Treatment of Opioid Use Disorder in Primary Care
A Practical Solution to an Urgent Need
Treatment
UR Medicine Recovery Center of Excellence provides comprehensive Program
Assistance on the treatment of opioid use disorder (OUD) in primary care to prepare
providers and staff to deliver evidence-based care to patients.
OUD is a chronic disease that affects the structure and function of the
brain.1 Provisional data from the CDC indicate there were 75,673 overdose deaths from
opioids in a 12-month period ending in April 2021.2 Heroin use can reduce lifespan by
decades.3 With the right treatment, however, the outlook can improve substantially.
Evidence-based medications for opioid use disorder (MOUD), such as buprenorphine,
can increase retention in treatment, reduce non-medical drug use, and reduce overdose
deaths from opioids by 50-70%.4
Buprenorphine prevents opioid withdrawal and blocks opioid euphoria. In primary care
settings, it can reduce medical morbidity associated with OUD, improve treatment
outcomes, and lower the overall cost of care.5 As a 2018 New England Journal of
Medicine article, “Primary Care and the Opioid Crisis—Myths and Realities,” states: “To
have any hope of stemming the overdose tide, we have to make it easier to obtain
buprenorphine than to get heroin and fentanyl.”6
More than 80% of those with OUD have not received MOUD treatment in the last year
or more, despite evidence of its efficacy.7 In rural communities this gap is even greater,
attributable to a limited number of providers of buprenorphine and other MOUD,8 long
travel times to providers, stigma, and lack of anonymity in small, rural communities that
can all present barriers to treatment.9 Rural communities also face barriers to evidence-
based provision of MOUD that are observed more generally, for example challenges in
disseminating evidence-based decision tools in real-world practices.10 Nonetheless,
these barriers are not insurmountable if addressed strategically and collaboratively
among rural partners.11 Most rural physicians regularly see patients who have OUD and
believe that, as their physician, they should be offering them treatment.12 Indeed,
primary care practices in rural communities are well positioned to offer office-based
buprenorphine treatment.13
Making MOUD available through primary care offices in rural communities removes the
hardship of travel distance for patients. It also provides a measure of privacy to reduce
the stigma that can inhibit patients from visiting behavioral health facilities. Patients
being treated in primary care offices are generally stable and in well-established
recovery, and they are prescribed buprenorphine as a long-term medication for a
chronic disease. If the need arises for more intensive treatment, the primary care
provider can refer the patient back to a treatment program.
Topics
To support rural primary care practices and help increase access to care for rural community members, we provide guidance and consultation on a range of topics in treatment of substance use disorder (SUD) and OUD specifically. Rurally adapted topics we provide support on include, but are not limited to:
Substance Use Disorder and Primary Care-Based MOUD
Approaching OUD as a chronic disease
Evidence-based treatments
Strategies to improve access to MOUD
Overcoming barriers to treatment of OUD in primary care
Connections with local treatment programs and referral process
Levels of care
The role of peers
Integrating SUD Treatment in Primary Care
Principles of treatment
Role and scope of primary care in treatment
Overcoming barriers
Applying screening tools with current patients
Addressing common concerns
Practical Applications for Integrating SUD Treatment into Primary Care
Local partnerships and referrals
Scheduling
Billing
Note templates
Managing return to use
Behavioral health care management
Screening, Brief Intervention, and Referral to Treatment
SBIRT assessment and its elements: screening, brief intervention, and referral to treatment
Other evidence-based screening tools for adults and adolescents
Evaluating risk
Communicating with patients
Considerations for referral to treatment
Workflow and documentation
Partnerships with treatment centers
SUD and the Hepatitis C Virus Epidemic
Hepatitis C virus (HCV) overview, statistics, and challenges
Treatment of SUD populations with HCV
Community-based prevention of HCV
Stimulants
Stimulant use trends and overdose deaths
Methamphetamine
Cocaine
Health effects
Screening tools
Treatment options
Pregnancy and Reproductive Care for Patients with OUD
Treatment options for pregnant patients with a history of OUD
Outcomes with and without treatment
Reproductive care for patients with OUD/SUD
Neonatal abstinence syndrome
Alcohol Use Disorder
Alcohol use prevalence and health risks
Screening tools
Levels of care
Pharmacotherapy
Overcoming barriers to treatment and supporting recovery
Synthetic Opioids
Evolution of the opioid overdose crisis
Types of synthetic opioids, xylazine, and mixture with other substances
Treatment approaches
Overcoming barriers to treatment
Overdose prevention
References
[1] National Academies of Sciences, Engineering, and Medicine. (2019). Medications for opioid use disorder save lives. National Academies Press, p. 2. https://doi.org/10.17226/25310
[2] Centers for Disease Control and Prevention. (2021, November 17). Drug overdose deaths top 100,000 annually [Press release].
[3] Darke, S., Marel, C., Mills, K. L., Ross, J., Slade, T., & Tessson, M. (2016). Years of potential life lost amongst heroin users in the Australian Treatment Outcome Study cohort, 2001-2015. Drug and Alcohol Dependence, 162, 206-210. https://doi.org/10.1016/j.drugalcdep.2016.03.010
[4] Winograd, R. P., Presnall, N., Stringfellow, E., Wood, C., Horn, P., Duello, A., Green, L., & Rudder, T. (2019). The case for a medication first approach to the treatment of opioid use disorder. American Journal of Drug and Alcohol Abuse, 45(4), 333-340. https://doi.org/10.1080/00952990.2019.1605372
[5] Deflavio, J., Rolin, S. A., Nordstrom, B. R., & Kazal, L. A. (2015). Analysis of barriers to adoption of buprenorphine maintenance therapy by family physicians. Rural and Remote Health, 15(1), 3019. https://www.rrh.org.au/journal/article/3019
[6] Wakeman, S. E., & Barnett, M. L. (2018). Primary Care and the Opioid-Overdose Crisis — Buprenorphine Myths and Realities. New England Journal of Medicine, 379(1), 1-4. https://doi.org/10.1056/NEJMp1802741
[7] Saloner, B., & Karthikeyan, S. (2015). Changes in substance abuse treatment use among individuals with opioid use disorders in the United States, 2004-2013. JAMA, 314(14), 1515–1517, https://doi.org/10.1001/jama.2015.10345; Substance Abuse and Mental Health Services Administration. (2020). Key substance use and mental health indicators in the United States: Results from the 2019 National Survey on Drug Use and Health. Center for Behavioral Health Statistics and Quality, p. 55.
[8] Lister, J. J., Weaver, A., Ellis, J. D., Himle, J. A., & Ledgerwood, D. M. (2020). A systematic review of rural-specific barriers to medication treatment for opioid use disorder in the United States. American Journal of Drug and Alcohol Abuse, 46(3), 273–288. https://doi.org/10.1080/00952990.2019.1694536
[9] Blanco, C., Ali, M.M., Beswick, A., Drexler, K. Hoffman, C., Jones, C.M., Wiley, T.R.A., & Coukell, A. (2020). The American opioid epidemic in special populations: Five examples. NAM Perspectives. Discussion Paper, National Academy of Medicine, pp. 5-6. https://doi.org/10.31478/202010b
[10] Rossom, Sperl-Hillen, J. M., O’Connor, P. J., Crain, A. L., Nightingale, L., Pylkas, A., Huntley, K. V., & Bart, G. (2021). A pilot study of the functionality and clinician acceptance of a clinical decision support tool to improve primary care of opioid use disorder. Addiction Science and Clinical Practice, 16(1), 1-37. https://doi.org/10.1186/s13722-021-00245-7
[11] Health Resources and Services Administration (HRSA). (2019). A guide for rural health care collaboration and coordination. U.S. Department of Health and Human Services, 2019.
[12] DeFlavio et al. (2015).
[13] Wakeman et al. (2018).
