Opioid-use Disorder, Opioid Dependence, Attitude of Health Personnel
Conditions
Brief summary
The prevalence of opioid use disorder (OUD) and opioid-related deaths has risen dramatically in recent years. Effective treatments, including medications for opioid use disorder (MOUDs; e.g., buprenorphine-naloxone and methadone) are under-utilized. There are few evidence-based interventions for changing attitudes toward Opioid Use Disorder (OUD) in the general public and especially among healthcare clinicians. This study proposed an innovative intervention to change attitudes of Primary Care Clinicians (PCCs) toward persons with OUD. Study participants were stratified into one of two online learning courses: the intervention training was compared with an attention-control training.
Detailed description
Primary care offers an ideal setting in which to treat OUD; however, few clinicians are waivered to prescribe buprenorphine and of those who are waivered, less than one-third do prescribe. One potential barrier to increasing access to MOUDs are primary care clinician (PCC) attitudes towards people with OUD. This study used a randomized controlled trial design to examine a novel intervention to change attitudes towards people with OUD among PCCs. PCCs in clinics randomized to the intervention in COMPUTE 2.0 (PCCs in 15 of the 30 clinics randomized in the parent study) were randomized 1:1 to the intervention or comparison training, stratified by clinic and waiver status. Training was conducted via MyLearning, an online learning software. All PCCs were asked to complete a brief training (25-35 minutes for both trainings) on the shared decision-making tool (SDM) called the Opioid Wizard, which alerts PCCs to screen, diagnose, and treat people with OUD. PCCs in the intervention arm heard patient narratives designed to shift attitudes about patients with OUD. PCCs in the comparison training had training on using the SDM tool. The PCCs were asked to complete a survey of attitudes and intentions to get waivered to prescribe buprenorphine immediately following the online training. Use of the CDS was monitored in both groups for 6 months.
Interventions
BEHAVIORALOnline training
This intervention consisted of two different interactive online trainings delivered through an online learning platform at HealthPartners.
Sponsors
Hennepin Healthcare Research Institute
National Institute on Drug Abuse (NIDA)
HealthPartners Institute
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
HEALTH_SERVICES_RESEARCH
Masking
SINGLE (Subject)
Masking description
Methods for concealment of allocation. PCCs were blind to their randomized MyLearning training assignment. The study statistician generated the randomization assignment, and a study team member submitted that list to HealthPartners (HP) MyLearning staff. Study team members collecting outcome data from surveys, Opioid Wizard, and Epic (including use rates, buprenorphine prescriptions) also were blinded to treatment assignment.
Intervention model description
This study used a randomized controlled trial (RCT) design embedded in a larger, multisite trial of a clinical decision support (CDS) tool to help PCCs identify, diagnose, and treat patients with OUD. PCCs in clinics randomized to Opioid Wizard were randomized 1:1 to the intervention or comparison training and stratified by clinic.
Eligibility
Sex/Gender
ALL
Healthy volunteers
No
Inclusion criteria
* Primary Care Clinician: Had to be a family physician, general internist, adult-care non-obstetric nurse practitioner, or a physician assistant * Had to practice at a study-eligible primary care clinic already involved in the main study intervention arm
Exclusion criteria
PCCs were ineligible to participate if they had fewer than 5 eligible patient encounters between Sep 2020 and Feb 2021.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Difference, Disdain, and Blame Scales | Immediately after completing online training. | Attitudes toward people with OUD were measured using the Difference, Disdain, and Blame scales, which measure attitudes toward people with mental illness and substance use disorders (SUDs). Difference, Disdain, and Blame scales measured stigma toward people with OUD, with three questions in each domain. Items are scored on a 9-point agreement scale. The range is 1-9; some items are reverse-scored. Items are averaged to obtain a score, with higher scores reflecting more stigma (range = 1-9). Evidence suggests that the scales demonstrate good internal consistency and are positively associated. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Intentions to Get Waivered to Prescribe Buprenorphine. | Immediately after completing online training | Non-waivered PCCs rated one question on their intention to get waivered to prescribe buprenorphine (How likely are you to get waivered to prescribe buprenorphine in the next year?) on a five-point Likert-type scale ranging from 1 (I definitely will not) to 5 (I definitely will). Higher scores correspond to greater intention to get waivered. |
| Intentions to Prescribe Buprenorphine Should a Waiver no Longer be Required. | Immediately after completing online training | Non-waivered PCCs rated one question on their intentions to prescribe buprenorphine if a waiver were no longer required (If your patient with OUD requested buprenorphine in the next year and a waiver were no longer required, would you prescribe buprenorphine?) on a five-point Likert-type scale ranging from 1 (I definitely would not) to 5 (I definitely would). Higher numbers indicate greater likelihood to prescribe buprenorphine. |
| Opioid Wizard Use | Six months following online training. | PCC Opioid Wizard use was defined as clicking within the tool, such as screening for OUD, making a diagnosis, providing a referral, prescribing a medication, printing patient education materials, or prescribing naloxone. This variable was dichotomized as whether the PCC ever clicked in the tool (1=yes; 0=no) in the 6 months following the training. |
Countries
United States
Participant flow
Recruitment details
Eligible participants for this study were primary care providers (PCCs) who practice at HealthPartners Clinics that were previously randomized into the intervention arm of the parent study (NCT04198428). Family physician, general internist or adult-care non-obstetric nurse practitioner or physician assistant were the titles included. PCCs were eligible to participate regardless of whether they were waivered to prescribe buprenorphine. 162 PCCs were invited by email to participate in this study.
Pre-assignment details
A total of 411 Primary Care Clinicians (PCCs) actively practicing at clinics within the parent study were screened for eligibility. They were ineligible to participate if: * They had fewer than 5 eligible patient encounters between Sep 2020 and Feb 2021 (N=50); * They practiced in a non-intervention clinic (n=199)
Participants by arm
| Arm | Count |
|---|---|
| Intervention The intervention arm received an online training in the use of the SDM tool that included patient narratives and videos and person-first language. | 48 |
| Comparison Training The comparison training arm received an online training in the use of the SDM tool. | 40 |
| Total | 88 |
Withdrawals & dropouts
| Period | Reason | FG000 | FG001 |
|---|---|---|---|
| Overall Study | Did not complete the survey | 2 | 1 |
Baseline characteristics
| Characteristic | Intervention | Comparison Training | Total |
|---|---|---|---|
| Age, Categorical <=18 years | 0 Participants | 0 Participants | 0 Participants |
| Age, Categorical >=65 years | 6 Participants | 5 Participants | 11 Participants |
| Age, Categorical Between 18 and 65 years | 40 Participants | 34 Participants | 74 Participants |
| Age, Continuous | 47.76 years STANDARD_DEVIATION 11.85 | 47.00 years STANDARD_DEVIATION 11.31 | 47.4 years STANDARD_DEVIATION 11.6 |
| Race (NIH/OMB) American Indian or Alaska Native | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Asian | 6 Participants | 2 Participants | 8 Participants |
| Race (NIH/OMB) Black or African American | 3 Participants | 3 Participants | 6 Participants |
| Race (NIH/OMB) More than one race | 1 Participants | 1 Participants | 2 Participants |
| Race (NIH/OMB) Native Hawaiian or Other Pacific Islander | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Unknown or Not Reported | 7 Participants | 5 Participants | 12 Participants |
| Race (NIH/OMB) White | 29 Participants | 28 Participants | 57 Participants |
| Region of Enrollment United States | 48 participants | 40 participants | 88 participants |
| Sex/Gender, Customized Female | 27 Participants | 22 Participants | 49 Participants |
| Sex/Gender, Customized Male | 17 Participants | 14 Participants | 31 Participants |
| Sex/Gender, Customized Not Listed | 1 Participants | 0 Participants | 1 Participants |
| Sex/Gender, Customized Prefer not to answer | 1 Participants | 3 Participants | 4 Participants |
| Type of provider degree Doctor of Medicine/Doctor of Osteopathic Medicine MD/DO | 30 Participants | 25 Participants | 55 Participants |
| Type of provider degree Physician Assistant/Nurse Practitioner PA/NP | 16 Participants | 14 Participants | 30 Participants |
| Waivered to prescribe buprenorphine | 3 Participants | 5 Participants | 8 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| deaths Total, all-cause mortality | 0 / 0 | 0 / 0 |
| other Total, other adverse events | 0 / 0 | 0 / 0 |
| serious Total, serious adverse events | 0 / 0 | 0 / 0 |
Outcome results
Primary
Difference, Disdain, and Blame Scales
Attitudes toward people with OUD were measured using the Difference, Disdain, and Blame scales, which measure attitudes toward people with mental illness and substance use disorders (SUDs). Difference, Disdain, and Blame scales measured stigma toward people with OUD, with three questions in each domain. Items are scored on a 9-point agreement scale. The range is 1-9; some items are reverse-scored. Items are averaged to obtain a score, with higher scores reflecting more stigma (range = 1-9). Evidence suggests that the scales demonstrate good internal consistency and are positively associated.
Time frame: Immediately after completing online training.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Intervention | Difference, Disdain, and Blame Scales | 4.1 score on a scale | Standard Deviation 1.3 |
| Comparison Training | Difference, Disdain, and Blame Scales | 4.3 score on a scale | Standard Deviation 1.2 |
p-value: 0.63t-test, 2 sided
Secondary
Intentions to Get Waivered to Prescribe Buprenorphine.
Non-waivered PCCs rated one question on their intention to get waivered to prescribe buprenorphine (How likely are you to get waivered to prescribe buprenorphine in the next year?) on a five-point Likert-type scale ranging from 1 (I definitely will not) to 5 (I definitely will). Higher scores correspond to greater intention to get waivered.
Time frame: Immediately after completing online training
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Intervention | Intentions to Get Waivered to Prescribe Buprenorphine. | 2.3 score on a scale | Standard Deviation 0.7 |
| Comparison Training | Intentions to Get Waivered to Prescribe Buprenorphine. | 2.1 score on a scale | Standard Deviation 0.8 |
p-value: 0.27t-test, 2 sided
Secondary
Intentions to Prescribe Buprenorphine Should a Waiver no Longer be Required.
Non-waivered PCCs rated one question on their intentions to prescribe buprenorphine if a waiver were no longer required (If your patient with OUD requested buprenorphine in the next year and a waiver were no longer required, would you prescribe buprenorphine?) on a five-point Likert-type scale ranging from 1 (I definitely would not) to 5 (I definitely would). Higher numbers indicate greater likelihood to prescribe buprenorphine.
Time frame: Immediately after completing online training
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Intervention | Intentions to Prescribe Buprenorphine Should a Waiver no Longer be Required. | 3.2 score on a scale | Standard Deviation 1 |
| Comparison Training | Intentions to Prescribe Buprenorphine Should a Waiver no Longer be Required. | 3.0 score on a scale | Standard Deviation 0.9 |
p-value: 0.37t-test, 2 sided
Secondary
Opioid Wizard Use
PCC Opioid Wizard use was defined as clicking within the tool, such as screening for OUD, making a diagnosis, providing a referral, prescribing a medication, printing patient education materials, or prescribing naloxone. This variable was dichotomized as whether the PCC ever clicked in the tool (1=yes; 0=no) in the 6 months following the training.
Time frame: Six months following online training.
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Intervention | Opioid Wizard Use | 3 Participants |
| Comparison Training | Opioid Wizard Use | 4 Participants |
p-value: 0.1295% CI: [0.86, 3.57]Regression, Logistic