Treating opioid use disorder in primary care

Clinical question

How well is opioid agonist therapy (OAT) managed in primary care?

Bottom line

For patients dependent on opioids, receiving OAT in a primary care setting versus a specialized opioid treatment program resulted in an additional 1 in 6 patients retained in treatment and abstinent from street opioids at 42 weeks. Additionally, almost twice as many patients (77% vs 38%) reported being very satisfied with their care. All studies had supports and training available to their primary care teams.

Evidence

Three RCTs (46 to 221 patients)^1–3 compared OAT (methadone or buprenorphine) in primary care versus a specialized opioid treatment program; mean follow-up was 42 weeks.

• Retention in treatment (3 RCTs of 287 patients; meta-analysis done by Tools for Practice authors) was 86% versus 67% in specialty care (number needed to treat of 6).

• Street opioid abstinence (3 RCTs of 313 patients; measured by urine toxicology or self-report; meta-analysis done by Tools for Practice authors) was 53% versus 35% in specialty care (number needed to treat of 6).

• Patient satisfaction was high:

  • -Patients were “very satisfied” more often in primary care (77% vs 38%; 1 RCT of 46 patients).¹
  • -Patients reported higher satisfaction with information provided in primary care (1 RCT; percentages not given).²

• Withdrawal symptoms were statistically significantly reduced from baseline, but there was no difference between groups (1 RCT of 46 patients).³

• Adverse events were not reported.

Context

The study populations varied^1–3:

• In 1 RCT, patients had been receiving methadone for 1 year or more and were abstinent from street drugs at randomization¹; in another, patients were not taking methadone or were switching from buprenorphine²; and in the third RCT, patients were on a methadone waiting list and had urine screening results positive for opioids.³

• In 2 studies, primary care providers were internists.^1,3

Supportive teams and training were used in the RCTs^1–3:

• Primary care settings were largely team based.^1,3

• Support and training were available.^1,2

• One primary care clinic was affiliated with a substance misuse clinic.³

• One study enrolled only physicians with experience in treating opioid or other drug dependence.²

• One study provided physicians with training and 24-hour pager support.¹

More than 50% of surveyed physicians reported inadequate staff support and training, time, and office space as barriers to prescribing OAT in their practices.^4,5

Implementation

Primary care practitioners can treat opioid use disorder and they do it well. Primary care teams and clinician support and training can facilitate improved outcomes.^1–3 Other specialist supports for primary care practitioners treating opioid use disorder are increasing across Canada through consultation and pain and addiction mentorship programs.^6–8 Other educational resources include online training.^9–11 In addition, practical patient handouts on topics such as home- or office-based induction of buprenorphine are available to assist practitioners.¹²

Tools for Practice articles in Canadian Family Physician are adapted from articles published on the Alberta College of Family Physicians (ACFP) website, summarizing medical evidence with a focus on topical issues and practice-modifying information. The ACFP summaries and the series in Canadian Family Physician are coordinated by Dr G. Michael Allan, and the summaries are co-authored by at least 1 practising family physician and are peer reviewed. Feedback is welcome and can be sent to toolsforpractice@cfpc.ca. Archived articles are available on the ACFP website: www.acfp.ca.