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 development and publication of the first edition of the provincial Guideline for the Clinical Management of Opioid Use Disorder, which was published in February 2017 and officially adopted as the provincial standard in June 2017. Since its publication, the guideline and aligned education and implementation efforts have had an instrumental role in improving access to evidence-based treatment for individuals with opioid use disorder (OUD) in BC by providing comprehensive clinical care guidance to health care providers across the OUD care continuum in the province. 

Despite significant advancements in the province’s system of substance use care, drug poisoning involving opioids continues to be the leading cause of unnatural death in British Columbia, surpassing homicides, suicides, and motor vehicle collisions combined. The primary driver of this ongoing crisis is the rapidly growing toxicity and unpredictability of illegally manufactured and distributed drugs. Higher fentanyl concentrations and novel, dangerous combinations of drugs (e.g., benzodiazepines and fentanyl) have been continually detected in multiple drug surveillance data sources across the province.

In response to the escalating drug toxicity crisis, which was also exacerbated by the COVID-19 pandemic, evidence and clinical experience have continued to develop, necessitating updated clinical guidance. The second edition of the Guideline for the Clinical Management of Opioid Use Disorder is intended to reflect this evolution and ensure that health care providers have access to updated clinical guidance aligned with the best available evidence on interventions across the continuum of OUD care. Accordingly, this updated guideline edition includes information on oral and injectable opioid agonist treatment, antagonist pharmacotherapies, withdrawal management strategies, psychosocial interventions including bed-based treatment programs, harm reduction services and programs, and peer-based support.

In aggregate, the updates in the present edition of the guideline have been developed to ensure that OUD care is accessible and flexible enough to sustainably engage and retain patients in evidence-based care and meet the diverse and evolving needs of patients. To support a system of OUD care with the capacity to effectively accommodate diverse patient populations, the guidance provided in the second edition begins with a comprehensive discussion of the foundational principles and values of care for people with substance use disorder, including: 

• Patient-centred care
• Awareness of social determinants of health 
• Indigenous cultural safety and humility
• Anti-racist practice
• Trauma- and violence-informed practice
• Care centred on self-defined recovery and wellness
• Harm reduction-oriented care
• Integrated continuum of care
• Comprehensive health management
• Family and social circle involvement

In keeping with the central principle of patient-centred care, one of the overarching clinical changes in this second edition guideline is the move away from ranking opioid agonist treatment (OAT) medications as first-line, second-line, and third-line options. Instead, this guideline recommends an individually tailored process whereby clinicians discuss the risks and benefits of all three oral OAT options (i.e., buprenorphine/naloxone, methadone, and slow-release oral morphine) with patients and collaboratively select a medication that aligns with their preferences, treatment history, and other individual circumstances. This change is not intended to equate OAT medications in terms of safety and efficacy evidence, but to ensure that the full range of available evidence-based medications is considered to appropriately meet specific patient needs and preferences with reference.

Other key added content and clinical updates informed by new evidence and accumulating clinical experience include:

• Modified maximum starting doses and titration protocols for OAT medication to address the needs of individuals with higher opioid tolerance (e.g., individuals who use fentanyl)
• Low-dose induction guidance for buprenorphine/naloxone to eliminate the need for a period of withdrawal prior to medication initiation
• Guidance on the provision of monthly extended-release buprenorphine as a less intensive, more flexible option for patients who are stable on sublingual buprenorphine/naloxone
• Guidance on emergency department initiation of buprenorphine/naloxone
• Guidance on initiation and continuing care for inpatient and acute care 
• Modified, more flexible guidance for addressing missed doses
• Revised, more flexible protocols for providing take-home doses of full agonist medications
• Incorporation of injectable OAT (iOAT) as an integrated component of the continuum of OUD care