Barriers to and Facilitators of Integrating Routine Screening for Opioid Use Disorder into Primary Care

As part of a clinical trial of integrated care for co-occurring opioid use disorder (OUD) and mental health conditions, investigators studied the implementation of routine OUD screening in 10 primary care clinics across the US. Clinics received training and coaching to use the National Institute on Drug Abuse-modified Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) instrument and independently established workflows, target populations, and screening frequency. Evaluation used ethnographic observation and interviews with clinic staff members to determine barriers to and facilitators of implementation.

• Choosing who to screen (all patients versus targeted populations) and how frequently to screen was challenging for clinics, while implementing universal screening (i.e., every patient, every visit) aided implementation.
• Other challenges included: clinic staff turnover, difficulty with the instrument, discomfort with screening, and discouragement from low screening yield.
• Clinicians were uncertain about how to document and respond to positive screens for OUD.
• Clinic policies that were previously established to promote opioid safety may have contributed to stigma and limited disclosure of unhealthy opioid use.

Comments: For OUD screening to succeed, primary care patients must trust that disclosing unhealthy opioid use will enhance, not compromise, their care. The US Preventive Services Task Force recommends screening all adults 18 years or older by asking questions about unhealthy drug use. While the evidence for screening and brief intervention for unhealthy drug use is weak, evidence-based OUD treatment can be delivered in primary care, which provides sufficient rationale to screen. Creating brief, simple and universal screening procedures should enhance OUD screening implementation, but clinics should also be prepared to deliver OUD care, which includes patient-centered policies and staff training to combat stigma toward OUD.

Aaron D. Fox, MD

Reference: Austin EJ, Briggs ES, Ferro L, et al. Integrating routine screening for opioid use disorder into primary care settings: experiences from a national cohort of clinics. J Gen Intern Med. 2022;1–9.