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OtherPractice

Treating opioid use disorder in primary care

Danielle Perry, Eliseo Orrantia and Scott Garrison
Canadian Family Physician February 2019, 65 (2) 117;
Danielle Perry
Master’s degree candidate and Knowledge Translation Expert with the PEER (Patients, Experience, Evidence, Research) Group in the Department of Family Medicine at the University of Alberta in Edmonton.
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Eliseo Orrantia
Rural family physician for the Marathon Family Health Team in Ontario and Associate Professor at the Northern Ontario School of Medicine.
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Scott Garrison
Associate Professor in the Department of Family Medicine at the University of Alberta.
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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 varied1–3:

  • 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 RCTs1–3:

  • 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

Notes

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{at}cfpc.ca. Archived articles are available on the ACFP website: www.acfp.ca.

Footnotes

  • Competing interests

    None declared

  • The opinions expressed in Tools for Practice articles are those of the authors and do not necessarily mirror the perspective and policy of the Alberta College of Family Physicians.

  • Copyright© the College of Family Physicians of Canada

References

  1. 1.
    1. Fiellin DA,
    2. O’Connor PG,
    3. Chawarski M,
    4. Pakes JP,
    5. Pantalon MV,
    6. Schottenfeld RS
    . Methadone maintenance in primary care: a randomized controlled trial. JAMA 2001;286(14):1724-31.
  2. 2.
    1. Carrieri PM,
    2. Michel L,
    3. Lions C,
    4. Cohen J,
    5. Vray M,
    6. Mora M,
    7. et al
    . Methadone induction in primary care for opioid dependence: a pragmatic randomized trial (ANRS Methaville). PLoS One 2014;9(11):e112328.
  3. 3.
    1. O’Connor PG,
    2. Oliveto AH,
    3. Shi JM,
    4. Triffleman EG,
    5. Carroll KM,
    6. Kosten TR,
    7. et al
    . A randomized trial of buprenorphine maintenance for heroin dependence in a primary care clinic for substance users versus a methadone clinic. Am J Med 1998;105(2):100-5.
  4. 4.
    1. DeFlavio JR,
    2. Rolin SA,
    3. Nordstrom BR,
    4. Kazal LA Jr
    . Analysis of barriers to adoption of buprenorphine maintenance therapy by family physicians. Rural Remote Health 2015;15:3019. Epub 2015 Feb 4.
  5. 5.
    1. Kermack A,
    2. Flannery M,
    3. Tofighi B,
    4. McNeely J,
    5. Lee JD
    . Buprenorphine prescribing practice trends and attitudes among New York providers. J Subst Abuse Treat 2017;74:1-6. Epub 2016 Oct 29.
  6. 6.
    1. Alberta College of Family Physicians
    . Collaborative Mentorship Network [website]. Edmonton, AB: Alberta College of Family Physicians; Available from: https://acfp.ca/tools-resources/tools-resources-opioid-response/collaborative-mentorship-network/. Accessed 2018 Dec 10.
  7. 7.
    1. Alberta Health Services
    . Opioid use disorder—telephone consultation [website]. Edmonton, AB: Alberta Health Services; Available from: www.albertahealthservices.ca/info/page15558.aspx. Accessed 2018 Oct 21.
  8. 8.
    Collaborative mentoring networks [website]. Toronto, ON: Ontario College of Family Physicians; Available from: https://ocfp.on.ca/cpd/collaborative-networks. Accessed 2018 Oct 21.
  9. 9.
    1. British Columbia Centre on Substance Use
    . Education and training [website]. Vancouver, BC: British Columbia Centre on Substance Use; Available from: www.bccsu.ca/education-training. Accessed 2018 Nov 5.
  10. 10.
    1. Centre for Addiction and Mental Health
    . Opioid dependence treatment ODT core course [website]. Toronto, ON: Centre for Addiction and Mental Health; Available from: www.camh.ca/en/education/about/AZCourses/Pages/odtcore_odt.aspx. Accessed 2018 Oct 21.
  11. 11.
    1. Centre for Addiction and Mental Health
    . Buprenorphine-naloxone treatment for opioid use disorder. Toronto, ON: Centre for Addiction and Mental Health; Available from: https://www.camh.ca/en/education/continuing-education/continuing-education-programs-and-courses/buprenorphinenaloxone-treatment-for-opioid-use-disorder. Accessed 2018 Dec 5.
  12. 12.
    1. BC Ministry of Health,
    2. BC Medical Association,
    3. BC Centre on Substance Use
    . Day 1 starting Suboxone (buprenorphine/naloxone). Victoria, BC: British Columbia Ministry of Health; Available from: www2.gov.bc.ca/assets/gov/health/practitioner-pro/bc-guidelines/oud-induction-handout.pdf. Accessed 2018 Nov 5.

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