A new Canadian guideline for managing opioid use disorders lays out the optimal strategies for the treatment of opioid addiction, including recommending opioid agonist treatment with buprenorphine–naloxone as the preferred first-line treatment. The guideline, published today in CMAJ (Canadian Medical Association Journal), was created for a wide range of health care providers to address an urgent need for evidence-based treatment of opioid use causing overdoses and death.
“Opioid use disorder is a public health emergency nationwide and this guideline provides a blueprint for health practitioners to step up and provide evidence-based care,” says Dr. Julie Bruneau lead author of the pan-Canadian guideline group and a physician at the Centre hospitalier de l’Université de Montréal (CHUM).
In 2016, the rate of opioid-related deaths in Canada was 7.9 per 100 000 (a total of 2861 deaths), and the number of deaths continues to increase. The opioid epidemic affecting both Canada and the United States is fuelled by a combination of overprescribing as well as the influx of highly potent illegal synthetic opioids, such as illicitly manufactured fentanyl.
“Traditionally, resources for the treatment of opioid addiction have been scarce, and guidelines outlining best practices and practices to avoid have been lacking,” says Dr. Evan Wood, senior author and director of the BC Centre on Substance Use at St. Paul’s Hospital and the University of British Columbia.
To address the traditional gaps in knowledge in this area, the guideline aims to provide Canadian health care professionals and health authorities with national clinical practice recommendations for treating opioid use disorder. The review panel included 43 health care practitioners with broad experience who are part of the Canadian Institutes of Health Research’s Canadian Research Initiative in Substance Misuse (CRISM). The guideline group also involved people with opioid use disorder experience and considered patient values and preferences in developing its recommendations.
- Start opioid agonist treatment with buprenorphine–naloxone whenever possible to reduce risk of toxicity, illness and death
- In people who respond poorly to buprenorphine–naloxone, consider transitioning to methadone treatment
- Start opioid agonist treatment with methadone when buprenorphine–naloxone is not the preferred option
- In people who respond well to methadone and who want simpler treatment, consider transitioning to buprenorphine–naloxone
- In patients who do not respond to the above therapies, consider slow-release oral morphine, prescribed as daily witnessed doses
- Avoid withdrawal management alone without transition to long-term treatment to reduce risk of relapse and death.
Opioid agonist treatment with buprenorphine–naloxone is recommended as first-line treatment because of its better safety record compared to methadone, including lower risk of overdose and lower risk of breathing suppression; ease of use, especially in rural and remote areas where daily witnessed ingestion is not practical; dosing flexibility; and milder withdrawal symptoms if stopping treatment, making it a better option for people with milder opioid dependence.
The guideline also identifies how certain common practices in the Canadian health care system should be avoided —specifically, how offering withdrawal management as an isolated strategy for the treatment of opioid use disorder actually increases rates of overdose.
“By encouraging physicians to work alongside their patients to identify the safest, most effective approach first, these new guidelines ensure the best science and evidence are integrated into care,” says Dr. Bruneau, who is also a professor in the Faculty of Medicine at Université de Montréal.
Opioid use disorder is often a chronic, relapsing condition associated with increased morbidity and risk of death. However, with appropriate treatment and follow-up, individuals can reach sustained long-term remission.
Next steps include increasing education of health care providers about recognizing and managing opioid use disorders and chronic pain, reducing stigma associated with substance use disorders, expanding prescribing access to opioid agonists and expanding access to harm reduction services.
The guideline was funded through the Canadian Research Initiative in Substance Misuse (CRISM), a network funded by the Canadian Institutes of Health Research (CIHR).
“Management of opioid use disorders: a national clinical practice guideline” is published March 5, 2018.
About the Canadian Research Initiative in Substance Misuse – Québec – Atlantic node
Established collaborations and resources invested in the development of these national guidelines have contributed to the growth and rooting of the Canadian Research Initiative in Substance Misuse (CRISM) - Québec-Atlantic node. The contribution of several should be highlighted, including Dr. Marie-Ève Goyer, physician in the CRAN Program of the CIUSS-CSIM, who took on the role of Clinical Delegate of the Quebec-Atlantic Regional Review Committee, Dr. Serge Dupont (Collège des médecins du Québec), Dr. Jacques Dumont (Laval University), Dr. Joseph Cox (McGill University), and Dr. Marie-Chantal Pelletier (CHUM), Dr. Peter Barnes and Dr. Bruce Hollett (Memorial University of Newfoundland and Labrador), Dr. Samuel Hickox (Nova Scotia Health Authority), Dr. Peter Hooley and Dr. David Martell (Dalhousie University), and Lynn Miller Inf.P. (College of Registered Nurses of Nova Scotia), as well as the support of the Ordre des pharmaciens du Québec through the participation of Patrick Boudreault, Director of External Affairs and Professional Support. It would not have been possible for all these individuals to join forces without the work of Dr. Sherry Stewart (Dalhousie University), responsible for the Atlantic section. The Québec-Atlantic node actively provides a dynamic research environment where clinical and community partners are working to identify the needs and priorities in addiction interventions.