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Research Snapshot: Canadian Prescribing Guidelines for Opioid Agonist Treatment Resulting in Inequitable Access

What You Need to Know

Opioid agonist treatment (OAT) is an effective treatment for opioid use disorder that is often administered daily under supervision. This makes it difficult for people to start and stay on treatment. Take-home doses (THD) of OAT are an effective alternative to daily treatment, and there are Canadian OAT guidelines that outline criteria for who is eligible. Yet OAT prescribers can still use their clinical judgement to decide whether an individual can receive THD. Researchers conducted a study to compare the different OAT guidelines and patient characteristics that might influence a prescriber’s decision to give out THD. The study was a systematic review of the published research comparing access to THD, as well as of all Canadian national and provincial OAT guidelines. The researchers found that current OAT guidelines are likely contributing to inequitable access to THD. For example, all the guidelines that had criteria for THD required patients to be “stable,” but they used different definitions of the term.

What Is This Research About?

Opioid use disorder is a complex chronic disease. People with opioid use disorder often have relapses and remissions, which increases their risk of illness and death. In Canada, clinical guidelines for the management of opioid use disorder recommend OAT as the standard of care for this disorder.

The usual way that people can access OAT is to visit their pharmacy every day and take each dose under supervision. However, many find it difficult to get to a clinic every day for a variety of reasons, so they discontinue their OAT or never start it. In Canada, there are several national and provincial guidelines for the management of opioid use disorder. Most guidelines suggest that after 2 to 3 months of daily supervised dosing, the person can switch to THD. This allows them to bring their OAT home and take it unsupervised.

These guidelines have criteria for who is eligible for THD for prescribers to follow, but each prescriber can decide based on their clinical judgment. This means that the decision on who is eligible may not be transparent and could result in a lack of fairness about who can have THD. During the COVID-19 pandemic, the guidelines for take-home dosing became more flexible. However, this increased flexibility made the criteria for eligibility more confusing, so many people still had difficulty accessing it.

To understand if there are different levels of access to THD and whether some individual characteristics are influencing who is receiving THD in Canada, researchers conducted a systematic review of published research and clinical OAT guidelines.

What Did the Researchers Do?

The researchers reviewed the available published research to compare the characteristics of people who had received THD to those who had not received them. They also reviewed and summarized current Canadian OAT guidelines on who can receive THD.

What Did the Researchers Find?

There were 56 guidelines and 7 research studies that fit the inclusion criteria for the review. Individuals included a range of ages, sexes, races/ethnicities, marital statuses, housing statuses, employment situations, neighbourhood incomes, level and type of drug use, mental health, health service use, and treatment durations.

All the guidelines that had criteria for THD mentioned “stability” but used different descriptions or definitions of the term. The most common criterion for “stability” was being able to store THD safely. Other common stability criteria were the following:

The guidelines had different time requirements before a person could receive THD. For example, most suggested that once the patient had been on methadone for 2 to 3 months and was clinically stable, they could receive an additional THD per month, up to a maximum of 6 doses per month. On the other hand, for buprenorphine/naloxone, some guidelines suggested that individuals could receive THD within a couple of weeks or a month, and the person could receive an additional dose every 2 to 4 weeks, up to a maximum of 13 weeks.

Some guidelines allowed prescribers to use their clinical judgment when providing THD, while other guidelines had more strict criteria. Some provinces had their own guidelines while others referred to other guidelines. Some guidelines rephrased, repeated, or re-interpreted existing guidance. This resulted in nuanced differences or duplication of criteria across guidelines.

The researchers concluded that distribution of THD of OAT is not equitable in Canada, mostly due to inconsistent stability criteria in clinical guidelines. They called for research on how prescriber decision-making might influence treatment and safety outcomes. They also called for a decision-making framework to be developed, incorporating clear definitions of stability criteria and indications for prescriber discretion.

Limitations of the Research

The researchers identified several limitations of their study, including that the single study reviewer did not capture the guideline-specific searches systematically or re-run them through a second independent reviewer. They also pointed out that most of the studies they reviewed used different research methods and had small sample sizes, which made it difficult to compare studies or identify common significant associations among them.

How Can You Use This Research?

The researchers note there is a need for a client-centred, equity-oriented, and evidence-informed decision-making framework for THD. Such a framework should include more clear definitions of “stability” and include a decision-making tool for prescribers that takes into consideration the diverse needs of patients.

About the Researchers

Cayley Russell,1,2,3 Jenna Ashley,1 Farihah Ali,1,2 Nikki Bozinoff,4,5 Kim Corace,6,7,8 David C. Marsh,9,10,11 Christopher Mushquash,12 Jennifer Wyman,5,13 Maria Zhang,14,15 Shannon Lange1,3,4,16

  1. Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, Canada
  2. Ontario Node, Canadian Research Initiative in Substance Misuse, CAMH, Toronto, Ontario, Canada
  3. Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
  4. Campbell Family Mental Health Research Institute, CAMH, Toronto, Ontario, Canada
  5. Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
  6. Department of Psychiatry, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
  7. Substance Use and Concurrent Disorders Program, The Royal Ottawa Mental Health Centre, Ottawa, Ontario, Canada
  8. University of Ottawa Institute of Mental Health Research, The Royal Ottawa Mental Health Centre, Ottawa, Ontario, Canada
  9. Northern Ontario School of Medicine University, Sudbury, Ontario, Canada
  10. Institute for Clinical Evaluative Sciences North, Sudbury, Ontario, Canada
  11. Health Science North Research Institute, Sudbury, Ontario, Canada
  12. Department of Psychology, Lakehead University, Thunder Bay, Ontario, Canada
  13. Women’s College Hospital, Toronto, Ontario, Canada
  14. Pharmacy Services, CAMH, Toronto, Ontario, Canada
  15. Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
  16. Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada

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