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 services as standard of care. In addition to revised clinical recommendations informed by updated literature reviews, this edition contains principles of care, considerations for providing care to specific populations, and updated dosing and titration protocols that reflect new evidence and accumulating clinical experience.
The objective of this guideline is to support clinicians in offering the full continuum of care to treat individuals with OUD, utilizing evidence-based recommendations and clinical guidance. This guideline includes information on oral and injectable opioid agonist treatments, antagonist pharmacotherapies, withdrawal management strategies, psychosocial interventions, harm reduction services and programs, and peer-based support.
Primary prevention, which includes safe prescribing of prescription opioids, is also outside the scope of this guideline. Readers are encouraged to consult the College of Physicians and Surgeons of BC’s Professional Standards and Guidelines for Safe Prescribing of Drugs with Potential for Misuse/Diversion and McMaster University’s 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain.
1.2.i Intended Audience
This guideline is intended to be used by physicians, pharmacists, nurse practitioners, nurse prescribers, and nursing and allied healthcare professionals with and without specialized training in addiction medicine. This guideline also serves as a resource for patients and their loved ones, to support treatment and wellness advocacy as well as promote system-level quality improvement. In addition, this guideline is intended to be a resource for policy makers and healthcare administrators in the development of strategies and programs to best address unmet addiction care needs within British Columbia in an evidence-based, cost-effective manner.
Additional and complementary documents for people with lived and living experience of opioid use and their loved ones have been published by the BCCSU since the release of the 2017 OUD guideline. These include From Grief to Action’s Coping Kit (which was updated through a partnership of From Grief to Action, the Canadian Mental Health Association—BC Division, and the BCCSU); Gone Too Soon, for families and friends who have lost a loved one to drug-related harm; and Opioids: A Survivor’s Guide, written by and for individuals on opioid agonist treatment.
1.2.ii Patient Populations and Settings
The recommendations made in this guideline are applicable to the general adult patient population. Other clinical guidelines and supplementary resources have been developed to guide best practices in specific populations and settings. These include:
- Treatment of Opioid Use Disorder During Pregnancy—Guideline Supplement
- Treatment of Opioid Use Disorder for Youth—Guideline Supplement
- Urine Drug Testing in Patients Prescribed Opioid Agonist Treatment—Breakout Resource
- Opioid Use Disorder: Diagnosis and Management in Primary Care (developed in partnership with the Guidelines and Protocols Advisory Committee)
- Guidance for Injectable Opioid Agonist Treatment for Opioid Use Disorder
- National Injectable Opioid Agonist Treatment Clinical Guideline
Specific populations and communities, including Indigenous peoples, 2S/LGBTQQIA+ individuals, individuals experiencing homelessness, and rural and remote populations, may have unique health needs or circumstances due to biological, societal, or resource-related factors. A brief overview of additional considerations for providing care to these populations, including links to resources, has been included in Section 4.0. Guidance on co-occurring substance use and concurrent mental health issues can be found in Appendix 7: Continuing Care.
1.2.iii Guideline Uptake
As part of the clinical guideline dissemination strategy, the BCCSU initiated the Opioid Use Disorder Seminar Series—a series of in-person and virtual education events, offered within all health authorities and often co-hosted with local Divisions of Family Practice—to provide an update on the opioid overdose crisis and review the key recommendations from the provincial guideline. These sessions provided opportunities for health care providers to ask an addiction medicine expert their questions, to bring forward clinical cases for discussion, and to build local networks to support one another in this important work. To date, the BCCSU has offered 82 seminars—reaching 3,179 clinicians since April 2017. In addition, in June 2017 the BCCSU assumed responsibility for the education and training pathways for prescribers of opioid use disorder treatment in BC and created the Provincial Opioid Addiction Treatment Support Program to improve knowledge and skills in managing OUD among prescribers and increase provincial capacity for providing OAT. This work has translated to more than 1,490 new authorizations for prescribers to provide OAT between July 2017 and July 2023.