Treating opioid use disorder in primary care—limited data, but looks feasible

Référence

Korownyk C, Perry D, Ton J, et al. Opioid use disorder in primary care: PEER umbrella systematic review of systematic reviews. Can Fam Physician 2019;65(5):e194-e206.

Sommaire

These authors searched several databases to identify published systematic reviews and randomized trials published "in the past 5 to 10 years" to identify data relevant to the detection, diagnosis, management, and drug treatment of OUDs in primary care settings. This is a beast of a study in which the authors evaluate many dimensions. This summary will only focus on a few. The authors included systematic reviews of observational studies only when randomized clinical trial (RCT) data were lacking. They included studies with a wide range of outcomes, including morbidity and mortality; societal outcomes (eg, crime, incarceration, employment, hepatitis transmission, and so forth.); quality of life and symptoms; and opioid use and treatment retention. They excluded studies with children, pregnant women, and patients with cancer; studies in prisons; and studies of detoxification. When no meta-analysis existed, they conducted their own. Overall, the authors identified 39 systematic reviews, 26 additional randomized trials, 1 cohort study (and a partridge in a pear tree). For 17 of their meta-analyses, 9 had no RCTs or had inconclusive findings (eg, for residential treatment; use of cannabinoids to treat OUD; or use of contracts, urine drug screening, or symptom management of pain, anxiety, insomnia). Four RCTs directly evaluated primary care treatment of OUD (46 to 221 participants), finding much higher levels of patient satisfaction (77% vs 38%) and higher rates of retention (86% vs 67%) and street opioid abstinence (53% vs 35%). The authors found a paucity of data on identifying patients with OUD, but note that 2 tools were evaluated in the aforementioned cohort study: the Current Opioid Misuse Measure (COMM) and the Prescription Opioid Misuse Index (POMI). The COMM is a 6-question checklist and the POMI is a 17-question scale and have positive likelihood ratios of 3.4 and 10.3, respectively. The authors found multiple systematic reviews and clinical trials of various drugs. Buprenorphine, alone or combined with naloxone, kept more patients in treatment than placebo (64% vs 39% for a period of 30 days to 52 weeks; number needed to treat = 4). Similarly, methadone and naltrexone all kept more patients in treatment than placebo. In head-to-head studies, methadone was more effective than buprenorphine (number needed to treat = 7, but with substantial heterogeneity), but methdone had a higher rate of sedation (58% vs 26% in a single RCT). There is much more in the paper—such as the use of supervised dosing, the speed of tapering off opioids, and psychosocial interventions—than can be summarized in this POEM. YOU SHOULD GET THIS PAPER!