Methadone treatment for people who use fentanyl: Recommendations

Preamble

Over the last five years, fentanyl and fentanyl analogues have infiltrated the illegal opioid supply across much of Canada, with devastating effects on people who use drugs. Addiction medicine providers seeking to support people who want opioid agonist therapy (OAT) have been challenged to find effective ways to use these medications to manage withdrawal, reduce cravings, and reduce overdose rates.

In 2020, a group of experienced addiction physicians in Ontario came together under the leadership of Mentoring, Education, and Clinical Tools for Addiction: Partners in Health Integration (META:PHI) to formulate a new guidance document for prescribing methadone to address the realities of opioid use in the current landscape. Using evidence from focused literature searches and expert opinion, we have made recommendations regarding issues such as methadone dosing and titration, some of which differ from previous guidelines.

This document incorporates feedback from three groups of reviewers: invited reviews from clinicians who work in various health disciplines and settings, anonymous reviews from members of the META:PHI Google Group, and feedback obtained from a focus group comprised of people with lived/living expertise and family members (see Acknowledgments section below). META:PHI recognizes the importance of meaningful collaboration with people with lived/living expertise at all stages of knowledge creation, and we acknowledge our late engagement with this group. We resolve to increase our collaborative engagement with these experts in future projects.

This document is not a comprehensive overview of methadone prescribing or an introduction to OAT; it is intended for the experienced prescriber who can apply clinical judgement with the evidence provided. Sections 4 and 5 are intended for hospital clinicians who are not experienced methadone prescribers.

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