Leveraging a Learning Collaborative Model to Develop and Pilot Quality Measures to Improve Opioid Prescribing in the Emergency Department.

The American College of Emergency Physicians (ACEP) Emergency Medicine Quality Network (E-QUAL) Opioid Initiative was launched in 2018 to advance the dissemination of evidence-based resources to promote the care of emergency department (ED) patients with opioid use disorder. This virtual platform-based national learning collaborative includes a low-burden, structured quality improvement project, data benchmarking, tailored educational content, and resources designed to support a nationwide network of EDs with limited administrative and research infrastructure. As a part of this collaboration, we convened a group of experts to identify and design a set of measures to improve opioid prescribing practices to provide safe analgesia while reducing opioid-related harms. We present those measures here, alongside initial performance data on those measures from a sample of 370 nationwide community EDs participating in the 2019 E-QUAL collaborative. Measures include proportion of opioid administration in the ED, proportion of alternatives to opioids as first-line treatment, proportion of opioid prescription, opioid pill count per prescription, and patient medication safety education among ED visits for atraumatic back pain, dental pain, or headache. The proportion of benzodiazepine and opioid coprescribing for ED visits for atraumatic back pain was also evaluated. This project developed and effectively implemented a collection of 6 potential measures to evaluate opioid analgesic prescribing across a national sample of community EDs, representing the first feasibility assessment of opioid prescribing-related measures from rural and community EDs.

Goals-of-Care Conversations for Older Adults With Serious Illness in the Emergency Department: Challenges and Opportunities.

During the last 6 months of life, 75% of older adults with preexisting serious illness, such as advanced heart failure, lung disease, and cancer, visit the emergency department (ED). ED visits often mark an inflection point in these patients' illness trajectories, signaling a more rapid rate of decline. Although most patients are there seeking care for acute issues, many of them have priorities other than to simply live as long as possible; yet without discussion of preferences for treatment, they are at risk of receiving care not aligned with their goals. An ED visit may offer a unique "teachable moment" to empower patients to consider their ability to influence future medical care decisions. However, the constraints of the ED setting pose specific challenges, and little research exists to guide clinicians treating patients in this setting. We describe the current state of goals-of-care conversations in the ED, outline the challenges to conducting these conversations, and recommend a research agenda to better equip emergency physicians to guide shared decisionmaking for end-of-life care. Applying best practices for serious illness communication may help emergency physicians empower such patients to align their future medical care with their values and goals.

Suspected involvement of fentanyl in prior overdoses and engagement in harm reduction practices among young adults who use drugs.

Background: From 2011 to 2016, the United States has experienced a 55% increase in overall overdose deaths and a 260% increase in fatal fentanyl-related overdoses. Increasing engagement in harm reduction practices is essential to reducing the rate of fentanyl-related overdoses. This study sought to examine the uptake of harm reduction practices among young adults who reported recent drug use and who were recruited for a study to assess the utility and acceptability of rapid fentanyl test strips. Methods: Between May and October 2017, 93 young adults who reported drug use in the past 30 days were recruited through word of mouth, Internet advertising, and public canvasing. Participants completed an interviewer-administered survey that assessed participants' sociodemographic and behavioral characteristics, suspected fentanyl exposure, and overdose history. We assessed harm reduction practices and other correlates associated with experiencing a suspected fentanyl-related overdose. Results: Of 93 eligible participants, 36% (n = 34) reported ever having experienced an overdose, among whom 53% (n = 18) suspected having experienced a fentanyl-related overdose. Participants who had ever experienced a fentanyl-related overdose were more likely to keep naloxone nearby when using drugs compared with those who had never experienced an overdose and those who had experienced an overdose that they did not suspect was related to fentanyl (P < .001). Additionally, experiencing a suspected fentanyl-related overdose was associated with having previously administered naloxone to someone else experiencing an overdose (P < .001). Conclusion: Those who had experienced a suspected fentanyl-related overdose were more likely to carry and administer naloxone. Future overdose prevention interventions should involve persons who have experienced a suspected fentanyl overdose and/or responded to an overdose in order to develop harm reduction programs that meet the needs of those at risk of an overdose.

High willingness to use rapid fentanyl test strips among young adults who use drugs.

BACKGROUND: Synthetic opioid overdose mortality among young adults has risen more than 300% in the USA since 2013, primarily due to the contamination of heroin and other drugs with illicitly manufactured fentanyl. Rapid test strips, which can be used to detect the presence of fentanyl in drug samples (before use) or urine (after use), may help inform people about their exposure risk. The purpose of this study was to determine whether young adults who use drugs were willing to use rapid test strips as a harm reduction intervention to prevent overdose. We hypothesized that those who had ever overdosed would be more willing to use the test strips. METHODS: We recruited a convenience sample of young adults who use drugs in Rhode Island from May to September 2017. Eligible participants (aged 18 to 35 with past 30-day drug use) completed an interviewer-administered survey. The survey assessed participant's socio-demographic and behavioral characteristics, overdose risk, as well as suspected fentanyl exposure, and willingness to use take-home rapid test strips to detect fentanyl contamination in drugs or urine. Participants were then trained to use the test strips and were given ten to take home. RESULTS: Among 93 eligible participants, the mean age was 27 years (SD = 4.8), 56% (n = 52) of participants were male, and 56% (n = 52) were white. Over one third (n = 34, 37%) had a prior overdose. The vast majority (n = 86, 92%) of participants wanted to know if there was fentanyl in their drug supply prior to their use. Sixty-five (70%) participants reported concern that their drugs were contaminated with fentanyl. After the brief training, nearly all participants (n = 88, 95%) reported that they planned to use the test strips. CONCLUSIONS: More than 90% of participants reported willingness to use rapid test strips regardless of having ever overdosed, suggesting that rapid fentanyl testing is an acceptable harm reduction intervention among young people who use drugs in Rhode Island. Study follow-up is ongoing to determine whether, how, and under what circumstances participants used the rapid test strips and if a positive result contributed to changes in overdose risk behavior.

Reaching Adolescents for Prevention: The Role of Pediatric Emergency Department Health Promotion Advocates.

OBJECTIVES: Almost 200,000 adolescents visit US emergency departments (EDs) yearly for conditions involving underage drinking but receive no follow-up referral. Other health risk behaviors resulting in sexually transmitted infections, car crashes, and assault-related injury are common among adolescents. A pediatric ED (PED) visit presents an opportunity to discuss and promote prevention. We report here on implementation of a new PED navigator/extender role, the Health Promotion Advocate (HPA). METHODS: Health Promotion Advocates surveyed patients to identify health risks, stresses, and needs. A positive screen triggered a brief conversation containing the following elements: permission to discuss risks/needs; exploration of context (a typical day in your life); brief feedback (information and norms); exploration of benefits and consequences of risk behaviors; assessment of readiness to change; calling up assets, instilling hope; discussing challenges of change; negotiating a menu of options and prescription for change; referrals to primary care, community resources; and treatment services as indicated. RESULTS: During 2009-2013, HPAs screened 2149 PED patients aged 14 to 21 years and referred 834 for an array of services (eg, primary care, mental health, insurance, personal safety, human immunodeficiency virus testing, general education diploma (GED), employment, housing, and food pantries) to address reported health risks; 785 screened positive for at-risk substance use (53% female, 36% without primary care). Among them, 636 received a brief intervention; 546 were referred to specialized substance abuse treatment. Two case studies are presented to illustrate the engagement and referral process. CONCLUSIONS: Health Promotion Advocates working as PED team members can extend PED services beyond the scope of the presenting complaint.

Differences by gender at twelve months in a brief intervention trial among Mexican-origin young adults in the emergency department.

In this study, we investigate the role of gender in prevalence and consequences of binge drinking and brief intervention outcomes among Mexican-origin young adults aged 18-30 years at the U.S.-Mexico border. We conducted a secondary analysis, stratified by gender, from a randomized controlled trial of a brief motivational intervention in a hospital emergency department. Intervention effects for males included reductions in drinking frequency, binge drinking, and alcohol-related consequences. For females the intervention was associated with reduction in drinking frequency and binge drinking but did not have a significant effect on alcohol-related consequences. Results suggest a new direction for tailoring interventions to gender.

Brief Intervention in the Emergency Department Among Mexican-Origin Young Adults at the US-Mexico Border: Outcomes of a Randomized Controlled Clinical Trial Using Promotores.

AIMS: A randomized controlled trial of brief intervention (BI), for drinking and related problems, using peer health promotion advocates (promotores), was conducted among at-risk and alcohol-dependent Mexican-origin young adult emergency department (ED) patients, aged 18-30. METHODS: Six hundred and ninety-eight patients were randomized to: screened only (n = 78), assessed (n = 310) and intervention (n = 310). Primary outcomes were at-risk drinking and Rapid Alcohol Problems Screen (RAPS4) scores. Secondary outcomes were drinking days per week, drinks per drinking day, maximum drinks in a day and negative consequences of drinking. RESULTS: At 3- and 12-month follow-up the intervention condition showed significantly lower values or trends on all outcome variables compared to the assessed condition, with the exception of the RAPS4 score; e.g. at-risk drinking days dropped from 2.9 to 1.7 at 3 months for the assessed condition and from 3.2 to 1.2 for the intervention condition. Using random effects modeling controlling for demographics and baseline values, the intervention condition showed significantly greater improvement in all consumption measures at 12 months, but not in the RAPS4 or negative consequences of drinking. Improvements in outcomes were significantly more evident for non-injured patients, those reporting drinking prior to the event, and those lower on risk taking disposition. CONCLUSIONS: At 12-month follow-up this study demonstrated significantly improved drinking outcomes for Mexican-origin young adults in the ED who received a BI delivered by promotores compared to those who did not. TRIAL REGISTER: ClinicalTrials.gov. CLINICAL TRIAL REGISTRATION NUMBER: NCT02056535.

Smoking Is Associated with Increased Risk of Binge Drinking in a Young Adult Hispanic Population at the US-Mexico Border.

BACKGROUND: This study examines factors related to general health and health behavior, including smoking, that may be associated with binge drinking, drinking "at risk," and potential for alcohol use disorder among young adults of Mexican ancestry. METHODS: A total of 2191 young adult emergency department (ED) patients (18-30 years) of Mexican ancestry in a public hospital proximate to the US-Mexico border completed health surveys while they were waiting to be treated, including questions on general health, drinking, smoking, and drug use. RESULTS: Thirty-seven percent of the study participants reported binge drinking, 38% were "at-risk" alcohol users (above National Institute on Alcohol Abuse and Alcoholism guidelines), and 22% were Rapid Alcohol Problem Screen (RAPS) positive (indicating potential for alcohol use disorder). Smoking was reported by 31%, marijuana use by 16%, and other drug use by 9%. Multiple variable models revealed that smoking was the strongest factor associated with binge drinking. Those who smoked were 3.1 (P < .0001) times more likely to binge drink. Other factors independently associated with binge drinking were age 22-25 years (odds ratio [OR] = 1.5, P = .003), male gender (OR = 1.5, P = .0001), and ED visit for injury (OR = 1.4, P = .007). CONCLUSIONS: There is a strong association of smoking and binge drinking. Study findings suggest that brief interventions designed to reduce preventable health risks for young Hispanics should include discussion of both binge drinking and smoking behaviors.

The impact of a brief motivational intervention on unprotected sex and sex while high among drug-positive emergency department patients who receive STI/HIV VC/T and drug treatment referral as standard of care.

This randomized, controlled trial, conducted among out-of-treatment heroin/cocaine users at an emergency department visit, tests the impact on sexual risk of adding brief motivational intervention (B-MI) to point-of-service testing, counseling and drug treatment referral. 1,030 enrollees aged 18-54 received either voluntary counseling/testing (VC/T) with drug treatment referral, or VC/T, referral, and B-MI, delivered by an outreach worker. We measured number and proportion of non-protected sex acts (last 30 days) at 6 and 12 months (n = 802). At baseline, 70% of past-30-days sex acts were non-protected; 35% of sex acts occurred while high; 64% of sexual acts involved main, 24% casual and 12% transactional sex partners; 1.7% tested positive for an STI, and 8.8% for HIV. At six or 12 month follow-up, 20 enrollees tested positive for Chlamydia and/or Gonorrhea, and 6 enrollees HIV sero-converted. Self-reported high-risk behaviors declined in both groups with no significant between-group differences in behaviors or STI/HIV incidence.

Sexually Transmitted and Blood-borne Infections Among Patients Presenting to a Low-barrier Substance Use Disorder Medication Clinic.

OBJECTIVE: To study the infection-related needs of patients with substance use disorders initiating care at a low-barrier-to-access program (LBAP) by describing the proportion with human immunodeficiency virus (HIV), hepatitis B and C virus (HBV, HCV), syphilis, gonorrhea, and chlamydia and determining rates of treatment and/or linkage to care. METHODS: We reviewed the records of patients who completed an intake visit at an LBAP in Boston, MA during the first 9 months after implementation of a standardized intake laboratory panel (January 30, 2017-September 30, 2017). RESULTS: Among 393 patients initiating care, 84.7% (n = 333) completed at least 1 screening test. Baseline rates of HIV (9/393, 2.3%), current or past HCV (151/393, 38.4%), and chronic HBV (2/393, 0.5%) were high. Sixty-one new, active infections were identified through screening, including 1 HIV, 3 syphilis, 4 gonorrhea, 3 chlamydia, 1 chronic, and 1 acute HBV, and 48 cases of viremic HCV. Many patients were nonimmune to HBV (102/270, 37.8%) and HAV (112/255, 43.9%). Among new diagnoses, treatment was documented in 88% of bacterial infections and linkage occurred in 0/1 HIV, 2/2 HBV (100.0%), and 16/48 HCV (33.3%) cases. CONCLUSIONS: Patients initiating SUD care at an LBAP have substantial, unmet infection-related needs. Results justify the inclusion of comprehensive infection prevention, screening, and linkage-to-treatment protocols in LBAPs.

Shorter outpatient wait-times for buprenorphine are associated with linkage to care post-hospital discharge.

BACKGROUND: Inpatient addiction consult services (ACS) lower barriers to accessing medications for opioid use disorder (MOUD), however not every patient recommended for MOUD links to outpatient care. We hypothesized that fewer days between discharge date and outpatient appointment date was associated with improved linkage to buprenorphine treatment among patients evaluated by an ACS. METHODS: We extracted appointment and demographic data from electronic medical records and conducted retrospective chart review of adults diagnosed with opioid use disorder (OUD) evaluated by an ACS in Boston, MA between July 2015 and August 2017. These patients were initiated on or recommended buprenorphine treatment on discharge and provided follow-up appointment at our hospital post-discharge. Multivariable logistic regression assessed whether arrival to the appointment post-discharge was associated with shorter wait-times (0-1 vs. 2+ days). RESULTS: In total, 142 patients were included. Among patients who had wait-times of 0-1 day, 63 % arrived to their appointment compared to wait-times of 2 or more days (42 %). There were no significant differences between groups based on age, gender, distance of residence from the hospital, insurance status, co-occurring alcohol use disorder diagnosis, or discharge with buprenorphine prescription. After adjusting for covariates, patients with 0-1 day of wait-time had 2.6 times the odds of arriving to their appointment [95 % CI 1.3-5.5] compared to patients who had 2+ days of wait-time. CONCLUSION: For hospitalized patients with OUD evaluated for initiating MOUD, same- and next-day appointments are associated with increased odds of linkage to outpatient MOUD care post-discharge compared to waiting two or more days.

Feasibility of a Brief Intervention to Facilitate Advance Care Planning Conversations for Patients with Life-Limiting Illness in the Emergency Department.

Background: Advance care planning (ACP) conversations are an important intervention to provide care consistent with patient goals near the end of life. The emergency department (ED) could serve as an important time and location for these conversations. Objectives: To determine the feasibility of an ED-based, brief negotiated interview (BNI) to stimulate ACP conversations among seriously ill older adults. Methods: We conducted a pre/postintervention study in the ED of an urban, tertiary care, academic medical center. From November 2017 to May 2019, we prospectively enrolled adults ≥65 years of age with serious illness. Trained clinicians conducted the intervention. We measured patients' ACP engagement at baseline and follow-up (3 ± 1 weeks) and reviewed electronic medical record documentation of ACP (e.g., medical order for life-sustaining treatment [MOLST]). Results: We enrolled 51 patients (mean age = 71; SD 12), 41% were female, and 51% of patients had metastatic cancer. Median duration of the intervention was 11.8 minutes; few (6%) of the interventions were interrupted. We completed follow-up for 61% of participants. Patients' self-reported ACP engagement increased from 3.0 to 3.7 out of 5 after the intervention (p < 0.01). Electronic documentation of health care proxy forms increased (75%-94%, n = 48) as did MOLST (0%-19%, n = 48) during the six months after the ED visit. Conclusion: A novel, ED-based, BNI intervention to stimulate ACP conversations for seriously ill older adults is feasible and may improve ACP engagement and documentation.

Appointment wait-times and arrival for patients at a low-barrier access addiction clinic.

INTRODUCTION: Same-day or next-day access to outpatient medication for addiction treatment (MAT) for both alcohol and opioid use disorders may facilitate sustained treatment with evidence-based therapies for substance use disorders (SUD). This study evaluates the association between appointment wait-times and odds of arrival to appointment for patients seeking outpatient MAT. METHODS: The study sample consisted of patients who scheduled an appointment with a low-barrier access addiction clinic between August 1, 2016, and July 31, 2017. The outcome of interest was the status of the appointment as a dichotomous variable: arrive or no-show/cancel. The primary independent variable (wait-time) was the number of overnights between the date a patient scheduled a clinic appointment and the date of service, categorized as 0 days, 1 day, and 2+ days. We conducted bivariable and multivariable logistic regressions to calculate unadjusted and adjusted odds ratios for arrival. Multivariable analyses were adjusted for gender, age, distance of residence from the clinic, and insurance type. RESULTS: Our analysis included 657 patients, of whom 410 (62%) arrived to their first appointment. Among the 657 patients, 47% (308) were scheduled the same day (0 days) and 82% (252) of them were seen, 23% (151) waited 1 day (next-day) and 53% (80) of them were seen, and 30% (198) waited 2+ days and 39% (78) of them were seen. Patients were more likely to be seen when they had a same-day (OR 6.9 [95% CI 4.6-10.4]; AOR 7.5 [4.9-11.4]) or next-day (OR 1.7 [1.1-2.7]; AOR 1.7 [1.1-2.6]) appointment compared to waiting 2+ days. CONCLUSION: Patients seeking MAT through a clinic that schedules same-day and next-day appointments for treatment are more likely to attend addiction appointments compared to patients who wait longer. Clinics should strive to reduce wait-times for patients seeking MAT.

A randomized clinical trial of a theory-based fentanyl overdose education and fentanyl test strip distribution intervention to reduce rates of opioid overdose: study protocol for a randomized controlled trial.

BACKGROUND: Opioid overdose deaths involving synthetic opioids, particularly illicitly manufactured fentanyl, remain a substantial public health concern in North America. Responses to overdose events (e.g., administration of naloxone and rescue breathing) are effective at reducing mortality; however, more interventions are needed to prevent overdoses involving illicitly manufactured fentanyl. This study protocol aims to evaluate the effectiveness of a behavior change intervention that incorporates individual counseling, practical training in fentanyl test strip use, and distribution of fentanyl test strips for take-home use among people who use drugs. METHODS: Residents of Rhode Island aged 18-65 years who report recent substance use (including prescription pills obtained from the street; heroin, powder cocaine, crack cocaine, methamphetamine; or any drug by injection) (n = 500) will be recruited through advertisements and targeted street-based outreach into a two-arm randomized clinical trial with 12 months of post-randomization follow-up. Eligible participants will be randomized (1:1) to receive either the RAPIDS intervention (i.e., fentanyl-specific overdose education, behavior change motivational interviewing (MI) sessions focused on using fentanyl test strips to reduce overdose risk, fentanyl test strip training, and distribution of fentanyl test strips for personal use) or standard overdose education as control. Participants will attend MI booster sessions (intervention) or attention-matched control sessions at 1, 2, and 3 months post-randomization. All participants will be offered naloxone at enrolment. The primary outcome is a composite measure of self-reported overdose in the previous month at 6- and/or 12-month follow-up visit. Secondary outcome measures include administratively linked data regarding fatal (post-mortem investigation) and non-fatal (hospitalization or emergency medical service utilization) overdoses. DISCUSSION: If the RAPIDS intervention is found to be effective, its brief MI and fentanyl test strip training components could be easily incorporated into existing community-based overdose prevention programming to help reduce the rates of fentanyl-related opioid overdose. TRIAL REGISTRATION: ClinicalTrials.gov NCT04372238 . Registered on 01 May 2020.

The timing of alcohol use and sexual initiation among a sample of Black, Hispanic, and White adolescents.

The goals of this study were to examine the relationship between age at first drink and age at first sex among an emergency department sample of Black, Hispanic, and White adolescents (N = 1,1110) and to assess two sexual behavior-related consequences of underage drinking. The authors used multivariable linear regression to analyze data from a self-reported survey. Age at first sex decreased linearly with decreasing age at first drink (p < .001) for all adolescents in the sample. In analyses stratified by race, significant positive trends between age at first drink and age at first sex were observed for all race and ethnic subgroups, although the relationship between age at first drink and age at first sex was not as strong for Black males and females as their White counterparts, respectively. Compared to White males, Black males were less likely to report having had sex without using a condom or birth control after drinking in the past month and during their lifetimes.

Empower Seriously Ill Older Adults to Formulate Their Goals for Medical Care in the Emergency Department.

BACKGROUND: Most seriously ill older adults visit the emergency department (ED) near the end of life, yet no feasible method exists to empower them to formulate their care goals in this setting. OBJECTIVE: To develop an intervention to empower seriously ill older adults to formulate their future care goals in the ED. DESIGN: Prospective intervention development study. SETTING: In a single, urban, academic ED, we refined the prototype intervention with ED clinicians and patient advisors. We tested the intervention for its acceptability in English-speaking patients ≥65 years old with serious illness or patients whose treating ED clinician answered "No" to the "surprise question" ("would not be surprised if died in the next 12 months"). We excluded patients with advance directives or whose treating ED clinician determined the patient to be inappropriate. MEASUREMENTS: Our primary outcome was perceived acceptability of our intervention. Secondary outcomes included perceived main intent and stated attitude toward future care planning. RESULTS: We refined the intervention with 16 mock clinical encounters of ED clinicians and patient advisors. Then, we administered the refined intervention to 23 patients and conducted semistructured interviews afterward. Mean age of patients was 76 years, 65% were women, and 43% of patients had metastatic cancer. Most participants (n = 17) positively assessed our intervention, identified questions for their doctors, and reflected on how they feel about their future care. CONCLUSION: An intervention to empower seriously ill older adults to understand the importance of future care planning in the ED was developed, and they found it acceptable.

Preparing Mexican-Origin Community Health Advocates (Promotores) to Conduct SBIRT for Problem Drinking in the Emergency Room.

Community Health Advocates (CHAs), known as Promotores in Spanish-speaking communities, are an important resource for the mobilization, empowerment, and the delivery of health education messages in Hispanic/Latino communities. This article focuses on understanding cultural, didactic, and logistical aspects of preparing CHAs to become competent to perform a brief intervention and referral to treatment (SBIRT) in the emergency room (ER). The CHAs training emphasizes making connections with Mexican-origin young adults aged 18-30, and capitalizing on a teachable moment to effect change in alcohol consumption and negative outcomes associated with alcohol use. We outline a CHA recruitment, content/methods training, and the analysis of advantages and challenges presented by the delivery of an intervention by CHAs.

Use of rapid fentanyl test strips among young adults who use drugs.

BACKGROUND: The overdose epidemic has been exacerbated by a dramatic increase in deaths involving illicitly manufactured fentanyl (IMF). Drug checking is a novel strategy to identify IMF in illicit drugs. We examined the uptake and acceptability of rapid fentanyl test strips among young adults. METHODS: From May to September 2017, we recruited 93 young adults in Rhode Island who reported injecting drugs or using heroin, cocaine, or illicitly obtained prescription pills in the past 30 days. Participants were asked to test either their urine after drug use (post-consumption) or a drug sample prior to use (pre-consumption) using rapid fentanyl test strips. After a questionnaire and a brief training, participants received ten strips for their personal use and were asked to return for a one-month follow-up visit, which assessed the uptake and acceptability of the rapid strips tests and the behavioral outcomes associated with receipt of a positive test. RESULTS: Of the 81 (87%) participants who returned for follow-up and who had complete data, the mean age was 27, 45 (56%) were male, and 37 (46%) were non-white. A total of 62 participants (77%) reported using at least one test strip. Of these, 31 (50%) received at least one positive result. A positive result was associated with older age, homelessness, heroin use, injection drug use, ever witnessing an overdose, and concern about overdose or drugs being laced with fentanyl (all p < 0.05). Receiving a positive result was significantly associated with reporting a positive change in overdose risk behavior between baseline and follow-up (p ≤ 0.01). Among all participants, 79 (98%) reported confidence in their ability to use the test strips and 77 (95%) wanted to use them in the future. CONCLUSIONS: Young adults reported high uptake and acceptability of fentanyl test strips to detect IMF in illicit drugs.

Predictors of disclosure of continued cocaine use.

Lack of disclosure of substance use is common in research and treatment settings and is frequently higher at follow-up than at baseline interviews. The aim of this study was to determine predictors of cocaine use disclosure at follow-up among 525 individuals who reported and tested positive for baseline use. Measurements included self-reported quantity and frequency of use, and hair analysis by radioimmune assay. Forty-two percent of individuals with biochemical evidence of continued cocaine use denied this use. In adjusted analyses, self-reported substance abuse treatment contact after enrollment was associated with lower disclosure (OR 0.63, 95% CI 0.43, 0.93). Other predictors were race, hair cocaine level, and opiates in hair. Failure to stop use after seeking treatment may result in reduced disclosure of continued use, possibly because of unwillingness to admit failure.