Summary of recommendations for the clinical management of opioid use disorder*
| Recommendation | Quality of evidence | Strength of recommendation |
|---|---|---|
| First- and second-line treatment options | ||
| 1. Initiate opioid agonist treatment with buprenorphine–naloxone whenever feasible, to reduce the risk of toxicity, morbidity and death, and to facilitate safer take-home dosing. | High | Strong |
| 2. For individuals responding poorly to buprenorphine–naloxone, consider transition to methadone treatment. | High | Strong |
| 3. Initiate opioid agonist treatment with methadone when treatment with buprenorphine–naloxone is not the preferred option. | High | Strong |
| 4. 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. | Moderate | Strong |
| Alternative or adjunct treatment options | ||
| 5. 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. | Moderate | Strong |
| 6. Offering withdrawal management alone (i.e., 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. | Moderate | Strong |
| 7. 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. | Moderate | Strong |
| 8. For patients with a successful and sustained response to opioid agonist treatment who wish to discontinue treatment (i.e., 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. | Moderate | Strong |
| 9. Psychosocial treatment interventions and supports should be routinely offered but should not be viewed as a mandatory requirement for accessing opioid agonist treatment. | Moderate | Strong |
| 10. Oral naltrexone can also be considered as an adjunct medication if cessation of opioid use is achieved. | Low | Weak |
| Adjunct harm-reduction strategies | ||
| 11. Information and referrals to take-home naloxone programs and other harm reduction services (e.g., 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. | Moderate | Strong |
↵* The evidence supporting these recommendations is discussed in detail in Appendix 1.
↵† Long-term addiction treatment: In this context, “addiction treatment” refers to continued care for opioid use disorder delivered by an experienced care provider, which could include pharmacologic treatment (opioid agonist treatment or antagonist treatment), evidence-based psychosocial treatment, residential treatment or combinations of these treatment options. In isolation, withdrawal management, harm reduction services, low-barrier housing and unstructured peer-based support would not be considered “addiction treatment.”
Opioid agonist treatment may be provided in an outpatient or in an inpatient addiction-treatment setting.