• Christina Korownyk, Danielle Perry, Joey Ton, Michael R Kolber, Scott Garrison, Betsy Thomas, G Michael Allan, Nicolas Dugré, Caitlin R Finley, Rhonda Ting, Peter Ran Yang, Ben Vandermeer, and Adrienne J Lindblad.
• Family physician and Associate Professor in the Department of Family Medicine at the University of Alberta in Edmonton. cpoag@ualberta.ca.
• Can Fam Physician. 2019 May 1; 65 (5): e194e206e194-e206.

ObjectiveTo summarize the best available evidence regarding various topics related to primary care management of opioid use disorder (OUD).Data SourcesMEDLINE, Cochrane Library, Google, and the references of included studies and relevant guidelines.Study SelectionPublished 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.SynthesisFrom 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).ConclusionThere 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.Copyright© the College of Family Physicians of Canada.

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