT.
All prescribers are also encouraged to consult with an addiction medicine specialist experienced in prescribing OAT as needed; this may include contacting an Addiction Medicine Consult Team, the RACEapp, or 24/7 Addiction Medicine Clinician Support Line. Nurses, midwives, front-line workers in Indigenous communities, and pharmacists may also access the 24/7 Addiction Medicine Clinician Support Line for guidance in the care of patients on OAT.
The general considerations outlined in this section are applicable to all oral OAT medications. Medication-specific information is provided in Buprenorphine-specific Guidance, Methadone-specific Guidance, or Slow-release oral morphine-specific Guidance in this appendix.
Detailed guidance on the provision of iOAT is beyond the scope of this guideline. For comprehensive iOAT guidance, refer to the CRISM National Injectable Opioid Agonist Treatment Clinical Guideline.
A3.1.i Assessment
The baseline assessment considerations provided in this section are applicable to all candidates for OAT, regardless of the choice of medication. For medication-specific contraindications, cautions, and considerations, refer to dedicated sections for buprenorphine, methadone, and slow-release oral morphine in this appendix.
Contraindications to opioid agonist treatment
Allergy to any components of the drug product
Cautions for OAT medications
- Concurrent use of other CNS depressants
- Severe respiratory insufficiency (e.g., acute or severe bronchial asthma, status asthmaticus, chronic obstructive airway, acute respiratory depression, or cor pulmonale)
- Acute alcohol intoxication
- Acute psychosis
- Hypotension, prostatic hypertrophy, or urethral stricture
- Myxedema coma, untreated hypothyroidism, or adrenal cortical insufficiency (e.g., Addison's disease)
- Acute gastrointestinal conditions (e.g., bowel obstruction, diarrhea, abnormal gut anatomy) that affect the amount of time medication remains in the stomach
- Head injuries or history of seizures
- Pregnancy and breastfeeding
- For guidance on the selection and dosing of OAT medications for pregnant patients, as well as relevant monitoring and support considerations for this population, refer to the BCCSU Guideline Supplement on the Treatment of Opioid Use Disorder During Pregnancy.
Patient assessment process
The patient assessment process should include:
- A baseline assessment, which will inform treatment planning and medication selection
- Continuing care assessment and testing procedures, which will aid in identifying and managing comorbid conditions and adjusting the treatment plan as needed
Tests that are listed under continuing care requirements (e.g., renal and liver function, sexually transmitted infections) may be performed at baseline but should not be viewed as a prerequisite for initiating care.
Baseline assessment
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Physical and mental health assessment including:
- Past medical history (e.g., ask about HIV, hepatitis C, liver dysfunction, COPD, arrhythmias, overdoses, seizures, any other acute or chronic conditions)
- Mental health (e.g., ask about depression, anxiety, PTSD, psychosis, violence, suicidality)
- Allergies
- DSM-5-TR confirmed diagnosis of opioid use disorder (see Appendix 2)
- Urine drug test (to confirm the presence of opioids and to identify other relevant substances such as benzodiazepines)
- NOTE: Although baseline UDT is best practice, it may be reasonable to forgo prior to initiating OAT in the following scenarios:
- Sufficient collateral information is available (e.g., prior documentation of OUD or OAT on PharmaNet, recent overdose)
- Opioid agonist treatment is initiated through telehealth in a remote setting where requiring UDT would pose an unreasonable barrier to initiating treatment
- Patient has been abstinent but is at risk of return to opioid use
- The clinical rationale for initiating OAT prior to obtaining UDT results should be documented
- For more information, refer to the BCCSU’s Breakout Resource – Urine Drug Testing in Patients Prescribed Opioid Agonist Treatment
- Pregnancy test (where applicable)
- Comprehensive review of substance use history including assessment for other substance use and substance use disorders (e.g., alcohol, tobacco, cocaine, amphetamine, and benzodiazepine use disorders); route of administration; frequency and amount of use; overdose and other harms; past treatment history; exploration of the role of each substance in the patient’s life; and the patient’s goals related to each substance
- Review of concurrent use of CNS depressants, including alcohol, benzodiazepines, and sedatives (both prescribed and unregulated)
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Review of PharmaNet and other requirements outlined in CPSBC’s Practice Standard for Safe Prescribing of Opioids and Sedatives.
- According the CPSBC, clinicians should refer to the BCCSU’s A Guideline for the Clinical Management of Opioid Use Disorder and the CPSBC’s Prescribing Methadone practice standard when initiating and implementing OAT. There are currently no CPSBC practice standards for buprenorphine/naloxone or slow-release oral morphine.
- Explore and document patient’s treatment goals and incorporate into the treatment plan; patient goals should form the basis for assessing patient progress in follow-up visits
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Document treatment choice and rationale for opioid agonist medication selected
Continuing care
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Laboratory tests: CBC; renal and liver function panels; HIV and hepatitis A, B, and C serology; syphilis, gonorrhea, and chlamydia tests;
- Consider assessing liver function tests soon after initiation in individuals with a history of severe liver dysfunction
- If patients have pre-existing hepatitis or hepatic dysfunction, it may be necessary to repeat liver function tests 4 weeks after treatment initiation to check for elevated liver enzymes
- Note that laboratory tests are not a requirement for treatment initiation, but may be offered as indicated in the course of treatment
- ECG may be indicated for some patients on methadone
A3.1.ii General Eligibility Criteria
- Opioid use disorder diagnosis
- Informed consent
A3.1.iii Treatment Selection and Initiation
Prior to initiation, discuss the risks and benefits of all 3 oral OAT options to assist treatment selection, including information on:
- Medication side effects and other medication-specific risks
- Requirements and limitations related to take-home doses and management of missed doses
Following medication selection, collaboratively develop a treatment plan with each patient and obtain informed consent.
Medication-specific guidance can be found below.
A3.1.iv Take-home Naloxone
All patients starting opioid agonist treatment should be offered training and a take-home naloxone kit (or information on where to acquire one). Take-home naloxone kits are available at no cost through the BCCDC and most provincial harm reduction programs. A list of sites can be found on the Toward the Heart website. Some patients may opt to purchase naloxone from a pharmacy, health care site, treatment centre, or community agency without a prescription. All patients enrolled in the First Nations Health Benefits (PharmaCare Plan W) are eligible for access to naloxone—including intranasal naloxone—and injection supplies from pharmacists at no cost and without a prescription.
A3.1.v Stabilization
An effective stabilization dose is reached when withdrawal symptoms are controlled for more than 24 hours, cravings for opioids are reduced or eliminated without causing excessive sedation or other intolerable side effects, and the patient reports a general level of comfort. Each patient’s personal treatment goals (e.g., reduction vs. cessation of unregulated opioid use) should also inform what constitutes an effective dose in their case.
A3.1.vi Missed Doses
See medication-specific guidance on addressing missed doses in this appendix.
While necessary in certain circumstances to ensure patient safety, OAT dose reduction or restart may present a barrier to treatment retention. To facilitate continued treatment, it is important to discuss the protocol for missed doses with the patient at initiation, and develop strategies to support medication adherence. If dose reduction or restart is indicated to ensure patient safety, explain the rationale for this decision to the patient, clarifying that dose adjustment and restart are not punitive measures, and that the goal is to get them back up to an effective dose as quickly as is safe.
A3.1.vii Specialist Consultation
Clinicians are encouraged to access the Rapid Access to Consultative Expertise app (RACEapp) or the 24/7 Addiction Medicine Clinician Support Line (778-945-7629) to speak with an addiction medicine specialist regarding any questions or concerns.
Reference
- Nurse practitioners and physicians must complete POATSP in order to prescribe methadone and slow-release oral morphine. While NPs and physicians are not required to complete POATSP to prescribe buprenorphine/naloxone, prescribers are strongly encouraged to do so in order to ensure that they are able to support their patients along the full continuum of care for opioid use disorder.
Registered nurses and registered psychiatric nurses must complete the nursing pathway of POATSP in order to prescribe any OAT medication.
The above appendix was developed to support clinical practice using a different methodology from the process utilized for the main body of the guideline.
The clinical guidance provided in the appendix has been derived through guideline committee consensus following iterative discussions in reference to existing evidence and national and international evidence-based clinical practice guidelines.
- The content presented in the appendix is also informed by the opinion of expert reviewers, personal communication with study authors, and a review of position papers and practice bulletins issued by recognized addiction medicine professional organizations and authorities. In addition, where appropriate, Health Canada-approved drug product monographs, and previous and current guidance from the College of Physicians and Surgeons of BC (CPSBC) and Health Canada were consulted to ensure compliance with provincial and national safety regulations and standards for practice.