1. META:PHI in Primary Care: Implementing Best Practices for Addictions
Long-Term Management of Patients with Substance Use Disorders

2. What is META:PHI?
Mentoring, Education, and Clinical Tools for Addiction: Primary Care–Hospital Integration
Collaborative project to implement integrated care pathways for addiction throughout Ontario
Partnership between hospitals, withdrawal management services, FHTs, CHCs, and community agencies
Goals:
Improve care for patients with addictions
Improve care provider experience
Improve population health
Reduce service use
Provide sustainable care

3. How it works
Patients presenting with addiction-related concerns receive evidence-based interventions and are referred to rapid access addiction medicine (RAAM) clinics for treatment
RAAM clinics offer substance use disorder treatment on walk-in basis; no formal referral/appointment needed
Patients stabilized at RAAM clinic referred back to primary care for long-term addiction treatment (with ongoing support from RAAM clinic as required)
Key components:
Integration of care at hospital, RAAM clinic, primary care
Training, support, and mentorship from addictions specialists
Capacity-building

4. Role of PCPs With support from META:PHI team:
Follow best practices for prescribing opioids
Screen and diagnose patients for substance use disorders
Refer patients to treatment at RAAM clinic when necessary
Assume long-term addiction care for patients from RAAM clinic (with ongoing support from RAAM clinic doctor)

5. Why manage addiction in primary care?

6. Myth-busting (1) “I can’t do anything for addicted patients.”
Addiction not just psychosocial; often has a strong biomedical component
Several effective treatments for substance use disorders
“I can’t manage these patients because I’m not an addiction specialist.”
PCPs often manage chronic conditions outside their specialization (e.g., prescribing anti-depressants, diuretics for hypertension, etc.)
Research has found that patients do just as well or better with primary care–based addiction treatment as with specialized addiction treatment

7. Myth-busting (2) “These patients are too complicated.”
Managing patients whose substance use disorders are well treated is very clinically satisfying
RAAM clinic doctors are available to consult and reassess patients as needed
Patients with substance use disorders need primary care as much as any other patient

8. An ideal setting
Primary care is the ideal setting for treating substance use disorders
Greater capacity than specialized care for long-term management
Other health concerns can also be addressed
Length of treatment more important than intensity of treatment
Patients prefer primary care setting
Good relationship with care provider important determinant of effective counselling
Less stigmatizing environment than a specialized addiction clinic

9. Patients with alcohol use disorder (AUD)

10. Goals for patients with AUD
Prescribe anti-craving medication
Monitor drinking through self-report, GGT, MCV
Monitor mood, functioning, and other substance use
Manage chronic medical conditions (e.g., liver disease) or psychiatric conditions (e.g., anxiety, depression)
Perform regular screening and health maintenance (e.g., pap tests, mammograms, immunizations, etc.)

11. Pharmacotherapy
Patients with AUD should be routinely offered pharmacotherapy
Patients may have been initiated at RAAM clinic
Maintain patient on dose, monitor effectiveness and side effects
Duration of medication six months or longer
May discontinue when:
Patient has achieved drinking goal (abstinent or reduced drinking for at least several months), minimal cravings, social supports and non-drug ways of coping with stress, and is confident that it is no longer needed to prevent relapse
Can be restarted if patient relapses

12. Naltrexone Action Blocks opioid receptor, reduces euphoric effect
Side effects
Nausea, headache, dizziness, insomnia, anxiety, sedation
Blocks analgesic action of opioids
Can cause reversible elevations in AST and ALT; order at baseline and at 3–4 weeks
Contraindications/
precautions
Pregnancy
Triggers severe withdrawal in patients on opioids
Discontinue if AST/ALT rise more than 3x baseline at 3–4 weeks
Dose
25 mg OD x 3 days to reduce GI side effects; then 50 mg PO OD
Titrate to 100–150 mg per day if 50 mg has minimal effect on craving
Patients do not need to abstain before starting
Note: Use LU code 532 “For the treatment of AUD in patients who meet clinical criteria for AUD; express a commitment to reduce or abstain from alcohol; and have confirmed participation in counselling and treatment for AUD”

13. Acamprosate Action Glutamate antagonist
Relieves subacute withdrawal symptoms
Side effects
Diarrhea
Contraindications/
precautions
Pregnancy
Renal insufficiency
Dose
666 mg tid; 333 mg tid if renal impairment or BW < 60 kg
Works best if patient is abstinent several days prior to initiation
Note: Use LU code 531 “For the treatment of AUD in patients who meet clinical criteria for AUD; express a commitment to abstain from alcohol; have been abstinent from alcohol for at least 3 days prior to starting acamprosate; and have confirmed participation in counselling and treatment for AUD”

14. Disulfiram Action Acetaldehyde accumulates when alcohol consumed
Most effective when dispensed by family member
Side effects
With alcohol: Vomiting, flushed face, headache
Without alcohol: Headache, anxiety, fatigue, garlic-like taste, acne, peripheral neuropathy (with prolonged use)
Contraindications/
precautions
Cirrhosis
Pregnancy
Unstable cardiovascular disease
Alcohol reaction can cause severe hypotension and arrhythmias, especially in patients with heart disease or on antihypertensives
May trigger psychosis at higher doses (500 mg)
Can cause toxic hepatitis
Dose
125 mg PO OD; increase to 250 mg if patient reports no reaction to alcohol
Wait at least 24–48 hours between last drink and first pill
Wait at least 7–10 days between last pill and first drink

15. Gabapentin Action Modulates dopamine Side effects
Dizziness, sedation, ataxia, nervousness
Contraindications/
precautions
Can cause suicidal ideation (rare)
Dose
Initial dose 300 mg bid–tid; optimal dose 600 mg tid

16. Topiramate Action Modulates GABA system
May improve sleep/mood disturbance in early abstinence
Side effects
Sedation, dose-related neurological effects (dizziness, ataxia, speech disorder, etc.) resolve over time
Contraindications/
precautions
Can cause weigh loss (risk for underweight patients)
Can clause glaucoma or renal stones
Dose
Initial dose 50 mg OD; titrate by 50 mg to a maximum dose of 200–300 mg daily
Lower dose needed in renal insufficiency

17. Baclofen Action GABA agonist Side effects
Drowsiness, weakness, can cause or worsen depression
Contraindications/
precautions
Use with caution in patients on tricyclic anti-depressants or MAO inhibitors
Dose
Initial dose 5 mg tid, increase to 10 mg tid; maximum daily dose 80 mg
Lower dose needed with renal insufficiency

18. General management
Ask about drinking and use GGT/MCV to confirm self-reports
Acknowledge patients’ successes
Ask about mood, cravings, triggers
Encourage activities that improve mood and promote health (exercise, hobbies, walks, alcohol-free socializing, consistent schedule for eating/sleeping)
Discuss coping strategies to deal with cravings (call someone, take a time-out, grounding exercises, leave the environment)
Brainstorm strategies to avoid triggering people/places and replace problematic habits with healthier ones
Consider pharmacotherapy/psych referral for persistent mood problems (depression, anxiety)

19. Patients with opioid use disorder (OUD)

20. Goals for patients with OUD
Prescribe buprenorphine
Monitor withdrawal symptoms and cravings
Collect urine drug screens
Monitor mood, functioning, and substance use
Manage chronic medical conditions (e.g., hepatitis C) or psychiatric conditions (e.g., anxiety, depression)
Perform regular screening and health maintenance (e.g., pap tests, mammograms, immunizations, etc.)

21. 24h What is buprenorphine? Medication used to manage OUD
Partial opioid agonist with a ceiling effect
Relieves opioid withdrawal symptoms and cravings for 24 hours without causing euphoria or sedation
Even very high doses rarely cause respiratory depression (unless combined with alcohol/sedatives)
Binds tightly to receptors, displacing other opioids
Optimal maintenance dose: 8–16 mg SL OD
Maximum maintenance dose: 24 mg SL OD
Usually combined 4:1 with naloxone as abuse deterrent
24h

22. Addressing concerns “I don’t have a methadone exemption.”
In Ontario, no special license required for buprenorphine
“I don’t know how to prescribe buprenorphine.”
Buprenorphine is easier to prescribe than other opioids!
Lower abuse potential
Lower risk of overdose
Small dose range
Online courses to increase knowledge and confidence
“What if the patient relapses?”
RAAM clinic physician available for consultation, advice, patient reassessment

23. How to prescribe
Patients being transferred from a RAAM clinic should be at stable dose (usually 8–16 mg)
At each visit, ask about withdrawal symptoms (nausea, sweating, aches, anxiety) and cravings
Minor dose adjustments of 2–4 mg may be required if patient does not have full 24 hours’ symptom relief
Two formulations of buprenorphine/naloxone:
2 mg/0.5 mg
8 mg/2 mg

24. Prescriptions Specify pharmacy and send by fax
Specify observed and take-home doses

25. Tapering buprenorphine
Indications
Wants to taper
At least six months without any substance use
Socially stable, supportive family or social network
Stable mood, good coping strategies
Protocol
Decrease by small amounts (1–2 mg)
Leave at least two weeks between dose decreases
Hold taper at patient’s request
Return to original dose if opioid use restarts
Provide regular support and encouragement: it is not a “failure” if taper has to be held/reversed

26. General management Ask about withdrawal symptoms or cravings
Sometimes minor dose adjustments required (2–4 mg)
Perform monthly urine drug screens as patient stabilizes
Ask about alcohol and cannabis use (usually not tested on urine drug screen)
Ask about overall mood and functioning
Encourage activities that improve mood and promote mental/physical health
Consider pharmacotherapy/psych referral for persistent mood problems (depression, anxiety)

27. Wrap-up: Key Messages

28. Our responsibility
Managing substance use disorders is our responsibility as health care providers
Addiction is the same as any other chronic illness: patients need specialist referrals, medication, treatment of co-occurring conditions, and regular follow-up
Effective addiction interventions are simple, safe, and satisfying
Purpose of META:PHI project is to facilitate adoption of best practices and support clinicians

29. Resources META:PHI website: www.metaphi.ca
META:PHI mailing list for clinical questions and discussion ( to join)
META:PHI contacts: Medical lead: Dr. Meldon Kahan Manager: Kate Hardy Knowledge broker: Sarah Clarke