Intended for healthcare professionals

Clinical Review State of the Art Review

Treatment of opioid use disorder in primary care

BMJ 2021; 373 doi: (Published 19 May 2021) Cite this as: BMJ 2021;373:n784
  1. Megan Buresh, assistant professor1 2,
  2. Robert Stern, assistant professor1,
  3. Darius Rastegar, associate professor1
  1. 1Department of Addiction Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
  2. 2Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
  1. Correspondence to: M Buresh mburesh2{at}


Opioid use disorder (OUD) is a common, treatable chronic disease that can be effectively managed in primary care settings. Untreated OUD is associated with considerable morbidity and mortality—notably, overdose, infectious complications of injecting drug use, and profoundly diminished quality of life. Withdrawal management and medication tapers are ineffective and are associated with increased rates of relapse and death. Pharmacotherapy is the evidence based mainstay of OUD treatment, and many studies support its integration into primary care settings. Evidence is strongest for the opioid agonists buprenorphine and methadone, which randomized controlled trials have shown to decrease illicit opioid use and mortality. Discontinuation of opioid agonist therapy is associated with increased rates of relapse and mortality. Less evidence is available for the opioid antagonist extended release naltrexone, with a meta-analysis of randomized controlled trials showing decreased illicit opioid use but no effect on mortality. Treating OUD in primary care settings is cost effective, improves outcomes for both OUD and other medical comorbidities, and is highly acceptable to patients. Evidence on whether behavioral interventions improve outcomes for patients receiving pharmacotherapy is mixed, with guidelines promoting voluntary engagement in psychosocial supports, including counseling. Further work is needed to promote the integration of OUD treatment into primary care and to overcome regulatory barriers to integrating methadone into primary care treatment in the US.


  • Series explanation: State of the Art Reviews are commissioned on the basis of their relevance to academics and specialists in the US and internationally. For this reason they are written predominantly by US authors

  • Contributors: MB, RS, and DR all made substantial contributions to the work according to the ICMJE authorship criteria, including literature review, writing of the manuscript, revision of the final manuscript, and final approval of the version to be published. All agree to be accountable for all aspects of work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. MB was the primary author for the pharmacotherapy, harm reduction, and conclusion sections, as well as the tables. DR was the primary author for the introduction, screening, diagnosis, brief treatment, and patient experience sections. RS was the primary author for the pregnancy, medical comorbidities, and psychiatric illness subsections. MB and DR are the guarantors.

  • Competing interests: We have read and understood the BMJ policy on declaration of interests and declare the following interests: None.

  • Provenance and peer review: Commissioned; externally peer reviewed.

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