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First-ever clinical guidelines for injectable opioid treatments

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Dr. Eugenia Oviedo-Joekes, CHÉOS Scientist and Associate Professor at the UBC School of Population and Public Health, is a co-author on the first-ever clinical guidelines for the use of injectable opioid agonist treatment (iOAT) for opioid use disorder, released today in the Canadian Medical Association Journal.

The development of the guidelines was supported by the Canadian Research Initiative in Substance Misuse (CRISM).
This is the first clinical document of its kind in the world to provide guidance on the use of injectable treatments; earlier documents from CRISM (2018), the World Health Organization (2009), and the American Society of Addiction Medicine (2015) only provide recommendations on oral treatment, such as methadone or buprenorphine.

“We have seen numerous clinical examples and research evidence that shows oral treatments work for many people, but are not enough to reach everyone,” said Dr. Eugenia Oviedo-Joekes “These guidelines will help clinicians, public health officials, and policymakers make evidence-based decisions about how and where to provide injectable medications in these circumstances.”

Dr. Eugenia Oviedo-Joekes

Much of the research that informed the writing of the guidelines was carried out at CHÉOS and led by Dr. Oviedo-Joekes and Dr. Martin Schechter, also a CHÉOS Scientist.

The guidelines make three overarching recommendations and provide evidence to support each: who should be considered for iOAT, which injectable medications should be used, and how treatment should be structured.

In particular, the Study to Assess Longer-term Opioid Medication Effectiveness (SALOME) informed a significant portion of the guidelines’ recommendations. SALOME is the only Canadian study to compare the effectiveness of hydromorphone (aka Dilaudid), a legal alternative to diacetylmorphine (pharmaceutical-grade heroin). Diacetylmorphine has been the focus of the majority of research in the field.

An announcement from Health Canada this summer loosened restrictions on both hydromorphone and diacetylmorphine for use as injectable treatments in this context, meaning that it will be easier for health care practitioners to access and provide iOAT.

Outside of who should receive iOAT and what treatments should be offered, the guidelines also discuss how treatment should be carried out long-term, concluding that it should be open-ended and that treatment decisions should be made with patients.

“One of the studies that informed this section of our recommendations is our analysis from the NAOMI trial that people who were involuntarily transitioned to methadone from injectables were much less likely to stay in treatment than those who chose to switch,” explained Dr. Oviedo-Joekes.

NAOMI (The North American Opiate Medication Initiative) was a randomized controlled trial that compared the effectiveness of injectable diacetylmorphine to oral methadone.

The guidelines also summarize the current gaps in knowledge about iOAT and calls for more research on the effectiveness of hydromorphone in comparison to diacetylmorphine, on top of the evidence from SALOME.

“There will always be more research to carry out and different methods to try but this document provides a clear framework of evidence for clinicians and officials to move forward with injectable treatments,” she added.

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