Safety planning intervention and follow-up: A telehealth service model for suicidal individuals in emergency department settings: Study design and protocol.

BACKGROUND: The Safety Planning Intervention with follow-up services (SPI+) is a promising suicide prevention intervention, yet many Emergency Departments (EDs) lack the resources for adequate implementation. Comprehensive strategies addressing structural and organizational barriers are needed to optimize SPI+ implementation and scale-up. This protocol describes a test of one strategy in which ED staff connect at-risk patients to expert clinicians from a Suicide Prevention Consultation Center (SPCC) via telehealth. METHOD: This stepped wedge, cluster-randomized trial compares the effectiveness, implementation, cost, and cost offsets of SPI+ delivered by SPCC clinicians versus ED-based clinicians (enhanced usual care; EUC). Eight EDs will start with EUC and cross over to the SPCC phase. Blocks of two EDs will be randomly assigned to start dates 3 months apart. Approximately 13,320 adults discharged following a suicide-related ED visit will be included; EUC and SPCC samples will comprise patients from before and after SPCC crossover, respectively. Effectiveness data sources are electronic health records, administrative claims, and the National Death Index. Primary effectiveness outcomes are presence of suicidal behavior and number/type of mental healthcare visits and secondary outcomes include number/type of suicide-related acute services 6-months post-discharge. We will use the same data sources to assess cost offsets to gauge SPCC scalability and sustainability. We will examine preliminary implementation outcomes (reach, adoption, fidelity, acceptability, and feasibility) through patient, clinician, and health-system leader interviews and surveys. CONCLUSION: If the SPCC demonstrates clinical effectiveness and health system cost reduction, it may be a scalable model for evidence-based suicide prevention in the ED.

Helping Practitioners Stop, Drop, and Roll: Suggestions to Help Improve Responses to Intense Clinical Events.

Community practitioners inconsistently implement evidence-based interventions. Implementation science emphasizes the importance of some practitioner characteristics, such as motivation, but factors such as practitioners' emotion regulation and cognitive processing receive less attention. Practitioners often operate in stressful environments that differ from those in which they received training. They may underestimate the impact of their emotional state on their ability to deliver evidence-based interventions. This "hot-cold state empathy gap" is not well studied in mental health care. In this Open Forum, the authors describe scenarios where this gap is affecting practitioners' ability to implement evidence-based practices. The authors provide suggestions to help practitioners plan for stressful situations.

A mixed-methods evaluation of organization and individual factors influencing provider intentions to use caregiver coaching in community-based early intervention.

BACKGROUND: Most psycho-social interventions contain multiple components. Practitioners often vary in their implementation of different intervention components. Caregiver coaching is a multicomponent intervention for young autistic children that is highly effective but poorly implemented in community-based early intervention (EI). Previous research has shown that EI providers' intentions, and the determinants of their intentions, to implement caregiver coaching vary across components. Organizational culture and climate likely influence these psychological determinants of intention by affecting beliefs that underlie attitudes, norms, and self-efficacy to implement an intervention. Research in this area is limited, which limits the development of theoretically driven, multilevel implementation strategies to support multi-component interventions. This mixed methods study evaluated the relationships among organizational leadership, culture and climate, attitudes, norms, self-efficacy, and EI providers' intentions to implement the components of caregiver coaching. METHODS: We surveyed 264 EI providers from 37 agencies regarding their intentions and determinants of intentions to use caregiver coaching. We also asked questions about the organizational culture, climate, and leadership in their agencies related to caregiver coaching. We used multilevel structural equation models to estimate associations among intentions, psychological determinants of intentions (attitudes, descriptive norms, injunctive norms, and self-efficacy), and organizational factors (implementation climate and leadership). We conducted qualitative interviews with 36 providers, stratified by strength of intentions to use coaching. We used mixed-methods analysis to gain an in-depth understanding of the organization and individual-level factors. RESULTS: The associations among intentions, psychological determinants of intentions, and organizational factors varied across core components of caregiver coaching. Qualitative interviews elucidated how providers describe the importance of each component. For example, providers' attitudes toward coaching caregivers and their perceptions of caregivers' expectations for service were particularly salient themes related to their use of caregiver coaching. CONCLUSION: Results highlight the importance of multi-level strategies that strategically target individual intervention components as well as organization-level and individual-level constructs. This approach holds promise for improving the implementation of complex, multicomponent, psychosocial interventions in community-based service systems.

An exposure-based implementation strategy to decrease clinician anxiety about implementing suicide prevention evidence-based practices: protocol for development and pilot testing (Project CALMER).

BACKGROUND: Clinicians often report that their own anxiety and low self-efficacy inhibit their use of evidence-based suicide prevention practices, including gold-standard screening and brief interventions. Exposure therapy to reduce clinician maladaptive anxiety and bolster self-efficacy use is a compelling but untested approach to improving the implementation of suicide prevention evidence-based practices (EBPs). This project brings together an interdisciplinary team to leverage decades of research on behavior change from exposure theory to design and pilot test an exposure-based implementation strategy (EBIS) to target clinician anxiety to improve suicide prevention EBP implementation. METHODS: We will develop, iteratively refine, and pilot test an EBIS paired with implementation as usual (IAU; didactic training and consultation) in preparation for a larger study of the effect of this strategy on reducing clinician anxiety, improving self-efficacy, and increasing use of the Columbia Suicide Severity Rating Scale and the Safety Planning Intervention in outpatient mental health settings. Aim 1 of this study is to use participatory design methods to develop and refine the EBIS in collaboration with a stakeholder advisory board. Aim 2 is to iteratively refine the EBIS with up to 15 clinicians in a pilot field test using rapid cycle prototyping. Aim 3 is to test the refined EBIS in a pilot implementation trial. Forty community mental health clinicians will be randomized 1:1 to receive either IAU or IAU + EBIS for 12 weeks. Our primary outcomes are EBIS acceptability and feasibility, measured through questionnaires, interviews, and recruitment and retention statistics. Secondary outcomes are the engagement of target implementation mechanisms (clinician anxiety and self-efficacy related to implementation) and preliminary effectiveness of EBIS on implementation outcomes (adoption and fidelity) assessed via mixed methods (questionnaires, chart-stimulated recall, observer-coded role plays, and interviews). DISCUSSION: Outcomes from this study will yield insight into the feasibility and utility of directly targeting clinician anxiety and self-efficacy as mechanistic processes informing the implementation of suicide prevention EBPs. Results will inform a fully powered hybrid effectiveness-implementation trial to test EBIS' effect on implementation and patient outcomes. TRIAL REGISTRATION: Clinical Trials Registration Number: NCT05172609 . Registered on 12/29/2021.

Mobile service delivery in response to the opioid epidemic in Philadelphia.

BACKGROUND: The harms of opioid use disorder (OUD) and HIV infection disproportionately impact marginalized populations, especially people experiencing homelessness and people who inject drugs (PWID). Mobile OUD service delivery models are emerging to increase access and reduce barriers to OUD care. While there is growing interest in these models, there is limited research about the services they provide, how they operate, and what barriers they face. We characterize the capacity, barriers, and sustainment of mobile OUD care services in a large city with a high incidence of OUD and HIV. METHODS: From May to August 2022, we conducted semi-structured interviews with leadership from all seven mobile OUD care units (MOCU) providing a medication for OUD or other substance use disorder services in Philadelphia. We surveyed leaders about their unit's services, staffing, operating location, funding sources, and linkages to care. Leaders were asked to describe their clinical approach, treatment process, and the barriers and facilitators to their operations. Interview recordings were coded using rapid qualitative analysis. RESULTS: MOCUs are run by small, multidisciplinary teams, typically composed of a clinician, one or two case managers, and a peer recovery specialist or outreach worker. MOCUs provide a range of services, including medications for OUD, wound care, medical services, case management, and screening for infectious diseases. No units provide methadone, but all units provide naloxone, six write prescriptions for buprenorphine, and one unit dispenses buprenorphine. The most frequently reported barriers include practical challenges of working on a MOCU (e.g. lack of space, safety), lack of community support, and patients with substantial medical and psychosocial needs. Interviewees reported concerns about funding and specifically as it relates to providing their staff with adequate pay. The most frequently reported facilitators include positive relationships with the community, collaboration with other entities (e.g. local nonprofits, the police department, universities), and having non-clinical staff (e.g. outreach workers, peer recovery specialists) on the unit. CONCLUSIONS: MOCUs provide life-saving services and engage marginalized individuals with OUD. These findings highlight the challenges and complexities of caring for PWID and demonstrate a need to strengthen collaborations between MOCU providers and the treatment system. Policymakers should consider programmatic funding for permanent mobile OUD care services.

Parent Coaching in Early Intervention for Autism Spectrum Disorder: A Brief Report.

Coaching caregivers of young children on the autism spectrum is a critical component of parent-mediated interventions. Little information is available about how providers implement parent coaching for children on the autism spectrum in publicly funded early intervention systems. This study evaluated providers' use of parent coaching in an early intervention system. Twenty-five early intervention sessions were coded for fidelity to established caregiver coaching techniques. We found low use of coaching techniques overall, with significant variability in use of coaching across providers. When providers did coach caregivers, they used only a few coaching strategies (e.g., collaboration and in-vivo feedback). Results indicate that targeted training and implementation strategies focused on individual coaching components, instead of coaching more broadly, may be needed to improve the use of individual coaching strategies. A focus on strengthening the use of collaboration and in-vivo feedback may be key to improving coaching fidelity overall.

Systematic review: emotion dysregulation and challenging behavior interventions for children and adolescents on the autism spectrum with graded key evidence-based strategy recommendations.

Challenging behavior, such as aggression, is highly prevalent in children and adolescents on the autism spectrum and can have a devastating impact. Previous reviews of challenging behavior interventions did not include interventions targeting emotion dysregulation, a common cause of challenging behavior. We reviewed emotion dysregulation and challenging behavior interventions for preschoolers to adolescents to determine which evidence-based strategies have the most empirical support for reducing/preventing emotion dysregulation/challenging behavior. We reviewed 95 studies, including 29 group and 66 single case designs. We excluded non-behavioral/psychosocial interventions and those targeting internalizing symptoms only. We applied a coding system to identify discrete strategies based on autism practice guidelines with the addition of strategies common in childhood mental health disorders, and an evidence grading system. Strategies with the highest quality evidence (multiple randomized controlled trials with low bias risk) were Parent-Implemented Intervention, Emotion Regulation Training, Reinforcement, Visual Supports, Cognitive Behavioral/Instructional Strategies and Antecedent-Based Interventions. Regarding outcomes, most studies included challenging behavior measures, while few included emotion dysregulation measures. This review highlights the importance of teaching emotion regulation skills explicitly, positively reinforcing replacement/alternative behaviors, using visuals and metacognition, addressing stressors proactively, and involving parents. It also calls for more rigorously designed studies and for including emotion dysregulation as an outcome/mediator in future trials.

Implementation resources to support teachers' use of behavioral classroom interventions: protocol of a randomized pilot trial.

BACKGROUND: Teacher-delivered behavioral classroom management interventions are effective for students with or at-risk for attention-deficit/hyperactivity disorder (ADHD) or other disruptive behavior challenges, but they can be difficult for teachers to use in the classroom. In this study, we will pilot test a package of implementation strategies to support teachers in using behavioral classroom interventions for students with ADHD symptoms. METHODS: We will use a 2-group, randomized controlled trial to compare outcomes for teachers who receive Positive Behavior Management Implementation Resources (PBMIR), a theory and data-driven implementation resource package designed to increase teacher implementation of behavioral classroom management interventions, with those who do not receive this additional implementation support. We will measure teacher implementation outcomes (e.g., observed fidelity to behavioral classroom interventions) and student clinical outcomes (e.g., ADHD-related impairment, ADHD symptoms, student-teacher relationship, academic performance) before and after an 8-week intervention period for both groups; we will also measure teacher-reported acceptability, appropriateness, and feasibility for the PBMIR group following the intervention period. DISCUSSION: If there is preliminary evidence of feasibility and effectiveness, this pilot study will provide the foundation for evaluation the PBMIR at a larger scale and the potential to improve outcomes for students with or at risk for ADHD. TRIAL REGISTRATION: This clinical trial was registered at ClinicalTrials.gov. ( https://clinicaltrials.gov/ ) on 8/5/2022 which was prior to the time of first participant enrollment. The registration number is: NCT05489081.

Years of life lost to drug overdose in the Latinx community during the most recent wave of overdose deaths.

BACKGROUND AND OBJECTIVES: This study estimated years of life lost (YLL) among US Latinx individuals during the most recent wave of drug overdose deaths. METHODS: A serial cross-sectional study of YLL (life expectancy minus age at death) from death certificate records of Latinx individuals who died from drug overdoses from 2015 to mid-2022. RESULTS: Over the study period, 58,209 Latinx individuals aged 15-64 years died from drug overdoses resulting in 2,266,784 YLL. Age-group YLL differences remained stable, but gender YLL trajectories diverged. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: This study extends our understanding of the immense loss to Latinx communities from preventable drug deaths.

A Digital Mental Health App Incorporating Wearable Biosensing for Teachers of Children on the Autism Spectrum to Support Emotion Regulation: Protocol for a Pilot Randomized Controlled Trial.

BACKGROUND: As much as 80% of children on the autism spectrum exhibit challenging behaviors (ie, behaviors dangerous to the self or others, behaviors that interfere with learning and development, and behaviors that interfere with socialization) that can have a devastating impact on personal and family well-being, contribute to teacher burnout, and even require hospitalization. Evidence-based practices to reduce these behaviors emphasize identifying triggers (events or antecedents that lead to challenging behaviors); however, parents and teachers often report that challenging behaviors surface with little warning. Exciting recent advances in biometric sensing and mobile computing technology allow the measurement of momentary emotion dysregulation using physiological indexes. OBJECTIVE: We present the framework and protocol for a pilot trial that will test a mobile digital mental health app, the KeepCalm app. School-based approaches to managing challenging behaviors in children on the autism spectrum are limited by 3 key factors: children on the autism spectrum often have difficulties in communicating their emotions; it is challenging to implement evidence-based, personalized strategies for individual children in group settings; and it is difficult for teachers to track which strategies are successful for each child. KeepCalm aims to address those barriers by communicating children's stress to their teachers using physiological signaling (emotion dysregulation detection), supporting the implementation of emotion regulation strategies via smartphone pop-up notifications of top strategies for each child according to their behavior (emotion regulation strategy implementation), and easing the task of tracking outcomes by providing the child's educational team with a tool to track the most effective emotion regulation strategies for that child based on physiological stress reduction data (emotion regulation strategy evaluation). METHODS: We will test KeepCalm with 20 educational teams of students on the autism spectrum with challenging behaviors (no exclusion based on IQ or speaking ability) in a pilot randomized waitlist-controlled field trial over a 3-month period. We will examine the usability, acceptability, feasibility, and appropriateness of KeepCalm as primary outcomes. Secondary preliminary efficacy outcomes include clinical decision support success, false positives or false negatives of stress alerts, and the reduction of challenging behaviors and emotion dysregulation. We will also examine technical outcomes, including the number of artifacts and the proportion of time children are engaged in high physical movement based on accelerometry data; test the feasibility of our recruitment strategies; and test the response rate and sensitivity to change of our measures, in preparation for a future fully powered large-scale randomized controlled trial. RESULTS: The pilot trial will begin by September 2023. CONCLUSIONS: Results will provide key data about important aspects of implementing KeepCalm in preschools and elementary schools and will provide preliminary data about its efficacy to reduce challenging behaviors and support emotion regulation in children on the autism spectrum. TRIAL REGISTRATION: ClinicalTrials.gov NCT05277194; https://www.clinicaltrials.gov/ct2/show/NCT05277194. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/45852.

Racial, Ethnic, and Sex Differences in Methadone-Involved Overdose Deaths Before and After the US Federal Policy Change Expanding Take-home Methadone Doses.

Importance: In March 2020, the Substance Abuse and Mental Health Services Administration (SAMHSA) permitted states to relax restrictions on take-home methadone doses for treatment-adherent patients to minimize COVID-19 exposures. Objective: To assess whether the methadone take-home policy change was associated with drug overdose deaths among different racial, ethnic, and sex groups. Design, Setting, and Participants: Interrupted time series analysis from January 1, 2018, to June 30, 2022. Data analysis was conducted from February 18, 2023, to February 28, 2023. In this population-based cohort study of drug overdose mortality including 14 529 methadone-involved deaths, monthly counts of methadone-involved drug overdose deaths were obtained for 6 demographic groups: Hispanic men and women, non-Hispanic Black men and women, and non-Hispanic White men and women. Exposure: On March 16, 2020, in response to the first wave of the COVID-19 pandemic, SAMHSA issued an exemption to the states that permitted up to 28 days of take-home methadone for stable patients and 14 days for less stable patients. Main Outcome Measures: Monthly methadone-involved overdose deaths. Results: From January 1, 2018, to June 30, 2022 (54 months), there were 14 529 methadone-involved deaths in the United States; 14 112 (97.1%) occurred in the study's 6 demographic groups (Black men, 1234; Black women, 754; Hispanic men, 1061; Hispanic women, 520; White men, 5991; and White women, 4552). Among Black men, there was a decrease in monthly methadone deaths associated with the March 2020 policy change (change of slope from the preintervention period, -0.55 [95% CI, -0.95 to -0.15]). Hispanic men also experienced a decrease in monthly methadone deaths associated with the policy change (-0.42 [95% CI, -0.68 to -0.17]). Among Black women, Hispanic women, White men, and White women, the policy change was not associated with a change in monthly methadone deaths (Black women, -0.27 [95% CI, -1.13 to 0.59]; Hispanic women, 0.29 [95% CI, -0.46 to 1.04]; White men, -0.08 [95% CI, -1.05 to 0.88]; and White women, -0.43 [95% CI, -1.26 to 0.40]). Conclusions and Relevance: In this interrupted time series study of monthly methadone-involved overdose deaths, the take-home policy may have helped reduce deaths for Black and Hispanic men but had no association with deaths of Black or Hispanic women or White men or women.

Systematic Review: Emotion Dysregulation and Challenging Behavior Interventions for Children andAdolescents with Autism with Graded Key Evidence-Based Strategy Recommendations.

Challenging behavior, such as aggression, is highly prevalent in children and adolescents with autism and can have a devastating impact. Previous reviews of challenging behavior interventions did not include interventions targeting emotion dysregulation, a common cause of challenging behavior. We reviewed emotion dysregulation and challenging behavior interventions for preschoolers to adolescents to determine which evidence-based strategies have the most empirical support for reducing/preventing emotion dysregulation/challenging behavior. We reviewed 95 studies, including 29 group and 66 single-case designs. We excluded non-behavioral/psychosocial interventions and those targeting internalizing symptoms only. We applied a coding system to identify discrete strategies based on autism practice guidelines with the addition of strategies common in childhood mental health disorders, and an evidence grading system. Strategies with the highest quality evidence (multiple randomized controlled trials with low bias risk) were Parent-Implemented Intervention, Emotion Regulation Training, Reinforcement, Visual Supports, Cognitive Behavioral/Instructional Strategies and Antecedent-Based Interventions. Regarding outcomes, most studies included challenging behaviors measures while few included emotion dysregulation measures. This review highlights the importance of teaching emotion-regulation skills explicitly, positively reinforcing replacement/alternative behaviors, using visuals and metacognition, addressing stressors proactively, and involving parents. It also calls for more rigorously-designed studies and for including emotion dysregulation as an outcome/mediator in future trials.

Fatal drug overdose among middle-aged Black men: A life table analysis.

BACKGROUND: For Black men of middle-age, the overdose mortality statistics are increasingly dire. To better understand the severity of the crisis, we estimated the cumulative risk of drug overdose deaths among non-Hispanic Black men in mid-life using a period life table approach. We report the chances of Black men aged 45 years dying of a drug overdose before age 60. METHODS: A period life table reflects what would happen to a hypothetical cohort if it experienced the prevailing age-specific probabilities of death. In our hypothetical cohort, we followed 100,000 non-Hispanic Black men aged 45 years for 15 years. All-cause death probabilities were obtained from the National Center for Health Statistics (NCHS) 2021 life table series. Overdose mortality rates were obtained from the National Vital Statistics System through the Wide-Ranging Online Data for Epidemiologic Research of the Centers for Disease Control and Prevention (CDC WONDER) database. We also constructed a period life table for a comparison group of White men. RESULTS: The life table shows that, for Black men who are 45 years of age in the United States, 1 in 52 (nearly 2%) is expected to die of drug overdose before reaching age 60, if current mortality rates persist. For White men, the estimate is 1 in 91 men (about 1%). The life table also shows that from age 45 to 59 years, the number of overdose deaths increased in the cohort of Black men but decreased in White men. CONCLUSIONS: This study extends our understanding of the immense loss to Black communities from the preventable drug deaths of Black men in middle-age.

Adapting psychotherapy in collaborative care for treating opioid use disorder and co-occurring psychiatric conditions in primary care.

INTRODUCTION: Opioid use disorder (OUD) and psychiatric conditions commonly co-occur yet are infrequently treated with evidence-based therapeutic approaches, resulting in poor outcomes. These conditions, separately, present challenges to treatment initiation, retention, and success. These challenges are compounded when individuals have OUD and psychiatric conditions. METHOD: Recognizing the complex needs of these individuals, gaps in care, and the potential for primary care to bridge these gaps, we developed a psychotherapy program that integrates brief, evidence-based psychotherapies for substance use, depression, and anxiety, building on traditional elements of the Collaborative Care Model (CoCM). In this article, we describe this psychotherapy program in a primary care setting as part of a compendium of collaborative services. RESULTS: Patients receive up to 12 sessions of evidence-based psychotherapy and case management based on a structured treatment manual that guides treatment via Motivational Enhancement; Cognitive Behavioral Therapies for depression, anxiety, and/or substance use disorder; and/or Behavioral Activation components. DISCUSSION: Novel, integrated treatments are needed to advance service delivery for individuals with OUD and psychiatric conditions and these programs must be rigorously evaluated. We describe our team's efforts to test our psychotherapy program in a large primary care network as part of an ongoing three-arm randomized controlled trial. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Association Between Medicaid Waivers and Medicaid Disenrollment Among Autistic Adolescents During the Transition to Adulthood.

This cohort study examines whether Medicaid waivers were associated with a reduced risk of Medicaid disenrollment among autistic adolescents who are transitioning to adulthood.

Large and small financial incentives may motivate COVID-19 vaccination: A randomized, controlled survey experiment.

INTRODUCTION: Experts continue to debate how to increase COVID-19 vaccination rates. Some experts advocate for financial incentives. Others argue that financial incentives, especially large ones, will have counterproductive psychological effects, reducing the percent of people who want to vaccinate. Among a racially and ethnically diverse U.S. sample of lower income adults, for whom vaccine uptake has lagged compared with higher income adults, we empirically examine such claims about relatively large and small guaranteed cash payments. METHODS: In 2021, we conducted a randomized, controlled experiment among U.S. residents with incomes below $80,000 who reported being unvaccinated against COVID-19. Study participants were randomized to one of four study arms. In two arms, respondents first learned about a policy proposal to pay $1,000 or $200 to those who received COVID-19 vaccination and were then asked if, given that policy, they would want to vaccinate. In the two other arms, respondents received either an educational message about this vaccine or received no vaccine information and were then asked if they wanted to vaccinate for COVID-19. The primary analyses estimated and compared the overall percentage in each study arm that reported wanting to vaccinate for COVID-19. In other analyses, we estimated and compared these percentages for subgroups of interest, including gender, race/ethnicity, and education. MAIN RESULTS: Among 2,290 unvaccinated adults, 79.7% (95%CI, 76.4-83.0%) of those who learned about the proposed $1,000 payment wanted to get vaccinated, compared with 58.9% (95%CI, 54.8-63.0%) in the control condition without vaccine information, a difference of 20 percentage points. Among those who learned of the proposed $200 payment, 74.8% (95% CI, 71.3-78.4%) wanted to vaccinate. Among those who learned only about the safety and efficacy of COVID-19 vaccines, 68.9% (95% CI, 65.1-72.7%) wanted to vaccinate. Findings were consistent across various subgroups. DISCUSSION: Despite several study limitations, the results do not support concerns that the financial incentive policies aimed to increase COVID-19 vaccination would have counterproductive effects. Instead, those who learned about a policy with a large or small financial incentive were more likely than those in the control condition to report that they would want to vaccinate. The positive effects extended to subgroups that have been less likely to vaccinate, including younger adults, those with less education, and racial and ethnic minorities. Financial incentives of $1,000 performed similarly to those offering only $200.

"There's absolutely no downside to this, I mean, except community opposition:" A qualitative study of the acceptability of vending machines for harm reduction.

BACKGROUND: Vending machines for harm reduction (VMHR) are an innovative approach to deliver life-saving materials, information, and treatment for hard-to-reach populations, particularly for persons who inject drugs. The current study explores stakeholders' perspectives on the feasibility and acceptability of VMHR in Philadelphia. METHODS: From October 2021 to February 2022, we conducted 31 semi-structured interviews with potential end users, staff, and leadership at a local federally qualified health center, and community members. Trained coders extracted themes from interview transcripts across four key domains: materials and logistics, location, access, and community introduction. RESULTS: Interviewees from all stakeholder groups endorsed using VMHR to provide supplies for wound care, fentanyl test strips, naloxone, and materials to connect individuals to treatment and other services. Dispensing syringes and medications for opioid use disorder were commonly endorsed by health center staff but were more controversial among potential end users. Even within stakeholder groups, views varied with respect to where to locate the machines, but most agreed that the machine should be placed in the highest drug use areas. Across stakeholder groups, interviewees suggested several strategies to introduce and gain community acceptance of VMHR, including community education, one-on-one conversations with community members, and coupling the machine with safe disposal of syringes and information to link individuals to treatment. CONCLUSIONS: Stakeholders were generally receptive to VMHR. The current study findings are consistent with qualitative analyses from outside of the USA and contribute new ideas regarding the anticipated community response and best methods for introducing these machines to a community. With thoughtful planning and design, VMHR could be a feasible and acceptable modality to reduce death and disease transmission associated with the opioid and HIV epidemics in cities like Philadelphia.

Identifying Common and Unique Barriers and Facilitators to Implementing Evidence-Based Practices for Suicide Prevention across Primary Care and Specialty Mental Health Settings.

OBJECTIVE: We identified common and unique barriers and facilitators of evidence-based suicide prevention practices across primary care practices with integrated behavioral health services and specialty mental health settings to identify generalizable strategies for enhancing future implementation efforts. METHOD: Twenty-six clinicians and practice leaders from behavioral health (n = 2 programs) and primary care (n = 4 clinics) settings participated. Participation included a semi-structured qualitative interview on barriers and facilitators to implementing evidence-based suicide prevention practices. Within that interview, clinicians participated in a chart-stimulated recall exercise to gather additional information about decision making regarding suicide screening. Interview guides and qualitative coding were informed by leading frameworks in implementation science and behavioral science, and an integrated approach to interpreting qualitative results was used. RESULTS: There were a number of similar themes associated with implementation of suicide prevention practices across settings and clinician types, such as the benefits of inter-professional collaboration and uncertainties about managing suicidality once risk was disclosed. Clinicians also highlighted barriers unique to their settings. For primary care settings, time constraints and competing demands were consistently described as barriers. For specialty mental health settings, difficulties coordinating care with schools and other providers in the community made implementation of suicide prevention practices challenging. CONCLUSION: Findings can inform the development and testing of implementation strategies that are generalizable across primary care and specialty mental health settings, as well as those tailored for unique site needs, to enhance use of evidence-based suicide prevention practices in settings where individuals at risk for suicide are especially likely to present.HIGHLIGHTSWe examined barriers and facilitators to suicide prevention across health settings.Common and unique barriers and facilitators across health-care settings emerged.Findings can enhance suicide prevention implementation across health-care settings.