Economic Evaluation Design within the HEAL Prevention Cooperative.

The rapid rise in opioid misuse, disorder, and opioid-involved deaths among older adolescents and young adults is an urgent public health problem. Prevention is a vital part of the nation's response to the opioid crisis, yet preventive interventions for those at risk for opioid misuse and opioid use disorder are scarce. In 2019, the National Institutes of Health (NIH) launched the Preventing Opioid Use Disorder in Older Adolescents and Young Adults cooperative as part of its broader Helping to End Addiction Long-term (HEAL) Initiative ( https://heal.nih.gov/ ). The HEAL Prevention Cooperative (HPC) includes ten research projects funded with the goal of developing effective prevention interventions across various settings (e.g., community, health care, juvenile justice, school) for older adolescent and young adults at risk for opioid misuse and opioid use disorder (OUD). An important component of the HPC is the inclusion of an economic evaluation by nine of these research projects that will provide information on the costs, cost-effectiveness, and sustainability of these interventions. The HPC economic evaluation is integrated into each research project's overall design with start-up costs and ongoing delivery costs collected prospectively using an activity-based costing approach. The primary objectives of the economic evaluation are to estimate the intervention implementation costs to providers, estimate the cost-effectiveness of each intervention for reducing opioid misuse initiation and escalation among youth, and use simulation modeling to estimate the budget impact of broader implementation of the interventions within the various settings over multiple years. The HPC offers an extraordinary opportunity to generate economic evidence for substance use prevention programming, providing policy makers and providers with critical information on the investments needed to start-up prevention interventions, as well as the cost-effectiveness of these interventions relative to alternatives. These data will help demonstrate the valuable role that prevention can play in combating the opioid crisis.

The Effects of Perceived Racial/Ethnic Discrimination on Substance Use Among Youths Living in the Cherokee Nation.

We examined frequency and intensity of racial/ethnic discrimination and the longitudinal relationship to substance use. The sample included (N = 1,421) American Indian, American Indian and White, and White adolescents. A high frequency of perceived racial discrimination was associated with an increased risk for heavy alcohol use, prescription drug misuse, and other illicit drug use. Experiences of perceived racial discrimination high in intensity were associated with further increased risk of prescription drug misuse and other illicit drug use. Race/ethnicity did not moderate the relationship between perceived racial discrimination and substance use. Interventions targeting the deleterious effects of racial discrimination may need to be designed to account for both the environment and the individual.

School Racial Composition as a Moderator of the Effect of Discrimination on Mental Health and Substance use Among American Indian Adolescents.

PURPOSE: To examine the relationships between individual-level perceived racial/ethnic discrimination and mental health and substance use outcomes by school-level racial composition among American Indian (AI) adolescents. METHOD: Self-reported survey data on individual-level variables come from a sample of AI adolescents (n = 510) living in or near the Cherokee Nation during the fall of 2021. School-level data come from publicly available databases. Multilevel linear and logistic regression analyses were performed to test for and examine the interaction between perceived racial/ethnic discrimination and school racial composition in relation to symptoms of anxiety and depression, past 30-day use of alcohol and marijuana, and misuse of prescription opioids. RESULTS: Adjusted analyses showed a significant interaction effect between discrimination and racial composition on anxiety symptoms, such that the effect of discrimination was more pronounced at lower % AI (10th percentile) than at more equivalently mixed (50th percentile) or higher % AI (90th percentile) school settings. No significant interactions were observed with depressive symptoms or substance use outcomes. DISCUSSION: School racial compositions of higher percentage AI may buffer the adverse effect of racial/ethnic discrimination on anxiety symptoms among AI adolescents.

Theory, Measurement, and Psychometric Properties of Risk and Protective Factors for Drug Misuse Among Adolescents Living on or near the Cherokee Nation Reservation.

A team of tribe-based behavioral health specialists and university-based researchers partnered to implement a cluster randomized trial for the prevention of drug misuse among adolescents attending public high schools on or near the Cherokee Nation Reservation in northeastern Oklahoma. The conceptual framework, which guided intervention and measurement design for the trial, incorporates indigenous knowledge and worldviews with empirically-based frameworks and evidence-based practices. Our goal is to serve multicultural youth, families, and schools and to provide a model of effective strategies for wide dissemination. This paper presents the conceptual model, survey design, and psychometric properties of scales to measure risk and protective factors for substance misuse. The survey includes common measures drawn from the PhenX Toolkit on substance use patterns-adolescent module, measured with standard items from the Monitoring the Future (MTF) study and items harmonized across ten NIH-funded research projects with diverse samples of youth. In our trial, brief (20-minute) self-report questionnaires were administered to 10th grade students in fall 2021 (n = 919, 87% response rate) and spring 2022 (n = 929, 89% response rate) in 20 participating high schools on or near the Cherokee Nation Reservation. The sample primarily fell into the following three categories of race/ethnicity identification: only American Indian (AI-only, 29%), AI and another race/ethnicity (AI+, 27%), and only White (35%). Results indicate that risk and protective factor scales were reliably and validly measured with 10 scales and 10 subscales. There were minimal differences between youth who identified as AI only, AI+, and White only, especially for the main scales, which provide confidence in the interpretation of trial outcomes across demographic groups. Study results may not be generalizable to AI/AN youth who live and attend school in more homogenous reservation lands, or alternatively, live in large diverse metropolitan areas.

Perceived Racial/Ethnic Discrimination and Depressive Symptoms among Adolescents Living in the Cherokee Nation.

The objective of this study was to examine the longitudinal relationship between perceived racial/ethnic discrimination and depressive symptoms among adolescents living in the Cherokee Nation, as well as the potential moderating roles of race and social support. Self-reported survey data were analyzed from a sample of high school students (n = 1,622) who identified as American Indian only, American Indian and White, and White only. Compared to students who reported no discrimination on the basis of race, those who reported ever having experienced discrimination scored, on average, 1.62 units higher on the depressive symptoms scale six months later (p = .0001, 95% CI: 0.90, 2.33), while adjusting for age, race, gender, baseline depressive symptoms, enrollment in a free/reduced-price lunch program, and social support. Discrimination intensity did not significantly predict depressive symptoms among those reporting some frequency of discrimination. Race and social support did not modify either effect. These findings may inform development of interventions to promote mental health among American Indian adolescents.

Study protocol for a cluster randomized trial of a school, family, and community intervention for preventing drug misuse among older adolescents in the Cherokee Nation.

BACKGROUND: The national opioid crisis has disproportionately burdened rural White populations and American Indian/Alaska Native (AI/AN) populations. Therefore, Cherokee Nation and Emory University public health scientists have designed an opioid prevention trial to be conducted in rural communities in the Cherokee Nation (northeast Oklahoma) with AI and other (mostly White) adolescents and young adults. Our goal is to implement and evaluate a theory-based, integrated multi-level community intervention designed to prevent the onset and escalation of opioid and other drug misuse. Two distinct intervention approaches-community organizing, as implemented in our established Communities Mobilizing for Change and Action (CMCA) intervention protocol, and universal school-based brief intervention and referral, as implemented in our established Connect intervention protocol-will be integrated with skill-based training for adults to strengthen social support for youth and also with strategic media. Furthermore, we will test systems for sustained implementation within existing organizational structures of the Cherokee Nation and local schools and communities. This study protocol describes the cluster randomized trial, designed to measure implementation and evaluate the effectiveness on primary and secondary outcomes. METHODS: Using a cluster randomized controlled design and constrained randomization, this trial will allocate 20 high schools and surrounding communities to either an intervention or delayed-intervention comparison condition. With a proposed sample of 20 high schools, all enrolled 10th grade students in fall 2021 (ages 15 to 17) will be eligible for participation. During the trial, we will (1) implement interventions through the Cherokee Nation and measure implementation processes and fidelity, (2) measure opioid and other drug use and secondary outcomes every 6 months among a cohort of high school students followed over 3 years through their transition out of high school, (3) test via a cluster randomized trial the effect of the integrated CMCA-Connect intervention, and (4) analyze implementation costs. Primary outcomes include the number of days during the past 30 days of (1) any alcohol use, (2) heavy alcohol use (defined as having at least four, among young women, or five, among young men, standard alcoholic drinks within a couple of hours), (3) any marijuana use, and (4) prescription opioid misuse (defined as "without a doctor's prescription or differently than how a doctor or medical provider told you to use it"). DISCUSSION: This trial will expand upon previous research advancing the scientific evidence regarding prevention of opioid and other drug misuse during the critical developmental period of late adolescent transition to young adulthood among a sample of American Indian and other youth living within the Cherokee Nation reservation. TRIAL REGISTRATION: ClinicalTrials.gov NCT04839978 . Registered on April 9, 2021. Version 4, January 26, 2022.

CONNECT: Implementation of a School-Based Alcohol Screening and Brief Intervention for Youth in the Cherokee Nation.

BACKGROUND: There is growing optimism regarding the use of screening and brief intervention (SBI) to identify and reduce risk behaviors during adolescence. However, understanding successful SBI implementation remains unclear. We previously reported the effects of CONNECT, a school-based SBI, on reducing the primary outcome, the rate of monthly alcohol use among primarily American Indian (AI) and White high school students in the Cherokee Nation. In this paper, we describe the design and implementation process for CONNECT. METHOD: CONNECT was designed to reduce alcohol use with 2 key strategies: (1) SBI with motivational interviewing (MI), implemented by a school-based CONNECT coach, and (2) a media campaign. RESULTS: Implementation results indicate that during each semester of the 2-1/2 years, between 73% and 100% of eligible students had at least one 15-minute meeting with a CONNECT coach. Postcards and posters with positive communication tips for parents were displayed in CONNECT communities. No statistically significant differences occurred between the CONNECT and control groups on the hypothesized intermediate outcomes. CONCLUSIONS: We describe implementation of a universal, school-based, culturally adapted SBI that was effective in reducing alcohol use among youth living in the Cherokee Nation. Schools provide an important context for universal delivery of SBI interventions, such as CONNECT, for diverse adolescent populations, including AI youth.

Fifteen-minute comprehensive alcohol risk survey: reliability and validity across American Indian and White adolescents.

OBJECTIVE: American Indians (AIs) suffer from significant alcohol-related health disparities, and increased risk begins early. This study examined the reliability and validity of measures to be used in a preventive intervention trial. Reliability and validity across racial/ethnic subgroups are crucial to evaluate intervention effectiveness and promote culturally appropriate evidence-based practice. METHOD: To assess reliability and validity, we used three baseline surveys of high school students participating in a preventive intervention trial within the jurisdictional service area of the Cherokee Nation in northeastern Oklahoma. The 15-minute alcohol risk survey included 16 multi-item scales and one composite score measuring key proximal, primary, and moderating variables. Forty-four percent of the students indicated that they were AI (of whom 82% were Cherokee), including 23% who reported being AI only (n = 435) and 18% both AI and White (n = 352). Forty-seven percent reported being White only (n = 901). RESULTS: Scales were adequately reliable for the full sample and across race/ethnicity defined by AI, AI/White, and White subgroups. Among the full sample, all scales had acceptable internal consistency, with minor variation across race/ethnicity. All scales had extensive to exemplary test-retest reliability and showed minimal variation across race/ethnicity. The eight proximal and two primary outcome scales were each significantly associated with the frequency of alcohol use during the past month in both the cross-sectional and the longitudinal models, providing support for both criterion validity and predictive validity. For most scales, interpretation of the strength of association and statistical significance did not differ between the racial/ethnic subgroups. CONCLUSIONS: The results support the reliability and validity of scales of a brief questionnaire measuring risk and protective factors for alcohol use among AI adolescents, primarily members of the Cherokee Nation.