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In this webinar, Erin Winstanley, PhD (University of Pittsburgh and West Virginia University, CTN Appalachian Node), described a NIDA Clinical Trials Network study, CTN-0135, examining clinician-reported challenges with initiating buprenorphine for people using fentanyl, including precipitated or prolonged withdrawal, patient reports that buprenorphine was ineffective, and patient preference for methadone. In response to these challenges, most clinicians surveyed reported modifying their standard induction protocols or patient counseling approaches. Clinicians treating larger patient volumes, seeing a high proportion of patients using fentanyl, or initiating treatment in non-inpatient settings were more likely to report difficulties starting patients on buprenorphine.
Related protocols: CTN-0135
This presentation provided a brief summary of the CTN-0135 study, Buprenorphine Treatment Engagement and Induction Problems Among Individuals Using Fentanyl, which aimed to determine whether there are regional variations in the prevalence of fentanyl use and problems initiating buprenorphine/naloxone. A secondary purpose was to characterize the specific problems that clinicians are encountering when initiating BUP treatment in patients using fentanyl and to determine how standard clinical protocols are being modified to engage patients in treatment, which was carried out via a survey administered to 396 clinicians.
The study team wanted to explore other dissemination strategies besides publishing in peer-reviewed journals in order to better share the results with a broader audience. To that end, they decided to develop an online data dashboard, which they developed using Shiny Apps. A second survey was sent out to original participants who had opted in for future contact (n=364) to ask questions about the dashboard, including questions about general usability, basic demographics, and some open-ended items.
Responses to the dashboard were positive, with 84.4% reporting they were at least “somewhat satisfied” with the dashboard. 91.7% found the study results to be relevant to clinical practice, and 77.7% said they would be likely to use a data dashboard to learn about study results. Strengths of the dashboard noted in the open-ended questions included “simplicity and ease of use,” while opportunities for improvement included “color scheme, scrolling reduction, and font sizes.”
Overall, the data dashboard evaluation results suggest it is a feasible dissemination strategy for a clinical audience: easy to use, something clinicians would recommend to colleagues, and clinically relevant. Future work should integrate users into the development process and consider visualization literacy as well as computer skills.
Find the Trends in Drug Use Study Dashboard here.
Related protocols: CTN-0135
Background and objectives: Patients using fentanyl have worse treatment outcomes; however, little is known about other drugs that complicate treatment.
Methods: A national survey (n = 396) was conducted for CTN-0135 using a random sample of clinicians waivered to prescribe buprenorphine in the United States. This study reports the results of a single survey item on clinicians’ perceptions of other drugs, besides IMF, complicating treatment.
Results: Clinicians reported methamphetamine (86.4%), synthetic cannabinoids (42.7%), and xylazine (41.4%) were complicating treatment; reports varied by geographic region.
Conclusions and scientific significance: Rapid clinician surveys can provide real-time data on changing patterns of drug use’s impact treatment outcomes.
Related protocols: CTN-0135
This is the primary outcomes article for CTN-0135.
Importance: Anecdotal accounts suggest an increase in problems initiating buprenorphine (BUP) treatment among individuals using illicitly manufactured fentanyl. Limited empirical data illuminate these challenges.
Objective: To determine the prevalence of clinician-reported problems initiating BUP treatment among patients using fentanyl and describe clinical strategies used to overcome engagement challenges.
Design, setting, and participants: For this survey study, an online survey was pilot tested and refined with a convenience sample of physicians. The final survey included 96 items and took less than 15 minutes to complete. The survey queried patients’ use of fentanyl, BUP induction problems (precipitated or prolonged withdrawal), strategies to overcome induction problems, clinician characteristics, and practice characteristics. Eligible clinicians initiated BUP for at least 10 patients with opioid use disorder in the past year and at least 1 patient in the past 90 days. The survey was live from June 2, 2023, to March 18, 2024.
Main outcome and measures: The main outcome of interest was precipitated and/or prolonged opioid withdrawal. Descriptive statistics are reported, and logistic regression was used to identify factors associated with BUP initiation problems.
Results: A random sample of physicians and advanced practice clinicians in the US Drug Enforcement Administration (DEA) registrant dataset from October 2022 (n = 3141) were invited to participate; of 2485 eligible for inclusion, 649 (26.1%) completed the prescreen survey. Of 421 (64.9%) eligible to complete the survey, the final sample included 396 (94.1%) clinicians who completed at least 50% of the survey items. Of 390 participants, 284 (72.8%) reported problems when initiating BUP in patients using fentanyl, with 242 of 394 (61.4%) reporting patients’ experiencing precipitated withdrawal. A total of 264 or 392 participants (67.3%) reported modifying their standard induction procedures, changing how they counsel patients, or changing both medication and counseling protocols. In multivariable modeling, clinicians were more likely to report problems initiating BUP in patients if they had a DEA waiver to treat more than 100 patients (OR, 1.92; 95% CI, 1.08-3.40), vs those waivered to treat fewer patients; if they reported at least 75% of their patients using fentanyl (OR, 6.31; 95% CI, 2.59-15.35), vs no patients; or if they inducted patients in noninpatient settings (OR, 2.79; 95% CI, 1.39-5.61), vs inpatient settings.
Conclusions and relevance: In this survey study of clinician-reported problems initiating BUP treatment, clinicians working in high-volume noninpatient settings reported more problems initiating BUP in patients using fentanyl, and many reported changing their clinical practices in response to these problems. Further research is warranted to match alternate BUP induction strategies by clinical settings.
Related protocols: CTN-0135