Attachment B_Screener_Buprenorphine

Attachment B

Exploring Barriers to Buprenorphine Access for Opioid Use Disorder

Screener

OMB Control Number 0910-0695

Expiration Date: 08/31/2027

Paperwork Reduction Act Statement: The Paperwork Reduction Act of 1995 provides that an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0910-0695. The time required to complete this information collection is estimated to average 2 minutes per response. Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing burden to PRAStaff@fda.hhs.gov

The survey we are conducting is on behalf of the U.S. Food and Drug Administration (FDA).

[Programing Instructions in Blue]

The U.S. Food and Drug Administration (FDA) has asked Sermo to conduct this short survey to gain health care professionals’ perspectives on buprenorphine-containing products for the treatment of opioid use disorder (OUD). Your input is extremely valuable.

S1. Which of the following best describes your profession?

1. Physician [At least 50%]

2. Physician Assistant [At least 10%]

3. Nurse Practitioner [At least 20%]

1. Other [screen out]

S2. In which areas are you board certified or licensed to practice medicine? Select all that apply.

General/Family Practice
Emergency Medicine
Internal Medicine
Urgent Care Medicine
Neurology
Pain Medicine
Psychiatry
Obstetrics & Gynecology
Pediatrics
Other: Specify _________

S3. What is your experience prescribing any buprenorphine-containing product(s) to treat OUD?

1. I do not have a DEA license to prescribe controlled substances. [screen out]

2. I have a DEA license to prescribe controlled substances, and I have prescribed a buprenorphine-containing product to treat OUD. [At least 25%]

3. I have a DEA license to prescribe controlled substances, and I have not prescribed a buprenorphine-containing product to treat OUD. [At least 25%]

4. I have a DEA license to prescribe controlled substances, but I’m not sure whether I have prescribed a buprenorphine containing product to treat OUD. [screen out]

S4. In a typical month, about what percentage of your time is spent doing the following. Responses are not mutually exclusive.

1. Caring for patients (regardless of setting)? [screen out if <5%]

2. providing patient care via telemedicine? [At least 20% of sample should be >0%]

3. treating patients with OUD? [at least 20% say >0%]

S5. To the best of your knowledge, what percentages of your patient population are the following. Responses are not mutually exclusive.

Pregnant Women
Children/Adolescents
People of Color
Unhoused/homeless
Enrolled in Medicaid
Veterans
People living in rural areas
Enrolled in Medicare
Incarcerated or presently in the correctional system

S6. What is your sex?

Male
Female

S7. What is your race and/or ethnicity?

Select all that apply and enter additional details in the spaces below.

□ American Indian or Alaska Native - Enter, for example, Navajo Nation,

Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of

Barrow lnupiat Traditional Government, Nome Eskimo Community, Aztec, Maya, etc.

________________________________________________________

□ Asian - Provide details below.

□ Chinese □ Asian Indian □ Filipino

□ Vietnamese □ Korean □ Japanese

Enter, for example, Pakistani, Hmong, Afghan, etc.

________________________________________________________

□ Black or African American - Provide details below.

□ African American □ Jamaican □ Haitian

□ Nigerian □ Ethiopian □ Somali

Enter, for example, Trinidadian and Tobagonian, Ghanaian, Congolese, etc.

________________________________________________________

□ Hispanic or Latino - Provide details below.

□ Mexican □ Puerto Rican □ Salvadoran

□ Cuban □ Dominican □ Guatemalan

Enter, for example, Colombian, Honduran, Spaniard, etc.

________________________________________________________

□ Middle Eastern or North African - Provide details below.

□ Lebanese □ Iranian □ Egyptian

□ Syrian □ Iraqi □ Israeli

Enter, for example, Moroccan, Yemeni, Kurdish, etc.

________________________________________________________

□ Native Hawaiian or Pacific Islander - Provide details below.

□ Native Hawaiian □ Samoan □ Chamorro

□ Tongan □ Fijian □ Marshallese

Enter, for example, Chuukese, Palauan, Tahitian, etc.

_________________________________________________________

□ White - Provide details below.

□ English □ German □ Irish

□ Italian □ Polish □ Scottish

Enter, for example, French, Swedish, Norwegian, etc.

_________________________________________________________

S8. Select those that apply to you:

Years in practice: Less than 10 years
Years in practice: 10 – 19 years
Years in practice: 20 – 29 years
Years in practice: 30 years or more
Practice location(s): Urban
Practice location(s): Suburban
Practice location(s): Rural