A newCanadian 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 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.
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 US 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.
Key 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; and 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, 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.
Beyond recommending best practices, like the use of buprenorphine-naloxone as first-line treatment whenever possible, 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.
“With these recommendations laid out, there is an urgent need for health systems to look at the historical gaps in care and invest in providing timely and evidence-based treatment, says Bruneau, who is also a professor in the faculty of medicine at Université de Montréal. “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.”
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.
For the full list of recommendations, see Table 1 in the guideline.
In a related commentary, Drs Joseph Donroe and Jeanette Tetrault from the Yale University School of Medicine, New Haven, Connecticut, write “this national guideline describing the pharmacologic management of opioid use disorder is timely and needed to address the expanding epidemic of opioid use disorder and overdose. Importantly, the guideline is geared toward front-line providers, who are vitally important to decrease the existing treatment gap.”
Next steps include increasing education of health care providers about recognising 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.
Joseph H Donroe, Jeanette M. Tetrault
Opioid use disorder is one of the most challenging forms of addiction facing the Canadian health care system, and a major contributor to the marked rises in opioid-related morbidity and death that Canada has been seeing in recent years. The evolving landscape of nonmedical opioid use has become increasingly dominated by prescription opioids diverted from the medical system and, more recently, by highly potent, illicitly manufactured synthetic opioids (e.g., fentanyl and its analogues, including carfentanil).1
The mean national rate of hospital admissions related to opioid poisonings increased from 9 hospital admissions per day in 2007/08 to more than 13 admissions per day in 2014/15.2 A corresponding rise in injection of prescription opioids has been observed among people who inject drugs in Canada,3,4 and has been associated with an increased risk of hepatitis C and HIV infections.5–7 For 2016, the mean rate of apparent opioid-related overdose deaths has reached 7.9 per 100 000 population (i.e., corresponding to a total of 2861 fatalities), with the highest death rates reported for western Canada.8 This upsurge in opioid-related harms, including overdose deaths,2–6,8,9 underscores the critical need for coordinated, evidence-based approaches to prevention, treatment and harm reduction to address this national public health emergency.
In most Canadian jurisdictions, poor geographic coverage and availability of evidence-based treatments for substance use disorders has limited the therapeutic options for individuals with opioid use disorder.10 Further, even in settings where multiple treatment options are offered, detailed clinical guidance articulating their optimal use for varying presentations of opioid use disorder is lacking. Therefore, this guideline is intended to promote the use of evidence-based interventions for treatment of opioid use disorder across the addiction care continuum in Canada
Julie Bruneau, Keith Ahamad, Marie-Ève Goyer, Ginette Poulin, Peter Selby, Benedikt Fischer, T Cameron Wild, Evan Wood