New Canadian guideline lays out optimal strategies for treatment of opioid addiction

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 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.

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.

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
• 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 Dr. 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.

In a related commentary http://www.cmaj.ca/lookup/doi/10.1503/cmaj.180209, 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 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.