Operational Mechanisms of Peer Support Groups and Support for Caregivers of People Living with Serious Mental Illness.

The challenges faced by caregivers of people living with serious mental illness in Canada are well documented in the literature including emotional distress, financial strain, social isolation, and concerns about their physical health following the impact of caregiving. Peer support programs (including peer support groups) emerged as a promising method to attempt to address these challenges. While there is evidence on the positive impacts of peer support groups in providing support for caregivers, the mechanisms by which peer support groups operate and influence support for caregivers of people living with serious mental illness are less understood. This qualitative study took on a co-designed participatory research approach. Fifteen adult caregivers of people living with serious mental illness across Canada were engaged through key informant interviews that lasted for 45 - 60 min each. A thematic analysis was carried out to help understand the operational mechanisms of peer support groups in influencing support for caregivers. The key informant interviews allowed for the identification and description of the following operational mechanisms that influenced the support caregivers received from peer support groups: (1) Group dynamics; (2) Messaging/content; (3) Equity and inclusion, (4) Group philosophy; and (5) Privacy concerns. Findings from this study showed that caregivers identified a number of operational mechanisms of peer support groups that explained how they felt supported when they participated in peer support groups. Among other operational mechanisms, group dynamics in terms of the gathering of caregivers of different age brackets and varying caregiving experience negatively influenced the peer support experience of caregivers. This pointed to the need for group dynamics that consider close age ranges and similar caregiving experience during group meetings to enhance support for caregivers. Caregivers also identified a gap in equity and inclusion in peer support groups that could have otherwise enriched their experience and enhanced the support they looked to receive from the group. Practical examples to enhance equity and inclusion include promoting active listening, using inclusive language, encouraging diverse representation and asking for feedback from peer support group members. While peer support groups in Canada exist independently of one another, it may help to consolidate evidence-based recommendations in the operational mechanisms of these groups, for the benefit of caregivers who turn to these groups for support, having been left on their own by an otherwise fractured mental health system.

How adolescents learn to build social bonds: A developmental computational account of social explore-exploit decision-making.

Building social bonds is a critical task of adolescence that affords opportunities for learning, identity formation, and social support. Failing to develop close relationships in adolescence hinders adult interpersonal functioning and contributes to problems such as loneliness and depression. During adolescence, increased reward sensitivity and greater social flexibility both contribute to healthy social development, yet we lack a clear theory of how these processes interact to support social functioning. Here, we propose synthesizing these two literatures using a computational reinforcement learning framework that recasts how adolescents pursue and learn from social rewards as a social explore-exploit problem. To become socially skilled, adolescents must balance both their efforts to form individual bonds within specific groups and manage memberships across multiple groups to maximize access to social resources. We draw on insights from sociological studies on social capital in collective networks and neurocognitive research on foraging and cooperation to describe the social explore-exploit dilemma faced by adolescents navigating a modern world with increasing access to diverse resources and group memberships. Our account provides important new directions for examining the dynamics of adolescent behavior in social groups and understanding how social value computations can support positive relationships into adulthood.

Comparison of peer, self, and faculty objective structured clinical examination evaluations in a PharmD nonprescription therapeutics course.

PURPOSE: Objective structured clinical examinations (OSCE) are a valuable assessment within healthcare education, as they provide the opportunity for students to demonstrate clinical competency, but can be resource intensive to provide faculty graders. The purpose of this study was to determine how overall OSCE scores compared between faculty, peer, and self-evaluations within a Doctor of Pharmacy (PharmD) curriculum. METHODS: This study was conducted during the required nonprescription therapeutics course. Seventy-seven first-year PharmD students were included in the study, with 6 faculty members grading 10-15 students each. Students were evaluated by 3 graders: self, peer, and faculty. All evaluators utilized the same rubric. The primary endpoint of the study was to compare the overall scores between groups. Secondary endpoints included interrater reliability and quantification of feedback type based on the evaluator group. RESULTS: The maximum possible score for the OSCE was 50 points; the mean scores for self, peer, and faculty evaluations were 43.3, 43.5, and 41.7 points, respectively. No statistically significant difference was found between the self and peer raters. However, statistical significance was found in the comparison of self versus faculty (p = 0.005) and in peer versus faculty (p < 0.001). When these scores were correlated to a letter grade (A, B, C or less), higher grades had greater similarity among raters compared to lower scores. Despite differences in scoring, the interrater reliability, or W score, on overall letter grade was 0.79, which is considered strong agreement. CONCLUSIONS: This study successfully demonstrated how peer and self-evaluation of an OSCE provides a comparable alternative to traditional faculty grading, especially in higher performing students. However, due to differences in overall grades, this strategy should be reserved for low-stakes assessments and basic skill evaluations.

Adolescent Peer Relationship Difficulties, Prosociality, and Parental Emotion Socialization: Moderating Roles of Adolescent Gender.

The present study examined longitudinal, transactional associations between youth social adjustment (prosociality, peer relationship difficulties) and parental emotion socialization in early adolescence. Adolescent gender was considered as a potential moderator. Eighty-seven adolescent-parent dyads (50 girls, 37 boys) participated in 8th grade, with follow-up waves in 9th and 10th grade. Adolescents reported their experiences of peer victimization and their parents' emotion socialization responses, and parents reported youth prosocial behavior and peer relation problems. Hierarchical linear modeling results indicated transactional associations between parent supportive/unsupportive responses and adolescent peer relations and prosociality over time, some of which were moderated by adolescent gender. Increases in parental supportive emotion socialization corresponded to decreased experiences of peer victimization over time for girls, but not boys. When peer victimization increased over time, girls reported less parental supportive responses and all adolescents reported receiving more unsupportive responses from parents. For all adolescents, parents' increased supportive responses also corresponded to decreased peer problems and increased prosocial behavior. As prosocial behavior increased, so did parental supportive responses. Increases in parents' unsupportive responses related to decreased prosocial behavior, and increases in adolescent prosocial behavior related to decreases in parents' unsupportive responses. Results suggest that there is mutual influence between parent emotion socialization and adolescent social adjustment. Adolescent girls appear to uniquely benefit from parents' supportive emotional socialization in relation to their experiences of peer victimization. Potential mechanisms and implications are discussed.

Implementation and Qualitative Analysis of Peer Support for New Pediatric Gastrostomy Tube Families.

INTRODUCTION: Gastrostomy tube (G-tube) insertion in children has frequent complications, including dislodgment and return to the system, which are associated with emotional burden for caregivers. To address these issues, we developed a peer support program for caregivers of children with new G-tubes and aimed to explore program feasibility and acceptability. METHODS: The G-tube Buddy Program is a peer support program that pairs an experienced G-tube caregiver with new G-tube caregivers. Between April 2022 and December 2022, seven mentors and 21 mentees participated in the program. Five mentors and ten mentees participated in semi-structured focus groups and interviews. Transcripts were analyzed using both inductive and deductive qualitative methods. RESULTS: We identified five prominent domains: peer support relationship dynamics; mentor and mentee-specific factors; determinants of program success; mentor and mentee perception of the program; and suggestions for program improvement. These domains encompassed main themes: support consisted primarily of assistance with daily life and social and emotional support; texting was usually the preferred communication method; mentee satisfaction is rooted in humanness, teaching, and generation of hope; mentors participated due to positive feelings regarding helping new caregivers with financial motivation being less important; and, participants perceived the program as a valuable source of support for new caregivers that complements and expands the reach of care they receive from clinical providers. CONCLUSIONS: A peer support model for families with new G-tubes appears feasible and acceptable from participant perspectives. Responses validate the program's potential to add value to the postoperative care of children with G-tubes and will guide program optimization.

To teach is to learn twice, revisited: a qualitative study of how residents learn through teaching in clinical environments.

BACKGROUND: Teaching helps the teacher's own learning as a professional-as the saying goes, 'to teach is to learn twice'. Near-peer teaching in clinical practice has been shown to contribute to the development of both teaching skills and necessary competencies for doctors. Research on how near-peer teachers learn through their teaching roles has mainly focused on classroom learning. However, understanding how the phenomenon of 'teaching is learning twice' occurs in clinical settings and its influencing factors is important for the development of a quality workplace learning environment. Therefore, this study investigated how residents learn through teaching in clinical practice and the factors influencing this process. METHODS: This study's methodology is based on the constructivist grounded theory from a social constructivist perspective. Several teaching hospitals in Japan were included, and the study participants were post-graduate year 2 residents (PGY2s) from these hospitals. The interviews were recorded, transcribed into text, and analysed by the first author. RESULTS: From January 2016 to July 2022, 13 interviews were conducted with 11 PGY2s from nine educational hospitals. The PGY2s played diverse educational roles in clinical settings and learned competencies as physicians in almost all areas through such roles. We found that knowledge transfer and serving as role models stimulated PGY2s' intrinsic motivation, encouraged reflection on their own experiences, and promoted self-regulated learning. Further, educating about procedural skills and clinical reasoning prompted reflection on their own procedural skills and thought processes. Supporting post-graduate year 1 residents' reflections led to the refinement of PGY2s' knowledge and thought processes through the verbal expression of their learning experiences. Such processes required the formation of a community of practice. Thus, education promoted learning through reflection and clarified the expert images of themselves that PGY2s envisaged. CONCLUSIONS: The study found that residents acquire various physician competencies through multiple processes by teaching as near-peer teachers in clinical settings, that a community of practice must be formed for near-peer teaching to occur in a clinical setting, and that teaching brings learning to those who teach by promoting reflection and helping them envision the professionals they aim to be.

The black box of the relationship between breast cancer patients and accompanying patients: the accompanied patients' point of view.

BACKGROUND: The PAROLE-Onco program was introduced in the province of Quebec, Canada in 2019. It integrates accompanying patients (APs), i.e., people who have been affected by cancer, into the clinical team as full members. These APs use their experiential knowledge with people undergoing treatment and with clinical teams. The aim of this paper is to evaluate, within the framework of two university medical centers, the perceptions of breast cancer patients who receive support from APs, particularly in terms of their active involvement in their care trajectory. METHODS: A qualitative study based on semi-structured interviews with accompanied patients was performed. Fourteen individual interviews were conducted between July and September 2021 with women presenting different profiles in terms of age, education, professional status, type of treatment, family situation, and clinical background. The data were analyzed using thematic analysis, focusing on patients' perceptions of APs' contributions and suggested improvements for accessing AP support. RESULTS: Three themes emerged from the semi-structured interviews: communication modalities used to connect patients with their APs, the characteristics of the support provided by APs, and the perceived effects of this support on the patients. Patients expressed a preference for telephone communication, highlighting its convenience and accessibility. The support provided by APs included emotional and informational support, neutrality, and adaptability. This relationship improved patient communication, reduced anxiety, helped regain control, and enhanced overall quality of life. The results emphasized the added value of APs in complementing the support offered by healthcare professionals. Patients noted the critical role of APs in helping them navigate the healthcare system, better understand their treatment processes, and manage their emotions. The ability of APs to provide practical advice and emotional reassurance was particularly valued. Overall, the findings underscored the significant impact of AP support on patients' experiences and highlighted areas for enhancing this service. CONCLUSION: This study highlights, during the care trajectory of people affected by breast cancer, APs' contribution to patients' emotional well-being because they improve, in particular, the management of emotions and communication with health professionals.

In 2019, we initiated the PAROLE-Onco program in Quebec, Canada, to support cancer patients by integrating Accompanying Patients (APs) into the medical team. These individuals, who have personally experienced cancer, join as full team members, sharing their insights with both patients and medical staff. Our study delved into the perceptions of breast cancer patients at two university hospitals regarding APs' involvement in their care trajectory. Through interviews with 14 women of diverse backgrounds and cancer experiences, we found that APs were instrumental in enhancing communication with doctors, facilitating the expression of challenging emotions, and aiding in treatment decisions. Patients valued the inclusion of APs in their care team and expressed gratitude for their support. Nonetheless, some encountered difficulties in reaching out to APs due to a lack of awareness or challenges involved in connecting. Overall, our research underscores the positive impact of involving APs in the care of breast cancer patients, and of enhancing emotional well-being and communication throughout the treatment journey.

Peer review of the pesticide risk assessment of the active substance mepiquat (evaluated variant mepiquat chloride).

The conclusions of the EFSA following the peer review of the initial risk assessments carried out by the competent authorities of the rapporteur Member State, Finland, and co-rapporteur Member State, Estonia, for the pesticide active substance mepiquat (evaluated variant mepiquat chloride) are reported. The context of the peer review was that required by Commission Implementing Regulation (EU) No 844/2012, as amended by Commission Implementing Regulation (EU) No 2018/1659. The conclusions were reached on the basis of the evaluation of the representative uses of mepiquat chloride as a plant growth regulator on cereals and grass (field uses). The reliable end points, appropriate for use in regulatory risk assessment, are presented. Missing information identified as being required by the regulatory framework is listed. Concerns are identified.

Feasibility and acceptability of an adapted peer-based walking intervention for adults with moderate-to-severe traumatic brain injury.

PURPOSE: To examine the feasibility and acceptability of a 6-week peer-based walking intervention for adults with moderate-to-severe TBI with telehealth supports. MATERIALS AND METHODS: Pre-post feasibility trial with 18 community-dwelling adults (10 men; 8 women) with moderate-to-severe TBI aged 21-61 years (M = 40.6, SD = 11.3). Feasibility outcomes included participation, attrition, safety across 12 90-minute sessions, and telehealth platform quality. Acceptability outcomes included program satisfaction. Exploratory outcomes included daily step count with activity trackers and pre-post intervention questionnaires (mood, leisure satisfaction, exercise self-efficacy, quality of life) through video conferencing. RESULTS: 15/18 (83%) participants completed ≥ 9 sessions (75%). Three participants were lost to attrition. No major adverse events reported. Minor events included fatigue and muscle soreness. Participants reported high satisfaction (M = 9.2/10, SD = 0.9). Average weekly steps per day rose from 10,011 to 11,177 steps (12%). Three participants' step count data were not included due to tremors or forgetting to wear the device (≥ 9 days). One major and several minor connectivity problems occurred. Wilcoxon Signed Ranks tests identified a significant change in negative affect (p < 0.002). CONCLUSIONS: Findings support the feasibility and acceptability of a 6-week peer-based walking intervention with telehealth supports for our sample.

It was feasible and acceptable for our sample of adults with moderate-to-severe traumatic brain injury (TBI) to engage in a peer-based walking program during unforeseen circumstances.A peer-based walking group program may be a method of promoting health-related outcomes and physical activity for adults with moderate-to-severe TBI.Telehealth supports may be used to adapt a fitness center-based physical activity program for adults with TBI to an outdoor community context.

"If everyone knew about this, how many lives could we save?": Do drug suppliers have a role in reducing overdose risk?

Introduction: An unpredictable illicit drug supply is driving high levels of overdose death in North America. Prior research has demonstrated the importance of involving people who use drugs in harm reduction intervention design and implementation. The inclusion of people who supply drugs in these efforts has been scant. We explore this possibility by interviewing persons targeted by a harm reduction educational program designed specifically for people who supply drugs. Methods: In-person interviews with people who use drugs were conducted in 2022 in Indianapolis, Indiana. We conducted a thematic analysis of data from six interviews with people who were either primarily or secondarily trained through this harm reduction training for people who supply drugs. Results: Participants described a diverse array of harm reduction strategies, some gained through the targeted education program, which they regularly practiced as they consumed and/or supplied drugs to others. People who supply drugs were regularly identified as key actors capable of widely reducing risk across drug networks. Participants described being motivated by a moral imperative to protect community members, tying the previous loss of friends and loved ones to overdose to their commitments to the safety of others. Conclusion: This article contributes to the scholarship on the role of people who supply drugs in implementing harm reduction interventions and reducing overdose risk. Better enabling grassroots harm reduction organizations to provide people who supply drugs with harm reduction training and access to harm reduction resources may help to reduce drug-related harms.

Leveraging Parents and Peer Recovery Supports to Increase Recovery Capital in Emerging Adults With Polysubstance Use: Protocol for a Feasibility, Acceptability, and Appropriateness Study of Launch.

BACKGROUND: Emerging adults (aged 18-26 years) are the most at-risk yet underserved age group among people with substance use disorder, especially rural emerging adults, and polysubstance use is common. Recovery capital is lower among emerging adults than older adults, and evidence-based treatments are typically unavailable or not developmentally tailored, especially in rural areas. Both supportive parents (or parental figures) and peer recovery support services (PRSS) can be leveraged to better support these emerging adults. Previous research indicates parents can be engaged to deliver contingency management (CM), an extensively researched evidence-based intervention for substance use. OBJECTIVE: This protocol describes a funded pilot of Launch, a novel, scalable service package that pairs web-based coaching for parents to deliver CM for emerging adults (CM-EA) at home and in-person PRSS with educational and vocational goal setting. Specifically, this protocol describes feasibility, acceptability, and appropriateness testing (implementation-related outcomes) and steps taken to prepare for a future large-scale trial of Launch. METHODS: Upon the recruitment of 48 emerging adult and parent pairs from sites serving primarily rural clients, participants will be randomized into 1 of 3 conditions for this randomized controlled trial: virtual parent coaching to deliver CM-EA, in-person PRSS for emerging adults, or both sets of services. Emerging adult eligibility includes polysubstance use, a substance use disorder, and availability of a consenting parent. Emerging adults will be interviewed at baseline and 6 months about substance use, quality of life, recovery capital, parental relationship, and Launch implementation-related outcomes (6-month follow-up only). Parents, peer workers delivering PRSS, and parent CM-EA coaches will be interviewed about implementation-related outcomes at the end of the study period. Peer workers and CM-EA coaches will be asked to complete checklists of services delivered after each session. Finally, payers and providers will be interviewed for additional insights into Launch implementation and to identify key outcomes of Launch. Data analysis for emerging adult outcomes will be primarily descriptive, but parent CM-EA training adherence will be assessed using nested mixed-effects regression models of repeated measures. RESULTS: Launch is currently ongoing, with funding received in August 2023, and is expected to end in September 2025, with data analysis and results in December 2026. Participants are expected to begin enrolling in June 2024. CONCLUSIONS: While this pilot is limited by the small sample size and restriction to emerging adults with an involved parent, this is mitigated by the study's strengths and is appropriate for the pilot stage. Launch uses an innovative combination of existing strategies to generate better outcomes for emerging adults while remaining scalable. This pilot will provide insights into the feasibility and acceptability of Launch from the perspectives of service recipients, providers, and payers to inform a larger-scale effectiveness trial. TRIAL REGISTRATION: ClinicalTrials.gov NCT06414993; https://clinicaltrials.gov/study/NCT06414993. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/60671.

Modeling of drinking and driving behaviors among adolescents and young adults in the United States: Complexities and Intervention outcomes.

Alcohol-impaired driving is a formidable public health problem in the United States, claiming the lives of 37 individuals daily in alcohol-related crashes. Alcohol-impaired driving is affected by a multitude of interconnected factors, coupled with long delays between stakeholders' actions and their impacts, which not only complicate policy-making but also increase the likelihood of unintended consequences. We developed a system dynamics simulation model of drinking and driving behaviors among adolescents and young adults. This was achieved through group model building sessions with a team of multidisciplinary subject matter experts, and a focused literature review. The model was calibrated with data series from multiple sources and replicated the historical trends for male and female individuals aged 15 to 24 from 1982 to 2020. We simulated the model under different scenarios to examine the impact of a wide range of interventions on alcohol-related crash fatalities. We found that interventions vary in terms of their effectiveness in reducing alcohol-related crash fatalities. In addition, although some interventions reduce alcohol-related crash fatalities, some may increase the number of drinkers who drive after drinking. Based on insights from simulation experiments, we combined three interventions and found that the combined strategy may reduce alcohol-related crash fatalities significantly without increasing the number of alcohol-impaired drivers on US roads. Nevertheless, related fatalities plateau over time despite the combined interventions, underscoring the need for new interventions for a sustained decline in alcohol-related crash deaths beyond a few decades. Finally, through model calibration we estimated time delays between actions and their consequences in the system which provide insights for policymakers and activists when designing strategies to reduce alcohol-related crash fatalities.

Using RE-AIM Framework to Evaluate Recovery Opioid Overdose Team Plus: A Peer-Led Post-overdose Quick Response Team.

Peer recovery coaches utilize their lived experiences to support overdose survivors, a role gaining prominence across communities. A convergent mixed methods design, informed by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework, was used to evaluate the Recovery Opioid Overdose Team Plus (ROOT +), through an iterative evaluation using web-based surveys and qualitative interviews. Reach: Over 27 months, ROOT + responded to 83% of suspected overdose referrals (n = 607) and engaged with 41% of survivors (n = 217) and 7% of survivors' family/friends (n = 38). Effectiveness: Among those initially engaged with ROOT +, 36% of survivors remained engaged, entered treatment, or were in recovery at 90 days post-overdose (n = 77). Adoption: First responders completed 77% of ROOT + referrals (n = 468). Implementation: Barriers included lack of awareness of ROOT + , working phones, and access to treatment from community partner interviews (n = 15). Maintenance: Adaptations to ROOT + were made to facilitate implementation. Peer-led teams are promising models to engage with overdose survivors.

Promoting long-acting reversible contraception among post-abortion clients with a provider-comparison intervention: a cluster randomized controlled trial in Nepal.

BACKGROUND: Although long-acting reversible contraception (LARC) is more effective and longer lasting than short-acting methods, uptake remains low among post-abortion clients. Using a stepped-wedge, cluster-randomized trial, we evaluate the impact of a provider-level peer-comparison intervention to encourage choice of LARC in Nepal among post-abortion clients. METHODS: The intervention used prominently displayed monthly posters comparing the health clinic's previous month performance on LARC uptake against peer clinics. To understand how the intervention affected behavior, while ensuring voluntarism and informed choice, we used mystery client visits, in-depth provider interviews, and client exit survey data. The trial examined 17,680 post-abortion clients in 36 clinics in Nepal from July 2016 to January 2017. The primary outcome was the proportion of clients receiving LARCs. Statistical analysis used ordinary least squares (OLS) regression with ANCOVA estimation to assess the intervention's impact on LARC uptake while controlling for client- and clinic-level characteristics. RESULTS: The intervention increased LARC use among post-abortion clients by 6.6% points [95% CI: 0.85 to 12.3, p-value < 0.05], a 29.5% increase in LARC use compared to control clinics. This effect persisted after the formal experiment ended. Analysis of provider and client experiences showed that the behavioral intervention generated significant change in providers' counseling practices, motivated the sharing of best practices. Quality of care indicators either remained stable or improved. CONCLUSION: We find that a provider-level behavioral intervention increases LARC uptake among post-abortion clients. This type of intervention represents a low-cost option to contribute to reducing unmet need for contraception through provider behavior change.

"Instead, You're Going to a Friend": Evaluation of a Community-Developed, Peer-Delivered Online Crisis Prevention Intervention.

OBJECTIVE: Online communities promote social connection and can be used for formal peer support and crisis intervention. Although some communities have programs to support their members' mental health, few programs have been formally evaluated. The authors present findings from a mixed-methods evaluation of the Stack Up Overwatch Program (StOP), a digital peer support intervention delivered in an online gaming community. METHODS: Data were collected from members of the Stack Up Discord server between June and October 2020 and included chat messages, survey responses, encounter forms (documenting information from private interactions between users and peer supporters), and interviews with peer support team members. The authors analyzed data on demographic characteristics, mental health and crises, use of and experiences with StOP, and chat posts. Thematic analysis and descriptive statistics were combined in a joint display table, with mixed-methods findings explained in narrative form. RESULTS: The findings show that StOP provides users in crisis with a source of mental health support when other options have been exhausted and that military and veteran users valued the connections and friendships they formed while using it. Participants reported that StOP met needs for support and connection when formal services were inaccessible or did not meet their needs, and volunteer peer supporters detailed how StOP's design facilitates use of the intervention. Volunteering offered members of the peer support team a "family feeling" facilitated by the unique chat room structure. CONCLUSIONS: Community-based crisis prevention programs administered through chat rooms may provide valuable support to both users and peer support providers.

Exploiting relationship directionality to enhance statistical modeling of peer-influence across social networks.

Risky-prescribing is the excessive or inappropriate prescription of drugs that singly or in combination pose significant risks of adverse health outcomes. In the United States, prescribing of opioids and other "risky" drugs is a national public health concern. We use a novel data framework-a directed network connecting physicians who encounter the same patients in a sequence of visits-to investigate if risky-prescribing diffuses across physicians through a process of peer-influence. Using a shared-patient network of 10 661 Ohio-based physicians constructed from Medicare claims data over 2014-2015, we extract information on the order in which patients encountered physicians to derive a directed patient-sharing network. This enables the novel decomposition of peer-effects of a medical practice such as risky-prescribing into directional (outbound and inbound) and bidirectional (mutual) relationship components. Using this framework, we develop models of peer-effects for contagion in risky-prescribing behavior as well as spillover effects. The latter is measured in terms of adverse health events suspected to be related to risky-prescribing in patients of peer-physicians. Estimated peer-effects were strongest when the patient-sharing relationship was mutual as opposed to directional. Using simulations we confirmed that our modeling and estimation strategies allows simultaneous estimation of each type of peer-effect (mutual and directional) with accuracy and precision. We also show that failing to account for these distinct mechanisms (a form of model mis-specification) produces misleading results, demonstrating the importance of retaining directional information in the construction of physician shared-patient networks. These findings suggest network-based interventions for reducing risky-prescribing.

Effect of a peer-led emergency department behavioral intervention on non-fatal opioid overdose: 18-month outcome in the Navigator randomized controlled trial.

BACKGROUND AND AIMS: Emergency departments (EDs) provide an opportunity to identify people at risk of overdose and reduce the risk. We evaluated the effect of an ED behavioral intervention delivered by peer recovery support specialists (PRSSs) on non-fatal opioid overdose. DESIGN: Two-arm, randomized trial. SETTING: Two EDs in Rhode Island, USA. PARTICIPANTS: ED patients presenting with an opioid overdose, complications of opioid use disorder or a recent history of opioid overdose (November 2018-May 2021). Among 648 participants, the mean age was 36.9 years, 68.2% were male and 68.5% were White. INTERVENTION AND COMPARATOR: Participants were randomized to receive a behavioral intervention from a PRSS (n = 323) or a licensed clinical social worker (LICSW) (n = 325). PRSS and LICSW used evidence-based interviewing and intervention techniques, informed by their lived experience (PRSS) or clinical theory and practice (LICSW). MEASUREMENTS: We identified non-fatal opioid overdoses in the 18 months following the ED visit through linkage to statewide emergency medical services data using a validated case definition. The primary outcome was any non-fatal opioid overdose during the 18-month follow-up period. FINDINGS: Among 323 participants randomized to the PRSS arm, 81 (25.1%) had a non-fatal opioid overdose during follow-up, compared with 95 (29.2%) of 325 participants randomized to the LICSW arm (P = 0.24). There was no statistically significant difference in the effectiveness of randomization to the PRSS arm versus the LICSW arm on the risk of non-fatal opioid overdose, adjusting for the history of previous overdose (relative risk = 0.86, 95% confidence interval = 0.67-1.11). CONCLUSIONS: In Rhode Island, USA, over one-in-four emergency department patients at high risk of overdose experience a non-fatal opioid overdose in the 18 months post-discharge. We found no evidence that the risk of non-fatal opioid overdose differs for emergency department patients receiving a behavioral intervention from a peer recovery support specialist versus a licensed clinical social worker.