10
Treatment
Î Patients transitioning from methadone to naltrexone must be
completely withdrawn from methadone and other opioids before they
can receive naltrexone.
• The only exception would apply when an experienced clinician receives consent
from the patient to embark on a plan of naltrexone-facilitated opioid withdrawal
management.
Î There is no recommended time limit for pharmacological treatment
with methadone.
• Patients who discontinue methadone treatment should be made aware of the risks
associated with opioid overdose, and especially the increased risk of overdose death
if they return to illicit opioid use.
• Treatment alternatives including buprenorphine (see below) and naltrexone
(see p. 12), as well as opioid overdose prevention with naloxone, should be
discussed with any patient choosing to discontinue treatment.
Buprenorphine
Î NEW – Buprenorphine is a recommended treatment for patients with
OUD who are able to give informed consent and have no specific
contraindication for this treatment.
Î For patients who are currently opioid dependent, buprenorphine
should not be initiated until there are objective signs of opioid
withdrawal to reduce the risk of precipitated withdrawal.
Î MAJOR REVISION – Once objective signs of withdrawal are observed,
initiation of buprenorphine should start with a dose of 2–4mg.
Dosages may be increased in increments of 2–8mg.
Î MAJOR REVISION – The setting for initiation of buprenorphine should
be carefully considered.
• Both office-based and home-based initiation are considered safe and effective
when starting buprenorphine treatment.
• Clinical judgement should be used to determine the most appropriate setting for
a given patient and may include consideration of the patient's past experience with
buprenorphine and assessment of their ability to manage initiation at home.
• Clinicians should observe patients in their offices during induction. However,
home buprenorphine induction may be considered.
Î MAJOR REVISION – Following initiation, buprenorphine dose should be
titrated to alleviate symptoms.
• To be effective, buprenorphine dose should be sufficient to enable patients to
discontinue illicit opioid use.
• Evidence suggests that 16mg per day or more may be more effective than lower
doses.
• There is limited evidence regarding the relative efficacy of doses higher than 24mg
per day, and the use of higher doses may increase the risk of diversion.
