A “Guideline of Guidelines”
CAMH takes lead in synthesizing recommendations for treating Opioid Use Disorder
CPSO Expectations and Right-Touch Regulation
In the spirit of right-touch regulation, CPSO no longer develops guidelines in opioid prescribing and does not endorse one practice guideline over another. Instead, we expect our members to consider the context of current expert guidance in the hope of minimizing morbidity, and the risk of opioid-related overdoses and deaths. When considering the current guidance presented in this Dialogue to treat or reduce the harms of opioid use disorder, physicians are reminded of the expectations In CPSO’s Prescribing Drugs policy.
As more evidence emerges that opioid overdose deaths have increased significantly since the onset of COVID-19, the Centre for Addiction and Mental Health (CAMH), in collaboration with subject matter experts and medical regulatory authorities across Canada, released updated national clinical guidelines for the treatment of opioid use disorder.
Opioid Agonist Therapy: A Synthesis of Canadian Guidelines for Treating Opioid Use Disorder serves as a “guideline of guidelines” by synthesizing key recommendations for treating and managing Opioid Use Disorder (OUD) from existing standards, guidelines, expert opinions and best practices across Canada.
COVID, said Dr. Peter Selby, Clinician Scientist, Addictions Division, and CAMH lead for this initiative, drastically changed the situation on the ground across Canada in regard to the opioid crisis. Old rules that made it hard to provide person-centred care and help people stay in treatment needed to be seen through the lens of a new reality, he said.
“The aim of this initiative was to compile existing guidelines, and minimize mixed messages to prescribers about treatment and harm reduction,” he said. “Given the complex nature of opioid addiction treatment, it is essential to support prescribers by providing access to information together in one guideline.”
The new guideline includes updated medication delivery options, such as offering injectables, and expanding the list of medications for those who don’t respond to traditional treatments.
The guideline also makes a strong push for e-prescribing. Dr. Selby described how using paper prescriptions or faxing prescriptions for controlled substances is problematic. “They can get lost, are prone to errors with potential lethal consequences to the patient, and/or they can get diverted or forged. E-prescribing, as it is evolving in Canada, can improve the safety of opioid prescribing and monitoring. E-prescribing also improves the pharmacist and prescriber communication, which is an essential component of safe OUD treatment.”
The guideline also features less regulatory restriction, and new strategies to combat stigma and make treatment adherence easier.
“That is key because the longer people are in treatment, the better they recover and the less likely they are to die from an opioid overdose,” said Dr. Selby.
Effective treatment exists for opioid use disorder, although evidence shows a modest level of treatment engagement and the continued rise of opioid overdoses. Harmonization of guidelines across Canada will improve the consistency and quality of care amid the worsening opioid epidemic, said Dr. Selby.
CAMH’s guidelines covers 26 topics divided into five parts. Part A offers guidance around harm reduction, engaging patients and initiating opioid agonist therapy (OAT). Part B details pharmacological treatment options. Part C presents guidance, recommendations and additional considerations to optimize outcomes in special contexts. Part D provides OAT recommendations for patients with various co-occurring disorders. And Part E presents guidance on discontinuing OAT.
The forthcoming CAMH publication, Opioid Agonist Therapy: A Prescriber’s Guide to Treatment, complements this guideline. The guideline outlines evidence-based standards and regulatory expectations (i.e., what should be done), and the guide provides further details and clinical anecdotes to help readers operationalize the guidelines (i.e., how to do it).
Anticipating the release of CAMH’s guideline, CPSO rescinded its Methadone Maintenance Treatment for Opioid Dependence policy and Methadone Maintenance Treatment Program Standards and Guidelines earlier this year. The move was in keeping with CPSO’s commitment to the continued modernization of our approach to regulation, and the evolution of medicine as it pertains to methadone and the treatment of opioid use disorder more broadly.
In coming to its decision, Council members agreed the current approach to regulating methadone created real or perceived barriers that compromise access to and the delivery of high-quality care to patients.
CPSO’s significant oversight of this space has acted as a disincentive to physicians wanting to include this treatment within their scope of practice. This limited access to care and restricted the availability of treatment modalities to patients otherwise within treatment programs.
Dr. Selby agreed with Council’s decision and is pleased to see less regulatory involvement in this clinical space. “The previous regulatory system was very discriminatory and stigmatizing for both patients and their providers. Moreover, it prevented many practitioners from treating their patients because of the red tape and monitoring that went above and beyond the usual practice of medicine. The cumbersome process did negatively affect the efficacy of the health system to respond effectively to the growing health crisis of opioid use disorders. The evolution of more fit-for-purpose regulatory actions allow for more nuanced and patient-centred care for patients with OUD, while still preventing harm to the patient, provider and society at large,” he said. Dr. Selby noted the importance of patient-centred care made it critical to involve people with lived experiences in the synthesis of guidelines.
“The art of providing excellent health care is to define it in terms of what is valuable and feasible for the individual patient, especially when they have a chronic condition, such as addiction, that requires chronic therapy. Health care providers learn from patients with lived experience about the issues that caused and perpetuate their use of opioids. The health care provider’s role is a partnership with the patient in a mindful, empathic and collaborative way,” he said.
For a select population who have higher levels of tolerance to opioids, Dr. Selby says the new guidance provided by META-PHI (see related article) strikes a reasonable balance between risk and benefit. “The guidance could help patients better manage their withdrawal by addressing their high levels of tolerance induced by fentanyls, and help the patients achieve a dose that prevents cravings and reduces the risk of overdose even if they should lapse or use fentanyls,” said Dr. Selby.