Evaluation of a Program Designed to Support Implementation of Prescribing Medication for Treatment of Opioid Use Disorder in Primary Care Practices

We are two independent researchers, one of whom is a family physician in Spain, and we have read Hall et al.’s article (1) with interest. The authors present a structured approach that includes practice facilitation, clear implementation steps, and support from an addiction medicine specialist. In Spain, opioid use disorder (OUD) is an increasing concern in primary care, but treating it effectively remains difficult due to several challenges. We would like to share our thoughts on how this model could be adapted to Spanish primary care, considering regulations, training, teamwork, early detection, and the needs of rural areas.

In Spain, the integration of medication for opioid use disorder (MOUD) into primary care remains highly relevant, given the organizational structure of our health system. Primary care centers often serve as the first and most continuous point of contact for patients, including those with substance use disorders. Hall et al. rightly emphasize that simply removing administrative obstacles (such as the former US X-waiver) does not suffice; clinicians need practical training, workflow support, and access to expert consultation. We perceive a similar dynamic here. While Spain does not use a waiver system, prescribing and dispensing of opioid agonist therapies are governed by Real Decreto 1675/2012 (2). This decree requires specific prescription forms, regulatory oversight, and controlled dispensing processes, which can inhibit timely prescribing if administrative tasks overshadow clinical duties. Consequently, any effort to implement a model akin to Hall et al.’s must carefully align with our existing legal framework, reducing unnecessary delays while preserving appropriate safeguards.

Another important consideration is the integration of addiction management into the broader scope of family practice. In our experience, many family physicians in Spain receive limited postgraduate education in addictions, and this gap often leads to uncertainty in diagnosing and treating OUD. We have seen, for example, that physicians who are unsure about the correct induction protocols for buprenorphine, or who are unaware of available psychosocial resources, tend to be less willing to engage in this type of care. Hall et al. provided structured guidance and milestones that supported clinicians through each step of MOUD implementation. We believe such a systematic curriculum, introduced within Spain’s robust continuing medical education programs, could fill a critical need. International studies have previously demonstrated that stepwise office-based training, combined with mentorship, can increase buprenorphine prescribing and improve retention in treatment (3). A comparable approach here would clarify best practices for prescribing, strengthen clinicians’ confidence in caring for patients with OUD, and highlight the value of a team-based care model.

In addition to clinician training, interdisciplinary collaboration is essential for a successful OUD treatment model. Hall et al. describe the importance of linking small primary care clinics with addiction specialists and practice facilitators who can address clinical questions and organizational issues. In Spain, we also see the necessity of involving mental health professionals and social workers to manage the frequent comorbidities and social determinants of health that accompany OUD. Studies indicate that maintenance therapies have more favorable outcomes when delivered alongside psychological and social support (4). Despite this, effective links between family medicine, mental health services, and specialized addiction units are sometimes inconsistent across different autonomous communities. An implementation model adapted from the Colorado experience could institutionalize clearer referral pathways and protocols, ensuring that patients move more fluidly between levels of care and that family physicians are not isolated in managing complex cases.

Moreover, local successes in certain regions of Spain could serve as practical examples for nationwide replication. Some autonomous communities have piloted integrated addiction pathways within primary care, allowing family physicians to initiate buprenorphine-naloxone after brief training and under specialist supervision. Although these regional programs are promising, a more systematic approach is still needed to reduce variability. Hall et al.’s consistent use of structured milestones -focused on “building your team,” “engaging and supporting patients,” and “connecting with recovery support services”- rovides an organized template that could unify these scattered efforts. We see a clear parallel between their roadmap and the Spanish Ministry of Health’s Estrategia Nacional sobre Adicciones 2017-2024, which emphasizes early detection, accessibility, and multidisciplinary intervention (5).

We also wish to highlight the matter of bureaucracy and its impact on primary care physicians’ willingness or capacity to prescribe opioid agonist therapies. The administrative load in Spain can be burdensome, given that each prescription must follow the stipulations of Real Decreto 1675/2012 (2), often requiring physical handling of controlled-substance forms. In our view, many family physicians would be more ready to take on the challenge of managing OUD if these processes were streamlined. This resonates with the findings in Hall et al.’s study, where financial incentives and structured facilitation seemingly reduced some of the daily hurdles clinics might have otherwise experienced. While direct financial incentives may be more variable in their effect, consistent facilitation and expert support appear to be powerful motivators, as demonstrated by the significant increases in buprenorphine prescriptions in their cohort (1).

Early identification of individuals who may develop or already have OUD is equally important. In Spanish primary care, many opportunities to detect risky opioid use go unrecognized, in part because validated screening tools are not universally adopted and because the conversation about opioid misuse can be challenging to initiate. The Colorado initiative prioritized active screening, outreach, and rapid access to treatment. Given that underdiagnosis can lead to delayed interventions, adopting similar protocols would help maximize one of the main strengths of Spanish family medicine: the close, continuous relationship between patients and their primary care teams. When we have tried to implement universal screening strategies here, we have seen a modest increase in identifying at-risk or dependent patients earlier in their trajectory, which can facilitate more prompt intervention.

The guidance offered by Hall et al. also underscores the importance of evidence-based protocols. In our setting, family physicians can refer to Spanish clinical guidelines and protocols published by the Ministry of Health, but many are not updated frequently or are not disseminated widely. We concur with the authors that a coherent, practice-friendly framework—one that covers screening, induction, maintenance, and referral to psychosocial services—encourages clinicians to standardize their approach, reducing uncertainty and improving adherence to best practices. Moreover, substantial research has confirmed that adherence to evidence-based protocols for opioid agonist treatments correlates with better patient retention and harm reduction outcomes, whether in the United States, Spain, or elsewhere in Europe (3,4).

Finally, we would emphasize that rural Spain, like rural Colorado, faces unique challenges regarding staffing, travel distances, and specialist availability. Hall et al.’s experience suggests that external consultation and telehealth solutions can help sustain MOUD services in smaller practices lacking immediate on-site resources. Building telemedicine capacity for addiction care would be a logical extension of current efforts in Spanish rural areas, where the distance to the nearest addiction unit can be prohibitive. This approach, coupled with carefully designed local protocols and practice facilitation, has the potential to close service gaps and ensure equitable access to OUD treatment.

In conclusion, we believe the model presented by Hall et al. (1) has strong potential for adaptation to our primary care landscape in Spain. Their structured facilitation, addiction specialist input, and standardized milestones could help overcome the administrative, educational, and logistical hurdles our family physicians face when prescribing MOUD. As our health system continues to grapple with the complexities of opioid use, structured and evidence-based frameworks can significantly strengthen the role of primary care in reducing the burden of OUD. We sincerely appreciate the authors’ contribution to this field and anticipate that future collaborative initiatives may further validate, refine, and implement such models across different health care contexts, including our own.

1. Hall TL, Mendez D, Sobczak C, Mathieu S, Wiggins K, Cebuhar K, et al. Evaluation of a Program Designed to Support Implementation of Prescribing Medication for Treatment of Opioid Use Disorder in Primary Care Practices. Ann Fam Med. 2025 Jan 1;23(1):44–51.
2. BOE-A-2012-15711 Real Decreto 1675/2012, de 14 de diciembre, por el que se regulan las recetas oficiales y los requisitos especiales de prescripción y dispensación de estupefacientes para uso humano y veterinario. [Internet]. [cited 2025 Feb 16]. Available from: https://www.boe.es/diario_boe/txt.php?id=BOE-A-2012-15711
3. Fiellin DA, O’Connor PG, Chawarski M, Schottenfeld RS. Processes of care during a randomized trial of office-based treatment of opioid dependence in primary care. Am J Addict. 2004;13 Suppl 1:S67-78.
4. Bart G. Maintenance Medication for Opiate Addiction: The Foundation of Recovery. J Addict Dis. 2012 Jul 1;31(3):207–25.
5. Portal Plan Nacional sobre Drogas - Estrategia Nacional sobre Adicciones [Internet]. [cited 2025 Feb 16]. Available from: https://pnsd.sanidad.gob.es/pnsd/estrategiaNacional/home.htm