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An updated evidence-based guideline aimed at helping clinicians and other health-care providers manage patients with opioid use disorder recommends both buprenorphine and methadone as first-line treatments.

Opioid use and opioid use disorder are the leading causes of drug-related deaths worldwide, and Canada has seen a 184 per cent increase is opioid-related deaths over seven years, from 2,831 in 2016 to 8,049 deaths in 2023. Treatment options have improved with the removal of methadone prescribing restrictions in 2018 in Canada, but opioid-related harms continue to rise.

"Opioid use disorder and opioid related harms have devastating outcomes for our communities across Canada and with the growing dangers associated with the illicit market, we need to ensure we are sharing the most relevant therapeutic tools and up-to-date knowledge to help providers and communities address this complex issue," says family physician Dr. Ginette Poulin, who is also with the University of Manitoba.

The guideline, an update to the 2018 National Guideline for the Clinical Management of Opioid Use Disorder from the Canadian Research Initiative in Substance Matters (CRISM), focuses on oral treatments and includes special considerations for pregnant people. Injectable opioid agonist therapy, extended-release agonists and antagonists are beyond the scope of this guideline.

"The management of opioid use disorder is a rapidly changing and ever-evolving landscape of new research and clinical considerations," says lead author Dr. Igor Yakovenko, associate professor in the Department of Psychology and Neuroscience and Department of Psychiatry at Dalhousie University.

"This guideline provides an important update to health practitioners on the latest science in the field so that Canadian providers can continue to maintain a high standard of evidence-based care."

The guideline is published in CMAJ (Canadian Medical Association Journal).

The recommendations, based on new research since the previous guideline was published, include the key change that opioid agonist treatment with buprenorphine-naloxone is no longer the sole first-line treatment and methadone is now also recommended as a first-line option.  

Key recommendations:

* Buprenorphine (also refers to buprenorphine-naloxone) and methadone can be used as standard first-line treatment options for opioid agonist therapy
* Slow-release oral morphine can be used as second-line treatment
* Avoid withdrawal management as stand-alone treatment and ensure long-term management to ensure safety and well-being of people with opioid-use disorder
* Psychosocial treatments and supports, such as therapy, should be offered as additional approaches but should not be mandatory nor prevent access to opioid agonist therapy
* Harm reduction strategies should be offered as part of the continuum of care for patients with opioid use disorder

The authors hope the guideline will provide evidence-based treatment for opioid users and recommend that provinces update their approaches to managing opioid use disorder to help Canadians.

"Too many people die from untreated opioid addiction in Canada," says Dr. Peter Selby of the Centre for Addictions and Mental Health (CAMH) and the University of Toronto. "We have medicines that help people stop using, but too few are treated due to stigma and lack of prescribers knowing what to do. These national guidelines help them use proven medications to not only prevent death but actually help people recover."

Media contacts:

Alison Auld
Senior Research Reporter
Dalhousie University
Cell: 1-902-220-0491
Email: alison.auld@dal.ca

Kim Barnhardt
CMAJ
Email: kim.barnhardt@cmaj.ca

(Please credit CMAJ, not the Canadian Medical Association (CMA). CMAJ is an independent medical journal; views expressed do not necessarily reflect those of its owner, CMA Impact Inc., or CMA.)