Buprenorphine Implementation at Syringe Service Programs to Reduce Overdoses (BISTRO)
Buprenorphine Implementation at Syringe Services Programs To Reduce Overdoses: A Type 1 Hybrid Effectiveness-Implementation Trial
This study is testing whether offering buprenorphine treatment directly at syringe service programs (SSPs) helps more people start and stay in treatment for opioid use disorder (OUD) than referring them to community buprenorphine treatment providers. Buprenorphine is a medication that helps reduce opioid cravings and withdrawal symptoms.
The study compares two ways of connecting people to treatment:
Referral to a community treatment provider (usual care before the new program begins).
Onsite, low-threshold buprenorphine treatment at the SSP, which allows participants to start medication quickly and without having to establish care at another provider.
Participants will be adults who have opioid use disorder and are SSP clients. Each SSP will begin offering the new onsite buprenorphine program at different times during the study. Researchers will collect information before and after the new program begins to see how it affects treatment engagement and health outcomes.
The study will also examine how easy or difficult it is for SSPs to start and run the new program, how acceptable it is to staff and participants, and whether it is cost-effective.
The overall goal is to find better ways to expand access to life-saving opioid treatment in community-based settings.
調査の概要
状態
詳細な説明
This is a Type 1 hybrid effectiveness-implementation study designed to evaluate the impact and feasibility of implementing low-threshold buprenorphine (BUP) treatment at syringe service programs (SSPs) in order to improve access to and retention in medications for opioid use disorder (MOUD) treatment among people with moderate to severe opioid use disorder (OUD). The study seeks to understand whether the low-threshold approach improves participant-level outcomes and how SSPs can successfully implement and sustain this model.
Study Design
The study uses a cluster randomized stepped wedge design, in which eight SSPs will be randomly and sequentially assigned to begin implementing the low-threshold BUP program until all sites have transitioned from the referral condition to the intervention condition. This design allows each site to serve as its own control and ensures equitable access to the intervention over time. The stepped wedge design also facilitates examination of temporal effects, while accounting for differences in local environments and SSP readiness for implementation.
Participants will be recruited across the eight SSPs in different geographic regions of the United States. SSPs will be selected to represent a range of community types (urban, suburban, and rural) and to reflect varying policy environments related to MOUD access.
Study Rationale and Background
Despite robust evidence that buprenorphine reduces overdose deaths and improves recovery outcomes, access to this medication remains limited, especially among people who use drugs and have difficulty navigating the healthcare system. Low-threshold buprenorphine models aim to reduce barriers by emphasizing same-day access, flexibility, and a treatment orientation that meets participants "where they are."
SSPs provide a trusted, nonjudgmental environment and are uniquely positioned to engage individuals who are at highest risk for overdose and least likely to access formal treatment. Integrating buprenorphine prescribing directly within SSPs could substantially expand access to life-saving treatment in community settings.
Study Objectives
Primary Objective:
To evaluate the effectiveness of low-threshold BUP treatment at SSPs compared to treatment as usual (TAU) for increasing 3-month retention in buprenorphine treatment.
Secondary Objectives:
Assess buprenorphine adherence, additional OUD treatment outcomes, and health-related quality of life.
Examine the cost-effectiveness of implementing low-threshold BUP at SSPs from both payer and societal perspectives.
Characterize implementation outcomes-adoption, acceptability, appropriateness, feasibility, reach, fidelity, and sustainability-across diverse SSP settings.
Exploratory Objectives:
Explore participant-level moderators (e.g., polysubstance use, co-occurring mental health conditions, housing status, rurality) that may predict outcomes or differential intervention effects.
Identify contextual determinants (organizational capacity, policy environment, leadership engagement) associated with successful SSP implementation.
Study Procedures
Participants will complete study assessments at baseline, 1 month, 3 months, and 6 months post-enrollment. Measures will include substance use patterns, treatment engagement, overdose events, hospitalizations, and self-reported recovery activities. Laboratory-confirmed urine drug screens will be used to verify buprenorphine adherence.
Pre-implementation (Treatment-as-Usual) Prior to implementing the low-threshold BUP model, SSPs will provide standard care, which includes referral to community MOUD providers for BUP treatment.
Post-implementation (Low-Threshold BUP Program) Once implementation begins, SSPs will offer onsite BUP treatment directly through trained prescribers and peer outreach workers. Clients identified as eligible and interested will receive a medical evaluation from a study clinician (SC), including assessment for contraindications, education on BUP use, and initiation via home induction or observed dosing as appropriate.
Follow-up visits will occur approximately every 4 weeks for 6 months and include focused psychosocial counseling, urine drug screening (when requested by the study clinician), and continued prescription management. Both in-person and telehealth models may be used to enhance accessibility. Participants may use any FDA-approved formulation of buprenorphine, including injectable long-acting formulations, based on shared decision-making between study clinician and participant.
Implementation Facilitation Strategy
To support successful and sustainable adoption of the low-threshold BUP model, the study's Lead Node (LN) will develop and deliver an Implementation Facilitation Package. This package will include:
Structured training for SSP staff and clinicians on low-threshold buprenorphine principles and program logistics.
Coaching on identifying a site champion, hiring or engaging a prescriber, and establishing clear protocols for medication management.
Ongoing facilitation meetings between the LN and SSP implementation teams (champion, prescriber, peer outreach worker) to troubleshoot challenges, monitor fidelity, and adapt workflows.
Tools for tracking and sustaining reach, fidelity, and acceptability over time.
Hypotheses and Analytical Approach
The central hypothesis is that embedding low-threshold buprenorphine treatment within SSPs will improve engagement and retention in MOUD compared to standard referral pathways. Analyses will use mixed-effects regression models accounting for site-level clustering and time effects. Effectiveness analyses will focus on 3-month retention as the primary outcome, with sensitivity analyses at 6 months. Cost-effectiveness analyses will use quality-adjusted life years (QALYs) as the main effectiveness measure.
Implementation analyses will use the Consolidated Framework for Implementation Research (CFIR) and Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) frameworks to identify determinants, measure outcomes, and map facilitation processes. Qualitative interviews with staff and participants will complement quantitative metrics, offering a comprehensive understanding of how and why the intervention succeeds or encounters barriers.
Expected Impact
This study addresses a critical public health need by testing a scalable, community-driven model of OUD treatment. If the low-threshold SSP-based buprenorphine program is found to be effective and cost-efficient, the Implementation Facilitation Package developed through this study will serve as a replicable framework for dissemination to SSPs or other community-based settings nationwide. The findings have the potential to directly inform national strategies for expanding access to evidence-based treatment, reducing overdose deaths, and promoting patient-centered care.
研究の種類
入学 (推定)
段階
- 適用できない
連絡先と場所
研究連絡先
- 名前：Megan M Ghiroli
- 電話番号：12036068136
- メール：mghiroli@montefiore.org
研究連絡先のバックアップ
- 名前：Aaron D Fox, MD, MS
- 電話番号：718-920-7173
- メール：adfox@montefiore.org
研究場所
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California
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Los Angeles、California、アメリカ、90029
- 募集
- Community Health Project Los Angeles (CHPLA)
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コンタクト：
- Site PI
- 電話番号：323-380-5469
- メール：info@chpla.org
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主任研究者：
- Amanda Cowan, MSc
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District of Columbia
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Washington D.C.、District of Columbia、アメリカ、20002
- 募集
- HIPS
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コンタクト：
- Phyllis Bijole
- 電話番号：202-834-3289
- メール：phyllis@hips.org
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Louisiana
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Baton Rouge、Louisiana、アメリカ、70806
- 募集
- CARPBR/Be Safe Syringe Program
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コンタクト：
- Site PI
- 電話番号：225-775-7988
- メール：gjvar.carpbr@gmail.com
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主任研究者：
- Gjvar Payne
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Minnesota
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Duluth、Minnesota、アメリカ、55805
- 募集
- Harm Reduction Sisters
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コンタクト：
- Jack Research Coordinator
- 電話番号：218-206-6482
- メール：jack@harmreductionsisters.org
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主任研究者：
- Sue Purchase
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New Mexico
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Roswell、New Mexico、アメリカ、88203
- 募集
- Alianza of New Mexico
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コンタクト：
- Ryan Nix Site PI
- 電話番号：575-623-1995
- メール：ryan.nix@alianzanm.org
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主任研究者：
- Ryan Nix
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Oregon
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Grants Pass、Oregon、アメリカ、97526
- 募集
- HIV Alliance
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コンタクト：
- Harmony Beckett
- 電話番号：541-342-5088
- メール：hbeckett@allianceor.org
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主任研究者：
- Harmony Beckett
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副調査官：
- Michaela Starr O'Leary
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South Carolina
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Greenville、South Carolina、アメリカ、29605
- 募集
- Challenges, Inc/Prisma Health
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主任研究者：
- Alain Litwin, MD
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コンタクト：
- Liam Diaz, MPH
- 電話番号：864-915-2528
- メール：Liam.Diaz@prismahealth.org
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副調査官：
- Marc Burrows, MSW, LMSW, CPSS
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Wisconsin
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Milwaukee、Wisconsin、アメリカ、53212
- 募集
- Vivent Health
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コンタクト：
- Site PI
- 電話番号：800-359-9272
- メール：ctgov.research@viventhealth.org
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主任研究者：
- Mikaela Becker
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参加基準
適格基準
就学可能な年齢
- 大人
- 高齢者
健康ボランティアの受け入れ
説明
Inclusion Criteria:
- ≥ 18 years old;
- Meet DSM-5 criteria for moderate or severe OUD;
- Interest in receiving buprenorphine treatment;
- Speaks English or Spanish;
- Currently an SSP client at the time of enrollment;
- Ability to provide informed consent.
Exclusion Criteria:
- Current use of prescribed opioid agonist treatment, as assessed by self-report, at the time of enrollment;
- Unstable mental health or medical condition that requires an immediate clinical evaluation or higher level of care;
- Allergy to buprenorphine;
- Currently detained in jail, prison, residential substance use treatment facility, or other overnight facility as required by court of law. or have pending legal action that could prevent participation on study activities.
研究計画
研究はどのように設計されていますか？
デザインの詳細
- 主な目的：ヘルスサービス研究
- 割り当て：ランダム化
- 介入モデル：順次割り当て
- マスキング：なし（オープンラベル）
武器と介入
参加者グループ / アーム |
介入・治療 |
|---|---|
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アクティブコンパレータ：Treatment As Usual (TAU)
Participants enrolled before the intervention is implemented at each syringe service program (SSP) will receive standard of care, consisting of referral to community-based buprenorphine treatment providers.
SSP staff will offer information and referral support but will not provide on-site buprenorphine treatment or prescribing.
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During the pre-implementation phase, SSP staff will refer participants with opioid use disorder to external community providers for buprenorphine treatment.
Services offered include information, referral assistance, and linkage to care, but buprenorphine will not be initiated or managed at the SSP site.
他の名前：
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実験的：Low-threshold Buprenorphine (LTB)
After implementation at each SSP site, participants will have access to on-site, low-threshold buprenorphine treatment integrated into SSP services.
This model focuses on minimizing barriers to treatment initiation and retention and includes , flexible policies and procedures and collaboration with a peer outreach worker.
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During the post-implementation phase, SSPs will implement a low-threshold model of care for buprenorphine treatment. This model includes: Low barrier to entry Flexible scheduling and follow-up procedures Risk reduction counseling Collaboration with a peer outreach worker Training and technical assistance for SSP staff and clinicians to deliver care in non-traditional, low-barrier settings This intervention focuses on implementing and evaluating a service delivery model to expand access to medication for opioid use disorder within SSPs.
他の名前：
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この研究は何を測定していますか？
主要な結果の測定
結果測定 |
メジャーの説明 |
時間枠 |
|---|---|---|
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3-month Buprenorphine treatment retention (3-month retention)
時間枠：Between baseline and 1-month following intervention, and between baseline and 3-months following intervention
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Buprenorphine (BUP) treatment retention will be defined as having an active buprenorphine prescription between baseline and 1-month and between the 1-month (days 1-30) and 3-month (days 31-90) time points. Participants will be asked to provide evidence of BUP prescriptions at study visits (i.e., confirmed prescriptions). If a participant receives a second BUP prescription before the 1-month follow-up and the number of days dispensed covers dates after day 30 (i.e., carries over into the 31-90 days interval), this participant will have met the primary outcome. The primary outcome will require at least one day of an active BUP prescription based on confirmed prescriptions within the 2 time-points. BUP treatment retention will be summarized as a binary ("Yes/No") variable. The number/percentage of participants who are retained at each timepoint will be summarized by arm. BUP treatment retention is the primary measure of effectiveness. |
Between baseline and 1-month following intervention, and between baseline and 3-months following intervention
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二次結果の測定
結果測定 |
メジャーの説明 |
時間枠 |
|---|---|---|
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Buprenorphine Adherence
時間枠：Baseline to 3-months following intervention
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Adherence to buprenorphine is a composite measure and will be defined as participants meeting the primary outcome AND having a urine drug screen (UDS) that is positive for BUP at the 3-month timepoint.
The number/percentage of participants who demonstrate BUP adherence will be summarized by arm.
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Baseline to 3-months following intervention
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6-month Buprenorphine Treatment Retention (6-month retention)
時間枠：From baseline to 6-months following intervention
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Buprenorphine (BUP) treatment retention at 6-months is a composite measure and will be defined as participants meeting the primary outcome AND having an active BUP prescription at the 1-month, 3-month, and 6-month timepoints.
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From baseline to 6-months following intervention
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Treatment and Recovery Activities
時間枠：6-months following intervention
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Treatment and Recovery activities will be measured using the Treatment Effectiveness Assessment (TEA).
The TEA is a patient-centered instrument for evaluating progress in recovery from addiction.
The TEA consists of 4 items used to measure recovery progress in substance use, health, lifestyle, and community domains.
Participants rate progress on a scale from 1 ("not better") to 10 ("very much better"), yielding a total score from 4-40, wherein higher scores indicate greater improvement.
Results will be summarized by study arm using descriptive statistics.
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6-months following intervention
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Non-prescribed Opioid Use
時間枠：1-month, 3-months, and 6-months following intervention
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Non-prescribed opioid use will be determined by the number of self-reported days of use of heroin, fentanyl, methadone, or opioid analgesics in the prior 30 days at each study visit (1-month, 3-months, and 6-months).
Results will be summarized by study arm.
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1-month, 3-months, and 6-months following intervention
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Overdose (non-fatal and fatal)
時間枠：6-months following intervention
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Non-fatal overdoses will be determined based on participant self-reporting during the 6 months of study participation.
Fatal overdoses will be based on data collected from available administrative records or other reliable sources.
This a continuous measure and the number/percentage of both fatal and non-fatal overdoses will be summarized by study arm.
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6-months following intervention
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Mean Intervention Costs
時間枠：6 months
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Mean cost (in US dollars) of buprenorphine treatment will be reported for participants in each study arm.
The resource utilization and resulting cost of implementing and administering the intervention will be estimated using micro-costing analysis and participant self-report.
Mean costs (in US dollars) will be summarized by study arm.
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6 months
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Health-related Quality of Life - PROPr
時間枠：1-month, 3-months, and 6-months following intervention
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Health-related Quality of Life will be assessed using the Patient-Reported Outcomes Measurement Information System (PROMIS) Preference (PROPr) questionnaire.
PROPr is a comprehensive, multi-attribute health utility measure that consolidates 7 PROMIS domains-Cognitive Function, Depression, Fatigue, Pain Interference, Physical Function, Sleep Disturbance, and Social Roles-into a single score, the health utility index value.
A single-attribute scoring function for each PROMIS domain is calculated, with 1 = "the utility of full health" and 0 = "the utility of that domain's disutility state.
The 7 single-attribute functions are combined to produce a multi-attribute summary scoring function, where 0 = "the utility of dead" and 1 = "the utility of full health," with scores less than 0 corresponding to states judged worse than dead.
Results will be summarized by study arm.
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1-month, 3-months, and 6-months following intervention
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Change in Health-related Quality of Life - QALYs
時間枠：From Baseline to 6-months following intervention
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Change in Health-related Quality of Life will be used to calculate quality-adjusted life-years (QALYs).
QALYs is a measure that incorporates both duration and health-related quality-of-life into a single assessment and is used to assess cost-effectiveness.
The health utility index value from the PROPr is converted into QALYs.
Mean years gained from baseline to 6 months intervention will be summarized by study arm.
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From Baseline to 6-months following intervention
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Cost effectiveness - incremental cost-effectiveness ratio (ICER)
時間枠：6-months following intervention
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The outcome of the cost-effectiveness analysis will be the incremental cost-effectiveness ratio (ICER), calculated as the adjusted-difference in costs (i.e., mean intervention costs per arm) divided by the adjusted-difference in effectiveness (i.e., mean change in Health-related Quality of Life per arm).
The outcome is reported as a ratio of the two numbers.
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6-months following intervention
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Satisfaction with BUP treatment
時間枠：6-months following intervention
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Satisfaction with BUP treatment will be measured by an adapted version of the Primary Care Buprenorphine Satisfaction Scale.
The adapted version will use 5 (out of 19) items, covering satisfaction with the following three domains: overall and specific service components; staff expertise, concern and responsiveness; and helpfulness of overall and specific treatment components.
Items are rated on a 5-point scale with 1 indicated low satisfaction and 5 indicating high satisfaction.
The mean score from the 5 items will be reported.
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6-months following intervention
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Initiation of BUP treatment
時間枠：Up to 6-months following intervention
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Initiation of BUP treatment will be defined as having any self-report of taking prescribed BUP over 6 months of follow-up.
Initiation of BUP treatment will be assessed as a binary ("Yes/No") variable.
The number/percentage of participants who initiate BUP treatment over the 6 months of follow up will be summarized by arm.
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Up to 6-months following intervention
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Retention in any MOUD treatment
時間枠：6-months following intervention
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Retention in any MOUD treatment will be measured based on participant self-reporting of having been engaged in an approved MOUD treatment service at 6 months.
Retention in any MOUD treatment will be assessed as a binary ("Yes/No") variable.
The number/percentage of participants who demonstrate retention in any MOUD treatment at the 6 months timepoint will be summarized by arm.
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6-months following intervention
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OUD severity
時間枠：6-months following intervention
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OUD severity will be measured using the Diagnostic and Statistical Manual for Opioid Use Disorder, 5th Edition (DSM-5 OUD) checklist.
The DSM-5 OUD checklist consists of 11 criteria, with diagnosis and severity based on the number of symptoms met within a specified period, in this case 6 months.
Scoring is calculated by counting the number of "yes" responses for the 11 criteria: mild (2-3 symptoms), moderate (4-5 symptoms), and severe (6 or more symptoms).
The number participants with mild, moderate, and severe symptoms will be summarized by study arm.
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6-months following intervention
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Number of days of other substance use
時間枠：1-month, 3-months, and 6-months following intervention
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The number of days of other substance use will be measured based on participant self-reporting, using a modified version of the Addiction Severity Index.
Assessments will ask separately about past-30 day use of heroin, fentanyl, methadone, buprenorphine, other opioids, benzodiazepines, other sedatives, cocaine, amphetamines, methamphetamine, cannabis, alcohol, and more than one substance.
A composite measure that represents the number of days (0-30) using benzodiazepines, other sedatives, cocaine, amphetamines, methamphetamine, or alcohol will be reported as "days of other substance use".
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1-month, 3-months, and 6-months following intervention
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Depression
時間枠：6-months following intervention
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Depression will be assessed using the individual Depression domain subscale from the PROMIS-PROPr instrument.
The PROMIS-PROPr Depression domain subscale consists of 4 items asking participants to rate their levels of depression over the prior 7-day period.
Scores are rated on a scale ranging from 1 "Never" to 5 "Always" for an overall possible raw score ranging from 4-20, such that higher scores are indicative of higher depression severity.
Scores will be summarized by study arm using descriptive statistics.
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6-months following intervention
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Anxiety
時間枠：6-months following the intervention
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Anxiety will be assessed using the individual Anxiety domain subscale from the PROMIS-PROPr instrument.
The PROMIS-PROPr Anxiety domain subscale consists of 4 items asking participants to rate their levels of anxiety over the prior 7-day period.
Scores are rated on a scale ranging from 1 "Never" to 5 "Always" for an overall possible raw score ranging from 4-20, such that higher scores are indicative of higher anxiety severity.
Scores will be summarized by study arm using descriptive statistics.
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6-months following the intervention
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Pain Intensity
時間枠：6-months following intervention
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Pain Intensity will be assessed using the individual Pain Intensity item from the PROMIS-PROPr.
The PROMIS-PROPr Pain Intensity item asks participants to rate their average intensity of pain over the prior 7-day period.
Scores are rated on a scale ranging from 1 "No Pain" to 10 "Worst Pain Imaginable" for an overall possible raw score ranging from 1-10, such that higher scores are indicative of higher pain intensity.
Scores will be summarized by study arm using descriptive statistics.
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6-months following intervention
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Safety Outcomes
時間枠：6-months following intervention
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A composite measure of experiencing one or more Targeted Safety Event (dichotomous, yes/no), which includes opioid overdoses (non-fatal and fatal), any hospitalization, or death, will be reported as an outcome measure.
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6-months following intervention
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協力者と研究者
捜査官
- 主任研究者：Aaron D Fox, MD, MS、Albert Einstein College of Medicine
研究記録日
主要日程の研究
研究開始 (実際)
一次修了 (推定)
研究の完了 (推定)
試験登録日
最初に提出
QC基準を満たした最初の提出物
最初の投稿 (実際)
学習記録の更新
投稿された最後の更新 (実際)
QC基準を満たした最後の更新が送信されました
最終確認日
詳しくは
本研究に関する用語
追加の関連 MeSH 用語
その他の研究ID番号
- 2025-17318
- 2025 (米国 NIH グラント/契約：Faculty of Social Sciences Scientific Grant at the University of Gdańsk)
- 3UG1DA013035-24S1 (米国 NIH グラント/契約)
- 25-08-529 (その他の識別子：Biomedical Research Alliance of New York (BRANY))
個々の参加者データ (IPD) の計画
個々の参加者データ (IPD) を共有する予定はありますか?
IPD プランの説明
De-identified demographic, clinical, laboratory, survey, qualitative data collected from case report forms (CRFs) will be preserved and shared.
The following data will be preserved but not shared as they may contain a large volume of personally identifiable information (PII): data derived from qualitative interviews, participant locator and other administrative forms. Likewise, data from all free-text and/or comments fields will not be shared due to the nature of the data and risk of exposing PI.
Scientific data will be processed and analyzed with Statistical Analysis System (SAS) software and shared in SAS and ASCII formats.
IPD 共有時間枠
IPD 共有アクセス基準
IPD 共有サポート情報タイプ
- STUDY_PROTOCOL
- SAP
- ICF
- ANALYTIC_CODE
医薬品およびデバイス情報、研究文書
米国FDA規制医薬品の研究
米国FDA規制機器製品の研究
この情報は、Web サイト clinicaltrials.gov から変更なしで直接取得したものです。研究の詳細を変更、削除、または更新するリクエストがある場合は、register@clinicaltrials.gov。 までご連絡ください。 clinicaltrials.gov に変更が加えられるとすぐに、ウェブサイトでも自動的に更新されます。