GUIDELINE VULNERABLE POPULATIONS
CPD
Management of opioid use disorders: a national
clinical practice guideline
Julie Bruneau MD MSc, Keith Ahamad MD, Marie-Ève Goyer MD MSc, Ginette Poulin MD,
Peter Selby MBBS MHSc, Benedikt Fischer PhD, T. Cameron Wild PhD, Evan Wood MD PhD; on
behalf of the CIHR Canadian Research Initiative in Substance Misuse
Cite as: CMAJ 2018 March 5;190:E247-57. doi: 10.1503/cmaj.170958
The full guideline in English and French is available in Appendix 1 at
www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.170958/-/DC1
CMAJ Podcasts: interview in English at https://soundcloud.com/cmajpodcasts/170958-guide-eng; entrevue en
français au https:// soundcloud.com/cmajpodcasts/170958-guide-fre
See related article at www.cmaj.ca/lookup/doi/10.1503/cmaj.180209
O
pioid use disorder is one of the most challenging
forms of addiction facing the Canadian health
care system, and a major contributor to the KEY POINTS
marked rises in opioid- • Opioid use disorder is often a chronic, relapsing
related morbidity and death that Canada has been condition associated with increased morbidity and
death; however, with appropriate treatment and
seeing in recent years. The evolving landscape of
follow-up, individuals can reach sustained long-
nonmedical opioid use has become increasingly term remission.
dominated by prescription opioids diverted from the • This guideline strongly recommends opioid agonist
medical system and, more recently, by highly potent, treatment with buprenorphine–naloxone as the
illicitly manufactured synthetic opioids (e.g., fentanyl preferred first-line treatment when possible, because
and its analogues, including carfentanil).1 of buprenorphine’s multiple advantages, which
include a superior safety profile in terms of overdose
The mean national rate of hospital admissions related
risk.
to opioid poisonings increased from 9 hospital
admissions per day in 2007/08 to more than 13
• Withdrawal management alone is not
recommended, because this approach has been
admissions per day in 2014/15.2 A corre- sponding rise associated with elevated risks (e.g., syringe
in injection of prescription opioids has been observed sharing) and death from overdose in comparison to
among people who inject drugs in Canada, 3,4 and has providing no treatment, and high rates of relapse
when implemented without immediate transition to
been associated with an increased risk of hepatitis C and
long-term evidence-based treatment.
HIV infec- tions.5–7 For 2016, the mean rate of apparent
opioid-related over- dose deaths has reached 7.9 per
• This guideline supports using a stepped and
integrated care approach, in which treatment
100 000 population (i.e., corre- sponding to a total of
2861 fatalities), with the highest death rates reported
for western Canada.8 This upsurge in opioid-related
harms, including overdose deaths,2–6,8,9 underscores the
critical need for coordinated, evidence-based
approaches to prevention,
treatment and harm reduction to address this opioid use disorder across the addiction care
national public health emergency. continuum in Canada.
In most Canadian jurisdictions, poor geographic
coverage and availability of evidence-based
treatments for substance use disorders has limited
the therapeutic options for individ- uals with opioid use
disorder.10 Further, even in settings where multiple
treatment options are offered, detailed clinical guid-
ance articulating their optimal use for varying
presentations of opioid use disorder is lacking.
Therefore, this guideline is intended to promote the
use of evidence-based interventions for treatment of
,Scope disorder in adults, including young adults.
This guideline is intended for use by physicians and
This guideline was developed to provide Canadian nurse prac- titioners, allied health care providers,
health profes- sionals with an educational tool and pharmacists, medical educa- tors and clinical care case
clinical practice recommen- dations for the treatment managers, with or without specialized experience in
of opioid use disorder. These recom- mendations are addiction treatment. Such guidelines are the main
primarily relevant for the clinical management of this resources to inform policy-makers and health care
administrators
© 2018 Joule Inc. or its licensors CMAJ | MARCH 5, 2018 | VOLUME 190 | ISSUE 9 E247
, at the provincial, territorial and national levels for the
development of evidence-based strategies. This Development of recommendations
guideline is intended to serve as a tool to address Recommendations were developed and graded using the
current gaps in care for opioid use disorder, Grading of Recommendations Assessment, Development
addiction-medicine training for clinicians and other and Evaluation (GRADE) tool11–14 (Box 1) through an
health care professionals, and treatment access policies iterative consensus process. The node principal
across the country. investigators developed draft recommenda-
The recommendations in this guideline are based on
the clin- ical evidence base regarding treatment
approaches for opioid use disorder currently available
in Canada, including oral opioid agonist treatment and
antagonist pharmacotherapies, as well as withdrawal
management strategies, residential treatment and
psychosocial treatment interventions. The evidence
base for pharmacotherapies not yet widely available in
Canada, including long-acting and extended-release
opioid antagonists, as well as injectable opioid agonist
treatment (i.e., diacetylmorphine and
hydromorphone), was not reviewed in this guideline.
Methods
The Canadian Research Initiative in Substance Misuse
(CRISM), a Canadian Institutes of Health Research
(CIHR)–funded research network composed of four
regional networks (nodes) distributed across Canada
(British Columbia, the Prairies, Ontario and Quebec–
Atlantic), developed this national guideline using a
structured literature review approach. Relevant
search terms and structured search strategies were
used to search PubMed, Web of Science, the Cochrane
Library databases and reference lists using a
hierarchical approach, whereby meta-analyses and
systematic reviews were given the most weight,
followed by indi- vidual randomized controlled trials
(RCTs), quasi-experimental studies, observational
studies and, lastly, expert opinion. At least two
independent CRISM staff members manually reviewed
titles, abstracts and full text of identified citations,
selected evidence for inclusion, and compiled
narrative evidence reviews for the guideline review
panel. A detailed description of the methods used to
compile evidence summaries for each recommendation
can be found in Appendices 1 and 2, available at
www.cmaj.ca/
lookup/suppl/doi:10.1503/cmaj.170958/-/DC1.
Composition of guideline review panel
Each of the four CRISM nodes nominated a clinical lead,
to whom the coordination of guideline review
activities was delegated in each region. In consultation
with the node principal investigator, relevant individual
experts and stakeholder organizations from their
region, each clinical lead invited 7–13 individuals to
partici- pate on the review committee. Including the
clinical leads and principal investigators, the pan-
Canadian review committee con- sisted of 43
individuals, including primary care physicians, addic-
tion medicine physicians and other specialists, nurse
practitio- ners and registered nurses, social workers,
pharmacists, program managers and administrators,
and policy-makers.
CPD
Management of opioid use disorders: a national
clinical practice guideline
Julie Bruneau MD MSc, Keith Ahamad MD, Marie-Ève Goyer MD MSc, Ginette Poulin MD,
Peter Selby MBBS MHSc, Benedikt Fischer PhD, T. Cameron Wild PhD, Evan Wood MD PhD; on
behalf of the CIHR Canadian Research Initiative in Substance Misuse
Cite as: CMAJ 2018 March 5;190:E247-57. doi: 10.1503/cmaj.170958
The full guideline in English and French is available in Appendix 1 at
www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.170958/-/DC1
CMAJ Podcasts: interview in English at https://soundcloud.com/cmajpodcasts/170958-guide-eng; entrevue en
français au https:// soundcloud.com/cmajpodcasts/170958-guide-fre
See related article at www.cmaj.ca/lookup/doi/10.1503/cmaj.180209
O
pioid use disorder is one of the most challenging
forms of addiction facing the Canadian health
care system, and a major contributor to the KEY POINTS
marked rises in opioid- • Opioid use disorder is often a chronic, relapsing
related morbidity and death that Canada has been condition associated with increased morbidity and
death; however, with appropriate treatment and
seeing in recent years. The evolving landscape of
follow-up, individuals can reach sustained long-
nonmedical opioid use has become increasingly term remission.
dominated by prescription opioids diverted from the • This guideline strongly recommends opioid agonist
medical system and, more recently, by highly potent, treatment with buprenorphine–naloxone as the
illicitly manufactured synthetic opioids (e.g., fentanyl preferred first-line treatment when possible, because
and its analogues, including carfentanil).1 of buprenorphine’s multiple advantages, which
include a superior safety profile in terms of overdose
The mean national rate of hospital admissions related
risk.
to opioid poisonings increased from 9 hospital
admissions per day in 2007/08 to more than 13
• Withdrawal management alone is not
recommended, because this approach has been
admissions per day in 2014/15.2 A corre- sponding rise associated with elevated risks (e.g., syringe
in injection of prescription opioids has been observed sharing) and death from overdose in comparison to
among people who inject drugs in Canada, 3,4 and has providing no treatment, and high rates of relapse
when implemented without immediate transition to
been associated with an increased risk of hepatitis C and
long-term evidence-based treatment.
HIV infec- tions.5–7 For 2016, the mean rate of apparent
opioid-related over- dose deaths has reached 7.9 per
• This guideline supports using a stepped and
integrated care approach, in which treatment
100 000 population (i.e., corre- sponding to a total of
2861 fatalities), with the highest death rates reported
for western Canada.8 This upsurge in opioid-related
harms, including overdose deaths,2–6,8,9 underscores the
critical need for coordinated, evidence-based
approaches to prevention,
treatment and harm reduction to address this opioid use disorder across the addiction care
national public health emergency. continuum in Canada.
In most Canadian jurisdictions, poor geographic
coverage and availability of evidence-based
treatments for substance use disorders has limited
the therapeutic options for individ- uals with opioid use
disorder.10 Further, even in settings where multiple
treatment options are offered, detailed clinical guid-
ance articulating their optimal use for varying
presentations of opioid use disorder is lacking.
Therefore, this guideline is intended to promote the
use of evidence-based interventions for treatment of
,Scope disorder in adults, including young adults.
This guideline is intended for use by physicians and
This guideline was developed to provide Canadian nurse prac- titioners, allied health care providers,
health profes- sionals with an educational tool and pharmacists, medical educa- tors and clinical care case
clinical practice recommen- dations for the treatment managers, with or without specialized experience in
of opioid use disorder. These recom- mendations are addiction treatment. Such guidelines are the main
primarily relevant for the clinical management of this resources to inform policy-makers and health care
administrators
© 2018 Joule Inc. or its licensors CMAJ | MARCH 5, 2018 | VOLUME 190 | ISSUE 9 E247
, at the provincial, territorial and national levels for the
development of evidence-based strategies. This Development of recommendations
guideline is intended to serve as a tool to address Recommendations were developed and graded using the
current gaps in care for opioid use disorder, Grading of Recommendations Assessment, Development
addiction-medicine training for clinicians and other and Evaluation (GRADE) tool11–14 (Box 1) through an
health care professionals, and treatment access policies iterative consensus process. The node principal
across the country. investigators developed draft recommenda-
The recommendations in this guideline are based on
the clin- ical evidence base regarding treatment
approaches for opioid use disorder currently available
in Canada, including oral opioid agonist treatment and
antagonist pharmacotherapies, as well as withdrawal
management strategies, residential treatment and
psychosocial treatment interventions. The evidence
base for pharmacotherapies not yet widely available in
Canada, including long-acting and extended-release
opioid antagonists, as well as injectable opioid agonist
treatment (i.e., diacetylmorphine and
hydromorphone), was not reviewed in this guideline.
Methods
The Canadian Research Initiative in Substance Misuse
(CRISM), a Canadian Institutes of Health Research
(CIHR)–funded research network composed of four
regional networks (nodes) distributed across Canada
(British Columbia, the Prairies, Ontario and Quebec–
Atlantic), developed this national guideline using a
structured literature review approach. Relevant
search terms and structured search strategies were
used to search PubMed, Web of Science, the Cochrane
Library databases and reference lists using a
hierarchical approach, whereby meta-analyses and
systematic reviews were given the most weight,
followed by indi- vidual randomized controlled trials
(RCTs), quasi-experimental studies, observational
studies and, lastly, expert opinion. At least two
independent CRISM staff members manually reviewed
titles, abstracts and full text of identified citations,
selected evidence for inclusion, and compiled
narrative evidence reviews for the guideline review
panel. A detailed description of the methods used to
compile evidence summaries for each recommendation
can be found in Appendices 1 and 2, available at
www.cmaj.ca/
lookup/suppl/doi:10.1503/cmaj.170958/-/DC1.
Composition of guideline review panel
Each of the four CRISM nodes nominated a clinical lead,
to whom the coordination of guideline review
activities was delegated in each region. In consultation
with the node principal investigator, relevant individual
experts and stakeholder organizations from their
region, each clinical lead invited 7–13 individuals to
partici- pate on the review committee. Including the
clinical leads and principal investigators, the pan-
Canadian review committee con- sisted of 43
individuals, including primary care physicians, addic-
tion medicine physicians and other specialists, nurse
practitio- ners and registered nurses, social workers,
pharmacists, program managers and administrators,
and policy-makers.
