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Management of opioid use disorders: a national clinical practice guideline – CIHR Canadian Research Initiative in Substance Misuse – 2018-03-05

KEY POINTS

  • Opioid use disorder is often a chronic, relapsing condition associated with increased morbidity and death; however, with appropriate treatment and follow-up, individuals can reach sustained long-term remission.
  • This guideline strongly recommends opioid agonist treatment with buprenorphine–naloxone as the preferred first-line treatment when possible, because of buprenorphine’s multiple advantages, which include a superior safety profile in terms of overdose risk.
  • Withdrawal management alone is not recommended, because this approach has been associated with elevated risks (e.g., syringe sharing) and death from overdose in comparison to providing no treatment, and high rates of relapse when implemented without immediate transition to long-term evidence-based treatment.
  • This guideline supports using a stepped and integrated care approach, in which treatment intensity is continually adjusted to accommodate individual patient needs and circumstances over time, and recognizes that many individuals may benefit from the ability to move between treatments.

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.

Management of opioid use disorders: a national clinical practice guideline – CIHR Canadian Research Initiative in Substance Misuse – 2018-03-05

 

Julie Bruneau, Keith Ahamad, Marie-Ève Goyer, Ginette Poulin, Peter Selby, Benedikt Fischer, T. Cameron Wild and Evan Wood; on behalf of the CIHR Canadian Research Initiative in Substance Misuse
CMAJ March 05, 2018 190 (9) E247-E257
https://doi.org/10.1503/cmaj.170958
http://www.cmaj.ca/content/190/9/E247