Buprenorphine Knowledge and Attitudes Among Sickle Cell Disease Providers

Background:

Buprenorphine is a potent opioid analgesic that has been studied in various settings including post-operative and chronic pain, and found to be equally effective compared to other opioids such as morphine, and safer due to its known ceiling effect on respiratory depression and other undesirable opioid side effects. Many patients with sickle cell disease (SCD) require high amounts of opioids to manage disease-related acute and chronic pain, but side effects and safety concerns are barriers to adequate analgesia. Adequate analgesia is a key contributor to improving the quality of life of patients with SCD. Buprenorphine’s pharmacological properties and various formulations approved for acute and chronic pain may be a desired alternative to traditional opioids in pain management for patients with SCD. Studies show that buprenorphine may be a safe treatment alternative for chronic pain in patients with SCD. Providers’ comfort with prescribing this medication is key to any scaling adoption. We thus sought to assess knowledge and attitudes about buprenorphine amongst providers of persons with SCD.

Methods:

We conducted a cross-sectional survey of 52 providers disseminated through sickle cell provider networks between March 2023 and May 2023. Providers answered a survey about their knowledge and attitudes towards buprenorphine. The survey was administered through Qualtrics. Participants who completed less than half of the questionnaire were excluded. We used descriptive statistics to summarize data. All tests were two-tailed and statistical significance was defined as P<0.05. All analyses were conducted in Stata 18.

Results:

Most participants were women (60%, n=30). About a third were White (32% n=17), another third was Black (34%, n=18), 9.4% were Hispanic (n=5), and 13.2% Asian (n=7). Most participants reported seeing only adult patients (56%, n=28), about a third reported seeing only pediatric patients (32%, n=16), and a minority reported seeing both (12%, n=6). A minority reported possessing a DEA DATA-2000 waiver (x-waiver) to prescribe buprenorphine for opioid use disorder when it was required (23%, n=12).

Most people knew that compared to other opioids, buprenorphine confers a lower risk of respiratory depression (88.5%, n=46), a lower overdose risk (92.3%, n=48), nearly no one knew about its protective effect against opioid-induced hyperalgesia (1.9%, n=1), and few people knew of it as a potent opioid analgesic (63.5%, n=33). When asked to compare buprenorphine’s potency to other opioids, a small minority (9.8%, n=5) correctly rated buprenorphine as less potent than Fentanyl but more potent that hydromorphone, methadone, morphine and oxycodone, and a third reported not knowing about buprenorphine’s potency compared to any of the aforementioned opioids (33.3%, n=17).

Scenarios in which participants thought buprenorphine may be beneficial included patients taking more than 50 morphine milligram equivalents per day in general (69.2%, n=36) and/or having unresolved pain (76.9%, n=40), concerns about adverse side-effects from traditional opioids (84%, n=44), and concerns about patients misusing their prescription opioids (80.7%, n=42).

Most did not know, or held wrong beliefs about the role of naloxone as an inactive agent in the buprenorphine-naloxone formulations (73.1%, n = 38), but about its role as an abuse-deterrent technology (55.8%, n= 29). Nearly a quarter did not know that buprenorphine formulations without naloxone existed (23.1%, n=12). A minority of participants knew which buprenorphine formulations were FDA-approved for pain (38.5%, n=20), and which could be used off-label for pain (40.4%, n=21). Participants who possessed an x-waiver were more likely to know which formulations were FDA-approved for pain (75% vs 30%, P=0.005) and which could be used off-label for pain (91.7% vs 22.5%, P=0.001).

Conclusion:

In this survey of providers who care for patients with SCD, overall knowledge about buprenorphine’s properties as a potent, effective opioid analgesic with fewer undesirable side-effects was low, but knowledge about its safety profile was high. Participants’ low buprenorphine knowledge and comfort prescribing it highlights a continuing medical education opportunity that may help improve provider knowledge and comfort prescribing buprenorphine, and as a result, also improve pain management for SCD patients.