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

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

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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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  
  • 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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  • 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.