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Canadian guidelines urge buprenorphine-naloxone to treat opioid use disorders
Canadian clinical practice guidelines published in CMAJ for the management of opioid use disorders recommend clinicians use buprenorphine–naloxone as first-line opioid agonist treatment when possible, utilize a stepped and integrated care approach and reject withdrawal management alone.
"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," Julie Bruneau, MD, Centre hospitalier de l'Université de Montréal, said in a press release.
"Traditionally, resources for the treatment of opioid addiction have been scarce, and guidelines outlining best practices and practices to avoid have been lacking," senior author Evan Wood, MD, PhD, director, British Colombia Centre on Substance Use, St. Paul's Hospital, University of British Columbia, added.
Like the U.S., Canada faces a growing opioid crisis, with opioid-related fatalities totaling 2,861 in 2016, according to the authors. Therefore, an expert panel of professionals from the Canadian Institutes of Health Research’s Canadian Research Initiative in Substance Misuse network developed new clinical practice guidelines to provide health care professionals with the evidence-based tools and strategies to manage and treat patients with opioid use disorders in Canada.
The panel recommends:
- buprenorphine-naloxone as the first-line treatment for opioid use disorders;
- avoiding withdrawal management alone; and
- a stepped and integrated care approach.
“By encouraging physicians to work alongside their patients to identify the most effective approach adapted to their specific needs, these recommendations are designed as a tool to ensure the best science are integrated into care,” Bruneau told Healio Psychiatry.
Based on high-quality clinical evidence, the panel advises that clinicians begin opioid agonist treatment with buprenorphine–naloxone when possible to lessen the risk for toxicity, morbidity and death, as well as to make take-home dosing safe and easy. If a patient responds poorly to buprenorphine–naloxone or if it is not the preferred option, treatment with methadone is recommended. Prior research has shown that compared with methadone, treatment with buprenorphine-naloxone was six times safer in terms of overdose risk and is associated with a lower frequency of adverse events and drug-drug interactions, according to the guidelines. If both the first- and second-line treatments are ineffective, the panel suggests opioid agonist treatment with slow-release oral morphine.
The guidelines urge clinicians to avoid offering withdrawal management alone because it has been associated with higher rates of relapse, HIV, hepatitis C transmission and overdose death when provided without long-term addiction treatment and care. The panel recommends offering psychosocial treatment interventions with pharmacologic treatment, but not as a mandatory requirement for receiving opioid agonist treatment.
The panel recommends a stepped and integrated care approach, where clinicians monitor and adjust treatment intensity based on an individual’s specific needs and circumstances over time. When choosing a treatment, clinicians should consider patient-specific factors like initial presentation, comorbidities, drug–drug interactions, treatment preference and response to treatment.
“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,” Bruneau said in the release.
These guidelines provide front-line health care professionals with the information needed to combat the expanding opioid epidemic, according to a related comment written by Joseph H. Donroe, MD, and Jeanette M. Tetrault, MD, department of general internal medicine, Yale School of Medicine.
“The critical next steps, at a national and international level, are to increase provider education in recognition and management of opioid use disorder and chronic pain, to reduce stigma associated with substance use disorders, to decrease provider barriers to prescribing opioid agonist treatment, to improve medication prescription coverage thereby increasing access to care, to expand access to harm-reduction modalities and to encourage ongoing research into best practices for the prevention and treatment of opioid use disorder,” they wrote. – by Savannah Demko
Disclosures: Bruneau and Wood report receiving grants from the Canadian Institutes of Health Research. Bruneau also reports monetary compensation as advisor from Gilead and Merck. Please see the full study for all other authors’ relevant financial disclosures. Donroe and Tetrault report no relevant financial disclosures.
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This is a really nice review and guideline article. It lays out a clear case for making agonist therapy first-line treatment for opioid use disorder, and reviews the data indicating that, in general, buprenorphine is typically as good in most cases of opioid use disorder as methadone and is much safer (six time safer by data-based estimates). Methadone is recommended in cases where buprenorphine does not confer positive response, and oral morphine is recommended thereafter in special cases, where buprenorphine and methadone do not work. Another important clinical guideline supported by the data review is that, while psychosocial treatment is recommended, receipt of agonist medications should not be made contingent on participating in such psychosocial treatment. In other words, if someone won’t attend groups, give them the medication anyway, but still provide medical management/monitoring of medication use, and stabilization and progress.
Missing is the inclusion of evidence on antagonist therapies (eg, depot naltrexone) and recent multisite head-to-head trial evidence suggesting that antagonist therapy may be as good, or in some cases better, for those who are stabilized and abstinent from opioids prior to depot naltrexone administration. More research in that regard is needed, as many patients do not want to take agonists but may go for antagonists. Some programs, such as physician’s health programs for addicted doctors and the prison system, may prefer an antagonist option because they are able to have people be stably abstinent before giving a long-acting antagonist shot. In other words, there may be certain circumstances and populations where antagonist may be at least as good, but we need more data on that as an equally viable option under the right circumstances.
Overall, this is a nice piece of work, well written, with great summaries and decision algorithms. Although other opioid treatment guidelines exist from American Society of Addiction Medicine and the WHO, this one is more up to date from an evidence-based standpoint and takes a long-term continuum of care approach. Important open questions remain regarding when and how best to taper from buprenorphine and who should and shouldn't do that.