Understand how primary care providers can treat opioid use disorder (OUD) following Drug Enforcement Administration changes. Learn about diagnosis, screening, medication-assisted treatment and managing OUD as a chronic disease.

Published: August 5, 2025

The landscape of opioid use disorder (OUD) treatment is evolving, with recent Drug Enforcement Administration regulation changes enabling physicians to treat patients without obtaining the X-waiver. This shift underscores the pivotal role primary care providers can play in addressing treatment gaps and offering care for patients with OUD.

Understanding opioid use disorder: Definitions and diagnosis

Addiction is defined by the American Society of Addiction Medicine as a chronic, relapsing disease marked by a compulsive behavioral component that includes cravings around the use of a substance, a lack of control around the use, and negative consequences. The definition is also known as the “three C’s”: craving, control and consequences.

Dependence is primarily physiological. The body reacts with withdrawal symptoms when the substance is removed, and tolerance develops over time, requiring higher doses for the same effect.

The DSM-5, the American Psychiatric Association’s diagnostic manual, outlines 11 criteria for diagnosing OUD, all centered around the “three C’s”. A mild diagnosis requires two or three criteria, moderate requires four or five, and severe requires six or more.

“In the primary care setting, opioid addiction is another chronic, relapsing disease,” Kelly C. Cooper, M.D., medical director of addiction services with Norton Behavioral Medicine, said during a recent episode of “MedChat,” a Norton Healthcare continuing medical education podcast. “It’s really not much different than asthma, COPD [chronic obstructive pulmonary disease], diabetes — all these things that we treat in primary care. We know we can’t cure them, but we can manage them.”

The importance of screening and early intervention

The U.S. Preventive Services Task Force (USPSTF) recommends screening adults ages 18 and over for substance use disorder. Screening should occur at least once and whenever the provider sees “red flags,” such as behavioral health issues, major stressors, grief or consistent early refills of controlled substances. Regular urine drug screens for patients on controlled substances are also vital to monitor for potential use disorders.

“One of the reasons we treat people with opioid use disorder, especially those using illicit opioids like fentanyl or with IV drug use, is to save lives,” Dr. Cooper said. “Also, people who are in treatment for opioid use disorder and are doing well can have a very good quality of life — they’re working again; they’ve rekindled relationships in their life. They’ve been able to rebuild their lives when they’re engaged in care”.

Treatment approaches in primary care

With the removal of the X-waiver, which required special certification to use buprenorphine as an opioid use disorder treatment, primary care providers are better positioned to initiate OUD treatment.

“Primary care providers can treat opioid use disorder. It’s absolutely doable in the primary care setting,” Dr. Cooper said.

Buprenorphine is an opioid partial agonist. Its effects are weaker than full opioid agonists such as methadone and heroin. When taken as prescribed, buprenorphine is safe and effective treatment to diminish the effects of physical opioid dependence — such as opioid withdrawal symptoms and cravings, increase safety in cases of overdose and lower the potential for misuse.

Medication-assisted treatment (MAT) or medications for opioid use disorder (MOUD) are cornerstone therapies. Options include buprenorphine treatment (sublingual, injectable, long-acting, weekly injectable), naltrexone (an opioid-free option requiring a washout period) and methadone. MAT is a broader term covering all medications used for substance use disorders, whereas MOUD specifically refers to those used for opioid use disorder.

Successful OUD treatment is not just about medication; it also involves comprehensive support. This can include mutual aid groups like Alcoholics Anonymous or Narcotics Anonymous, intensive outpatient programs (IOPs), and even inpatient care for higher levels of support. Abstinence-only approaches often lead to relapse, with 60% relapsing within the first three months. However, this drastically changes when patients are on opioid therapy. Treatment length varies per patient and can be lifelong, depending on individual needs and stability.

Behavioral health issues frequently co-occur with OUD, often acting as a “progenitor” for substance use.

Dr. Cooper advocates concurrent behavioral therapy: “We try to treat them at the same time. Delaying treatment for either one is generally not a good idea.”

Treating both simultaneously is crucial to prevent relapse and improve outcomes.

Initiating OUD treatment in primary care

For primary care providers looking to integrate OUD treatment, Dr. Cooper advises discussing all treatment options with patients, including higher levels of care, like inpatient facilities and other treatment services. In the outpatient setting, buprenorphine-based medications (specifically buprenorphine/naloxone combinations for safety) are often the preferred choice due to the challenge of naltrexone’s required washout period.

Patient titration of buprenorphine typically starts with 2 milligrams to 4 milligrams and is increased every four hours based on withdrawal symptoms until a target dose is reached.

When to consider inpatient detox

Referral to an inpatient detox facility is necessary if there are medical complications such as cardiac history or unstable social situations that might hinder successful outpatient care. Fentanyl use also presents a significant challenge due to its potency, requiring either very conservative or aggressive dosing, depending on the amount used. Additionally, co-occurring addiction to multiple substances, such as benzodiazepines or alcohol, warrants inpatient detox due to the risk of dangerous withdrawals like seizures or delirium tremens.

Challenges and guardrails in outpatient treatment

• Treating OUD in primary care requires establishing clear guardrails to ensure patient safety and treatment efficacy. These include:
• Objective data: Regular urine drug screens are crucial for objective data on patient adherence.
• Informed consent: Implementing an informed consent process up front ensures patients understand the treatment plan, rules around refills and accountability for their medication.
• Accountability: Clear policies around lost medication and early refills are essential to prevent misuse.
• Follow-up care: Follow-up care is more intensive during the initial three months, particularly the first month, with weekly visits for the first four to eight weeks, gradually spreading out as the patient stabilizes.

Resources for providers and families

Providers seeking to enhance their OUD treatment capabilities can access resources from organizations like the American Society of Addiction Medicine and the Providers Clinical Support System. Additionally, state guidelines often have specific regulations for prescribing.

For families affected by OUD, involving them in visits (with patient consent) can help bridge communication gaps and foster understanding. Recommending family or marital therapy and support groups like Al-Anon Family Groups also can provide crucial support and education.