Is daily supervised buprenorphine-naloxone dosing necessary?

An estimated 40.5 million people worldwide met criteria for opioid dependence in 2017, and 109 500 people had fatal opioid overdoses.1 Treatment with buprenorphine, a partial agonist at the µ-opioid receptor, is associated with reduced fatal and non-fatal overdoses among people with opioid dependence and opioid use disorder.2

Guidelines in many countries, including Australia, Canada, and the United Kingdom, require clients starting buprenorphine to attend a pharmacy or clinic daily and be supervised while taking the medication. However, supervision frameworks were temporarily relaxed in many jurisdictions in response to the need to restrict contacts during covid-19.34 For example, in Ontario, Canada, dispensing intervals could be extended based on a clinical assessment of clients’ ability to safely manage doses at home, and doses administered at pharmacies did not need to be witnessed.4 These changes were welcomed by clients, who have previously described freedom from daily attendance for opioid agonist treatment as increasing their independence and sense of “normality” and reducing stigma.5 We consider the evidence from relaxing supervision frameworks during the pandemic and elsewhere and suggest that buprenorphine prescribing guidelines should be permanently revised for many clients.