Injectable opioid agonist treatment for opioid use disorder: a national clinical guideline.

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From: CMAJ: Canadian Medical Association Journal(Vol. 191, Issue 38)
Publisher: CMA Impact Inc.
Document Type: Report
Length: 5,386 words
Lexile Measure: 1870L

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In 2018, at least 4460 Canadians died from an opioid overdose, of which 94% were determined to be unintentional (accidental) overdoses. This represents a 9% increase in overdose deaths from 2017 and a 48% increase from 2016.1 The recent emergence of street fentanyl, carfentanil and other highly potent synthetic opioids increasingly cut into heroin and other street drugs is a pressing public health concern that has contributed substantially to the overdose emergency. Contamination of street drugs is ongoing and progressive, with new agents such as benzodiazepine analogs being found in substances sold as opioids. (2) Fentanyl and other synthetic analogs were implicated in 73% of opioid-related deaths in Canada in 2018, compared with 67% in 2017 and 50% in 2016.1 Although pan-Canadian opioid-related deaths were not tracked before 2016, at least 655 fentanyl-related deaths occurred between 2009 and 2014, (3) compared with an estimated 3256 deaths involving fentanyl or fentanyl analogs in 2018 alone. (1)

Opioid agonist treatment has proven to be the most effective approach to reducing all-cause mortality in individuals with opioid use disorder (4) and harms associated with illicit opioid use, including morbidity and mortality. (5-9) However, individuals with severe opioid use disorder who inject opioids may not adequately benefit from oral opioid agonist treatment medications for a variety of reasons, including cravings that persist despite optimal opioid agonist treatment dosing; inability to reach a therapeutic dose; or intolerable adverse effects or contraindications. Individuals who are unable to achieve stabilization or cessation of illicit opioids from first-line medications, or whose circumstances and risks otherwise indicate that they may benefit from injectable opioid agonist treatment, like other individuals using illicit opioids, face substantial risks, including premature death, nonfatal overdose, blood-borne infectious diseases (e.g., HIV and hepatitis C), violence and arrest. (10,11)

Meta-analyses have shown that, among individuals who are refractory to treatment with methadone, supervised injectable diacetylmorphine is beneficial in terms of reducing illicit opioid use, premature treatment discontinuation (or "treatment dropout"), criminal activity, incarceration and mortality, as well as improving overall health and social functioning, quality of life and stability. (12-17) In response to regulatory barriers limiting the provision of diacetylmorphine for the treatment of opioid use disorder in Canada, the Study to Assess Longer-term Opioid Medication Effectiveness (SALOME) trial compared injectable hydromorphone to injectable diacetylmorphine and found that both medications, delivered in identical conditions, showed positive outcomes such as high retention rates and reduction of street opioid use (from daily to a few days per month) and illegal activities. (14) Thus, in jurisdictions where diacetylmorphine is currently not available, or for patients in whom it is contraindicated or unsuccessful, hydromorphone may provide an effective, licensed alternative. (14)

This clinical guideline provides 3 key recommendations focused on defining the patient population that should be considered for injectable opioid agonist treatment and outlining considerations for medication selection and length of treatment. Additionally, this document contains expert opinion on clinical care approaches, including eligibility, titration and missed doses.


This guideline was created to provide Canadian health professionals with...

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Gale Document Number: GALE|A600449965