Experiences of patients at high risk of opioid overdose accessing emergency department and behavioral health interventions: a qualitative analysis in an urban emergency department.

BACKGROUND: Emergency Departments (EDs) have become critical 'touchpoints' for the identification and early engagement of patients at risk of overdose or who have an opioid use disorder (OUD). Our objectives were to examine patients' ED experiences, identify barriers and facilitators of service uptake in ED settings, and explore patients' experiences with ED staff. METHODS: This qualitative study was part of a randomized controlled trial that evaluated the effectiveness of clinical social workers and certified peer recovery specialists in increasing treatment uptake and reducing opioid overdose rates for people with OUD. Between September 2019 and March 2020, semi-structured interviews were conducted 19 participants from the trial. Interviews sought to assess participants' ED care experiences across intervention type (i.e., clinical social worker or peer recovery specialist). Participants were purposively sampled across intervention arm (social work, n = 11; peer recovery specialist, n = 7; control, n = 1). Data were analyzed thematically with a focus on participant experiences in the ED and social and structural factors shaping care experiences and service utilization. RESULTS: Participants reported varied ED experiences, including instances of discrimination and stigma due to their substance use. However, participants underscored the need for increased engagement of people with lived experience in ED settings, including the use of peer recovery specialists. Participants highlighted that ED provider interactions were critical drivers of shaping care and service utilization and needed to be improved across EDs to improve post-overdose care. CONCLUSIONS: While the ED provides an opportunity to reach patients at risk of overdose, our results demonstrate how ED-based interactions and service provision can impact ED care engagement and service utilization. Modifications to care delivery may improve experiences for patients with OUD or at high risk for overdose. TRIAL REGISTRATION: Clinical trial registration: NCT03684681.

Developing and Implementing Electronic Consent Procedures in Response to Covid-19 Restrictions.

The Covid-19 pandemic resulted in unprecedented restrictions on many public, private, and workplace activities throughout the United States and elsewhere. When restrictions were imposed, we were conducting a type III hybrid effectiveness-implementation trial in 10 pediatric trauma centers. In response to several pandemic-based restrictions, we had to develop procedures for engaging with potential research participants while limiting nonclinical, in-person interactions. This manuscript describes the procedures and challenges of obtaining electronic informed consent and assent in a multisite trauma center-based research study. We developed, tested, and trained staff to implement three options for obtaining informed consent. Twenty-five participants were enrolled in the effectiveness-implementation multisite trial during the first six months of utilization of the consent options, with eleven of these individuals enrolled using hybrid or electronic consent procedures. The challenges we identified involving electronic consent procedures included confusion over who would complete the electronic consent process and difficulties reconnecting with families. Lessons learned can strengthen electronic consent and assent procedures for future studies. More research is needed to further strengthen this process and increase its utilization.

Screening Adolescent Trauma Patients for Substance Use at 10 Pediatric Trauma Centers.

BACKGROUND: The American College of Surgeons Committee on Trauma recommends universal alcohol screening be part of the evaluation of admitted trauma patients. Yet, suboptimal screening rates have been reported for admitted adult and adolescent trauma patients. This lack of screening, in turn, has limited the ability of trauma services to provide patients with brief interventions during their hospital admission and subsequent referrals to treatment after discharge. The primary aim of this study was to examine current rates of alcohol and other drug screening with admitted injured adolescents across a national cohort of 10 pediatric trauma centers. METHODS: This retrospective observational study was nested within a larger adolescent screening, brief intervention, and referral to treatment implementation study (Clinicaltrials.gov NCT03297060). Ten pediatric trauma centers participated in a retrospective chart review of a random sample of adolescent trauma patients presenting for care between March 1, 2018, and November 30, 2018. RESULTS: Three hundred charts were abstracted across the 10 participating trauma centers (n = 30 per site). Screening rates varied substantially across centers from five (16.7%) to 28 (93.3%) of the 30 extracted charts. The most frequent screening type documented was blood alcohol concentration (BAC) (N = 80, 35.2% of all screens), followed by the CRAFFT (N = 79, 26.3%), and then the urine drug screen (UDS) (N = 77, 25.6%). The BAC test identified 11 patients as positive for recent alcohol use. The CRAFFT identified 11 positive patients. CONCLUSIONS: Alcohol and drug screening is underutilized for adolescents admitted to pediatric trauma centers. More research is warranted on how best to utilize the teachable moment of the pediatric trauma visit to ensure comprehensive screening of adolescent alcohol or other drug (AOD) use.

Mobile Peer-Support for Opioid Use Disorders: Refinement of an Innovative Machine Learning Tool.

BACKGROUND: The majority of individuals with Opioid Use Disorder (OUD) do not receive any formal substance use treatment. Due to limited engagement and access to traditional treatment, there is increasing evidence that patients with OUDs turn to online social platforms to access peer support and obtain health-related information about addiction and recovery. Interacting with peers before and during recovery is a key component of many evidence-based addiction recovery programs, and may improve self-efficacy and treatment engagement as well as reduce relapse. Commonly-used online social platforms are limited in utility and scalability as an adjunct to addiction treatment; lack effective content moderation (e.g., misinformed advice, maliciousness or "trolling"); and lack common security and ethical safeguards inherent to clinical care. METHODS: This present study will develop a novel, artificial-intelligence (AI) enabled, mobile treatment delivery method that fulfills the need for a robust, secure, technology-based peer support platform to support patients with OUD. Forty adults receiving outpatient buprenorphine treatment for OUD will be asked to pilot a smartphone-based mobile peer support application, the "Marigold App", for a duration of six weeks. The program will use (1) a prospective cohort study to obtain text message content and feasibility metrics, and (2) qualitative interviews to evaluate usability and acceptability of the mobile platform. ANTICIPATED FINDINGS AND FUTURE DIRECTIONS: The Marigold mobile platform will allow patients to access a tailored chat support group 24/7 as a complement to different forms of clinical OUD treatment. Marigold can keep groups safe and constructive by augmenting chats with AI tools capable of understanding the emotional sentiment in messages, automatically "flagging" critical or clinically relevant content. This project will demonstrate the robustness of these AI tools by adapting them to catch OUD-specific "flags" in peer messages while also examining the adoptability of the platform itself within OUD patients.

Reliability of the Clinical SBIRT Proficiency Checklist for Medical Students.

INTRODUCTION: The Substance Abuse and Mental Health Services Agency (SAMHSA) recognizes Screening, Brief Intervention, and Referral to Treatment (SBIRT) as a comprehensive approach to identify individuals with or at risk of developing substance use disorders. Few studies have explored tools for assessing medical student SBIRT competencies. METHODS: First-year medical students trained in SBIRT and Motivational Interviewing completed an Objective Structured Clinical Encounter (OSCE) with a standardized patient who presented with substance use. Six trained members of our research team reviewed 118 OSCE videos utilizing the Clinical SBIRT Proficiency Checklist (CSPC); additionally 30% (n = 37) were randomly selected for pair-review to examine interrater reliability. RESULTS: Interrater reliability was Cohen's kappa of 0.89 for the presence of SBIRT skills and 0.39 agreement for the absence of skills. Across the videos, the most commonly observed skill was screening for alcohol use (75.4%, 95%CI 66.5, 84.3), while organizing referral for treatment was infrequently observed (36.4%, 95% CI 22.0, 50.8). CONCLUSIONS: The CSPC is a reliable tool for assessing medical student SBIRT skills on an OSCE. These findings provide insights on medical student SBIRT knowledge and provides a practical tool for providing early clinically relevant feedback on these skills.