The Canadian Research Initiative in Substance Misuse (CRISM) National Injectable Opioid Agonist Treatment Steering Committee has released a new guideline on the use of injectable opioid agonist treatment for opioid use disorder, particularly for patients with severe treatment-refractory opioid use disorder and concomitant opioid injection use. The full guideline was published in the Canadian Medical Association Journal.
Members from the CRISM steering committee convened to create a clinical guideline and an operational guidance document based on a structured literature review.
Treatment with injectable opioid agonists is recommended for patients with severe and treatment-refractory opioid use disorder as well as for those with ongoing illicit injection opioid use (quality of evidence, moderate; strength of recommendation, conditional). Evidence supports the efficacy of supervised injection of diacetylmorphine in combination with flexible doses of methadone over oral methadone for keeping patients with refractory opioid use disorder in treatment.
Both diacetylmorphine and hydromorphone are deemed acceptable treatment options for patients who are considered for injectable opioid agonist therapy (quality of evidence, low; strength of recommendation, strong). Both treatments were found to be helpful for retaining patients in treatment. The guideline also recommends providing injectable opioid agonist treatment as an open-ended treatment, with the option to switch to oral opioid agonist therapy after discussion between patient and provider (quality of evidence, low; strength of recommendation, strong).
A limitation of many studies in which the use of injectable opioid agonist therapy in opioid use disorder is examined is the sole inclusion of participants who have previously received oral opioid agonist treatment.
“This guideline provides a framework for how to build a clinical practice of injectable opioid agonist treatment and recommends that this treatment should be considered for individuals with severe, treatment-refractory opioid use disorder and ongoing illicit injection opioid use,” concluded the guideline authors.
Fairbairn N, Ross J, Trew M, et al. Injectable opioid agonist treatment for opioid use disorder: a national clinical guideline. CMAJ. 2019;191(38):E1049-E1056.