An International Policy Comparison of Opioid Use Disorder Treatment in Primary Care

Context: Opioid agonist therapy (OAT) is used worldwide to treat opioid use disorder (OUD). Integrating OAT into primary care has been proposed to improve patient accessibility. The degree of prescribing regulation in primary care varies by country; those with more restrictions may draw upon experiences and outcomes (e.g. overdose mortality reduction) from less restrictive countries to promote relaxed prescribing. However, OAT delivery and any resultant health outcomes may be dependent on broader sociocultural, political, health system, and epidemiological factors.

Objective: To compare contextual and health system factors between France and the US, and explore how this may affect buprenorphine provision.

Study design & analysis: The health system dynamics framework takes a system-level approach to examine health systems and the dynamics/interactivity of its components. In this comparative policy analysis, we used it to explore the drug context regarding opioid use and related harms, and health system factors regarding prescriber supply, sector organization, and primary care insurance coverage.

Setting/dataset: For both countries, we used national reports on health systems and health data, national drug strategies/policies, published scientific reports, and OUD treatment guidelines.

Results: The different scale and nature of drug use and primary care delivery between France and the US suggest that relaxing restrictions on buprenorphine prescribing is unlikely to achieve the desired reductions in opioid overdose mortality. Rates of buprenorphine prescribing in the US already surpass those achieved nearly a decade into the French model of care. Variations in the drug supply, coordination with pharmacists and specialists, level of health insurance coverage and healthcare costs, and a higher supply of primary care providers in France are likely to affect buprenorphine and OAT prescribing policy and subsequent health outcomes.

Conclusions: Our analysis showed that contextual factors are crucial to understanding how OUD treatment policies are designed and implemented, and how they may affect outcomes. Using a health system framework allowed us to consider the complex, non-linear dynamics in OUD treatment and the role of primary care. Strengthening the health system by focusing on structural primary care factors such as prescriber supply, coverage, and coordination as policy targets may yield greater change than relaxing OAT prescribing restrictions in isolation.