Update to Canadian clinical practice guideline for management of opioid use disorder

Opioid use and opioid use disorder continue to be the leading causes of drug-related deaths worldwide. The total number of apparent opioid-related deaths in Canada increased from 2,831 in 2016 to 8,049 in 2023.In view of the substantial surge in opioid-related harms, the Canadian Research Initiative in Substance Matters guideline development team updated the 2018 National Guideline for the Clinical Management of Opioid Use Disorder. The updated guideline presents new recommendations based on the most recent literature for management of opioid use disorder, to assist provincial and territorial bodies to develop guidance for optimal care. The update was warranted based on the ongoing opioid-related harms, new scientific evidence regarding treatment options, changes in medication accessibility, and the need for adequate, evidence-based treatments and interventions.Recommended opioid agonist treatments1. Buprenorphine and methadone should both be considered as standard first-line treatment options for opioid agonist therapy. (High certainty of evidence; Strong recommendation)For people who initiate opioid agonist therapy with buprenorphine, clinicians should be aware of the higher risk of attrition after the first month of initiation and offer alternative opioid agonist medications in these circumstances (high certainty).When considering methadone, clinicians should be aware of the higher risk of mortality during the first month compared with the remainder of the treatment period (moderate certainty).Revision: Methadone is now an equally recommended first-line treatment option. The 2018 guideline recommended initiating opioid agonist therapy with buprenorphine whenever feasible to reduce the risk of toxicity, morbidity and death, and to facilitate safer take-home dosing. The 2024 guideline recommends offering both methadone and buprenorphine as first-line options, with different precautions for each.2. Opioid agonist therapy with slow-release oral morphine should be available and offered as a second-line treatment option. (Moderate certainty of evidence; Strong recommendation)Revision: Slow-release oral morphine is now a second-line treatment option. It was a third-line option in the 2018 guideline.Withdrawal management strategies3. Patients with opioid use disorder should not be offered withdrawal management alone because of the increased rates of relapse, morbidity and mortality. Concurrent long-term addiction treatment is recommended. (Moderate certainty of evidence; Strong recommendation)Revision: No change (minor rewording for clarity)4. When withdrawal management alone is pursued, a supervised slow opioid agonist taper (depending on the patient) should be provided, with close follow-up, and opioid agonist therapy should immediately be offered if the risk of relapse emerges. (Moderate certainty of evidence; Strong recommendation)Revision: No change (minor rewording for clarity)5. For patients with a successful and sustained response to opioid agonist therapy who wish to discontinue opioid agonist therapy (i.e., desiring medication cessation), clinicians should consider a slow taper approach (depending on the patient). Ongoing addiction care should be considered upon cessation of opioid use. (Moderate certainty of evidence; Strong recommendation)Revision: No changeAdjunct psychosocial interventions and harm reduction strategies6. Psychosocial treatments, interventions and supports can be offered as adjunct treatments to opioid agonist therapy to increase treatment retention. (Moderate certainty of evidence; Strong recommendation)Revision: Psychosocial interventions increase treatment retention7. Psychosocial treatment should not be a mandatory component of standard treatment for opioid use disorder and should not prevent access to opioid agonist therapy. (Moderate certainty of evidence; Strong recommendation)Revision: Clarity regarding the optional aspect of psychological interventions8. Harm reduction strategies should be offered as part of the continuum of care for patients with opioid use disorder. (Moderate certainty of evidence; Strong recommendation)Current evidence supports the use of the following harm reduction programs: provision of sterile consumption equipment, overdose prevention education, and access to take-home naloxone kits.Revision: Addition of a list of evidence-based harm reduction programsSpecial considerationsAlternate option: For patients who decline or are not on standard treatments for opioid use disorder and have withdrawn from opioids, oral naltrexone could be discussed as an adjunct pharmacologic option.Special populations: Pregnant people with opioid use disorder who are not in treatment should be encouraged to start a first-line treatment as soon as possible during pregnancy.Revision: Change from a recommendation to a special consideration for oral naltrexone. Addition of a special consideration for pregnant people based on a systematic review of the literature published since 2018.Summary figure and tableThe 2024 guideline includes a figure summarizing the clinical considerations for opioid use disorder management in adults. It also offers a summary table of other national peer-reviewed guidelines on the clinical management of opioid use disorder published since 2018.Reference:Yakovenko I, Mukaneza Y, Germé K, et al; Canadian Research Initiative in Substance Matters guideline development team. Management of opioid use disorder: 2024 update to the national clinical practice guideline. CMAJ 2024;196:E1280-90. (accessed November 12, 2024).

Update to Canadian clinical practice guideline for management of opioid use disorder

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