Do a Lot More About Opioid Use Disorder in Primary Care

 Hi, everyone. I'm Dr Kenny Lin. I am a family physician and associate director of the Lancaster General Hospital Family Medicine Residency, and I blog at Common Sense Family Doctor.

Increasing reports of tranq dope, the street name for fentanyl adulterated with xylazine, an animal sedative, highlight the latest hazard for patients with opioid use disorder (OUD) and our lack of progress against the opioid overdose crisis despite widespread awareness and federal funding. In 2021, in an effort to identify undiagnosed patients in primary care who could be linked to treatment, the US Preventive Services Task Force (USPSTF) recommended asking every adult screening questions about unhealthy drug use. However, this statement underestimated potential harms and made the doubtful assumption that the benefits of treating OUD in treatment-seeking populations would extend to screen-detected populations. For these reasons, the American Academy of Family Physicians decided to recommend selective rather than universal screening for OUD.

Although my staff routinely asks about tobacco and alcohol use as part of the rooming process, these substances are legal and carry less stigma than does heroin, fentanyl, or oxycodone. Primary care practices that decide to implement screening for OUD despite limited evidence face some practical questions. Should screening questions be self-administered or asked by staff or clinicians? How many patients with positive screens will want to start medications for OUD in primary care or be referred to specialty addiction services? Does systematic screening increase diagnosis and appropriate treatment over usual care enough for the workflow changes to be worthwhile?

To answer these questions, researchers performed a cluster randomized trial involving 20 geographically and structurally diverse US primary care practices. Intervention practices asked patients OUD questions from the National Institute of Drug Abuse's Modified Alcohol, Smoking, and Substance Involvement Screening Test (NM-ASSIST) or used a simpler two-item screen developed for the study. To their surprise, there was no meaningful change in the percentage of patients with new OUD diagnoses in the 6 months after initiation of screening compared with the prior 6 months. Possible reasons are that patients with OUD don't go to primary care, patients answered no to screening questions to avoid negative legal or medical consequences (such as discontinuing pain medications), or that clinicians didn't have time to follow up on positive screens and formally diagnose OUD.

A qualitative evaluation of a sample of participating clinics identified several barriers to screening implementation: uncertainty about who to screen, the complexity of the NM-ASSIST tool, discomfort with screening, workflows, staff shortages and turnover, feeling that screening is ineffective and burdensome, and stigma. Another study by the same group found that administrative obstacles such as inflexible schedules and visit durations made it challenging to engage patients with OUD in care, and many primary care clinicians had low knowledge of and confidence in prescribing medications for OUD.

Though this study suggests that screening for OUD in primary care isn't effective despite the USPSTF recommendation, it doesn't mean that there is nothing family physicians can do to address the opioid epidemic. First, prescribing buprenorphine to motivated patients with OUD reduces mortality and improves quality of life. Now that the X-waiver has been eliminated, more primary care clinicians should be prescribing this drug to patients in recovery.

Second, there is a difference between asking impersonal screening questions and expressing genuine interest in our patients' lives. If I see a that patient is struggling with relationships or losing job after job, asking about depression and drug use isn't screening, it's being a good doctor. Finally, we can work with community leaders and organizations to reduce the stigma surrounding OUD and help them understand that it is a chronic relapsing disease that is treatable with evidence-based medicine tailored to individuals' needs.

https://www.medscape.com/viewarticle/997932