Treatment of opioid use disorder in primary care.

Opioid use disorder (OUD) is a common, treatable chronic disease that can be effectively managed in primary care settings. Untreated OUD is associated with considerable morbidity and mortality-notably, overdose, infectious complications of injecting drug use, and profoundly diminished quality of life. Withdrawal management and medication tapers are ineffective and are associated with increased rates of relapse and death. Pharmacotherapy is the evidence based mainstay of OUD treatment, and many studies support its integration into primary care settings. Evidence is strongest for the opioid agonists buprenorphine and methadone, which randomized controlled trials have shown to decrease illicit opioid use and mortality. Discontinuation of opioid agonist therapy is associated with increased rates of relapse and mortality. Less evidence is available for the opioid antagonist extended release naltrexone, with a meta-analysis of randomized controlled trials showing decreased illicit opioid use but no effect on mortality. Treating OUD in primary care settings is cost effective, improves outcomes for both OUD and other medical comorbidities, and is highly acceptable to patients. Evidence on whether behavioral interventions improve outcomes for patients receiving pharmacotherapy is mixed, with guidelines promoting voluntary engagement in psychosocial supports, including counseling. Further work is needed to promote the integration of OUD treatment into primary care and to overcome regulatory barriers to integrating methadone into primary care treatment in the US.

Adapting a Low-threshold Buprenorphine Program for Vulnerable Populations During the COVID-19 Pandemic.

OBJECTIVES: To examine patient characteristics and outcomes among opioid use disorder patients enrolled in low-threshold buprenorphine treatment during the COVID-19 pandemic. METHODS: This paper describes the adaptation of the Project Connections (PC) program, a low-threshold buprenorphine program in Baltimore, in response to the COVID-19 pandemic. This paper examines patient characteristics and initial outcomes of patients served during a rapid protocol shift to telehealth that allowed buprenorphine initiation without an in-person encounter following a state-mandated stay-at-home order. Patient characteristics were compared to a subsample of patients enrolled in the program before the COVID-19 pandemic. RESULTS: In March 2020, there was a sharp increase in new enrollments to the PC program. A total of 143 patients completed an intake assessment between March and May 2020 and 140 began treatment with buprenorphine/naloxone. Those who completed an intake assessment were primarily male (68.5%), Black (83.2%), had a mean age of 43.2 years (SD = 11.7), and reported a mean of 17.0 years of opioid use (SD = 12.9). The majority of patients were unemployed (72.7%) and reported previous criminal justice involvement (69.2%). Of those who completed an intake assessment, 96.5% returned for a second visit. Among those for whom 30-day retention data was available (n = 113), 63.7% were engaged for 30 days or longer. CONCLUSIONS: The PC program illustrates that offering on-demand, flexible treatment is an opportunity to increase opioid use disorder treatment access, even during a public health emergency that disrupted access to services. Relaxation of buprenorphine telehealth regulations allowed for flexibility in treatment and benefits vulnerable populations.