Buprenorphine/naloxone is an effective treatment for opioid use disorder (OUD)  and is now considered a first-line treatment for OUD [2, 3] over methadone treatment because of its favourable safety profile and its feasibility in primary care settings. However, the majority of patients currently on opioid agonist treatment (OAT) in Ontario are still prescribed methadone. In 2017, there were 60,758 patients (4.3 per 1000 population) on OAT in Ontario and, of these, 44,375 were on methadone . This is relevant considering that in 2017, methadone was involved in 211/1265 (16.7%) of opioid-related deaths and cited as one of the three opioids most commonly responsible in single-opioid deaths [5, 6].
Various facilitators and barriers have likely contributed to the current prevalence of methadone prescribing compared with buprenorphine in Ontario. Methadone has been available for the treatment of OUD in Canada for decades, whereas buprenorphine was only approved for use in Canada in 2007, and full public drug coverageFootnote 1 for buprenorphine has been in place in Ontario only since 2016. While the rate of buprenorphine prescribing increased from 0.23 to 0.85 per 1000 Ontarians between 2012 and 2016, the rate of methadone prescribing remained robust and increased from 2.0 to 2.6 per 1000 Ontarians in the same period . This finding suggests that there are other potential barriers to buprenorphine being prescribed.
We hypothesized that one of the main barriers for both addiction physicians and primary care physicians to prescribing buprenorphine is the recommendation that the initial doses of buprenorphine be taken in the office under the observation of a clinician. This could play a role in some addiction medicine prescribers’ preference for methadone overall.
Most buprenorphine guidelines have recommended that the initial dose be taken in an observed clinical setting [8, 9] to prevent diversion, buprenorphine toxicity, and precipitated withdrawal. Yet, the logistics of observed office induction are onerous, as physicians or nurses are required to assess the patient several times over a period of a few hours and the initiation process has been described as a barrier to buprenorphine prescribing [10,11,12,13]. Recent studies have demonstrated the safety of unobserved induction [14, 15] and that this is becoming a more widely accepted practice in some jurisdictions [16, 17].
We designed a survey of Ontario OAT providers, who are largely primary care physicians with focused addiction practices, to better understand their attitudes towards buprenorphine. In particular, we explored potential barriers to buprenorphine’s use, including attitudes and practices regarding home induction.