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Canadian Guideline Proposes Best Practices for Injectable Opioid Agonist Treatment

September 26, 2019
Recommendations may help those patients unable to tolerate oral OAT for opioid use disorder.

A PPM Brief

The first-ever best practices guidelines for prescribing injectable opioid agonist treatment (iOAT) have been released1 in Canada. Written by the Canadian Research Initiative in Substance Misuse (CRISM), the guidelines offer providers strategies for delivering the treatment using prescription heroin (diacetylmorphine) and hydromorphone; the treatment targets those with severe opioid use disorder (OUD).

In 2018, Canada published guidelines for providing oral opioid agonist treatments (OAT). While effective for treating OUD, some patients failed to benefit from the treatment and continued to have opioid cravings, had an inability to achieve an effective dose, or experienced adverse reactions. Researchers later found that injectable OAT may offer an alternative for those unable to tolerate oral OAT.

“Offering injectable opioid treatments is an effective way for clinicians to address the toxicity of the fentanyl-adulterated drug supply and help people achieve stability,” said Christy Sutherland, MD, medical director of PHS Community Services Society and co-chair of the guideline writing committee, in a press release.

Resources for the treatment of opioid addiction have been scarce and guidelines outlining best practices for innovative treatments have been lacking. (Source: 123RF)

The committee, led by CRISM, included healthcare practitioners with OUD experience. They used a Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach to outline three key clinical recommendations:

  • iOAT should be considered for those with severe opioid addiction who do not respond to oral treatments, as well as those who actively use illicit injectable opioids
  • Diacetylmorphine and hydromorphone, two injectable opioid agonist therapies, are recommended as options for patients likely to benefit from iOAT; decision-making should take into consideration product availability, patient preference, and prescriber judgment
  • Assigning an end date to treatment may be associated with a return to illicit opioid use; therefore, iOAT should be prescribed on an open-ended basis with the decision to transition to another treatment made in collaboration with the patient.

Along with the clinical guideline, the Canadian group also released an operational guidance document to provide an overview of the rationale for and evidence supporting iOAT, as well as guidance on implementation, operation, and evaluation. Both documents include expert opinion on approaches, eligibility, doses, and patient preferences.

“Our hope is that these guidelines will remove any barriers those in primary care have in delivering what is, in the context of our current public health emergency, a life-saving treatment,” Dr. Sutherland said in the release.

Last updated on: September 26, 2019
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