Microdose Suboxone Initiation from Acute Care


Project Details

  • Departments/Divisions: Emergency Medicine, Family Practice, Addictions Medicine, Hospitalist Medicine
  • Physician Leads: Dr. Jason Wale, Emergency Medicine
  • Budget: $7,695.00

About the Project

Five to six patients die every day in this province due to unintentional overdose on opioids. Most of these will be seen in the ER in the months leading up to their death. This is sometimes their only point of contact with the medical system. Since 2017, Victoria ERs have given patients the option to initiate Suboxone treatment as a form of bridging opioid agonist therapy. Considering that patients without treatment will go on to have a 6-8% mortality in the next year, this option has been demonstrated to save lives.

In the past, some patients would be lost to follow up if they were unable to stay in ER long enough to develop early withdrawal symptoms needed for safe initiation of Suboxone. ER physician Dr. Jason Wale wanted to offer a better option for these patients. He initiated a multidisciplinary project to offer micro-dosing Suboxone to any interested opioid use disorder patient presenting to the ER. Micro-dosing has been demonstrated to be a safe and effective means to gradually introduce opioid agonist therapy in patients immediately regardless of last opioid use. They can continue to use their own opioids or safer supply opioids while gradually increasing the dose of Suboxone over several days.  The result is protection from overdose and elimination of withdrawal symptoms after several days.

Dr. Wale and fellow ER colleagues Dr. Alex Hoechsmann and Dr. Tim Findlay reached out to:

  • Colleagues in Family Practice, Addictions Medicine, Hospitalist Medicine, and Pharmacy,
  • Clinical Nurse Educators Rebecca Kirkwood and Sandra McLeod,
  • Medical Leaders Dr. Richard Crow, Dr. Theo Jankowski, Dr. Ramm Hering, and Dr. William Cunningham, and
  • Community organizations the Umbrella Society Peer Support, Foundry, and Cool Aid.

Their primary goal was to develop and implement an evidence-based Suboxone micro-dosing protocol for use in the ER and inpatient settings.

To date, several dozen patients have begun on micro-dosing in the ER. To help reach opioid use patients who may present at the ER for other reasons, the group set up screening posters in patient care areas to encourage patients to come forward and ask for help. Island Health Pharmacist Richard Wanbon developed pre-packaged Suboxone micro-dose kits that could be dispensed from any ER across the island to facilitate easy dispensation. The idea behind this project was so compelling that the Campbell River, Nanaimo, and Comox Emergency Departments have already adapted the protocol into their own implementation strategies. Speaking about this unexpected development, Dr. Jason Wale said, “Early spread was not our original goal, but grew naturally from the need for this service and the earnest desire or ER physicians at other sites to do what’s best for their patients”

The group is now collecting adherence rate data along with subjective patient feedback on the program to continue to make improvements in this ever-changing landscape of BC’s other pandemic.


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