Prescription Opioid Dose Change Prior to Fatal Opioid-Detected Overdose.

BACKGROUND: The opioid overdose crisis continues within the U.S., and the role of prescribed opioids and prescribing patterns in overdose deaths remains an important area of research. This study investigated patterns of prescription opioids dispensed in the 12 months prior to opioid-detected overdose death in Connecticut between May 8th, 2016 and January 2nd, 2018, considering differences by demographic characteristics. METHODS: The sample included decedents who had an opioid dispensed within 30 days preceding death. Using multilevel modeling, we estimated the slope of change in mean morphine equivalent (MME) daily dose over 12 months prior to death, considering linear and quadratic effects of time. We estimated the main effects of age, sex, race, and ethnicity and their interactions with time on MME. A sensitivity analysis examined how excluding decedents who did not receive long-term (≥90 days) opioid therapy affected mean MME slopes. Secondary analysis explored differences by toxicology results. RESULTS: Among 1,580 opioid-detected deaths, 179 decedents had prescribed opioids dispensed within 30 days preceding death. Decedents' mean age was 47.3 years (±11.5), 65.5% were male, 81% White non-Hispanic, 9.5% Black non-Hispanic, and 9.5% Hispanic. In the time-only model, linear (ß=6.25, p<0.01) and quadratic (ß=0.49, p=0.02) effects of time were positive, indicating exponentially increasing dose prior to death. Linear change in MME was significantly attenuated in men compared to women (ß=-4.87, p=0.03); however, men were more likely to have non-prescription opioids in their toxicology results (p=0.02). Sensitivity analysis results supported primary findings. CONCLUSION: Rapid dose increases in dispensed opioids may be associated with opioid-detected overdose deaths, especially among women.

Accessibility of Opioid Treatment Programs Based on Conventional vs Perceived Travel Time Measures.

Importance: Transportation barriers have long been associated with poorer health outcomes; this burden is especially acute for individuals with opioid use disorder (OUD), a chronic disease often associated with low socioeconomic status. Conventional travel time analyses may not fully account for experiential components of travel, thereby understating the true travel burden and overstating treatment accessibility to opioid treatment programs (OTPs). Objective: To develop a metric of feels-like accessibility for those using public transit to access OTPs that accounts for the realistic travel burden on individuals with OUD. Design, Setting, and Participants: This cross-sectional study integrated high-resolution transit schedules and operating hours of OTPs to measure feels-like accessibility. Feels-like accessibility considers the differential outcomes of out-of-vehicle travel components and more realistically reflects individuals' transportation burden than conventional accessibility measures. Gini indices and spatial regression models were used to investigate inequities in accessibility. Geocoded data for residential addresses of 1018 overdose fatalities in Connecticut in 2019 were used as a proxy for the treatment needs of individuals with OUD. Data were analyzed between May and August 2023. Main Outcomes and Measures: Conventional and feels-like accessibility scores. Exposures: Fluctuations in public transit frequencies over the course of the day and the limited operating hours of the OTPs. Results: Of the 1018 individuals in the study, the mean (SD) age at death was 43.7 (12.6) years, 784 individuals (77%) were men, 111 (11%) were African American, and 889 (87%) were White, with other racial and ethnic categories including 18 individuals (2%). A total of 264 individuals in the sample (26%) could not access an OTP within 180 minutes. For those who could access these facilities, the average 1-way travel time was 45.6 minutes, with individuals spending approximately 70% of their trip duration on out-of-vehicle travel components. The conventional accessibility metric underestimates individuals' travel burden to OTPs as well as the inequity in accessibility compared with the feels-like accessibility metric. For example, the median (range) conventional accessibility score, defined as the number of OTPs within 120 minutes of transit travel time, was 5.0 (0.0-17.0); the median (range) feels-like accessibility score, defined as the number of OTPs within 120 minutes of transit travel time weighted to account for in- and out-of-vehicle segments, was 1.0 (0.0-10.0). There is a considerable temporal variation in travel time and accessibility depending on the departure times. Conclusions and Relevance: In this cross-sectional study of travel burdens, the calculated feels-like accessibility scores, which consider the differential outcomes of out-of-vehicle travel components (eg, walking and waiting), could better and more realistically reflect passengers' transportation burden. Policy recommendations derived from the conventional accessibility metric could be misleading, and decision-makers should use feels-like accessibility metrics that adequately capture individuals' travel burdens. In the context of access to OTPs, the findings from this study suggest that opening new OTP sites to address gaps in access due to distance to services or extending hours of operation at existing sites may ameliorate the travel burden for individuals.

Understanding chronic pain in Neurofibromatosis Type 1 using the Neurofibromatosis Pain Module (NFPM).

Neurofibromatosis Type 1 (NF1) is an autosomal dominant genetic disorder that can cause an individual significant chronic pain (CP). CP affects quality of life and daily functioning, yet there are limited effective treatments for CP within NF1. The current study describes the impact of CP using the Neurofibromatosis Pain Module (NFPM). The NFPM is a self-reported clinical assessment that evaluates the impact of CP across multiple domains (e.g., interference, severity, tolerance, and symptomology) and three prioritized pain regions. A cross-sectional study (N = 242) asked adults with NF1 to describe and rate their pain using the NFPM. The results indicated that they reported moderate pain severity (M = 6.6, SD = 2.0) on a 0-10 scale, that 54% (n = 131) had been in pain at least 24 days in the last 30, for 75% (n = 181) sleep was affected, and 16% reported that nothing was effective in reducing their CP for their primary pain region. The current results extend previously published work on CP within adults with NF1 and indicate that more emphasis on understanding and ameliorating CP is required. The NFPM is a sensitive clinical measure that provides qualitative and quantitative responses to inform medical providers about changes in CP.

Receipt of opioid use disorder treatments prior to fatal overdoses and comparison to no treatment in Connecticut, 2016-17.

OBJECTIVE: To determine the relative risk of death following exposure to treatments for OUD compared to no treatment. METHODS: In this retrospective cohort study we compiled and merged state agency data on accidental and undetermined opioid overdose deaths in 2017 and exposures to OUD treatment in the prior six months to determine incidence rates following exposure to different treatment modalities. These rates were compared to the estimated incidence among those exposed to no treatment to determine relative risk of death for each treatment exposure. RESULTS: Incidence rates for opioid poisoning deaths for those exposed to treatment ranged from 6.06±1.40 per 1000 persons exposed to methadone to 17.36±3.22 per 1000 persons exposed to any non-medication treatment. The estimated incidence rate for those not exposed to treatment was 9.80±0.72 per 1000 persons. With no exposure to treatment as referent, exposure to methadone or buprenorphine reduced the relative risk by 38% or 34%, respectively; the relative risk of non-medication treatments was equal to or worse than no exposure to treatment (RR = 1.27-1.77). PRINCIPAL CONCLUSIONS: Exposure to non-MOUD treatments provided no protection against fatal opioid poisoning whereas the relative risk was reduced following exposures to MOUD treatment, even if treatment was not continued. Population level efforts to reduce opioid overdose deaths need to focus on expanding access to agonist-based MOUD treatments and are unlikely to succeed if access to non-MOUD treatments is made more available.

"It's starting to weigh on me": Exploring the Experiences and Support Needs of Harm Reduction Staff in Connecticut using the Social-Ecological Model.

BACKGROUND: The experiences and perceived support needs of harm reduction workers in the USA have been understudied. While previous research has explored staff burnout and role-related stress, there is a research gap around potential supports for staff wellbeing and individual longevity in their roles. This is especially critical given the growing overdose crisis and the need for sustainable harm reduction programming. Thus, we sought to describe the experiences of harm reduction staff and identify the perceived support that could empower harm reduction staff to successfully navigate their roles. METHODS: Purposive sampling methods were used to recruit harm reduction staff working in Connecticut. Seventeen semi-structured, one-on-one interviews were conducted between December 2022 and March 2023. Participants were asked about their experiences with role-related stressors and supports. Informed by the Social-Ecological Model, transcripts were coded using both inductive and deductive codes, and themes were developed using thematic analysis approaches. RESULTS: Study participants described their experiences working in harm reduction and the numerous ways they already are or could be receiving support in their roles. These experiences were organized into eight themes according to the levels of the Social-Ecological Model. At the individual level, participants explained that support could help them navigate the variability of the physical environment, boundary setting, and self-care. Relationships between clients and co-workers were both identified as means of support at the interpersonal level, helping participants navigate difficult situations and feelings of stress. At the organizational level, study participants explained how they look to their organization to provide sufficient support by way of training, staffing, compensation, and benefits. Additionally, participants stressed the importance of having supervisors who valued their work and provided emotional support. Lastly, at the community level, participants discussed how support was needed to help them navigate complex systems while working with a stigmatized population in an often-stigmatized field. CONCLUSIONS: To best support harm reduction staff in their day-to-day roles, our findings underscore the need for support on multiple levels. Future research could explore how the provision of support to harm reduction staff impacts not only staff perceptions of support but also the success of clients accessing harm reduction services.

Exploring stakeholders perspectives on TB contact investigation in Cali, Colombia: a qualitative study.

Introduction: Contact investigation is a proven intervention for tuberculosis (TB) case finding and prevention. Although widely endorsed by national public health authorities and the World Health Organization, many countries struggle to implement it effectively. The objective of the study is to describe and characterize the barriers and facilitators of TB contact investigation in Cali, Colombia from the perspective and experience of the key stakeholders involved. Methods: We collected data from group discussions during two workshop sessions with clinic and public health staff involved in TB contact investigation (June 2019 and March 2020 respectively) and semi-structured interviews with TB cases and their household contacts (July 2019 to April 2020). We undertook an inductive thematic analysis with the RADaR technique to characterize the barriers and facilitators of the TB contact investigation process. Results: The two workshops included 21 clinics and 12 public health staff. We also conducted 26 semi-structured interviews with TB cases and their household contacts. Using thematic analysis, we identified four common themes: Healthcare Operations, Essential Knowledge, Time Limitations and Competing Responsibilities, and Interpersonal Interactions. The main barriers to conducting household visits were low data quality, stigma and mistrust, safety concerns for health workers, and limited resources. The main barriers to TB uptake by contacts were competing responsibilities, low TB risk perceptions among contacts, and difficulty accessing diagnostic tests for contacts. In contrast, good communication and social skills among health workers and accurate TB knowledge facilitated successful household visits and TB test uptake, according to key stakeholders. Conclusion: This study provides a deeper understanding of TB contact investigation barriers and facilitators in a high-prevalence urban setting in a middle-income country from the perspective and experience of key stakeholders. The study shed light on the barriers that hinder household contacts engagement and TB test uptake such as issues of systemic capacity and TB knowledge. Also, highlighted facilitators such as the importance of interpersonal communication skills among health workers in the public and private sector. The insights from this study can serve as a valuable resource for public health organizations seeking to enhance their contact investigation efforts and improve TB control in similar settings.

Xylazine in the drug supply: Emerging threats and lessons learned in areas with high levels of adulteration.

BACKGROUND: Xylazine, a sedative analgesic drug approved as an animal tranquilizer but not for human use, has become an adulterant in the illicit opioid marketplace in North America. Recently declared an emerging health threat in the U.S., the prevalence of xylazine in overdose deaths increased 5.5-fold between 2019 and 2021. More information is needed about the impact of xylazine on opioid users and harm reduction service providers. METHODS: The impact of xylazine adulteration was triangulated through examination of (1) opioid overdose fatalities in Connecticut between 2017 and 2021 reported by the Office of the Chief Medical Examiner data, (2) a convenience survey of people in Connecticut who use drugs (PWUD) regarding their knowledge of and attitude about the local illicit drug supply, and (3) semi-structured interviews of harm reduction service providers in Connecticut and Philadelphia in response to prompts on the impacts of and responses to xylazine adulteration. RESULTS: The presence of fentanyl or its analogues in fatal opioid overdoses was a statistically significant predictor of xylazine presence [OR = 25.0, 95%CI (10.7,81.1)] as was being Hispanic [OR = 1.36, 95%CI (1.03,1.77)]. A survey of people who used drugs revealed that 43% (n = 286) were concerned that the drug supply was always unpredictable. Three-quarters of respondents were aware of xylazine and two-thirds would use a xylazine test strip if one was available. Respondents who identified as White, Hispanic were most likely to be aware of xylazine, to have used a fentanyl test strip, and to be interested in a xylazine test strip. Respondents who injected drugs were 3.6-fold more likely than those who did not inject to endorse an interest in a xylazine test strip. Harm reduction service providers were cognizant of a range of problems surrounding the use and injection of xylazine. Although they reported implementing practices to better respond to xylazine harms, they recognized the absence of solutions to many of the problems encountered. CONCLUSION: The prevalence of xylazine has expanded, especially in combination with fentanyl. Harm reduction education efforts with fidelity to best practices have emerged, but the harms persist and community prevention needs are largely unmet.

Technical violations and infractions are drivers of disengagement from methadone treatment among people with opioid use disorder discharged from Connecticut jails 2014-2018.

BACKGROUND: We investigated the interaction between arrests for technical violations vs. receiving new charges with receiving community-based methadone treatment on time-to reincarceration (TTR) in a cohort of men with opioid use disorder (OUD) released from custody from two Connecticut jails from 2014 to 2018. METHODS: Hazard ratios (HR) were estimated for time to reincarceration for technical violations/infractions, misdemeanors only, felonies only, and both misdemeanors and felonies after adjusting for age, race/ethnicity, and receiving methadone treatment during incarceration or in the community following release. Moderation analyses tested the hypotheses that the benefits of receiving methadone in jail or the community on TTR were significantly different for people with only technical violations and infractions compared to misdemeanor and felony charges. RESULTS: In the sample of 788 men who were reincarcerated, 29.4% received technical violations with no new charges (n = 232) with the remainder of the sample receiving new charges consisting of 26.9% new misdemeanor charges, 6.5% felony charges, and 37.2% both felony and misdemeanor charges. Compared to men who received new misdemeanor charges, TTR was significantly shorter among those who received technical violations and infractions with no new charges amounting to a 50% increase in TTR (334.5 days, SD = 321.3 vs. 228.1 days, SD = 308.0, p < 0.001; aHR = 1.5, 95% CI = 1.3, 1.8, p < 0.001). TTR of men who resumed methadone and were charged with a new crime was 50% longer than those who resumed methadone and received technical violations/infractions with no new charges. (230.2 days, SD = 340.2 vs. 402.3 days, SD = 231.3; aHR = 1.5, 95%CI = 1.0, 2.2, p = 0.038). CONCLUSIONS: Reducing technical violations may enhance the benefits of providing community-based methadone following release from incarceration on extending the time between incarcerations during the vulnerable time post-incarceration and reduce the burden on correctional systems.

Concordance between controlled substance receipt and post-mortem toxicology in opioid-detected overdose deaths: A statewide analysis.

BACKGROUND: Opioid overdoses are a leading cause of preventable death in the United States. There is limited research linking decedents' receipt of controlled substances and presence of controlled substances on post-mortem toxicology (PMT). METHODS: We linked data on opioid-detected deaths in Connecticut between May 3, 2016, and December 31, 2017 from the Office of the Chief Medical Examiner, Department of Consumer Protection, and Department of Mental Health and Addiction Services. Exposure was defined as receipt of an opioid or benzodiazepine prescription within 90 days prior to death. Our primary outcome was concordance between medication received and metabolites in PMT. RESULTS: Our analysis included 1412 opioid-detected overdose deaths. 47 % received an opioid or benzodiazepine 90 days prior to death; 36 % received an opioid and 27 % received a benzodiazepine. Concordance between receipt of an opioid or benzodiazepine and its presence in PMT was observed in 30 % of opioid-detected deaths. Concordance with an opioid was present in 17 % of opioid-detected deaths and concordance with a benzodiazepine was present in 21 % of opioid-detected deaths. Receipt of an opioid or benzodiazepine and concordance with PMT were less common in fentanyl or heroin-detected deaths and more common in pharmaceutical opioid-detected deaths. DISCUSSION: Our results suggest medically supplied opioids and benzodiazepines potentially contributed to a substantial number, though minority, of opioid-detected deaths during the study period. Efforts to reduce opioid and benzodiazepine prescribing may reduce risk of opioid-detected deaths in this group, but other approaches will be needed to address most opioid-detected deaths that involved non-pharmaceutical opioids.

Geographic and temporal trends in fentanyl-detected deaths in Connecticut, 2009-2019.

PURPOSE: Since 2012 fentanyl-detected fatal overdoses have risen from 4% of all fatal overdoses in Connecticut to 82% in 2019. We aimed to investigate the geographic and temporal trends in fentanyl-detected deaths in Connecticut during 2009-2019. METHODS: Data on the dates and locations of accidental/undetermined opioid-detected fatalities were obtained from Connecticut Office of the Chief Medical Examiner. Using a Bayesian space-time binomial model, we estimated spatiotemporal trends in the proportion of fentanyl-detected deaths. RESULTS: During 2009-2019, a total of 6,632 opioid deaths were identified. Among these, 3234 (49%) were fentanyl-detected. The modeled spatial patterns suggested that opioid deaths in northeastern Connecticut had higher probability of being fentanyl-detected, while New Haven and its neighboring towns and the southwestern region of Connecticut, primarily Greenwich, had a lower risk. Model estimates also suggested fentanyl-detected deaths gradually overtook the preceding non-fentanyl opioid-detected deaths across Connecticut. The estimated temporal trend showed the probability of fentanyl involvement increased substantially since 2014. CONCLUSIONS: Our findings suggest that geographic variation exists in the probability of fentanyl-detected deaths, and areas at heightened risk are identified. Further studies are warranted to explore potential factors contributing to the geographic heterogeneity and continuing dispersion of fentanyl-detected deaths in Connecticut.

Cost-Effectiveness of Smoking Cessation Approaches in Emergency Departments.

INTRODUCTION: Americans of lower SES use tobacco products at disproportionately high rates and are over-represented as patients of emergency departments. Accordingly, emergency department visits are an ideal time to initiate tobacco treatment and aftercare for this vulnerable and understudied population. This research estimates the costs per quit of emergency department smoking-cessation interventions and compares them with those of other approaches. METHODS: Previously published research described the effectiveness of 2 multicomponent smoking cessation interventions, including brief negotiated interviewing, nicotine replacement therapy, quitline referral, and follow-up communication. Study 1 (collected in 2010-2012) only analyzed the combined interventions. Study 2 (collected in 2017-2019) analyzed the intervention components independently. Costs per participant and per quit were estimated separately, under distinct intervention with dedicated staff and intervention with repurposed staff assumptions. The distinction concerns whether the intervention used dedicated staff for delivery or whether time from existing staff was repurposed for intervention if available. RESULTS: Data were analyzed in 2021-2022. In the first study, the cost per participant was $860 (2018 dollars), and the cost per quit was $11,814 (95% CI=$7,641, $25,423) (dedicated) and $227 per participant and $3,121 per quit (95% CI=$1,910, $7,012) (repurposed). In Study 2, the combined effect of brief negotiated interviewing, nicotine replacement therapy, and quitline cost $808 per participant and $6,100 per quit (dedicated) (95% CI=$4,043, $12,274) and $221 per participant and $1,669 per quit (95% CI=$1,052, $3,531) (repurposed). CONCLUSIONS: Costs varied considerably per method used but were comparable with those of other smoking cessation interventions.

Successful Optimization of Tobacco Dependence Treatment in the Emergency Department: A Randomized Controlled Trial Using the Multiphase Optimization Strategy.

STUDY OBJECTIVE: Tobacco dependence treatment initiated in the hospital emergency department (ED) is effective. However, trials typically use multicomponent interventions, making it difficult to distinguish specific components that are effective. In addition, interactions between components cannot be assessed. The Multiphase Optimization Strategy allows investigators to identify these effects. METHODS: We conducted a full-factorial, 24 or 16-condition optimization trial in a busy hospital ED to examine the performance of 4 tobacco dependence interventions: a brief negotiation interview; 6 weeks of nicotine replacement therapy with the first dose delivered in the ED; active referral to a telephone quitline; and enrollment in SmokefreeTXT, a free short-messaging service program. Study data were analyzed with a novel mixed methods approach to assess clinical efficacy, cost-effectiveness, and qualitative participant feedback. The primary endpoint was tobacco abstinence at 3 months, verified by exhaled carbon monoxide using a Bedfont Micro+ Smokerlyzer. RESULTS: Between February 2017 and May 2019, we enrolled 1,056 adult smokers visiting the ED. Odd ratios (95% confidence intervals) from the primary analysis of biochemically confirmed abstinence rates at 3 months for each intervention, versus control, were: brief negotiation interview, 1.8 (1.1, 2.8); nicotine replacement therapy, 2.1 (1.3, 3.2); quitline, 1.4 (0.9, 2.2); SmokefreeTXT, 1.1 (0.7, 1.7). There were no statistically significant interactions among components. Economic and qualitative analyses are in progress. CONCLUSION: The brief negotiation interview and nicotine replacement therapy were efficacious. This study is the first to identify components of ED-initiated tobacco dependence treatment that are individually effective. Future work will address the scalability of the brief negotiation interview and nicotine replacement therapy by offering provider-delivered brief negotiation interviews and nicotine replacement therapy prescriptions.

"I can't do it": A qualitative study exploring case and contact experiences with COVID-19 contact tracing.

BACKGROUND: Low engagement in contact tracing for COVID-19 dramatically reduces its impact, but little is known about how experiences, environments and characteristics of cases and contacts influence engagement. METHODS: We recruited a convenience sample of COVID-19 cases and contacts from the New Haven Health Department's contact tracing program for interviews about their contact tracing experiences. We analyzed transcripts thematically, organized themes using the Capability, Opportunity, Motivation, Behavior (COM-B) model, and identified candidate interventions using the linked Behavior Change Wheel Framework. RESULTS: We interviewed 21 cases and 12 contacts. Many felt physically or psychologically incapable of contact tracing participation due to symptoms or uncertainty about protocols. Environmental factors and social contacts also influenced engagement. Finally, physical symptoms, emotions and low trust in and expectations of public health authorities influenced motivation to participate. CONCLUSION: To improve contact tracing uptake, programs should respond to clients' physical and emotional needs; increase clarity of public communications; address structural and social factors that shape behaviors and opportunities; and establish and maintain trust. We identify multiple potential interventions that may help achieve these goals.

Healthcare Providers' Perceptions about the Role of Spiritual Care and Chaplaincy Services in Substance Use Outpatient Treatment.

Addressing patients' religion and spirituality (R/S) needs has been associated with positive health outcomes. However, despite receiving extensive training in spiritual assessment and care, chaplaincy services are primarily confined to inpatient settings, with few studies occurring in outpatient settings. The study sought to understand mental health providers' views about what shaped provider and patient motivation to engage in R/S discussions and seek referrals to chaplaincy services. We conducted five one-hour focus group sessions with a total of 38 staff members and thematically analyzed the resulting session and field notes. We identified four themes concerning provider knowledge and attitudes about R/S and chaplaincy services: Staff Information Needs, Staff Motivation to Discuss R/S and Refer, Patient Motivation to Use Chaplaincy Services, and Chaplain Accessibility. The study findings suggest that providers in outpatient substance use treatment clinics in the Veterans Health Administration are receptive to learning about R/S care and the possibility of expanding chaplaincy services. However, staff have misconceptions about the roles and responsibilities of chaplains. Attitudes about and experiences with R/S discussions varied. Trust and confidence in the benefits of chaplaincy services may be improved among both providers and patients by increasing chaplains' accessibility and visibility within these outpatient settings.

Perspectives on adapting a mobile application for pain self-management in neurofibromatosis type 1: results of online focus group discussions with individuals living with neurofibromatosis type 1 and pain management experts.

OBJECTIVE: Neurofibromatosis type 1 (NF1) is a genetic disorder in which chronic pain commonly occurs. The study sought to understand the needs of individuals with NF1 and pain management experts when adapting a pain self-management mobile health application (app) for individuals with NF1. DESIGN: We conducted a series of online, audio-recorded focus groups that were then thematically analysed. SETTING: Online focus groups with adults currently residing in the USA. PARTICIPANTS: Two types of participants were included: individuals with NF1 (n=32 across six focus groups) and pain management experts (n=10 across three focus groups). RESULTS: Six themes across two levels were identified. The individual level included lifestyle, reasons for using the mobile app and concerns regarding its use. The app level included desired content, desired features and format considerations. Findings included recommendations to grant free access to the app and include a community support feature for individuals to relate and validate one another's experience with pain from NF1. In addition, participants noted the importance of providing clear instructions on navigating the app, the use of an upbeat, hopeful tone and appropriate visuals. CONCLUSIONS: Both participant groups endorsed the use of iCanCope (iCC) as an NF1 pain self-management mobile app. Differences between groups were noted, however. The NF1 group appeared interested in detailed and nuanced pain tracking capabilities; the expert group prioritised tracking information such as mood, nutrition and activity to identify potential associations with pain. In tailoring the existing iCC app for individuals with NF1, attention should be paid to creating a community support group feature and to tailoring content, features and format to potential users' specific needs.

A qualitative study of smokers' assessments of four smoking cessation interventions delivered in a hospital emergency department.

BACKGROUND: A recent clinical trial of 1056 adults who smoke tested the efficacy of four components of a treatment intervention initiated in a hospital emergency department (ED) and found two of them to be clinically effective. This paper explores study participants' attitudes towards the four components, whether they identified important interactions, and suggestions for further tailoring. METHODS: Telephone interviews were conducted with participants at the end of the three-month study period. Each participant had received at least one intervention component: nicotine replacement therapy, referral to a smokers' telephone quitline, a brief negotiation interview, or the smartphone-enabled SmokefreeTXT program. Interviews were audio-recorded, transcribed, and analyzed using an iterative approach, grounded in the data, using thematic analysis. RESULTS: Between March 2017 and September 2018, 63 interviews were conducted with participants who received at least one intervention component. The sample was diverse with respect to race, ethnicity, gender, and sociodemographic status. Intervention components were generally well-received by participants. Four themes were identified: Intervention Context, Intervention Content, Communications, and Recommendations. Provision of smoking cessation interventions to ED patients led to reduced self-reported smoking for most. Nicotine replacement therapy diminished cravings, while behavioral interventions provided social support that helped motivate and sustain behavior change. CONCLUSIONS: Intervention components were feasible and acceptable. The data suggest that pharmacological and behavioral interventions be offered simultaneously, that communication skills training be provided to those who deliver the interventions, and that interventions should respect participants' autonomy and preferences concerning intervention timing, frequency, and termination.

Innovation in the treatment of persistent pain in adults with Neurofibromatosis Type 1 (NF1): Implementation of the iCanCope mobile application.

Neurofibromatosis Type 1 (NF1) is a genetic disorder presenting with chronic pain symptoms that has limited treatment options for addressing the pain. The utilization of a mobile application allows for greater reach and scalability when using empirically valid psychosocial self-management treatments for pain. The iCanCope mobile application has been utilized in several different populations dealing with pain symptoms and has demonstrated initial effectiveness. To address the need for this population, we have customized the iCanCope mobile application for the NF1 population and included additional tailored features. We describe the rationale and design of a pilot randomized control study with a sample of 108 adults with NF1, in which two groups will receive access to the mobile application, of which one group will be incentivized to engage in the mobile application and the third group will treatment as usual over the course of 8-week period with a six-week follow-up. Outcomes will focus on the acceptability of the iCanCope-NF mobile application within the NF1 population and the impact of pain related activity on psychometric evaluations to determine if the contingency management will impact the engagement of mobile application, as well as to identify the participants' experiences in relationship to their treatment satisfaction and perceived support.

Development and pilot-testing of a hepatitis C reinfection prevention intervention for patients in treatment for hepatitis C infection.

•We developed a two-session behavioral intervention to prevent HCV reinfection.•The intervention was piloted at an OTP and integrated into HCV treatment.•Baseline data showed limited knowledge & application of safer injection practices.•Implementation barriers included logistics and the lack of financial incentive.•Adaptations addressed barriers, yielding a more feasible and acceptable intervention.

Pilot Evaluations of Two Bluetooth Contact Tracing Approaches on a University Campus: Mixed Methods Study.

BACKGROUND: Many have proposed the use of Bluetooth technology to help scale up contact tracing for COVID-19. However, much remains unknown about the accuracy of this technology in real-world settings, the attitudes of potential users, and the differences between delivery formats (mobile app vs carriable or wearable devices). OBJECTIVE: We pilot tested 2 separate Bluetooth contact tracing technologies on a university campus to evaluate their sensitivity and specificity, and to learn from the experiences of the participants. METHODS: We used a convergent mixed methods study design, and participants included graduate students and researchers working on a university campus during June and July 2020. We conducted separate 2-week pilot studies for each Bluetooth technology. The first was for a mobile phone app ("app pilot"), and the second was for a small electronic "tag" ("tag pilot"). Participants validated a list of Bluetooth-identified contacts daily and reported additional close contacts not identified by Bluetooth. We used these data to estimate sensitivity and specificity. Participants completed a postparticipation survey regarding appropriateness, usability, acceptability, and adherence, and provided additional feedback via free text. We used tests of proportions to evaluate differences in survey responses between participants from each pilot, paired t tests to measure differences between compatible survey questions, and qualitative analysis to evaluate the survey's free-text responses. RESULTS: Among 25 participants in the app pilot, 53 contact interactions were identified by Bluetooth and an additional 61 by self-report. Among 17 participants in the tag pilot, 171 contact interactions were identified by Bluetooth and an additional 4 by self-report. The tag had significantly higher sensitivity compared with the app (46/49, 94% vs 35/61, 57%; P<.001), as well as higher specificity (120/126, 95% vs 123/141, 87%; P=.02). Most participants felt that Bluetooth contact tracing was appropriate on campus (26/32, 81%), while significantly fewer participants felt that using other technologies, such as GPS or Wi-Fi, was appropriate (17/31, 55%; P=.02). Most participants preferred technology developed and managed by the university rather than a third party (27/32, 84%) and preferred not to have tracing apps on their personal phones (21/32, 66%), due to "concerns with privacy." There were no significant differences in self-reported adherence rates across pilots. CONCLUSIONS: Convenient and carriable Bluetooth technology may improve tracing efficiency while alleviating privacy concerns by shifting data collection away from personal devices. With accuracy comparable to, and in this case, superior to, mobile phone apps, such approaches may be suitable for workplace or school settings with the ability to purchase and maintain physical devices.

Lessons Learned From COVID-19 Contact Tracing During a Public Health Emergency: A Prospective Implementation Study.

Background: Contact tracing is a core element of the public health response to emerging infectious diseases including COVID-19. Better understanding the implementation context of contact tracing for pandemics, including individual- and systems-level predictors of success, is critical to preparing for future epidemics. Methods: We carried out a prospective implementation study of an emergency volunteer contact tracing program established in New Haven, Connecticut between April 4 and May 19, 2020. We assessed the yield and timeliness of case and contact outreach in reference to CDC benchmarks, and identified individual and programmatic predictors of successful implementation using multivariable regression models. We synthesized our findings using the RE-AIM implementation framework. Results: Case investigators interviewed only 826 (48%) of 1,705 cases and were unable to reach 545 (32%) because of incomplete information and 334 (20%) who missed or declined repeated outreach calls. Contact notifiers reached just 687 (28%) of 2,437 reported contacts, and were unable to reach 1,597 (66%) with incomplete information and 153 (6%) who missed or declined repeated outreach calls. The median time-to-case-interview was 5 days and time-to-contact-notification 8 days. However, among notified contacts with complete time data, 457 (71%) were reached within 6 days of exposure. The least likely groups to be interviewed were elderly (adjusted relative risk, aRR 0.74, 95% CI 0.61-0.89, p = 0.012, vs. young adult) and Black/African-American cases (aRR 0.88, 95% CI 0.80-0.97, pairwise p = 0.01, vs. Hispanic/Latinx). However, ties between cases and their contacts strongly influenced contact notification success (Intraclass Correlation Coefficient (ICC) 0.60). Surging caseloads and high volunteer turnover (case investigator n = 144, median time from sign-up to retirement from program was 4 weeks) required the program to supplement the volunteer workforce with paid public health nurses. Conclusions: An emergency volunteer-run contact tracing program fell short of CDC benchmarks for time and yield, largely due to difficulty collecting the information required for outreach to cases and contacts. To improve uptake, contact tracing programs must professionalize the workforce; better integrate testing and tracing services; capitalize on positive social influences between cases and contacts; and address racial and age-related disparities through enhanced community engagement.