Improving primary care for patients with opioid use disorder

Earlier this year, the National Center for Health Statistics announced that in 2023, the estimated number of drug overdose deaths decreased for the first time since 2018 from 111,029 in 2022 to 107,543 in 2023. Mirroring the overall trend, overdose deaths involving opioids decreased from an estimated 84,181 in 2022 to 81,083 in 2023. However, medical care of patients who survive overdoses remains suboptimal. A cohort study of more than 130,000 Medicare beneficiaries who experienced a nonfatal drug overdose in 2020 found that although 88.8% received behavioral health services, only 4.2% were prescribed medications for opioid use disorder (OUD) and 6.2% filled a naloxone prescription during the following year.

An analysis of 2022 data from the National Survey on Drug Use and Health suggests that 3.7% of U.S. adults meet DSM-5 diagnostic criteria for OUD. Of this group, 55.2% received some form of OUD treatment, and 25.1% received medications for OUD. Another survey study highlighted one significant barrier to care: Most people either do not know that primary care physicians can prescribe medications for OUD or incorrectly believe that they cannot. Although family physicians make up the largest share of buprenorphine prescribers, according to a 2020 Graham Center Policy One-Pager, the vast majority of family physicians are not prescribing. A systematic review found that physicians are reluctant to address substance use and addiction in their practices because of lack of institutional support, knowledge and skills, and cognitive capacity.

Collectively, these health care system limitations create major gaps in the cascade of care for OUD, according to a JAMA commentary:

The care cascade—widespread screening regardless of the point of care; ensuring diagnosed patients receive treatment, including medications; and retaining patients in care—has been part of medical care for many years and most clinicians, regardless of medical specialty or practice setting, have understood its importance. … With 1 in 27 adults needing OUD treatment, most US clinicians are likely to have patients who need treatment in their practices, whether they are aware of it or not.

For patients with OUD who decline treatment with sublingual or long-acting injectable buprenorphine, clinicians can offer harm reduction strategies such as naloxone distribution, needle and syringe programs, and long-acting reversible contraception, if applicable. A previous AFP article on primary care for persons who inject drugs recommends screening for HIV infection, latent tuberculosis, and hepatitis B and C; providing vaccinations for hepatitis A and B, tetanus, and pneumonia if indicated; and offering HIV pre-exposure prophylaxis.

A cluster randomized trial conducted from July 2021 to June 2022 evaluated the effect of a community-level intervention to increase uptake of evidence-based practices to reduce opioid-related overdose deaths: overdose education and naloxone distribution, medications for OUD, and prescription opioid safety. In the United States, 67 communities in Kentucky, Massachusetts, New York, and Ohio were randomized to the intervention or a wait-list control. Unfortunately, opioid overdose death rates were similar in the intervention and control groups. The intervention’s apparent lack of effect may have been due to the short follow-up period, a coincidental spike in fentanyl-related overdoses, challenges in implementing practice changes during the COVID-19 pandemic, and a low (less than 20%) rate of medications for OUD–prescribing in intervention communities.

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This post first appeared on the AFP Community Blog.

Get out the vote: supporting civic health in primary care

The national organization Vot-ER designated August as Civic Health Month, “a time to showcase the link between voting and health and celebrate efforts that ensure each and every voter has the opportunity to support their community’s health at the ballot box.” Partners, including the American Association of Medical Colleges, encourage clinicians and health care organizations to support an inclusive democracy by providing patients with nonpartisan education and voter registration services.




A narrative review in The Milbank Quarterly explored the role of primary care in advancing civic engagement and health equity. Research shows that poorer population health is associated with lower voter turnout, with stronger associations occurring in early adulthood rather than in middle age. On the other hand, voting is associated with positive mental health and health behaviors, and higher levels of individual happiness strongly predict future civic engagement. Similarly, volunteers are less likely to be hospitalized and more likely to receive preventive care, even after controlling for age, gender, race, income, education, and insurance status: “In one study of US adults, volunteers spent 38% fewer nights in a hospital and were more likely to receive services such as flu shots, cholesterol screening, mammograms, and prostate exams as compared with nonvolunteers.”

Primary care physicians have successfully engaged patients with “civic health check-ups” at federally qualified health centers and other outpatient locations. In a voter registration project in the waiting areas of two family medicine residency clinics in the Bronx, volunteers registered 114 of 128 eligible patients during a 12-week period, 65% of whom were younger than 40 years. During the COVID-19 pandemic, a general internal medicine clinic in North Carolina used its patient portal to disseminate a REDCap survey containing embedded links to voter resources, including safer alternatives to in-person voting during the 2020 elections.

Outside of these and other individual case studies, voter enfranchisement remains, to borrow from the title of a 2020 perspective article in the Journal of General Internal Medicine, “an underused treatment strategy." To make voting a “standard of care,” Vot-ER is hosting several online events this month for clinicians who are interested in empowering patients to support their community’s health at the ballot box.

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This post first appeared on the AFP Community Blog.

Assessing new screening strategies: collaboration and persistence pay off

One strategy that I've found ensures a long and productive academic career is collaborating with talented and curious colleagues. I first put it into practice as a medical officer at the Agency for Healthcare Research and Quality, writing evidence summaries and systematic reviews with other staffers and rotating Preventive Medicine residents. At Georgetown, I collaborated with a terrific team of health researchers to write papers on interpreting and managing test results for Zika virus and COVID-19. I've collaborated with members of the AAFP's Commission on Health of the Public and Science on clinical practice guidelines on COPD exacerbations and blood pressure targets in adults with hypertension. I've collaborated on articles on social media for doctors and advocacy curricula in family medicine residency programs. Through the Lown Institute, I have collaborated on original work estimating the U.S. rate of overuse of screening colonoscopy and the associated harms. And most recently, I worked with a longtime mentor and sometime mentee on an analysis piece in BMJ Evidence Based Medicine that assesses evidence thresholds for proposals for updating established screening strategies.

How this paper came about deserves some explanation. In spring 2021, a company interested in developing a new screening test approached me to ask whom they should consult about the type of evidence required for that test to be endorsed by guideline panels and be covered by insurance. I recommended Russ Harris, a former U.S. Preventive Services Task Force (USPSTF) member who had retired from his academic position at UNC-Chapel Hill but was still interested in pursuing new scholarly projects. Russ then reached out to me in an e-mail: "I don’t think the methods are well worked out for replacing an established screening strategy with a new one in the absence of a formal RCT. Do you have any interest in [doing] some scholarly work on making a contribution to this problem?"

I responded: "I agree with you that it's not clear what kind of evidence is needed to recommend a new screening strategy without a RCT with mortality outcomes. I've been puzzling over this problem since the USPSTF first recommended CT colonography and FIT-DNA for colorectal cancer screening, apparently on the basis of being able to plug their diagnostic accuracy studies into a decision model. I don't see how the TF got to 'high certainty of substantial net benefit' for these tests."

Not long after that, we recruited the third member of our team: Alison Huffstetler, whom I met when she was completing her policy fellowship at Georgetown (we both saw patients in the same family medicine office on Fridays) and had subsequently taken a research faculty position at Virginia Commonwealth University. We decided that we would each study a different condition where the USPSTF had adopted a new screening strategy (cervical, colorectal, and breast cancer) and formulate some common principles that would drive the paper's analysis. Ambitiously, in early May I proposed a timeline that would allow us to "get the bulk of the paper written in the second half of June / first half of July [2021]."

It took a bit longer than that. I moved back to DC from Utah, then moved to Lancaster the following summer to start a new job. Alison got married, changed jobs, and had a baby. Russ kept us on task and, though many Zoom calls, we kept making progress.

Finally, in January 2023 (a year and a half later), we completed a manuscript that we submitted to the American Journal of Preventive Medicine. It was peer reviewed but rejected. We did some rewriting and resubmitted it to JAMA Internal Medicine in June 2023. It was "desk rejected" (not sent out for review) by JAMA-IM, then, in rapid succession, transferred to and rejected by JAMA Health Forum and JAMA Network Open. We moved on to the Journal of Clinical Epidemiology, Annals of Internal Medicine, and then the Journal of General Internal Medicine: same outcome. In the meantime, I presented our paper at the Preventing Overdiagnosis conference in Copenhagen and received some encouraging feedback, which provided enough motivation to keep trying. We embarked on another rewrite and resubmitted the paper as an analysis piece to BMJ in January 2024. The journal's editors rejected it after peer review, but they advised that it could be a good fit for BMJ Evidence Based Medicine. We revised our paper in response to the reviews and submitted it to BMJ-EBM in April 2024. More revision requests ensued. Finally, on August 21, our paper was accepted, and it was published online on September 3.

If you've been keeping count, 8 journals had a chance to publish our manuscript but passed after varying degrees of editorial and peer review. Number 9 turned out to be the charm. This paper required not only collaboration, but dogged persistence and an unswerving belief that we had something of value to contribute to the dialogue around screening. I hope you will agree.