The first such national clinical practice guideline in Canada was published in 2018 to assist clinicians in making informed decisions about the clinical management of OUD. In November 2024, updated guidelines developed by the Canadian Research Initiative in Substance Matters (CRISM) were published in the scientific journal CMAJ:

Yakovenko I., Mukaneza Y., Germe K., et al. Management of opioid use disorder: 2024 update to the national clinical practice guideline. CMAJ, Nov 12, 2024 (EN)

Opioid use and OUD remain the leading causes of drug-related death worldwide. In Canada, the number of apparent opioid-related deaths increased from 2831 in 2016 to 8049 in 2023. Despite the expansion of treatment options, including the lifting of restrictions on methadone prescribing in 2018, there has been a substantial surge in opioid-related harms, the authors wrote.

This guideline is intended for use by healthcare providers, including physicians, nurse practitioners, pharmacists, clinical psychologists, social workers, medical educators, and clinical care case managers with or without specialized experience in addiction treatment.

The CRISM guideline development team which included patients with OUD carried out a comprehensive systematic review of the literature published from January 1, 2017, to September 14, 2023.

Highlights of the guideline include the following recommendations:

• Buprenorphine, with or without naloxone, and methadone can be used as standard first-line treatment options.
• Opioid agonist treatment with slow-release oral morphine should be made available and offered as a second-line option.
• Patients with OUD should not be offered withdrawal management as stand-alone treatment because it is associated with increased rates of relapse, morbidity, and mortality.
• Psychosocial treatment, interventions, and supports can be offered as adjunct treatments but should not be a mandatory component of standard treatment for OUD and should not prevent access to opioid agonist therapy.
• Harm reduction strategies should be offered as part of the continuum of care for patients with OUD.
• Pregnant people can be offered buprenorphine or methadone as treatment options.

That both buprenorphine and methadone are now to be considered first-line therapy for the management of OUD is an important change to the guideline. There is a lot of good evidence that these agents are effective for the management of OUD. Previously it was thought that methadone was harder or somehow more unsafe than buprenorphine, and that buprenorphine was therefore a safer therapy that should be used more widely. Now methadone is considered, as a strong opioid agonist, and has an important role to play. Clinical experience has borne that out, and this is reflected in the guidelines.

Patients who are using fentanyl, for example, or fentanyl analogs, sometimes need another agent. Also, a lot of patients do not respond very well to buprenorphine, so for many people, a full agonist like methadone is needed.

The guideline was supported by Health Canada and the Canadian Institutes of Health Research (CIHR) via CRISM.