Impact of Provider-Facing Interventions to Reduce Opioid Use on Pain Related Outcomes in Primary Care: A Cluster Randomized Trial.

Opioids for persistent non-cancer pain: recommendations for clinical practice

Objectives:The PINPOINT (PaIn aNd oPiOId maNagemenT) intervention in Oregon aimed to support primary care clinics in applying evidence-based guidelines for pain management and opioid use disorder treatment. We evaluated the impact of this intervention on opioid use disorder treatment and overdose outcomes.Methods:Data from the voluntary Oregon All Payer All Claims datasets were integrated with several administrative datasets to create the Provider Results of Opioid Management and Prescribing Training dataset, which tracks clinical and prescribing activities at the provider level. We employed difference-in-differences models to assess the impact of PaIn aNd oPiOId maNagemenT enrollment on changes in opioid use disorder treatment and overdose outcomes. The intervention sample consisted of 289 primary care providers from clinics participating in PaIn aNd oPiOId maNagemenT, compared with 2000 control providers identified through administrative claims.Results:The difference-in-differences models indicated statistically significant associations between intervention enrollment and treatment with medications for opioid use disorder (incidence rate ratio [IRR] = 1.214, 95% confidence interval [CI] = 1.100-1.340), any substance use disorder treatment (IRR = 1.120, 95% CI = 1.070-1.172), and any outpatient opioid use disorder treatment (IRR = 1.102, 95% CI = 1.034-1.175) compared to controls. No statistically significant changes were observed in overall non-fatal drug overdoses, non-fatal opioid overdoses, and naloxone overdose reversals, though absolute event rates were low.Conclusions:We found that multi-faceted, evidence-based approaches to improve clinical practice in primary care settings were associated with increased treatment for opioid use disorder, however differences in overdose outcomes were not observed. Further research is needed to assess the scalability and clinical impact of these interventions across diverse care environments.

Back to table of contents Previous article Professional NewsFull AccessPain, Opioid Addiction Addressed Simultaneously in Special ClinicAaron LevinAaron LevinSearch for more papers by this authorPublished Online:19 May 2016https://doi.org/10.1176/appi.pn.2016.5b10AbstractUniversity of Colorado addictions specialists want to integrate better care for patients and better training for colleagues into the clinic.“We need to train our way out of the opioid crisis,” said Kaylin Klie, M.D., M.A., at the American Society of Addiction Medicine’s annual conference in April in Baltimore.The use of opioid medications—most often prescribed in primary care—has risen sharply in recent years, despite a lack of evidence for their efficacy for noncancer pain, noted Klie, an instructor in psychiatry at the University of Colorado School of Medicine in Aurora. In 2014, 19,000 Americans died from overdoses of prescription opioids.Denizens of separate medical silos traditionally have had a hard time crossing professional boundaries, said Klie.“Addiction providers are uncomfortable treating pain; pain management providers are uncomfortable treating addiction; and primary care people are uncomfortable treating either,” she said.The University of Colorado has tackled that problem by establishing a Controlled Substance Clinic (CSC) within its Family Medicine primary care clinic.The CSC was set up under the direction of Patricia Pade, M.D., an assistant professor of family medicine and the program director of the University of Colorado Addiction Medicine Fellowship. Pade was formerly director of the Co-occurring Disorders Clinic at the New Mexico Veterans Administration Health Care System, and the Colorado clinic is modeled on that experience. Fellows from the Addiction Medicine Fellowship take part as well, both treating patients and working to educate their primary care colleagues.The clinic evaluates, treats, manages, and monitors comorbid pain and addiction, focusing on high-risk opioid patients, said Klie. “High-risk” includes younger patients and individuals with a family or personal history of substance use disorder or with a comorbid psychiatric disorder.“We treat both chronic pain and addiction at the same time,” she said. “We tell them that chronic opioid therapy has never been shown to be successful over a lifetime. We take an hour for the initial intake visit, but we’ve found that it’s rare to assess opioid dependence or substance use disorder in one visit. Building trust between patient and provider over time helps as they taper off opioids.” Patients worry that if they enter addiction treatment, their pain will not be addressed. So work often begins by dealing with pain to lessen the patient’s fear of losing medication. Treatment may include using drugs and behavioral therapy for pain to reduce opioid use. Patients can move in either direction between primary and addictions care. The CSC providers are available for immediate consultation from their primary care colleagues, who develop a better sense of pain and addiction as true medical conditions, lessening stigma. It also means that every patient has a primary care physician, allowing treatment of the whole patient.“Patients with co-occurring chronic pain and opioid dependence can be successfully treated in a primary care setting,” said Klie. “Buprenorphine or naloxone can be successfully used with adjunctive treatments available to primary care providers.”Following treatment, pain scores drop on average for these patients. Furthermore, about 77 percent remain in treatment, about half in primary care and the rest in the CSC.Most of the behavioral health care is provided by two psychologists on the team. Psychiatrist Laura Martin, M.D., an associate professor of psychiatry at the University of Colorado School of Medicine, is co-director of the fellowship and connects any patients with serious mental illnesses, such as personality disorders or schizophrenia, to a psychiatrist.Klie sees her clinic as a step toward future modes of expanding treatment.“The meat and potatoes of medicine come in training,” she said. “We can train ourselves, our patients, and the upcoming generation of physicians while we show that patients can be cared for without antagonizing their doctors.” ■ ISSUES NewArchived

Opioid use disorder (OUD) is commonly treated in specialized care settings with long-acting opioid agonists, also known as opioid agonist therapy, or OAT. Despite the rise in opioid use globally and evidence for a 50% reduction in mortality when OAT is employed, the proportion of people with OUD receiving OAT remains small. One initiative to improve the access and uptake of OAT could be to offer OAT in a primary care setting; primary care clinics are more numerous, might reduce the visibility and potential stigma of receiving treatment for OUD, and may facilitate the care of other medical conditions that are unrelated to OUD. However, it is unknown how effective treating OUD in primary care would be. To assess the benefits and harms of using opioid agonist therapy (OAT) to treat people with opioid use disorder (OUD) in a primary care setting, as compared to a traditional specialty care setting. We searched the Cochrane Drugs and Alcohol Group Specialized Register, Cochrane Central Register of Controlled Trials, MEDLINE, Embase, three other databases, and two trials registers in March 2025. We did not restrict searches by language or publication date. Eligible studies were parallel randomized controlled trials (RCTs) and cluster-randomized trials comparing OAT for OUD treatment in primary care versus specialty care settings. Participants were community-dwelling adults with OUD, as identified and defined by trial-specific inclusion criteria. We excluded trials if they included only pregnant women, or those who were incarcerated, but accepted all other comorbidity requirements (e.g. being HIV positive). Primary outcomes included treatment retention, abstinence from non-prescribed opioids, major adverse events, and withdrawals due to adverse events. Secondary outcomes were other patient-oriented outcomes, including quality of life, patient satisfaction, all-cause mortality, opioid-related mortality, all-cause hospitalization or emergency room visit, all-cause incarceration, and minor adverse events. Two review authors independently extracted data using a predesigned RCT template in Covidence. We assessed risk of bias using the Cochrane RoB 1 tool, and certainty of evidence using GRADE. We analyzed outcomes using Review Manager and a random-effects model to account for variability in care models and populations. We included seven RCTs involving 1992 participants. The studies were completed in France (1 study), Ukraine (1 study), and the US (5 studies), and enrolled predominantly males (75%) with a mean age of 38 years. Risk of bias in individual trials was typically low or unclear in all domains except for blinding, where it was high, given participants and providers could not realistically be blinded to setting. One trial was at high risk of bias related to random sequence generation and another for incomplete outcome data. The evidence is very uncertain whether there was a difference in treatment retention in a primary care setting (risk ratio (RR) 1.15, 95% confidence interval (CI) 0.98 to 1.34; 7 studies, 1952 participants; very low-certainty evidence). Abstinence from non-prescribed opioids at the end of follow-up may have been higher in participants managed in primary care (RR 1.59, 95% CI 1.03 to 2.46; 5 studies, 428 participants; low-certainty evidence). Major adverse events were infrequently reported. Only one trial reported all-cause death (one in primary care versus four in specialty care), but these numbers were too small to be meaningful (very low-certainty evidence). Although data from three studies regarding patient satisfaction could not be combined, patients in primary care may have had greater satisfaction. We downgraded certainty in the evidence twice for indirectness for all outcomes given the studies excluded high-risk patients (e.g. those who were pregnant, had co-dependence on alcohol or benzodiazepines, had psychiatric illness, or were homeless) and primary care providers were often atypical of primary care in general (with connections to, or proximity with, OUD-specialized clinics). We downgraded treatment retention an additional level for inconsistency due to high heterogeneity (I2 = 69%). For lower-risk people with OUD who were stable on OAT, managing their OAT in primary care, as compared to specialty care, the evidence is very uncertain for treatment retention and may have resulted in better abstinence from non-prescribed opioids and better patient satisfaction. Further trials in primary care clinics that have less experience with, or connection to, OUD specialty clinics is warranted.

Preoperative opioid use: a modifiable risk factor for poor postoperative outcomes

Three educational interventions were simulated in a system dynamics model of the medical use, trafficking, and nonmedical use of pharmaceutical opioids. The study relied on secondary data obtained in the literature for the period of 1995 to 2008 as well as expert panel recommendations regarding model parameters and structure. The behavior of the resulting systems-level model was tested for fit against reference behavior data. After the base model was tested, logic to represent three educational interventions was added and the impact of each intervention on simulated overdose deaths was evaluated over a 7-year evaluation period, 2008 to 2015. Principal findings were that a prescriber education intervention not only reduced total overdose deaths in the model but also reduced the total number of persons who receive opioid analgesic therapy, medical user education not only reduced overdose deaths among medical users but also resulted in increased deaths from nonmedical use, and a "popularity" intervention sharply reduced overdose deaths among nonmedical users while having no effect on medical use. System dynamics modeling shows promise for evaluating potential interventions to ameliorate the adverse outcomes associated with the complex system surrounding the use of opioid analgesics to treat pain.

Adults with opioid use disorder (OUD), co-occurring with depression and/or posttraumatic stress disorder (PTSD), may benefit from collaborative care. Although collaborative care is an evidence-based model to treat behavioral health conditions in primary care, it has not been widely tested for OUD with co-occurring mental illness. To determine whether collaborative care, tailored for low-resource settings, improves outcomes for patients with OUD and co-occurring depression and/or PTSD more so than enhanced usual care (EUC). This 2-group single-masked pragmatic randomized clinical trial was conducted in 18 primary care clinics in California and New Mexico from January 8, 2021, to December 5, 2023, and included adult participants with probable OUD as well as major depression and/or PTSD. Data analysis was performed August 2024 to May 2025. Six months of a care manager and addiction psychiatrist working with a primary care practitioner to deliver evidence-based treatments for OUD, major depression, and PTSD; care managers were community health workers who monitored and addressed biopsychosocial symptoms and referred patients for psychotherapy. Primary outcomes at 6 months were time to first filled buprenorphine prescription for participants entering the study not taking medication for OUD; cumulative days of prescribed buprenorphine for participants entering the study while not taking methadone, obtained from the state Prescription Drug Program; and Patient Health Questionnaire-9 and PTSD Checklist for DSM-5 scores from participant surveys. Secondary outcomes included days of opioid and other drug use, the Patient-Reported Outcomes Measurement Information System's substance use short form, and the Veterans RAND 12-item health survey. Of 2396 participants assessed for eligibility, 797 were randomized (397 to EUC; 400 to intervention); 433 (54.3%) were female and 364 (45.7%) male, with a mean (SD) age of 40.2 (11.9) years. Six-month survey retention was 68% for EUC and 64% for collaborative care. Adjusted mean (SD) differences on primary outcomes for collaborative care vs EUC were: 7.0 (95% CI, -3.4 to 17.4; P = .19) for days until first buprenorphine prescription; 4.3 (95% CI, -7.4 to 16.0; P = .47) for cumulative days of prescribed buprenorphine; -1.0 (95% CI, -2.3 to 0.3; P = .13) for Patient Health Questionnaire-9 score; and -0.9 (95% CI, -4.6 to 2.8; P = .63) for PTSD Checklist for the DSM-5 score; none were statistically significant. There were also no observed differences between groups for any secondary or exploratory outcomes; both groups improved over baseline. As-treated exploratory analyses showed evidence for improvements in OUD outcomes in the as-treated population. This randomized clinical trial found that among participants with OUD co-occurring with depression and/or PTSD, collaborative care did not demonstrate evidence of greater improvements in outcomes compared with EUC. Explanations include a possible spillover effect, spontaneous improvement, or the fit of collaborative care for clinically complex patients and settings with few behavioral health practitioners. ClinicalTrials.gov Identifier: NCT04559893 and NCT04634279.

Editorial

Health Care Reform and Care at the Behavioral Health--Primary Care Interface

In Europe and France, the use of opioid analgesic drugs has become widespread as an option for pain management. However, their use can lead to nonmedical use and/or opioid use disorder (OUD). This work aimed to assess the perceived risk of OUD secondary to opioid analgesic drugs use by the general population. We conducted a cross-sectional observational study using the GrippeNet web-based cohort, comprising about 10,000 French volunteers from the general population, using a self-administered questionnaire. The main outcome was the perceived risk of OUD secondary to opioid analgesic drugs use, assessed by a 4-item scale and modelled using logistic regression (backward procedure). Among 5046 French respondents, after adjustment, 65% believed that the use of analgesic drugs could likely or very likely lead to OUD. Factors associated with the perception of a higher risk were being over 50 and having heard about opioids in the media. Previous opioid use and a high level of education decreased the perception of the risk. Among those having used opioids in the past 2years (N=1770), 71.1% reported being not at all concerned by this risk. The majority of the sample perceived the risk of OUD but those having already used opioid analgesics drugs expressed no concern about this risk for themselves. This finding highlight the need to reinforce warning on the package insert documents, therapeutic education and collaborative care between the prescribing general practitioners and pharmacists to increase awareness of opioid medications users on the risk of OUD. This study found that the risk of OUD secondary to opioid analgesics use is well perceived in the general population, but that those having already used opioid analgesics expressed little concern for themselves. This finding could potentially help to raise awareness of healthcare providers and policy makers on the lack of perceived risk regarding these drugs and the need to inform and identify at-risk patients in primary care.

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The Veterans Health Administration (VA) has prioritized addressing opioid use disorder (OUD) due to rising opioid overdose rates among Veterans, aiming to expand evidence-based OUD treatment in primary care. The purpose of this project was to (1) examine VA provider perspectives regarding OUD treatment in primary care, and (2) explore provider perceptions about stigma related to OUD. From September 2021 to June 2022, we held 6 semi-structured focus groups with multidisciplinary VA primary care providers (n = 91 participants) via Microsoft Teams and in person. Each group, comprising 13 to 24 providers, engaged in interviews lasting 50 to 80 minutes. We employed qualitative interviewing techniques to collect feedback on provider perspectives concerning OUD treatment within VA primary care. Participants viewed 2 to 3 short videos from the Insights Into Recovery series. Focus group interviews were recorded, transcribed, and checked for accuracy. Directed content analysis was used to identify themes and patterns. Participants identified several barriers to treating OUD in primary care. Patient-level challenges reported by providers included establishing clinician-patient trust and differing views on OUD diagnoses. Provider-level barriers included limited experience, discomfort with treatment, and managing complex care needs. System-level obstacles involved time constraints, administrative burdens, and stigma, which affected attitudes toward OUD and opioid medication use. Facilitators of OUD care included satisfaction with patient success, training in buprenorphine prescribing, and the use of motivational interviewing (MI) techniques tailored to the patient's level of readiness. Providers identified barriers to OUD care, including patient trust issues, limited provider experience, lack of support, and stigma from both patients and providers. Facilitators included enhanced training in buprenorphine prescribing and MI. To strengthen OUD care, 3 key strategies are recommended: addressing provider stigma, prioritizing OUD-specific training, and integrating MI. These initiatives could enhance OUD care in primary care settings within the VA, benefiting Veterans with chronic pain and OUD.

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