Managing Opioid-Use Disorders: A Clinical Practice Guideline

Peter M. Yellowlees, MBBS, MD


July 24, 2018

This is the Medscape Psychiatry Minute. I am Dr Peter Yellowlees.

Opioid-use disorder is often a chronic, relapsing condition associated with increased morbidity and death; however, with appropriate treatment and follow-up, individuals can reach sustained, long-term remission. Now a team of investigators[1] from the University of Montreal has written a clinical practice guideline for managing patients with opioid-use disorder. Though these recommendations are intended for clinicians practicing in Canada, they are useful to all clinicians treating patients with opioid-use disorder.

The investigators concluded that medication-assisted treatment is certainly effective and recommend the following first-line and second-line treatment options:

  1. Initiate opioid agonist treatment with buprenorphine-naloxone, whenever feasible, to reduce the risk for toxicity, morbidity, and death, and to facilitate safer take-home dosing.

  2. Consider transitioning to methadone treatment for patients who respond poorly to buprenorphine-naloxone.

  3. Initiate opioid agonist treatment with methadone when treatment with buprenorphine-naloxone is not the preferred option.

  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.

So where does this leave us in the United States, where buprenorphine-naloxone is already the preferred treatment for most patients with opioid-use disorder, but methadone prescription is heavily restricted (unlike in many other countries where it is more available as a first-line treatment)?

As clinicians, we should continue to prescribe buprenorphine-naloxone combinations, but we should also question why it is not easier for us to prescribe methadone.

Thank you for listening to this Medscape Psychiatry Minute. Do continue to enjoy your practice.


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