Managing opioid use disorder: buprenorphine/naloxone opioid agonist treatment

By Christy Sutherland MD CCFP dABAM (biography and disclosures) and Emily Wagner MSc (biography and disclosures)

Disclosures Dr. Christy Sutherland: I have received funding from the BC Naturopathic Association and Canadian Society of Addiction Medicine for speaking at conferences. I am the physician education lead for the BC Center on Substance Use. I have participating in guideline writing committees for the Center and use these guidelines in my clinical practice and educational sessions. I am the Medical Director of the PHS Community Services Society, a non profit who provide low barrier housing and supervised injection facilities.

What I did before

Opioid use disorder can be devastating for a person. It has a high incidence of morbidity and mortality, especially in British Columbia where we are experiencing unprecedented rates of death for people who use drugs. Over 960 people in BC died last year from an illicit drug overdose, and we are on track for more than 1500 deaths for 2017.

In the past, when caring for someone with opioid use disorder, I would offer them a rapid methadone taper. People could do this in an inpatient facility (i.e. “detox”), or some would want to do it as outpatients. From clinical experience and from the addiction literature, I knew that these rapid tapers were not effective in helping people to achieve recovery (1,2,3,4). Almost 100% of people would relapse to opioid use quickly after the taper (5,6,7,8,9). The taper was physically and emotionally painful, but patients would often request this option, as they wanted to be off all medications and all drugs.

What changed my practice

Over the past few years, research has demonstrated that methadone tapers are not only ineffective interventions, but they cause harm by increasing risk of overdose mortality and HIV seroconversion (1,10,11,12,14). In fact, the risks associated with rapid tapers are higher than if individuals received no treatment at all. When people stop using opioids, they lose their tolerance very quickly. If a person relapses following a rapid taper, they often re-initiate use at the same dose they were accustomed to using before the taper. This same dose has the potential to be lethal, due to the loss of tolerance. In the current context of a fentanyl-adulterated toxic drug supply, these risks are even higher.

The increased risk of HIV seroconversion following a rapid taper is thought to be due to the risky nature of the relapse to drug use. Often, relapse to opioid use is unplanned, which can result in behaviours that carry a higher risk of HIV transmission, like sharing needles and injection equipment.

What I do now

I no longer offer rapid methadone tapers to my patients. When they request them, I explain that I can’t provide a medical intervention that I know causes harm. Instead, I work with them to start opioid agonist treatment. Offering sustained ongoing treatment for opioid use disorder helps a patient think of their addiction as a chronic relapsing remitting disease rather than as a personal failure or moral weakness.

I find it helpful to say to a patient: “It is not surprising that you have ongoing opioid use, even when you don’t want to be using opioids anymore. We need to treat you well, and give your brain a rest from this cycle of withdrawal and intoxication. Medication will help with this.”

It’s also important for physicians and other health care professionals to view opioid use disorder as a chronic, relapsing medical condition, that, like other chronic diseases (diabetes, hypertension, heart disease), requires ongoing monitoring, support, and compassionate care. Just like other chronic conditions, opioid use disorder can be managed effectively in primary care practice, and there are safe and effective treatment options available that are proven to substantially reduce or eliminate illicit opioid use and opioid-related harms among people with opioid use disorder – namely, opioid agonist treatments.

Buprenorphine/naloxone is now recommended as the first-line opioid agonist treatment for opioid use disorder in British Columbia. This is because of its superior safety profile when compared with methadone as well as an easier transition to take-home dosing (15,16,17,18,19, 20,).

Buprenorphine/naloxone does not cause QTc prolongation, and has few drug-drug interactions. It is in tablet form, and needs to dissolve sublingually. It can take up to 10 minutes to fully dissolve, and during this time, patients are advised not to eat, drink, or smoke, and to avoid swallowing their saliva, which some patients find frustrating. It is important to discuss with patients why they need to keep the tablet in their mouth until it is dissolved, and resist the urge to swallow it – if the tablet is swallowed, less buprenorphine will be absorbed into the body, and they could experience emergent withdrawal symptoms as a result.

Buprenorphine/naloxone acts as a partial agonist at the opioid mu receptor. It blocks the euphoric effects of opioids, alleviates withdrawal, and reduces cravings. Patients maintained on an adequate dose of buprenorphine/naloxone will have few to no withdrawal symptoms, reduced opioid cravings, and significantly lower risks of relapse to illicit opioid use and associated morbidity and mortality (5,8).

Buprenorphine/naloxone can be challenging to initiate, as it is a partial agonist with a strong affinity to the opioid receptor. If a person has a full agonist opioid that is active on the receptor – for example, if they are using heroin – the buprenorphine/naloxone will displace the heroin from the opioid receptor and cause a precipitated withdrawal. Patients report precipitated withdrawal is much worse than regular opioid withdrawal, and are often reluctant to try buprenorphine/naloxone again if they have experienced this.

Buprenorphine/naloxone is best-started 12-24 hours after the last dose of short acting opioids (i.e., heroin, hydrocodone, immediate release oxycodone). The Clinical Opioid Withdrawal Scale (COWS) helps a clinician measure how much withdrawal a person is experiencing to know when it is safe to start buprenorphine/naloxone. When a person has a COWS score of 13 or higher, it is best to start with a test dose of 2mg and wait for 30 minutes. If they feel better, the dose can be titrated up quickly, usually by 2-4mg every 2-3 hours. If they feel worse, more time is needed before induction – you can wait another few hours before trying again, or reschedule induction for the following day. Some patients may benefit from inpatient detox stays to help them get through this induction and stabilization period. (Readers can refer to the Provincial Guideline on the Clinical Management of Opioid Use Disorder for more detailed buprenorphine/naloxone dosing recommendations.)

Inductions can be done in the office, or at home with take-home doses.  An office induction is best for someone who is starting buprenorphine/naloxone for the first time.   You can perform the COWS scale, initiate the medication, and monitor them in the office post-dose.

People who have successfully started buprenorphine/naloxone in the past are good candidates for a home induction.  They are aware of how much withdrawal is required before taking their first dose, and often have experience using the Subjective Opioid Withdrawal Scale (SOWS) to know when it is safe to start buprenorphine/naloxone (SOWS score of 17 or higher). Similar to in-office inductions, if an individual feels better after taking their first dose, the dose is titrated up by 2-4mg every 2-3 hours up to a daily maximum (12mg daily maximum on Day 1, 16mg daily maximum on Day 2; 24mg daily maximum thereafter). It is recommended to schedule daily or as-needed check-ins over the phone with individuals and their caregivers (if applicable) doing home inductions, and at least one in-office visit during the first week of a home induction. Additionally, prescribers should provide individuals and caregivers (if applicable) with written instructions, reviewed in-office prior to home induction, and a daytime and off-hours phone number to call should any problems occur. There is a learning module about how to support a patient for a home induction in our online course: https://www.bccsu.ca/provincial-opioid-addiction-treatment-support-program/.

The goal for dosing buprenorphine/naloxone is to have people stabilized on 16mg or above as their ongoing therapeutic dose. When stable on buprenorphine/naloxone, people are able to avoid the dangers of illicit IV drug use such as cellulitis, HIV and HCV infection, and fatal overdose. People are able to rebuild their lives, connect with family and friends, and pursue education and employment.  Having a patient on a dose lower than 16mg puts them at risk of relapse and death. (21)

In light of the overdose crisis, it is more important than ever before to expand access to evidence-based interventions with proven safety and effectiveness in treatment of opioid use disorder. As I have learned, rapid detox is not an effective treatment for opioid use disorder, and all clinicians in BC need to know that offering this as a standalone option to your patients can no longer be viewed as appropriate or safe. In contrast, there are treatments available for opioid use disorder that can be incorporated into and prescribed effectively in primary care practice.

There are several recent initiatives and resources available to support BC health care providers in changing their practice in this way, as well, there have been policy changes to expand physician and patient access to buprenorphine/naloxone.

1. Any physician in BC can prescribe buprenorphine/naloxone; unlike methadone, there is no need for prescribers to hold a special license.
2. The BC PharmaCare and First Nations Health Authority prescription drug plans provide coverage for buprenorphine/naloxone as a first-line medication; there is no longer a need for patients to try methadone first.
3. Buprenorphine/naloxone was recently added to the PharmaCare Plan G (Psychiatric Medication Plan) formulary, and is now eligible for 100% coverage for individuals with a net family income of $42,000 per annum (plus $3,000 per dependent).

Additionally, there is a new provincial education and training resource to support physicians who wish to prescribe buprenorphine/naloxone in their practice. The BC Center on Substance Use has a free online CME course to learn about how to prescribe this life saving medication as part of the Provincial Opioid Addiction Treatment Support Program. Physicians can also call the Rapid Access to Consultative Expertise (RACE) line to consult with an addiction medicine specialist if they have any questions about prescribing buprenorphine/naloxone.

Rapid Access to Consultative Expertise
Vancouver Area: 604-696-2131
Toll Free: 1-877-696-2131
Hours of operation are Monday to Friday 0800-1700
www.raceconnect.ca

For more information, check out the Provincial Opioid Addiction Treatment Support Program at this link: http://www.bccsu.ca/provincial-opioid-addiction-treatment-support-program/

References

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2. Gowing L, Ali R, White JM. Buprenorphine for the management of opioid withdrawal. Cochrane Database Syst Rev. 2009:CD002025. (View with CPSBC or UBC) DOI: 10.1002/14651858.CD002025.pub4
3. Gowing L, Farrell MF, Ali R, White JM. Alpha2-adrenergic agonists for the management of opioid withdrawal. Cochrane Database Syst Rev. 2016;5:CD002024. (View with CPSBC or UBC) DOI: 10.1002/14651858.CD002024.pub5
4. Amato L, Minozzi S, Davoli M, Vecchi S. Psychosocial and pharmacological treatments versus pharmacological treatments for opioid detoxification. Cochrane Database Syst Rev. 2011:CD005031. (View with CPSBC and UBC) DOI: 1002/14651858.CD005031.pub4
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