Busting myths: Substance use disorder management in primary care

Just like other chronic diseases, substance use disorder (SUD) management is well-suited for primary care. Ideally, family physicians have a long-term knowledge of the patient, an established relationship and, hopefully, the patient’s trust.It’s also a condition that includes working on both a series of physical symptoms (e.g., chronic pain) and mental health symptoms. Physicians practising in primary care can make sure that these aren’t treated in silos, but as part of a holistic management of the patient’s health. Despite addiction medicine being a mainstay of primary care, myths remain that can make physicians hesitant to incorporate substance use management in their practice.Myth: All SUD cases are difficultA 2024 paper in Canadian Family Physician featured results from a survey of 218 Saskatchewan family physicians asking why they don’t prescribe opioid agonist therapy (OAT) to treat opioid use disorder. One reason was that they were “difficult” patients.People with SUDs are like other patients with a chronic condition who need an initial flurry of support and care, but who stabilize and need less care. Like in other chronic conditions, there’s a variety of cases. There are some patients who benefit from an intervention, a medication and other resources and do very well, noted Dr. Jennifer Wyman, medical director of the substance use service at Women’s College Hospital in Toronto, and clinical programs lead for META:PHI (Mentoring education and clinical tools for addiction: Partners in health integration). “Not everyone has multi-layered, complex medical and psychiatric conditions, even though there is a lot of trauma.” Clinicians have to figure out their scope on balancing all these aspects and when to seek help in complicated cases.Myth: It takes too much time“I think it’s a bit of a myth that it has to take a lot of time,” Dr. Wyman said. “Just like with other patients with chronic conditions that require a lot of support with a new diagnosis, there’s often a lot of effort, counselling and coordination in the early stages that then settles into much more routine check-ins and followup when the person stabilizes.”She compared it to providing mental health counselling in primary care. It does take time, but, “It’s not forever, and not always super complex and involved,” she said.Time is, of course, linked to a physician’s concern about appropriate remuneration. Comparing physician payment for SUD management across jurisdictions is tricky, since each one tackles it in different ways. Some have billing fee codes that take time into account. Others acknowledge complexity in other ways. In Manitoba, family physicians get additional payments for caring for people with a SUD (excluding caffeine and tobacco) as part of Manitoba’s new longitudinal primary care funding model, Family Medicine Plus. Medical associations across Canada are working to increase family physician pay in this area. For example, family physicians in Saskatchewan should see an increase in fee codes for managing SUD in April 2025 (pending Ministry of Health approval).Myth: Abstinence is the only goalTreating substance use isn’t only about abstinence, but more of a continuum of harm reduction, explained Dr. Wyman. It’s engaging and supporting patients where they are to help them become healthier and move them towards recovery.When physicians don’t grasp this concept, “I think sometimes physicians don’t understand the point of some of our interventions,” Dr. Wyman said.Evidence suggests that OAT allows people to build their “recovery capital,” a concept that helps the patient gain a better quality of life that will support SUD recovery in a holistic way.For alcohol use, some treatments are indicated for reducing alcohol use, while others are used to support a goal of abstinence. Patients’ goals may differ, but evidence-based medicines exist to help patients, and family physicians should be comfortable prescribing them.Integrating SUDThat “initial flurry of care” can often be managed outside the primary care clinic. Most provinces have clinics that provide rapid access to addiction medicine (RAAM) care. In Ontario, Manitoba, Saskatchewan and Alberta, these are called RAAM clinics, and RAAC (the C is for care) clinics in British Columbia, with similar services having different names in other regions. The goal is to stabilize the patient and then transition them back to their primary care provider, said Dr. Erin Knight, president of the Canadian Society for Addiction Medicine (CSAM) and a family physician who practices general and addiction medicine in Winnipeg.Transitioning back to primary care can be challenging if family physicians don’t prescribe the medications that RAAM clinics use. Regulatory requirements differ across jurisdictions for prescribing opioid agonist therapies such as methadone or slow-release oral morphine. In most provinces, prescribers need a specific authorization from their medical regulator to prescribe those medications, but often not to prescribe buprenorphine or buprenorphine/naloxone (Suboxone). Regardless of regulatory requirements, like with all medications, physicians must have sufficient knowledge and competencies to prescribe OAT. Most medical regulators provide or recommend training courses for various types of SUD management. CSAM has some training, including a one-day course run during its annual conference in October. The B.C. Centre on Substance Use also has an online addiction training program.“It’s really great when physicians have enough of an understanding of medications like buprenorphine and methadone that they can support their patients around co-prescribing or transitions of care or disruptions of care,” Dr. Wyman said. Disruptions in care can occur when a person receiving OAT gets another medical procedure, and the physicians in the hospital are reluctant to provide OAT. This leaves the patient dealing with the pain from the procedure as well as withdrawal from medication on which they’re physiologically dependent.Physicians should also familiarize themselves with medications to support patients who are wanting to change their alcohol use. As a physician who works in an addiction clinic, “I’m really gratified to see family doctors initiating medications before referring their patients,” Dr. Wyman said.For physicians interested in incorporating more SUD treatment in their practice, Dr. Knight advises starting with taking referrals from RAAM (or similar) clinics and/or taking new patients who are stabilized. “Then you can build your comfort level in more straightforward situations and then gradually increase your knowledge base over time,” she said.British Columbia has a telephone consult service available for primary care and other physicians working with patients with SUD. Dr. Wyman said this would be useful to have in Ontario, both for community-based and hospital-based physicians.“It’s really a challenge, not only in community practice, but for when patients are admitted to hospital and when clinicians don’t know how to manage alcohol withdrawal well or opioid withdrawal or chronic pain on top of opioid withdrawal or methadone withdrawal,” Dr. Wyman said.Another complex part of SUD management in primary care is differentiating if a person needs opioids to combat chronic pain, or if they seek opioids because of an addiction.“Honestly, the overlap between chronic pain and opioid use disorder in particular is probably one of the more challenging clinical situations to manage,” Dr. Knight said. “One of the things I encourage people to think about is that it’s not specifically the dose of medication that they’re using, or the total amount. What’s important is their relationship with the substance use—so, trying to work with patients who identify the impact of that substance on their lives.”Addiction care needs to be trauma-informed care. “Think about what happened to them that got them to this situation, as opposed to what’s wrong with them,” Dr. Wyman said. These patients often have faced a lot of stigma within the healthcare system and may be reluctant to seek care, making them seem non-compliant, Dr. Wyman said. “Building trust is really important.”Physicians need to recognize that addiction is common human behaviour, Dr. Knight said. She urged physicians to, “normalize talking about it and incorporate it into periodic health exams as much as possible so we can help people to live well, despite substance use.”

Busting myths: Substance use disorder management in primary care

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