A quick-reference guide for prescribing buprenorphine/naloxone (Suboxone) in the outpatient setting
ABSTRACT: British Columbia is in the midst of an opioid crisis. Treatment with buprenorphine/naloxone (Suboxone) is one way to mitigate the many harms resulting from opioid use, yet studies show that few physicians are prescribing this medication. A quick-reference guide for physicians that supports Suboxone induction in the outpatient setting was proposed as part of a Resident Scholar Project required for completing a residency in family medicine at the University of British Columbia. The project involved the creation and evaluation of a teaching tool for physicians based on recent guidelines from the British Columbia Centre on Substance Use as well as peer-reviewed articles grounded in evidence-based medicine. While the project was undertaken at the Nanaimo site of the UBC Island Medical Program, key stakeholders considered during development included primary care physicians, trainees, and people with opioid use disorder throughout BC. Feedback was obtained from physicians with an interest in addiction medicine. The clinical tool that resulted from the project is intended to be a supplementary resource, not a stand-alone one. Further improvement of the tool is expected in future as physicians using the resource participate in a self-test survey and feedback process.
By empowering physicians to treat opioid use disorder in their own clinics, an easy-to-use resource supporting Suboxone induction could have important impacts on both individual and public health.
British Columbia is experiencing one of the greatest public health emergencies in its history. Opioid-related deaths continue to climb because opioid use is increasing and illicit drugs are being contaminated with devastatingly potent opioids such as fentanyl and carfentanil. In 2017 the province had 1210 illicit drug overdose deaths associated with fentanyl compared with 667 the year before.
In April 2016 the sharply rising number of deaths related to fentanyl led BC’s provincial health officer to declare an “opioid overdose emergency.” Shortly after, the special licensure requirement was removed for prescribing Suboxone, a formulation of buprenorphine and naloxone combined at a ratio of 4:1 and administered sublingually. This made it legal for any physician with prescribing privileges to use Suboxone to treat opioid use disorder, a complex neurobehavioral illness recognized in the DSM-5. Opioid use disorder is characterized not only by negative changes in a person’s ability to function at home, at work, and in society, but by the development of physical tolerance and withdrawal symptoms. Suboxone can be used to manage these symptoms because the buprenorphine it contains is a partial agonist at the mu opioid receptor with a very high binding affinity. Once bound, buprenorphine activates the receptor less than a full agonist such as morphine, fentanyl, heroin, or methadone. The naloxone content of Suboxone deters tampering and misuse as it is active only when administered parenterally, often precipitating withdrawal symptoms in the opioid-tolerant user.
When prescribed skillfully, Suboxone results in the reduction or elimination of withdrawal symptoms without providing the reinforcing “high” or potentially deadly sedative effects of a full agonist, and is now recommended as first-line therapy for the management of opioid use disorder in BC.
Suboxone prescribing resource
A resource designed to reduce barriers to treating opioid use disorder with Suboxone in the family practice setting was proposed as part of the Resident Scholar Project required for the University of British Columbia family medicine residency program. A quick-reference guide was seen as a way to fill the knowledge gap felt by many would-be prescribers considering starting a patient on Suboxone and to support clinicians in need of a refresher who fear “deskilling” after taking a course on how to prescribe this medication. The tool proposed was intended to serve as a supplement to published guidelines and online courses, and to provide contact information for specialists in addiction medicine should further support be needed. By empowering physicians to treat opioid use disorder in their own clinics, the resource could reduce referrals to more specialized clinics, which is preferable according to a meta-analysis published by Srivastava and colleagues, who state that “opioid addiction is best managed in a primary care setting.” A resource supporting Suboxone use could have important impacts on both individual and public health. Greater access to and acceptance of Suboxone as an opioid substitution therapy initiated by family physicians could increase the number of patients treated for addiction, thus reducing overdose deaths and bloodborne illnesses stemming from use of IV drug paraphernalia. This could also improve treatment retention, a factor associated with higher rates of abstinence. Finally, greater physician willingness to prescribe Suboxone could lessen the stigma associated with seeking treatment for opioid use disorder, creating opportunities for a stronger therapeutic relationship between patients with this disorder and their physicians.
Studies have shown that treatment with opioid substitution therapy leads to sustained abstinence from opioid use, reduced risk of morbidity and mortality, and better rates of treatment retention when compared with abstinence or withdrawal-only therapies. Suboxone and methadone are considered equally efficacious for opioid substitution therapy and are the two medications recommended in the latest British Columbia guideline. The College of Physicians and Surgeons of BC recommends completing an online Suboxone training program, although this is not required in order to prescribe Suboxone. Still, relatively few family physicians in BC prescribe the medication. Although no studies have been conducted in BC specifically, several qualitative studies elsewhere have examined the barriers that prevent family doctors from prescribing Suboxone to their patients. One of the most commonly cited barriers is a perceived lack of knowledge and confidence in the induction phases of treatment.[4-11] Respondents in a 2012 Australian study identified “de-skilling” after undertaking Suboxone training as another barrier. Other barriers frequently identified were a lack of local mental health support services/institutional support,[7,9-11] a lack of time (and space) in a busy practice,[5,7-9,11] fear of misuse and diversion of the medication,[7,8] a lack of interest in prescribing, and practice partners unwilling to allow Suboxone prescribing in a shared clinic.[5,7,9] A lack of addiction specialist support was a further barrier highlighted in a number of studies.[7-10] These studies are from countries comparable to Canada, and we believe the results are generalizable to British Columbia. Therefore, any intervention aimed at encouraging family physicians to become Suboxone prescribers must reduce some of these barriers. While it is not currently known how best to do this, or which barriers should be the focus, there is clearly a knowledge gap that needs to be addressed to help more family physicians prescribe Suboxone.
What little literature could be found regarding physician education for Suboxone prescribing practices tended to focus on chronic pain rather than opioid use disorder, other teaching modalities (e.g., web-based or telehealth-based courses),[12-15] or standard guidelines and their effectiveness. There was nothing in the literature about using information-at-a-glance guides designed to support physician prescribing of Suboxone for opioid use disorder, making it likely that the resource produced for this Resident Scholar Project is the first of its kind.
Development of resource
We obtained the information included in our resource from provincial guidelines, as well as peer-reviewed articles grounded in evidence-based medicine. In addition, we asked physicians already practising addiction medicine to review our tool to ensure that we were providing only high-quality information. While the project was undertaken at the Nanaimo site of the UBC Family Medicine Residency Program, key stakeholders considered during development included primary care physicians, trainees, and people with opioid use disorder throughout BC.
Based on the information collected and analyzed, we developed a document to assist physicians with in-office assessment, Suboxone induction, and maintenance. The resource includes induction algorithms for Day 1 and Day 2, advice on gauging withdrawal severity using the clinical opiate withdrawal scale (COWS), suggestions for mitigating precipitated withdrawal, and considerations such as urine drug testing (UDT) and take-home doses or “carries” versus daily witnessed ingestions.
The information in our clinical tool is based on A Guideline for the Clinical Management of Opioid Use Disorder published by the British Columbia Centre on Substance Use and the BC Ministry of Health, as well as online Suboxone training. The recommendations within the BC guideline that were used to inform our resource are of moderate to strong quality according to the GRADE criteria for evidence appraisal.
In order to give clinicians the opportunity to test their knowledge after using our guide, we provided a link to a self-test on Suboxone induction, as well as an email address where they can send feedback they may have for us about the tool itself.
Strengths and limitations of resource
The novel resource that we developed for the project is portable, easy to reproduce, easy to use, and has the potential to influence clinician prescribing practices. Creating the tool provided us with the opportunity to further refine our skills as physician-teachers and physician-leaders. The time-limited nature of the project restricted uptake of the resource throughout the community despite our best efforts, and also meant we were unable to quantitatively assess the impact of our tool on physician prescribing.
Further improvement of resource
We plan to collect feedback from users of the quick-reference guide and hope to implement suggested improvements in future iterations of the resource. We also hope that in future we or another resident group can quantitatively assess the effectiveness of this resource and its impact on prescribing practices in the community.
A quick-reference guide for physicians that supports Suboxone induction in the outpatient setting was proposed to encourage prescribing of this medication to mitigate the many harms resulting from opioid use disorder. Data for the resource were obtained from A Guideline for the Clinical Management of Opioid Use Disorder, as well as other provincial guidelines and peer-reviewed articles. The needs of primary care physicians, trainees, and people with opioid use disorder were considered during development, and feedback was obtained from physicians with an interest in addiction medicine. The clinical tool that resulted from the project is intended to be a supplementary resource, not a stand-alone one. Further improvement of the tool is expected as physicians using the resource participate in a self-test survey and feedback process.
We would like to thank Dr Marcus Barron, a family medicine and addiction medicine physician who acted as our research project advisor, for providing guidance and input as the resource was created and helping to solicit feedback from other physicians who routinely treat opioid use disorder in the community. We would also like to thank the physicians who generously provided comments and feedback on the quick-reference guide during development: Dr Elizabeth Plant, Dr Mark Mclean, Dr Patricia Mark, and Dr Marcus Barron.
This article has been peer reviewed.
1. BC Coroner Service. Fentanyl-detected illicit drug overdose deaths January 1, 2012 to December 31, 2017. Accessed 12 July 2018. www2.gov.bc.ca/assets/gov/public-safety-and-emergency-services/death-investigation/statistical/fentanyl-detected-overdose.pdf.
2. British Columbia Centre on Substance Use. A guideline for the clinical management of opioid use disorder. Accessed 12 July 2018. www.bccsu.ca/wp-content/uploads/2017/06/BC-OUD-Guidelines_June2017.pdf.
3. Srivastava A, Kahan M, Nader M. Primary care management of opioid use disorders: Abstinence, methadone, or buprenorphine-naloxone? Can Fam Physician 2017;63:200.
4. Hser Y, Evans E, Grella C, et al. Long-term course of opioid addiction. Harv Rev Psychiatry 2015;23:76.
5. Longman C, Temple-Smith M, Gilchrist G, Lintzeris N. Reluctant to train, reluctant to prescribe: Barriers to general practitioner prescribing of opioid substitution therapy. Aust J Prim Health 2012;18:346-351.
6. Huhn AS, Dunn KE. Why aren’t physicians prescribing more buprenorphine? J Subst Abuse Treat 2017;78:1-7.
7. Andrilla CHA, Coulthard C, Larson EH. Barriers rural physicians face prescribing buprenorphine for opioid use disorder. Ann Fam Med 2017;15:359-362.
8. DeFlavio JR, Rolin SA, Nordstron BR, Kazal LA Jr. Analysis of barriers to adoption of buprenorphine maintenance therapy by family physicians. Rural Remote Health 2015;15:3019.
9. Hutchinson E, Catlin M, Cheng DM et al. Barriers to primary care physicians prescribing buprenorphine. Ann Fam Med 2014;12:128-133.
10. Li X, Shorter D, Kosten TR, Taenzer P, et al. Buprenorphine in the treatment of opioid addiction: opportunities, challenges and strategies. Expert Opin Pharmacother 2014;15:2263-2275.
11. Walley AY, Alperen JK. Office-based management of opioid dependence with buprenorphine: Clinical practices and barriers. J Gen Intern Med 2008;23:1393-1398.
12. Dubin RE, Flannery J. ECHO Ontario chronic pain & opioid stewardship: Providing access and building capacity for primary care providers in underserviced, rural, and remote communities. Stud Health Technol Inform 2015;209:15-22.
13. Kahan M, Gomes T, Juurlink DN, et al. Effect of a course-based intervention and effect of medical regulation on physicians’ opioid prescribing. Can Fam Physician 2013;59:e231-239.
14. Webster J. Prescriber education on opioids. Ann Intern Med 2012;157:917.
15. Stoner SA, Mikko AT, Carpenter KM. Web-based training for primary care providers on screening, brief intervention, and referral to treatment (SBIRT) for alcohol, tobacco, and other drugs. J Subst Abuse Treat 2014;47:362-370.
16. Pinto D, Heleno B, Rodrigues DS, et al. An open cluster-randomized, 18-month trial to compare the effectiveness of educational outreach visits with usual guideline dissemination to improve family physician prescribing. Implement Sci 2014;9:10.
17. INDIVIOR Canada Ltd. Welcome to the Suboxone training program. Accessed 12 July 2018. www.suboxonetrainingprogram.ca/en/.
Dr Caddy is currently completing her residency in family medicine at the Nanaimo site of the University of British Columbia Family Medicine Residency Program. Dr Smith has completed his residency in family medicine at the Nanaimo site of the University of British Columbia Family Medicine Residency Program.
Patricia Caddy, MD, Kesh Smith, MD. A quick-reference guide for prescribing buprenorphine/naloxone (Suboxone) in the outpatient setting. BCMJ, Vol. 60, No. 8, October, 2018, Page(s) 392-397 - Clinical Articles.
Above is the information needed to cite this article in your paper or presentation. The International Committee
of Medical Journal Editors (ICMJE) recommends the following citation style, which is the now nearly universally
accepted citation style for scientific papers:
Halpern SD, Ubel PA, Caplan AL, Marion DW, Palmer AM, Schiding JK, et al. Solid-organ transplantation in HIV-infected patients. N Engl J Med. 2002;347:284-7.
About the ICMJE and citation styles
The ICMJE is small group of editors of general medical journals who first met informally in Vancouver, British Columbia, in 1978 to establish guidelines for the format of manuscripts submitted to their journals. The group became known as the Vancouver Group. Its requirements for manuscripts, including formats for bibliographic references developed by the U.S. National Library of Medicine (NLM), were first published in 1979. The Vancouver Group expanded and evolved into the International Committee of Medical Journal Editors (ICMJE), which meets annually. The ICMJE created the Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals to help authors and editors create and distribute accurate, clear, easily accessible reports of biomedical studies.
An alternate version of ICMJE style is to additionally list the month an issue number, but since most journals use continuous pagination, the shorter form provides sufficient information to locate the reference. The NLM now lists all authors.
BCMJ standard citation style is a slight modification of the ICMJE/NLM style, as follows:
- Only the first three authors are listed, followed by "et al."
- There is no period after the journal name.
- Page numbers are not abbreviated.
For more information on the ICMJE Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals, visit www.icmje.org