International Clinical Practice Guidelines: 2018 Midyear Review

John Anello; Brian Feinberg; John Heinegg; Yonah Korngold; Richard Lindsey; Cristina Wojdylo; Olivia Wong, DO


July 10, 2018

In This Article

Opioid Use Disorder

Canadian Research Initiative in Substance Misuse (CRISM)

Strongly recommend opioid agonist treatment with buprenorphine–naloxone as the preferred first-line treatment when possible, because of buprenorphine’s multiple advantages, which include a superior safety profile in terms of overdose risk.

Withdrawal management alone is not recommended, because this approach has been associated with elevated risks (eg, syringe sharing) and death from overdose in comparison to providing no treatment, and high rates of relapse when implemented without immediate transition to long-term evidence-based treatment.

Support using a stepped and integrated care approach, in which treatment intensity is continually adjusted to accommodate individual patient needs and circumstances over time, and recognizes that many individuals may benefit from the ability to move between treatments.

For individuals responding poorly to buprenorphine–naloxone, consider transition to methadone treatment.

Initiate opioid agonist treatment with methadone when treatment with buprenorphine–naloxone is not the preferred option.

For individuals with a successful and sustained response to methadone who express a desire for treatment simplification, consider transition to buprenorphine–naloxone, because its superior safety profile allows for more routine take-home dosing and less frequent medical appointments.

In patients for whom first- and second-line treatment options are ineffective or contraindicated, opioid agonist treatment with slow-release oral morphine (initially prescribed as once-daily witnessed doses) can be considered. Slow-release oral morphine treatment should be prescribed only by physicians with a Section 56 exemption to prescribe methadone, or following consultation with an addiction practitioner experienced in opioid agonist treatment with slow-release oral morphine.

Offering withdrawal management alone (ie, detoxification without immediate transition to long-term addiction treatment) should be avoided, because this approach has been associated with increased rates of relapse, morbidity, and death.

When withdrawal management (without transition to opioid agonist treatment) is pursued, provide supervised slow (>1 mo) opioid agonist taper (in an outpatient or residential treatment setting) rather than a rapid (<1 wk) taper. During opioid-assisted withdrawal management, patients should be transitioned to long-term addiction treatment to help prevent relapse and associated health risks.

For patients with a successful and sustained response to opioid agonist treatment who wish to discontinue treatment (ie, desiring medication cessation), consider a slow taper approach (over months to years, depending on the patient). Ongoing addiction care should be considered on cessation of opioid use.

Psychosocial treatment interventions and supports should be routinely offered but should not be viewed as a mandatory requirement for accessing opioid agonist treatment.

Oral naltrexone can also be considered as an adjunct medication if cessation of opioid use is achieved.

Information and referrals to take-home naloxone programs and other harm reduction services (eg, provision of clean drug paraphernalia), as well as other general health care services, should be routinely offered as part of standard care for opioid use disorders.



Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.