Canadian opioid use disorder management guideline updated

The Canadian Research Initiative in Substance Matters (CRISM) has recently updated their guideline for the clinical management of opioid use disorder in Canada.¹ The guideline was first published in 2018.² The guideline reviews the evidence on various treatment approaches for opioid use disorder (including withdrawal management, psychosocial interventions and peer-based support) and recommends opioid agonist treatment (OAT) as the preferred first-line treatment. OAT involves prescribing medications that reduce opioid withdrawal symptoms and cravings, helping individuals manage opioid use disorder. By stabilizing individuals and reducing risks such as overdose and death from all causes,³ OAT supports overall health and well-being. 

Updates were made to reflect new evidence, changes in accessibility of treatments, and the need for evidence-based interventions. The guideline aims to help improve access to OAT and retention in OAT. 

The guideline emphasizes the importance of a standard of care:

• A patient-centred approach should be taken, by respecting people’s rights and dignity in the development of treatment plans that are based on patient goals, preferences, and experiences. 
• Access to an integrated continuum of care should be provided, including harm reduction services, OAT, withdrawal management services and psychosocial treatments. These services should be trauma- and violence-informed and be prepared to refer patients to additional social supports and services. 
• Anti-racism and cultural safety should be integrated into treatment programs to prevent discrimination and stigma. 

The updated guideline includes some important changes to recommended OAT medications, including the following:

• Both buprenorphine and methadone are recommended as first-line treatment options. This change reflects evidence that both medications are effective and that they have different benefits and risks. 
• Slow-release oral morphine is recommended as a second-line treatment option. This change reflects updated evidence.

The updated guideline also includes minor changes to other recommendations, including the following:

• The guideline recommends that psychosocial supports be offered alongside OAT to increase retention in treatment. It clarifies that participation in psychosocial supports should not be a mandatory requirement for accessing OAT, ensuring that individuals can still receive OAT without barriers.
• The guideline clarifies that harm reduction supports with harm reduction supplies, overdose prevention education and naloxone distribution should be offered alongside OAT.

The updated guideline recommends avoiding withdrawal management as a stand-alone intervention. 

The guideline focuses on the use of oral medications for opioid use disorder. A separate guideline exists for injectable opioid agonist treatment (iOAT). 

References

1. Yakovenko I, Mukaneza Y, Germé K et al. Management of opioid use disorder: 2024 update to the national clinical practice guideline. Canadian Medical Association Journal. 2024 Nov 12;196(38):E1280-90. 
2. Bruneau J, Ahamad K, Goyer MÈ et al. Management of opioid use disorders: a national clinical practice guideline. Canadian Medical Association Journal. 2018;190:E247-57. 
3. Santo JR T, Brodie Clark, Matt Hickman et al. Association of opioid agonist treatment with all-cause mortality and specific causes of death among people with opioid dependence: a systematic review and meta-analysis. JAMA Psychiatry. 2021 Sep;78(9):1-15.

About the author(s)

Magnus Nowell is CATIE’s knowledge specialist in harm reduction. Magnus has previously worked in harm reduction research, community organizing and housing. He has a master’s degree in health promotion.