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Can Fam Physician. 2019 May;65(5):e194-e206.

Opioid use disorder in primary care: PEER umbrella systematic review of systematic reviews.

Author information

1
Family physician and Associate Professor in the Department of Family Medicine at the University of Alberta in Edmonton. cpoag@ualberta.ca.
2
Nurse and Clinical Evidence Expert at the Alberta College of Family Physicians in Edmonton.
3
Pharmacist and Clinical Evidence Expert at the College of Family Physicians of Canada in Mississauga, Ont.
4
Family physician and Professor in the Department of Family Medicine at the University of Alberta.
5
Family physician and Associate Professor in the Department of Family Medicine at the University of Alberta.
6
Pharmacist; Project Manager, Education and Knowledge Translation at the Alberta College of Family Physicians; and Assistant Adjunct Professor in the Department of Family Medicine at the University of Alberta.
7
Family physician, Director of Programs and Practice Support at the College of Family Physicians of Canada, and Professor in the Department of Family Medicine at the University of Alberta.
8
Pharmacist at the CIUSSS du Nord-de-l'Ile-de-Montréal and Clinical Associate Professor in the Faculty of Pharmacy at the University of Montreal in Quebec.
9
Medical student at the University of Alberta.
10
Doctoral student in the Faculty of Pharmacy and Pharmaceutical Sciences at the University of Alberta.
11
Research Associate at the Alberta Research Centre for Health Evidence.
12
Pharmacist and Knowledge Translation and Evidence Coordinator at the Alberta College of Family Physicians and Associate Clinical Professor in the Department of Family Medicine at the University of Alberta.

Abstract

OBJECTIVE:

To summarize the best available evidence regarding various topics related to primary care management of opioid use disorder (OUD).

DATA SOURCES:

MEDLINE, Cochrane Library, Google, and the references of included studies and relevant guidelines.

STUDY SELECTION:

Published systematic reviews and newer randomized controlled trials from the past 5 to 10 years that investigated patient-oriented outcomes related to managing OUD in primary care, diagnosis, pharmacotherapies (including buprenorphine, methadone, and naltrexone), tapering strategies, psychosocial interventions, prescribing practices, and management of comorbidities.

SYNTHESIS:

From 8626 articles, 39 systematic reviews and an additional 26 randomized controlled trials were included. New meta-analyses were performed where possible. One cohort study suggests 1 case-finding tool might be reasonable to assist with diagnosis (positive likelihood ratio of 10.3). Meta-analysis demonstrated that retention in treatment improves when buprenorphine or methadone are used (64% to 73% vs 22% to 39% for control), when OUD is treated in primary care (86% vs 67% in specialty care, risk ratio [RR] of 1.25, 95% CI 1.07 to 1.47), and when counseling is added to pharmacotherapy (74% vs 62% for controls, RR = 1.20, 95% CI 1.06 to 1.36). Retention was also improved with naltrexone (33% vs 25% for controls, RR = 1.35, 95% CI 1.11 to 1.64) and reduced with medication-related contingency management (eg, loss of take-home doses as a punitive measure; 68% vs 77% for no contingency, RR = 0.86, 95% CI 0.76 to 0.99).

CONCLUSION:

There is reasonable evidence that patients with OUD should be managed in the primary care setting. Diagnostic criteria for OUD remain elusive, with 1 reasonable case-finding tool. Methadone and buprenorphine improve treatment retention, while medication-related contingency methods could worsen retention. Counseling is beneficial when added to pharmacotherapy.

PMID:
31088885
PMCID:
PMC6516704

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