Reducing the Health Consequences of Opioid Addiction in Primary Care


      Addiction to prescription opioids is prevalent in primary care settings. Increasing prescription opioid use is largely responsible for a parallel increase in overdose nationally. Many patients most at risk for addiction and overdose come into regular contact with primary care providers. Lack of routine addiction screening results in missed treatment opportunities in this setting. We reviewed the literature on screening and brief interventions for addictive disorders in primary care settings, focusing on opioid addiction. Screening and brief interventions can improve health outcomes for chronic illnesses including diabetes, hypertension, and asthma. Similarly, through the use of screening and brief interventions, patients with addiction can achieve improved health outcome. A spectrum of low-threshold care options can reduce the negative health consequences among individuals with opioid addiction. Screening in primary care coupled with short interventions, including motivational interviewing, syringe distribution, naloxone prescription for overdose prevention, and buprenorphine treatment are effective ways to manage addiction and its associated risks and improve health outcomes for individuals with opioid addiction.


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        • Paulozzi L.J.
        • Ryan G.W.
        Opioid analgesics and rates of fatal drug poisoning in the United States.
        Am J Prev Med. 2006; 31: 506-511
        • Beletsky L.
        • Burris S.
        • Kral A.H.
        Closing death's door: action steps to facilitate emergency opioid drug overdose reversal in the United States.
        Social Science Research Network eLibrary. 2009; (Available at:) (Accessed February 1, 2012)
        • Centers for Disease Control (CDC)
        CDC grand rounds: prescription drug overdoses - a U.S. epidemic.
        MMWR Morb Mortal Wkly Rep. 2012; 61: 10-13
        • Paulozzi L.J.
        Opioid analgesic involvement in drug abuse deaths in American metropolitan areas.
        Am J Public Health. 2006; 96: 1755-1757
        • Pletcher M.J.
        • Kertesz S.G.
        • Kohn M.A.
        • Gonzales R.
        Trends in opioid prescribing by race/ethnicity for patients seeking care in US emergency departments.
        JAMA. 2008; 299: 70-78
        • Fingerhut L.
        Increases in Methadone-Related Deaths: 1994-2004.
        Centers for Disease Control, Atlanta, GA2007
        • Bruce R.D.
        Medical interventions for addictions in the primary care setting.
        Top HIV Med. 2010; 18: 8-12
        • Swenson-Britt E.
        • Carrougher G.
        • Martin B.W.
        • Brackley M.
        Project Hope: changing care delivery for the substance abuse patient.
        Clin Nurse Spec. 2000; 14: 92-100
        • McLellan A.T.
        • Lewis D.C.
        • O'Brien C.P.
        • Kleber H.D.
        Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation.
        JAMA. 2000; 284: 1689-1695
        • Knight J.R.
        • Harris S.K.
        • Sherritt L.
        • et al.
        Prevalence of positive substance abuse screen results among adolescent primary care patients.
        Arch Pediatr Adolesc Med. 2007; 161: 1035-1041
        • Inciardi J.A.
        • Surratt H.L.
        • Cicero T.J.
        • et al.
        Prescription drugs purchased through the internet: who are the end users?.
        Drug Alcohol Depend. 2010; 110: 21-29
        • Fischer B.
        • Bibby M.
        • Bouchard M.
        The global diversion of pharmaceutical drugsnon-medical use and diversion of psychotropic prescription drugs in North America: a review of sourcing routes and control measures.
        Addiction. 2010; 105: 2062-2070
        • Martyres R.F.
        • Clode D.
        • Burns J.M.
        Seeking drugs or seeking help? Escalating "doctor shopping" by young heroin users before fatal overdose.
        Med J Aust. 2004; 180: 211-214
        • Mertens J.R.
        • Weisner C.
        • Ray G.T.
        • et al.
        Hazardous drinkers and drug users in HMO primary care: prevalence, medical conditions, and costs.
        Alcohol Clin Exp Res. 2005; 29: 989-998
        • Fleming M.F.
        • Barry K.L.
        The effectiveness of alcoholism screening in an ambulatory care setting.
        J Stud Alcohol. 1991; 52: 33-36
        • Hall A.J.
        • Logan J.E.
        • Toblin R.L.
        • et al.
        Patterns of abuse among unintentional pharmaceutical overdose fatalities.
        JAMA. 2008; 300: 2613-2620
        • Smith P.C.
        • Schmidt S.M.
        • Allensworth-Davies D.
        • Saitz R.
        A single-question screening test for drug use in primary care.
        Arch Intern Med. 2010; 170: 1155-1160
        • Brown R.L.
        • Rounds L.A.
        Conjoint screening questionnaires for alcohol and other drug abuse: criterion validity in a primary care practice.
        Wis Med J. 1995; 94: 135-140
        • Maisto S.A.
        • Carey M.P.
        • Carey K.B.
        • et al.
        Use of the AUDIT and the DAST-10 to identify alcohol and drug use disorders among adults with a severe and persistent mental illness.
        Psychol Assess. 2000; 12: 186-192
        • Yudko E.
        • Lozhkina O.
        • Fouts A.
        A comprehensive review of the psychometric properties of the Drug Abuse Screening Test.
        J Subst Abuse Treat. 2007; 32: 189-198
        • Bedregal L.E.
        • Sobell L.C.
        • Sobell M.B.
        • Simco E.
        Psychometric characteristics of a Spanish version of the DAST-10 and the RAGS.
        Addict Behav. 2006; 31: 309-319
        • Knight J.R.
        • Sherritt L.
        • Shrier L.A.
        • et al.
        Validity of the CRAFFT substance abuse screening test among adolescent clinic patients.
        Arch Pediatr Adolesc Med. 2002; 156: 607-614
        • Glassroth J.
        • Adams G.D.
        • Schnoll S.
        The impact of substance abuse on the respiratory system.
        Chest. 1987; 91: 596-602
        • Pankratz L.
        • Hickam D.H.
        • Toth S.
        The identification and management of drug-seeking behavior in a medical center.
        Drug Alcohol Depend. 1989; 24: 115-118
        • Weaver M.
        • Schnoll S.
        Abuse liability in opioid therapy for pain treatment in patients with an addiction history.
        Clin J Pain. 2002; 18: S61-S69
        • Basu S.
        • Bruce R.D.
        • Barry D.T.
        • Altice F.L.
        Pharmacological pain control for human immunodeficiency virus-infected adults with a history of drug dependence.
        J Subst Abuse Treat. 2007; 32: 399-409
        • Jamison R.N.
        • Ross E.L.
        • Michna E.
        • et al.
        Substance misuse treatment for high-risk chronic pain patients on opioid therapy: a randomized trial.
        Pain. 2010; 150: 390-400
        • Savage S.R.
        Management of opioid medications in patients with chronic pain and risk of substance misuse.
        Curr Psychiatry Rep. 2009; 11: 377-384
        • Moos R.H.
        Iatrogenic effects of psychosocial interventions for substance use disorders: prevalence, predictors, prevention.
        Addiction. 2005; 100: 595-604
        • Zahradnik A.
        • Otto C.
        • Crackau B.
        • et al.
        Randomized controlled trial of a brief intervention for problematic prescription drug use in non-treatment-seeking patients.
        Addiction. 2009; 104: 109-117
        • Miller W.R.
        • Rollnick S.
        Motivational Interviewing: Preparing People for Change.
        2nd ed. The Guilford Press, New York, NY2002
        • Burke B.L.
        • Arkowitz H.
        • Menchola M.
        The efficacy of motivational interviewing: a meta-analysis of controlled clinical trials.
        J Consult Clin Psychol. 2003; 71: 843-861
        • Martino S.
        • Carroll K.M.
        • O'Malley S.S.
        • Rounsaville B.J.
        Motivational interviewing with psychiatrically ill substance abusing patients.
        Am J Addict. 2000; 9: 88-91
        • Saunders B.
        • Wilkinson C.
        • Phillips M.
        The impact of a brief motivational intervention with opiate users attending a methadone programme.
        Addiction. 1995; 90: 415-424
        • Schneider R.J.
        • Casey J.
        • Kohn R.
        Motivational versus confrontational interviewing: a comparison of substance abuse assessment practices at employee assistance programs.
        J Behav Health Serv Res. 2000; 27: 60-74
        • Stephens R.S.
        • Roffman R.A.
        • Curtin L.
        Comparison of extended versus brief treatments for marijuana use.
        J Consult Clin Psychol. 2000; 68: 898-908
        • Hagan H.
        • McGough J.P.
        • Thiede H.
        • et al.
        Syringe exchange and risk of infection with hepatitis B and C viruses.
        Am J Epidemiol. 1999; 149: 203-213
        • Valleroy L.A.
        • Weinstein B.
        • Jones T.S.
        • et al.
        Impact of increased legal access to needles and syringes on community pharmacies' needle and syringe sales—Connecticut, 1992-1993.
        J Acquir Immune Defic Syndr Hum Retrovirol. 1995; 10: 73-81
        • Lurie P.
        • Reingold A.L.
        • Lee P.R.
        • et al.
        The Public Health Impact of Needle Exchange Programs in the United States and Abroad: Summary, Conclusions and Recommendations.
        (Prepared for the Centers for Disease Control and Prevention (CDC) by the School of Public Health, University of California, Berkeley, and the Institute for Health Policy Studies, University of California, San Francisco) CDC, Atlanta, GA1993
      1. Normand J. Vlahov D. Moses L.E. Preventing HIV Transmission: The Role of Sterile Needles and Bleach. National Academies Press, Washington DC1995
        • Fisher D.G.
        • Fenaughty A.M.
        • Cagle H.H.
        • Wells R.S.
        Needle exchange and injection drug use frequency: a randomized clinical trial.
        J Acquir Immune Defic Syndr. 2003; 33: 199-205
        • Huo D.
        • Ouellet L.J.
        Needle exchange and injection-related risk behaviors in Chicago: a longitudinal study.
        J Acquir Immune Defic Syndr. 2007; 45: 108-114
        • Hurley S.F.
        • Jolley D.J.
        • Kaldor J.M.
        Effectiveness of needle-exchange programmes for prevention of HIV infection.
        Lancet. 1997; 349: 1797-1800
        • Strathdee S.A.
        • van Ameijden E.J.
        • Mesquita F.
        • et al.
        Can HIV epidemics among injection drug users be prevented?.
        AIDS. 1998; 12: S71-S79
        • Strathdee S.A.
        • Celentano D.D.
        • Shah N.
        • et al.
        Needle-exchange attendance and health care utilization promote entry into detoxification.
        J Urban Health. 1999; 76: 448-460
        • Rich J.D.
        • McKenzie M.
        • Macalino G.E.
        • et al.
        A syringe prescription program to prevent infectious disease and improve health of injection drug users.
        J Urban Health. 2004; 81: 122-134
        • Rich J.D.
        • Green T.C.
        • McKenzie M.S.
        Opioids and deaths.
        N Engl J Med. 2011; 364: 686
        • Dettmer K.
        • Saunders B.
        • Strang J.
        Take home naloxone and the prevention of deaths from opiate overdose: two pilot schemes.
        BMJ. 2001; 322: 895-896
        • Maxwell S.
        • Bigg D.
        • Stanczykiewicz K.
        • Carlberg-Racich S.
        Prescribing naloxone to actively injecting heroin users: a program to reduce heroin overdose deaths.
        J Addict Dis. 2006; 25: 89-96
        • Seal K.H.
        • Thawley R.
        • Gee L.
        • et al.
        Naloxone distribution and cardiopulmonary resuscitation training for injection drug users to prevent heroin overdose death: a pilot intervention study.
        J Urban Health. 2005; 82: 303-311
        • Sporer K.A.
        • Kral A.H.
        Prescription naloxone: a novel approach to heroin overdose prevention.
        Ann Emerg Med. 2007; 49: 172-177
        • Strang J.
        • Powis B.
        • Best D.
        • et al.
        Preventing opiate overdose fatalities with take-home naloxone: pre-launch study of possible impact and acceptability.
        Addiction. 1999; 94: 199-204
        • Galea S.
        • Worthington N.
        • Piper T.M.
        • et al.
        Provision of naloxone to injection drug users as an overdose prevention strategy: early evidence from a pilot study in New York City.
        Addict Behav. 2006; 31: 907-912
        • Strang J.
        • Best D.
        • Man L.
        • et al.
        Peer-initiated overdose resuscitation: fellow drug users could be mobilised to implement resuscitation.
        Int J Drug Policy. 2000; 11: 437-445
        • Sherman S.G.
        • Gann D.S.
        • Tobin K.E.
        • et al.
        "The life they save may be mine": diffusion of overdose prevention information from a city sponsored programme.
        Int J Drug Policy. 2009; 20: 137-142
        • Tobin K.E.
        • Sherman S.G.
        • Beilenson P.
        • et al.
        Evaluation of the Staying Alive programme: training injection drug users to properly administer naloxone and save lives.
        Int J Drug Policy. 2009; 20: 131-136
        • Pollini R.A.
        • McCall L.
        • Mehta S.H.
        • et al.
        Non-fatal overdose and subsequent drug treatment among injection drug users.
        Drug Alcohol Depend. 2006; 83: 104-110
        • Lazarus P.
        Project Lazarus, Wilkes County, North Carolina: Policy Briefing Document Prepared for the North Carolina Medical Board in Advance of the Public Hearing Regarding Prescription Naloxone.
        (Policy Briefing Document for the North Carolina Board) Project Lazarus, Raleigh, NC2007
        • Beletsky L.
        • Ruthazer R.
        • Macalino G.E.
        • et al.
        Physicians' knowledge of and willingness to prescribe naloxone to reverse accidental opiate overdose: challenges and opportunities.
        J Urban Health. 2007; 84: 126-136
        • Johnson R.E.
        • Chutuape M.A.
        • Strain E.C.
        • et al.
        A comparison of levomethadyl acetate, buprenorphine, and methadone for opioid dependence.
        N Engl J Med. 2000; 343: 1290-1297
        • Gibson A.E.
        • Doran C.M.
        • Bell J.R.
        • et al.
        A comparison of buprenorphine treatment in clinic and primary care settings: a randomised trial.
        Med J Aust. 2003; 179: 38-42
        • Mattick R.P.
        • Kimber J.
        • Breen C.
        • Davoli M.
        Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence.
        Cochrane Database Syst Rev. 2008; (Available at:) (Accessed November 3, 2012): CD002207
        • Mintzer I.L.
        • Eisenberg M.
        • Terra M.
        • et al.
        Treating opioid addiction with buprenorphine-naloxone in community-based primary care settings.
        Ann Fam Med. 2007; 5: 146-150
        • Stenbacka M.
        • Leifman A.
        • Romelsjo A.
        The impact of methadone treatment on registered convictions and arrests in HIV-positive and HIV-negative men and women with one or more treatment periods.
        Drug Alcohol Rev. 2003; 22: 27-34
        • Gossop M.
        • Marsden J.
        • Stewart D.
        • Rolfe A.
        Patterns of improvement after methadone treatment: 1 year follow-up results from the National Treatment Outcome Research Study.
        Drug Alcohol Depend. 2000; 60: 275-286
        • Marsch L.A.
        The efficacy of methadone maintenance interventions in reducing illicit opiate use, HIV risk behavior and criminality: a meta-analysis.
        Addiction. 1998; 93: 515-532
        • Davstad I.
        • Stenbacka M.
        • Leifman A.
        • Romelsjo A.
        An 18-year follow-up of patients admitted to methadone treatment for the first time.
        J Addict Dis. 2009; 28: 39-52
        • Stock C.
        • Shum J.H.
        Buprenorphine: a new pharmacotherapy for opioid addictions in treatment.
        J Pain Palliat Care Pharmacother. 2004; 18: 35-54
        • Substance Abuse and Mental Health Services Administration (SAMHSA)
        Results from the 2008 National Survey on Drug Use and Health: National Findings.
        Office of Applied of Applied Studies, SAMHSA, U.S. Dept. of Health and Human Services, Rockville, MD2009
        • Gavin DR.
        • Ross HE.
        • Skinner HA.
        Diagnostic validity of the drug abuse screening test in the assessment of DSM-III drug disorders.
        Br J Addict. 1989; 84: 301-307
        • Fleming MF.
        • Barry KL.
        • Manwell LB.
        • et al.
        Brief physician advice for problem alcohol drinkers. A randomized controlled trial in community-based primary care practices.
        JAMA. 1997; 277: 1039-1045
        • Bien TH.
        • Miller WR.
        • Tonigan JS.
        Brief interventions for alcohol problems: a review.
        Addiction. 1993; 88: 315-335
        • Bernstein J.
        • Bernstein E.
        • Tassiopoulos K.
        • et al.
        Brief motivational intervention at a clinic visit reduces cocaine and heroin use.
        Drug Alcohol Depend. 2005; 77: 49-59
      2. The Effectiveness of AIDS Prevention Efforts. Washington DC: Office of Technology Policy Assessment of the US Congress, 1995 September 1995. Report No.

        • Wood E.
        • Tyndall MW.
        • Stoltz J.
        • et al.
        Safer injecting education for HIV prevention within a medically supervised safer injecting facility.
        Int J Drug Pol. 2005; 16: 281-284

      Linked Article

      • Screening and Brief Intervention for Opioid Addiction in Primary Care Is Not Evidence Based
        The American Journal of MedicineVol. 126Issue 11
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          Bowman et al1 assert that brief intervention in patients identified by screening in primary care will have efficacy. They also recommend annual screening and motivational interviewing. They conclude that “screening all patients … is critical.”1 No data support these assertions and recommendations.
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      • Comments on Reducing the Health Consequences of Opioid Addiction
        The American Journal of MedicineVol. 126Issue 11
        • Preview
          No discussion of overdose deaths caused by opioids1 would be complete without pointing out the exceptional risk posed by methadone. The Centers for Disease Control and Prevention notes that “while methadone accounts for only 2 percent of painkiller prescriptions in the United States, it is involved in more than 30 percent of prescription painkiller overdose deaths” and that “six times as many people died of methadone overdoses in 2009 as died in 1999.”2 It appears that any effort to slow the rising number of opioid overdose deaths will require special attention to reducing the risk posed by methadone.
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