Integrating methadone into primary care improves care quality

1. In this randomized controlled trial, integrating opioid agonist therapy (OAT) into primary care improved guideline-concordant health care while maintaining retention rates comparable to specialty methadone clinics among Ukrainians with opioid use disorder (OUD).

2. In both primary care and specialty clinic settings, the proportion of participants receiving optimal methadone doses  (>85 mg) increased over time.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Integrating opioid agonist therapy (OAT), such as methadone and buprenorphine, into routine care facilitates preventative screening and management of comorbidities associated with opioid use disorder (OUD), reducing excess premature mortality. While studies in high-income countries suggest that buprenorphine management in primary care can improve retention and reduce illicit drug use, evidence from low- and middle-income countries, where methadone is more commonly used, remains limited. This study examined health care utilization among patients receiving methadone in addiction treatment clinics versus primary care centers in Ukraine, a middle-income country. Composite quality health indicator (QHI) scores were calculated as the percentage of applicable services and screenings accessed by each patient. Participants receiving methadone through primary care consistently achieved higher composite QHI scores than those in specialty clinics. Given that the composite encompassed 17 services, this difference translates to an average of one to two additional services per patient. Primary care QHI, which included nine core services, was similarly elevated at all follow-up points. Sensitivity analyses confirmed these trends. Notably, methadone retention at two years was similar across primary care and specialty clinic groups, indicating that integration into primary care does not compromise treatment continuity. Limitations include disruptions from the COVID-19 pandemic and the 2022 Russian invasion, lack of direct measurement of health outcomes, and equal weighting of QHIs despite varying clinical importance. Nevertheless, these findings suggest that incorporating methadone treatment into primary care can enhance adherence, optimize dosing, and maintain retention, potentially improving overall care quality for patients with OUD in resource-limited settings.

Click to read this study in AIM

Relevant Reading: Primary healthcare-based integrated care with opioid agonist treatment: First experience from Ukraine

In-Depth [randomized-controlled trial]: This randomized controlled trial evaluated health care use among individuals with opioid use disorder (OUD) receiving methadone in specialty clinics versus primary care centers in Ukraine. The study included 12 cities initially, with one specialty clinic and two primary care centers per city. Enrollment occurred between January 2018 and December 2023, with follow-up through June 2024. Due to the Russian invasion, Mariupol sites closed and were replaced with three sites in Lviv, bringing the total to 13 cities. Participants were recruited from specialty clinics and randomized to receive methadone either in specialty clinics (control) or in primary care centers (intervention). The primary outcome was the difference in composite quality health indicator (QHI) scores at 24 months. Secondary outcomes included QHI scores at earlier time points, primary and specialty care QHI scores, EMR-based QHI measures, individual health care use, and methadone retention. A total of 1,459 participants were enrolled across 39 clinics (509 in specialty clinics, 950 in primary care). The mean age was 39 years, 83% were men, and HIV and HCV prevalence were 42% and 57%, respectively. EMR-based methadone retention at 24 months was similar between groups (specialty clinics 69.9%, primary care 70.4%; difference, 0.5 percentage points [95% confidence interval [CI], -5.4 to 4.4]). Self-reported retention was slightly higher in primary care (68.2% vs. 64.8%). Optimal methadone dosing (>85 mg) and take-home doses increased in both groups, with greater improvements in primary care centers (optimal dosing 33% to 67%) compared with specialty clinics (optimal dosing 31% to 58%). Composite QHI scores were consistently higher in primary care at all time points, with a 24-month mean difference of 9.1 percentage points (95% CI, 6.9 to 11.3; p < 0.001). EMR-based composite QHI scores also favored primary care (27.1 percentage points difference), driven largely by primary care QHI scores. Subgroup and sensitivity analyses confirmed these trends. Overall, the study demonstrates that integrating methadone treatment into primary care settings can enhance health care utilization while maintaining retention, supporting broader adoption in middle-income settings.

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