An international policy comparison of primary care and health system contexts on opioid use disorder treatment

CONTEXT: Opioid agonist therapy (OAT) is an effective, evidence-based treatment for opioid use disorder (OUD), but access is limited across health systems. Improving delivery of OAT through primary care is an important route through which access can be improved. How OAT is delivered in primary care in different countries is influenced by the health system, political and sociocultural contexts, along with differences in policy design and implementation.

OBJECTIVE: To compare and describe OUD treatment policies found in complex health systems across different countries, and to understand how they are shaped by their context.

SETTING/DATASET: We compared nine countries using documentary data and interviews. We gathered documents on each nation’s health system, drug use epidemiology, national drug policies, and OUD treatment. We conducted interviews with people with lived/living experience, clinicians, and policymakers with insight into OUD and primary care.

RESULTS: The OAT pharmacological agents used were similar among countries; however, preferred OAT, treatment settings, primary care and specialist physicians’ roles, and funding were vastly different. The overall direction of national drug policy impacted societal stigma, accessibility, and resources to tackle OUD in primary care. Jurisdictions with more abstinence- or recovery-oriented approaches focused on OAT delivery in specialist care settings. Such settings may hinder accessibility in nations where OAT is not covered under public insurance as it requires partial or complete out-of-pocket payments. Challenges to integrating OAT into primary care stem from the historical development of treatment settings, professional views that segregate OUD care from primary care, and a lack of governance and remuneration support.

CONCLUSIONS: Contextual political and health system factors are crucial to understanding OUD treatment development, implementation, and engagement. Promoting policy learning between jurisdictions and identifying combinations of macro- and micro-level factors that impact care and policy trajectories can provide actionable guidance for policymakers to improve OUD care.