A new guideline published in the Canadian Medical Association Journal recommends opioid agonist therapy with buprenorphine-naloxone as first-line treatment of opioid use disorder.
The guideline also advises against withdrawal management alone, and supports a stepwise and integrated approach for the treatment of opioid use disorder.
To develop this guideline, the Canadian Research Initiative in Substance Misuse (CRISM) conducted a comprehensive literature review of recently published randomized-controlled trials, quasi-experimental or observational studies, and expert opinion pieces focused on the management of opioid addiction.
The first guideline recommends the use of opioid agonist treatment with buprenorphine-naloxone, due to its flexible take-home dosing and its superior safety profile compared with other opioid agonists. The CRISM also recommends that individuals who do not respond to buprenorphine-naloxone take methadone as a second-line treatment option. These recommendations aim to reduce toxicity risks, improve illicit opioid use abstinence rates, and as a consequence reduce the risk for morbidity and mortality.
In patients who do not respond to first- and second-line opioid agonist treatment options, or in patients for whom these options are contraindicated, a once-daily (initially) opioid agonist with slow-release oral morphine is recommended. Since November 2014, slow-release oral morphine can be covered under Health Canada’s Non-Insured Health Benefits Program for treating opioid addiction. The CRISM note that only physicians with a Section 56 exemption to prescribe methadone should prescribe slow-release oral morphine
A detoxification strategy that does not immediately precede transition to long-term addiction treatment is highly discouraged in this guideline, considering current literature indicates an increased risk for relapse, HIV and hepatitis C transmission, and drug overdose death with this approach.
The investigators suggest a buprenorphine-naloxone taper may be helpful for expediting symptom relief and improving withdrawal rates if psychosocial or residential treatment is offered immediately after withdrawal management.
“It is paramount to develop a multidisciplinary and actionable care roadmap to improve clinical care strategies (ie, address wait times for treatment and linkage to care), and strengthen the integration of care and research across the public health and clinical domains,” concluded the guideline authors.
Bruneau J, Ahamad K, Goyer MÈ, et al; for the CIHR Canadian Research Initiative in Substance Misuse. Management of opioid use disorders: a national clinical practice guideline. CMAJ. 2018;190(9):E247-E257.