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#221 Location, Location, Location: Treating patients with opioid use disorder in primary care


CLINICAL QUESTION
QUESTION CLINIQUE
How well is opioid use disorder (OUD) managed in primary care?


BOTTOM LINE
RÉSULTAT FINAL
For patients with OUD, receiving opioid agonist therapy (OAT) in a primary care setting, an additional 1 in 5 patients were opioid abstinent at 46 weeks, compared to patients receiving care in a specialty care setting. Patients were also more satisfied with their treatment and physician explanations in primary care. Rates of retention were similar between groups. Provision of support and/or training was reported consistently throughout the literature



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EVIDENCE
DONNÉES PROBANTES
Six randomized controlled trials (RCTs, 22-221 patients)1-6 compared OAT (methadone or buprenorphine) in primary care versus specialized opioid treatment; mean follow-up 46 weeks 
  • Opioid abstinence (five RCTs; 428 patients; measured by urine toxicology and/or self-report; meta-analyzed by TFP authors): 
    • 55% versus 34%; Number Needed to Treat (NNT)=5 
  • Retention in treatment (six RCTs; 493 patients; meta-analyzed by TFP authors): 
    • 80% versus 63% specialty care; not statistically different  
  • Patient satisfaction:  
    • Patients were “very satisfied” more often in primary care (77% versus 38%one RCT, 46 patients)2 more satisfied with explanations provided by their physicians (numbers not reported; one RCT, 221 patients)1  and reported higher preference for primary care (70% versus 21% specialty care, 9% no preference) 
    • One RCT found similar patient satisfaction between groups3 
  • Withdrawal symptoms:  
    • Statistically reduced from baseline, but no difference between groups3 
  • Adverse events:  
    • One RCT (93 patients) found no difference in emergency department visits or hospitalizations (35% versus 36% specialty care)4 
    • No other adverse events reported  
Context: 
  • Included populations varied 
    • Patients stabilized for 6-12 months in methadone maintenance programs2,3,6 
    • Patients not on methadone or switching from buprenorphine1 
    • Patients recruited from a methadone wait-list or referred5 
    • Primary care providers varied, including general internists2,4,5, infectious disease-trained physicians4, and an addictions-trained physician3 
  • Additional supports were used 
    • Primary care settings were team-based2-6 
    • Primary care providers had prior training and/or experience1,4 
    • Support/training was provided1,2,4,6 and 24-hour pager support2 
    • Primary care settings were affiliated with or located near a specialty program1,3,5 
  • Over 50% of surveyed physicians reported inadequate staff, training, time and space as barriers to initiating OAT in their practice7,8 


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Author(s)
Auteur(s)
  • Danielle Perry BScN RN
  • Scott Garrison MD PhD CCFP

1. Carrieri PM, Michel L, Lions C, et al. PLoS One. 2014; 9(11):e112328

2. Fiellin DA, O’Connor PG, Chawarski M, et al. JAMA. 2001 Oct; 286(14):1724-31

3. King VL, Kidorf MS, Stoller KB, et al. J Subst Abuse Treat. 2006; 31(4):385-93.

4. Lucas GM, Chaudhry A, Hsu J, et al. Ann Intern Med. 2010; 152(11):704-11.

5. O’Connor PG, Oliveto AH, Shi JM, et al. Am J Med. 1998; 105(2):100-5.

6. Tuchman E, Gregory C, Simson M, et al. Addict Dis and Treat. 2006; 5(2):43-51.

7. DeFlavio JR, Rolin SA, Nordstrom BR, et al. Rural Remote Health. 2015; 15:3019. Epub 2015 Feb 4.

8. Kermack A, Flannery M, Tofighi B, et al. J Subst Abuse Treat. 2017 Mar; 74:1-6.

Authors do not have any conflicts of interest to declare.

Les auteurs n’ont aucun conflit d’intérêts à déclarer.