Engagement, initiation, and retention in medication treatment for opioid use disorder among young adults: A narrative review of challenges and opportunities.

INTRODUCTION: Opioid Use Disorder (OUD) is a catastrophic public health problem for young adults (YAs) and their families. While medication for OUD (MOUD) is safe, effective, and recognized as the standard of care, its' uptake and success have been limited in YAs compared to older adults. METHODS: This narrative review summarizes the existing literature and highlights select studies regarding barriers to YA MOUD, potential explanations for those barriers, and strategies to overcome them. RESULTS: Barriers are prominent along the entire cascade of care, including: treatment engagement and entry, MOUD initiation, and MOUD retention. Hypothesized explanations for barriers include: developmental vulnerability, inadequate treatment system capacity, stigma against MOUD, among others. Interventions to address barriers include: promotion of family involvement, increasing provider capacity, integration of MOUD into primary care, assertive outreach, and others. CONCLUSIONS: Integrating an adapted version of family coaching from the Community Reinforcement Approach and Family Training (CRAFT) and other models into YA MOUD treatment serves as an example of an emerging novel practice that holds promise for broadening the funnel of engagement in treatment and initiation of MOUD, and enhancing treatment outcomes. This and other developmentally-informed approaches should be evaluated as part of a high-priority clinical and research agenda for improving OUD treatment for YAs.

Implementing a pharmacist-integrated collaborative model of medication treatment for opioid use disorder in primary care: study design and methodological considerations.

BACKGROUND: Pharmacists remain an underutilized resource in the treatment of opioid use disorder (OUD). Although studies have engaged pharmacists in dispensing medications for OUD (MOUD), few studies have evaluated collaborative care models in which pharmacists are an active, integrated part of a primary care team offering OUD care. METHODS: This study seeks to implement a pharmacist integrated MOUD clinical model (called PrIMO) and evaluate its feasibility, acceptability, and impact across four diverse primary care sites. The Consolidated Framework for Implementation Research is used as an organizing framework for study development and interpretation of findings. Implementation Facilitation is used to support PrIMO adoption. We assess the primary outcome, the feasibility of implementing PrIMO, using the Stages of Implementation Completion (SIC). We evaluate the acceptability and impact of the PrIMO model at the sites using mixed-methods and combine survey and interview data from providers, pharmacists, pharmacy technicians, administrators, and patients receiving MOUD at the primary care sites with patient electronic health record data. We hypothesize that it is feasible to launch delivery of the PrIMO model (reach SIC Stage 6), and that it is acceptable, will positively impact patient outcomes 1 year post model launch (e.g., increased MOUD treatment retention, medication regimen adherence, service utilization for co-morbid conditions, and decreased substance use), and will increase each site's capacity to care for patients with MOUD (e.g., increased number of patients, number of prescribers, and rate of patients per prescriber). DISCUSSION: This study will provide data on a pharmacist-integrated collaborative model of care for the treatment of OUD that may be feasible, acceptable to both site staff and patients and may favorably impact patients' access to MOUD and treatment outcomes. TRIAL REGISTRATION: The study was registered on Clinicaltrials.gov (NCT05310786) on April 5, 2022, https://www. CLINICALTRIALS: gov/study/NCT05310786?id=NCT05310786&rank=1.

Implementation of substance use screening in rural federally-qualified health center clinics identified high rates of unhealthy alcohol and cannabis use among adult primary care patients.

BACKGROUND: Screening for substance use in rural primary care clinics faces unique challenges due to limited resources, high patient volumes, and multiple demands on providers. To explore the potential for electronic health record (EHR)-integrated screening in this context, we conducted an implementation feasibility study with a rural federally-qualified health center (FQHC) in Maine. This was an ancillary study to a NIDA Clinical Trials Network study of screening in urban primary care clinics (CTN-0062). METHODS: Researchers worked with stakeholders from three FQHC clinics to define and implement their optimal screening approach. Clinics used the Tobacco, Alcohol, Prescription Medication, and Other Substance (TAPS) Tool, completed on tablet computers in the waiting room, and results were immediately recorded in the EHR. Adult patients presenting for annual preventive care visits, but not those with other visit types, were eligible for screening. Data were analyzed for the first 12 months following implementation at each clinic to assess screening rates and prevalence of reported unhealthy substance use, and documentation of counseling using an EHR-integrated clinical decision support tool, for patients screening positive for moderate-high risk alcohol or drug use. RESULTS: Screening was completed by 3749 patients, representing 93.4% of those with screening-eligible annual preventive care visits, and 18.5% of adult patients presenting for any type of primary care visit. Screening was self-administered in 92.9% of cases. The prevalence of moderate-high risk substance use detected on screening was 14.6% for tobacco, 30.4% for alcohol, 10.8% for cannabis, 0.3% for illicit drugs, and 0.6% for non-medical use of prescription drugs. Brief substance use counseling was documented for 17.4% of patients with any moderate-high risk alcohol or drug use. CONCLUSIONS: Self-administered EHR-integrated screening was feasible to implement, and detected substantial alcohol, cannabis, and tobacco use in rural FQHC clinics. Counseling was documented for a minority of patients with moderate-high risk use, possibly indicating a need for better support of primary care providers in addressing substance use. There is potential to broaden the reach of screening by offering it at routine medical visits rather than restricting to annual preventive care visits, within these and other rural primary care clinics.

Patient Engagement in a Multimodal Digital Phenotyping Study of Opioid Use Disorder.

BACKGROUND: Multiple digital data sources can capture moment-to-moment information to advance a robust understanding of opioid use disorder (OUD) behavior, ultimately creating a digital phenotype for each patient. This information can lead to individualized interventions to improve treatment for OUD. OBJECTIVE: The aim is to examine patient engagement with multiple digital phenotyping methods among patients receiving buprenorphine medication for OUD. METHODS: The study enrolled 65 patients receiving buprenorphine for OUD between June 2020 and January 2021 from 4 addiction medicine programs in an integrated health care delivery system in Northern California. Ecological momentary assessment (EMA), sensor data, and social media data were collected by smartphone, smartwatch, and social media platforms over a 12-week period. Primary engagement outcomes were meeting measures of minimum phone carry (≥8 hours per day) and watch wear (≥18 hours per day) criteria, EMA response rates, social media consent rate, and data sparsity. Descriptive analyses, bivariate, and trend tests were performed. RESULTS: The participants' average age was 37 years, 47% of them were female, and 71% of them were White. On average, participants met phone carrying criteria on 94% of study days, met watch wearing criteria on 74% of days, and wore the watch to sleep on 77% of days. The mean EMA response rate was 70%, declining from 83% to 56% from week 1 to week 12. Among participants with social media accounts, 88% of them consented to providing data; of them, 55% of Facebook, 54% of Instagram, and 57% of Twitter participants provided data. The amount of social media data available varied widely across participants. No differences by age, sex, race, or ethnicity were observed for any outcomes. CONCLUSIONS: To our knowledge, this is the first study to capture these 3 digital data sources in this clinical population. Our findings demonstrate that patients receiving buprenorphine treatment for OUD had generally high engagement with multiple digital phenotyping data sources, but this was more limited for the social media data. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.3389/fpsyt.2022.871916.

Augmenting project ECHO for opioid use disorder with data-informed quality improvement.

BACKGROUND: National opioid-related overdose fatalities totaled 650,000 from 1999 to 2021. Some of the highest rates occurred in New Hampshire, where 40% of the population lives rurally. Medications for opioid use disorder (MOUD; methadone, buprenorphine, and naltrexone) have demonstrated effectiveness in reducing opioid overdose and mortality. Methadone access barriers disproportionally impact rural areas and naltrexone uptake has been limited. Buprenorphine availability has increased and relaxed regulations reduces barriers in general medical settings common in rural areas. Barriers to prescribing buprenorphine include lack of confidence, inadequate training, and lack of access to experts. To address these barriers, learning collaboratives have trained clinics on best-practice performance data collection to inform quality improvement (QI). This project sought to explore the feasibility of training clinics to collect performance data and initiate QI alongside clinics' participation in a Project ECHO virtual collaborative for buprenorphine providers. METHODS: Eighteen New Hampshire clinics participating in a Project ECHO were offered a supplemental project exploring the feasibility of performance data collection to inform QI targeting increased alignment with best practice. Feasibility was assessed descriptively, through each clinic's participation in training sessions, data collection, and QI initiatives. An end-of-project survey was conducted to understand clinic staff perceptions of how useful and acceptable they found the program. RESULTS: Five of the eighteen health care clinics that participated in the Project ECHO joined the training project, four of which served rural communities in New Hampshire. All five clinics met the criteria for engagement, as each clinic attended at least one training session, submitted at least one month of performance data, and completed at least one QI initiative. Survey results showed that while clinic staff perceived the training and data collection to be useful, there were several barriers to collecting the data, including lack of staff time, and difficulty standardizing documentation within the clinic electronic health record. CONCLUSIONS: Results suggest that training clinics to monitor their performance and base QI initiatives on data has potential to impact clinical best practice. While data collection was inconsistent, clinics completed several data-informed QI initiatives, indicating that smaller scale data collection might be more attainable.

Relative Effectiveness of Social Media, Dating Apps, and Information Search Sites in Promoting HIV Self-testing: Observational Cohort Study.

BACKGROUND: Social media sites, dating apps, and information search sites have been used to reach individuals at high risk for HIV infection. However, it is not clear which platform is the most efficient in promoting home HIV self-testing, given that the users of various platforms may have different characteristics that impact their readiness for HIV testing. OBJECTIVE: This study aimed to compare the relative effectiveness of social media sites, dating apps, and information search sites in promoting HIV self-testing among minority men who have sex with men (MSM) at an increased risk of HIV infection. Test kit order rates were used as a proxy to evaluate promotion effectiveness. In addition, we assessed differences in characteristics between participants who ordered and did not order an HIV test kit. METHODS: Culturally appropriate advertisements were placed on popular sites of three different platforms: social media sites (Facebook, Instagram), dating apps (Grindr, Jack'D), and information search sites (Google, Bing). Advertisements targeted young (18-30 years old) and minority (Black or Latinx) MSM at risk of HIV exposure. Recruitment occurred in 2 waves, with each wave running advertisements on 1 platform of each type over the same period. Participants completed a baseline survey assessing sexual or injection use behavior, substance use including alcohol, psychological readiness to test, attitudes toward HIV testing and treatment, and HIV-related stigma. Participants received an electronic code to order a free home-based HIV self-test kit. Follow-up assessments were conducted to assess HIV self-test kit use and uptake of pre-exposure prophylaxis (PrEP) at 14 and 60 days post enrollment. RESULTS: In total, 271 participants were enrolled, and 254 were included in the final analysis. Among these 254 participants, 177 (69.7%) ordered a home HIV self-test kit. Most of the self-test kits were ordered by participants enrolled from dating apps. Due to waves with low enrollment, between wave statistical comparisons were not feasible. Within wave comparison revealed that Jack'D showed higher order rates (3.29 kits/day) compared to Instagram (0.34 kits/day) and Bing (0 kits/day). There were no associations among self-test kit ordering and HIV-related stigma, perceptions about HIV testing and treatment, and mistrust of medical organizations. CONCLUSIONS: Our findings show that using popular dating apps might be an efficient way to promote HIV self-testing. Stigma, perceptions about HIV testing and treatment, or mistrust of medical organizations may not affect order rates of HIV test kits promoted on the internet. TRIAL REGISTRATION: ClinicalTrials.gov NCT04155502; https://clinicaltrials.gov/ct2/show/NCT04155502. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/20417.

Technology-Based Interventions in Substance Use Treatment to Promote Health Equity Among People Who Identify as African American/Black, Hispanic/Latinx, and American Indian/Alaskan Native: Protocol for a Scoping Review.

BACKGROUND: Technology-based interventions (TBIs; ie, web-based and mobile interventions) have the potential to promote health equity in substance use treatment (SUTx) for underrepresented groups (people who identify as African American/Black, Hispanic/Latinx, and American Indian/Alaskan Native) by removing barriers and increasing access to culturally relevant effective treatments. However, technologies (emergent and more long-standing) may have unintended consequences that could perpetuate health care disparities among people who identify as a member of one of the underrepresented groups. Health care research, and SUTx research specifically, is infrequently conducted with people who identify with these groups as the main focus. Therefore, an improved understanding of the literature at the intersection of SUTx, TBIs, and underrepresented groups is warranted to avoid exacerbating inequities and to promote health equity. OBJECTIVE: This study aims to explore peer-reviewed literature (January 2000-March 2021) that includes people who identify as a member of one of the underrepresented groups in SUTx research using TBIs. We further seek to explore whether this subset of research is race/ethnicity conscious (does the research consider members of underrepresented groups beyond their inclusion as study participants in the introduction, methods, results, or discussion). METHODS: Five electronic databases (MEDLINE, Scopus, Cochrane Library, CINAHL, and PsycInfo) were searched to identify SUTx research using TBIs, and studies were screened for eligibility at the title/abstract and full-text levels. Studies were included if their sample comprised of people who identify as a member of one of the underrepresented groups at 50% or more when combined. RESULTS: Title/abstract and full-text reviews were completed in 2021. These efforts netted a sample of 185 studies that appear to meet inclusionary criteria. Due to the uniqueness of tobacco relative to other substances in the SUTx space, as well as the large number of studies netted, we plan to separately publish a scoping review on tobacco-focused studies that meet all other criteria. Filtering for tobacco-focused studies (n=31) netted a final full-text sample for a main scoping review of 154 studies. The tobacco-focused scoping review manuscript is expected to be submitted for peer review in Spring 2022. The main scoping review data extraction and data validation to confirm the accuracy and consistency of data extraction across records was completed in March 2022. We expect to publish the main scoping review findings by the end of 2022. CONCLUSIONS: Research is needed to increase our understanding of the range and nature of TBIs being used in SUTx research studies with members of underrepresented groups. The planned scoping review will highlight research at this intersection to promote health equity. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/34508.

The Feasibility and Utility of Harnessing Digital Health to Understand Clinical Trajectories in Medication Treatment for Opioid Use Disorder: D-TECT Study Design and Methodological Considerations.

Introduction: Across the U.S., the prevalence of opioid use disorder (OUD) and the rates of opioid overdoses have risen precipitously in recent years. Several effective medications for OUD (MOUD) exist and have been shown to be life-saving. A large volume of research has identified a confluence of factors that predict attrition and continued substance use during substance use disorder treatment. However, much of this literature has examined a small set of potential moderators or mediators of outcomes in MOUD treatment and may lead to over-simplified accounts of treatment non-adherence. Digital health methodologies offer great promise for capturing intensive, longitudinal ecologically-valid data from individuals in MOUD treatment to extend our understanding of factors that impact treatment engagement and outcomes. Methods: This paper describes the protocol (including the study design and methodological considerations) from a novel study supported by the National Drug Abuse Treatment Clinical Trials Network at the National Institute on Drug Abuse (NIDA). This study (D-TECT) primarily seeks to evaluate the feasibility of collecting ecological momentary assessment (EMA), smartphone and smartwatch sensor data, and social media data among patients in outpatient MOUD treatment. It secondarily seeks to examine the utility of EMA, digital sensing, and social media data (separately and compared to one another) in predicting MOUD treatment retention, opioid use events, and medication adherence [as captured in electronic health records (EHR) and EMA data]. To our knowledge, this is the first project to include all three sources of digitally derived data (EMA, digital sensing, and social media) in understanding the clinical trajectories of patients in MOUD treatment. These multiple data streams will allow us to understand the relative and combined utility of collecting digital data from these diverse data sources. The inclusion of EHR data allows us to focus on the utility of digital health data in predicting objectively measured clinical outcomes. Discussion: Results may be useful in elucidating novel relations between digital data sources and OUD treatment outcomes. It may also inform approaches to enhancing outcomes measurement in clinical trials by allowing for the assessment of dynamic interactions between individuals' daily lives and their MOUD treatment response. Clinical Trial Registration: Identifier: NCT04535583.

An Examination of the Feasibility of Detecting Cocaine Use Using Smartwatches.

As digital technology increasingly informs clinical trials, novel ways to collect study data in the natural field setting have the potential to enhance the richness of research data. Cocaine use in clinical trials is usually collected via self-report and/or urine drug screen results, both of which have limitations. This article examines the feasibility of developing a wrist-worn device that can detect sufficient physiological data (i.e., heart rate and heart rate variability) to detect cocaine use. This study aimed to develop a wrist-worn device that can be used in the natural field setting among people who use cocaine to collect reliable data (determined by data yield, device wearability, and data quality) that is less obtrusive than chest-based devices used in prior research. The study also aimed to further develop a cocaine use detection algorithm used in previous research with an electrocardiogram on a chestband by adapting it to a photoplethysmography sensor on the wrist-worn device which is more prone to motion artifacts. Results indicate that wrist-based heart rate data collection is feasible and can provide higher data yield than chest-based sensors, as wrist-based devices were also more comfortable and affected participants' daily lives less often than chest-based sensors. When properly worn, wrist-based sensors produced similar quality of heart rate and heart rate variability features to chest-based sensors and matched their performance in automated detection of cocaine use events. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT02915341.

Implementation of a New Hampshire community-initiated response to the opioid crisis: A mixed-methods process evaluation of Safe Station.

BACKGROUND: New Hampshire (NH) ranked first for fentanyl- and all opioid-related overdose deaths per capita from 2014 to 2016 and third in 2017 with no rate reduction from the previous year relative to all other states in the US. In response to the opioid crisis in NH, Manchester Fire Department (MFD), the state's largest city fire department, launched the Safe Station program in 2016 in partnership with other community organizations. This community-based response to the crisis-described as a connection to recovery-focuses on reducing barriers to accessing resources for people with substance use and related problems. The study aim is to characterize the multi-organizational partnerships and workflow of the Safe Station model and identify key components that are engaging, effective, replicable, and sustainable. METHODS: A mixed-methods design included: semi-structured qualitative interviews conducted with 110 stakeholders from six groups of community partners (Safe Station clients, MFD staff and leadership, and local emergency department, ambulance, and treatment partner staff); implementation and sustainability surveys (completed by MFD stakeholders); and ethnographic observations conducted at MFD. Qualitative data were content analyzed and coded using the Consolidated Framework for Implementation Research. Survey subscales were scored and evaluated to corroborate the qualitative findings. RESULTS: Community partners identified key program characteristics including firefighter compassion, low-threshold access, and immediacy of service linkage. Implementation and sustainability survey data corroborate the qualitative interview and observation data in these areas. All participants agreed that community partnerships are key to the program's success. There were mixed evaluations of the quality of communication among the organizations. CONCLUSION: Safe Station is a novel response to the opioid crisis in New Hampshire that offers immediate, non-judgmental access to services for persons with opioid use disorders requiring community-wide engagement and communication. Data convergence provides guidance to the sustainability and replicability of the program.

Is telemedicine the answer to rural expansion of medication treatment for opioid use disorder? Early experiences in the feasibility study phase of a National Drug Abuse Treatment Clinical Trials Network Trial.

Telemedicine (TM) enabled by digital health technologies to provide medical services has been considered a key solution to increasing health care access in rural communities. With the immediate need for remote care due to the COVID-19 pandemic, many health care systems have rapidly incorporated digital technologies to support the delivery of remote care options, including medication treatment for individuals with opioid use disorder (OUD). In responding to the opioid crisis and the COVID-19 pandemic, public health officials and scientific communities strongly support and advocate for greater use of TM-based medication treatment for opioid use disorder (MOUD) to improve access to care and have suggested that broad use of TM during the pandemic should be sustained. Nevertheless, research on the implementation and effectiveness of TM-based MOUD has been limited. To address this knowledge gap, the National Drug Abuse Treatment Clinical Trials Network (CTN) funded (via the NIH HEAL Initiative) a study on Rural Expansion of Medication Treatment for Opioid Use Disorder (Rural MOUD; CTN-0102) to investigate the implementation and effectiveness of adding TM-based MOUD to rural primary care for expanding access to MOUD. In preparation for this large-scale, randomized controlled trial incorporating TM in rural primary care, a feasibility study is being conducted to develop and pilot test implementation procedures. In this commentary, we share some of our experiences, which include several challenges, during the initial two-month period of the feasibility study phase. While these challenges could be due, at least in part, to adjusting to the COVID-19 pandemic and new workflows to accommodate the study, they are notable and could have a substantial impact on the larger, planned pragmatic trial and on TM-based MOUD more broadly. Challenges include low rates of identification of risk for OUD from screening, low rates of referral to TM, digital device and internet access issues, workflow and capacity barriers, and insurance coverage. These challenges also highlight the lack of empirical guidance for best TM practice and quality remote care models. With TM expanding rapidly, understanding implementation and demonstrating what TM approaches are effective are critical for ensuring the best care for persons with OUD.

Early implementation of screening for substance use in rural primary care: A rapid analytic qualitative study.

Background: Few primary care patients are screened for substance use. As part of a phased feasibility study examining the implementation of electronic health record-integrated screening with the Tobacco, Alcohol, and Prescription Medication Screening (TAPS) Tool and clinical decision support (CDS) in rural primary care clinics, focus groups were conducted to identify early indicators of success and challenges to screening implementation. Method: Focus groups (n = 6) were conducted with medical assistants (MAs: n = 3: 19 participants) and primary care providers (PCPs: n = 3: 13 participants) approximately one month following screening implementation in three Federally Qualified Health Centers in Maine. Rapid analysis and matrix analysis using Proctor's Taxonomy of Implementation Outcomes were used to explore implementation outcomes. Results: There was consensus that screening is being used, but use of the CDS was lower, in part due to limited positive screens. Fidelity was high among MAs, though discomfort with the CDS surfaced among PCPs, impacting adoption and fidelity. The TAPS Tool's content, credibility and ease of workflow integration were favorably assessed. Challenges include screening solely at annual visits and self-administered screening for certain patients. Conclusions: Results reveal indicators of implementation success and strategies to address challenges to screening for substance use in primary care.

The application of digital health to the assessment and treatment of substance use disorders: The past, current, and future role of the National Drug Abuse Treatment Clinical Trials Network.

The application of digital technologies to better assess, understand, and treat substance use disorders (SUDs) is a particularly promising and vibrant area of scientific research. The National Drug Abuse Treatment Clinical Trials Network (CTN), launched in 1999 by the U.S. National Institute on Drug Abuse, has supported a growing line of research that leverages digital technologies to glean new insights into SUDs and provide science-based therapeutic tools to a diverse array of persons with SUDs. This manuscript provides an overview of the breadth and impact of research conducted in the realm of digital health within the CTN. This work has included the CTN's efforts to systematically embed digital screeners for SUDs into general medical settings to impact care models across the nation. This work has also included a pivotal multi-site clinical trial conducted on the CTN platform, whose data led to the very first "prescription digital therapeutic" authorized by the U.S. Food and Drug Administration (FDA) for the treatment of SUDs. Further CTN research includes the study of telehealth to increase capacity for science-based SUD treatment in rural and under-resourced communities. In addition, the CTN has supported an assessment of the feasibility of detecting cocaine-taking behavior via smartwatch sensing. And, the CTN has supported the conduct of clinical trials entirely online (including the recruitment of national and hard-to-reach/under-served participant samples online, with remote intervention delivery and data collection). Further, the CTN is supporting innovative work focused on the use of digital health technologies and data analytics to identify digital biomarkers and understand the clinical trajectories of individuals receiving medications for opioid use disorder (OUD). This manuscript concludes by outlining the many potential future opportunities to leverage the unique national CTN research network to scale-up the science on digital health to examine optimal strategies to increase the reach of science-based SUD service delivery models both within and outside of healthcare.

Understanding the increase in opioid overdoses in New Hampshire: A rapid epidemiologic assessment.

BACKGROUND: New Hampshire (NH) has had among the highest rates of fentanyl-related overdose deaths per capita in the United States for several years in a row-more than three times the national average in 2016. This mixed-methods study investigated drug-using practices and perspectives of NH residents who use opioids to inform policy in tackling the overdose crisis. METHODS: Seventy-six participants from six NH counties completed demographic surveys and semi-structured interviews focused on drug-using practices and perspectives, including use precursors, fentanyl-seeking behaviors, and experiences with overdose. Rigorous qualitative methods were used to analyze interview data including transcription, coding and content analysis. Descriptive statistics were calculated on quantitative survey data. RESULTS: Eighty-four percent of interviewees had knowingly used fentanyl in their lifetime, 70 % reported overdosing at least once, and 42 % had sought a batch of drugs known to have caused an overdose. The majority stated most heroin available in NH was laced with fentanyl and acknowledged that variability across batches increased overdose risk. Participants reported high availability of fentanyl and limited access to prevention, treatment, and harm reduction programs. There was widespread support for expanding education campaigns for youth, increasing treatment availability, and implementing needle exchange programs. CONCLUSIONS: A confluence of factors contribute to the NH opioid overdose crisis. Despite consensus that fentanyl is the primary cause of overdoses, individuals continue to use it and affirm limited availability of resources to address the problem. Policies targeting innovative prevention, harm reduction, and treatment efforts are needed to more effectively address the crisis.

Barriers to naloxone use and acceptance among opioid users, first responders, and emergency department providers in New Hampshire, USA.

BACKGROUND: The United States is in the midst of a devastating opioid crisis, and the state of New Hampshire (NH) has been disproportionately impacted. Naloxone is an opioid overdose reversal medication that is critical for saving lives. This study was conducted to understand emergency responders' and opioid users' experiences with, and opinions about, naloxone use and distribution in NH. METHODS: Semi-structured interviews were conducted with 76 opioid users and 36 emergency responders in six NH counties in 2016-2017. Interviews focused on respondents' experiences with opioid use and overdose. Interviews were transcribed, coded, and reviewed for consensus among coders. Directed content analysis was used to review high-level domains and identify subthemes. RESULTS: Users and responders largely agreed that naloxone had become increasingly available in NH at the time of the study. Reported responder barriers to naloxone acceptance included perceptions that increased naloxone availability may enable riskier opioid use and fails to address the underlying causes of addiction. Reported opioid-user barriers included cost, legality, and lack of knowledge regarding distribution locations and indications for use. CONCLUSION: Opioid users' and emergency responders' perceptions about naloxone may limit the optimal use of naloxone within the community. This study identifies opportunities to address misconceptions about naloxone and challenges in accessing naloxone, which may improve opioid overdose prevention strategies.

"You can see those concentric rings going out": Emergency personnel's experiences treating overdose and perspectives on policy-level responses to the opioid crisis in New Hampshire.

BACKGROUND: In parallel to a substantial increase in opioid overdose deaths in New Hampshire (NH), emergency personnel experienced an increase in opioid-related encounters. To inform public health responses to this crisis, insights into the experiences and perspectives of those emergency personnel who treat opioid-related overdoses are warranted. AIMS: Systematically examine emergency personnel's experiences treating opioid overdoses and obtain their perspectives on policy-level responses to the opioid crisis in NH. METHODS: Semi-structured qualitative interviews were conducted with 18 first responders [firefighters (n = 6), police officers (n = 6), emergency medical service providers (n = 6)] and 18 emergency department personnel employed in six NH counties. Interviews focused on emergency personnel's perspectives on fentanyl/heroin formulations, experiences treating overdoses, harm reduction strategies, and experiences with treatment referral. Interviews were audio recorded, transcribed verbatim, and analyzed using content analysis. RESULTS: Emergency personnel cited the potency and inconsistency of fentanyl-laced heroin as primary drivers of opioid overdose. Increases in overdose-related encounters took a substantial emotional toll on emergency personnel, who described a range of responses including feelings of burnout, exhaustion, and helplessness. While some emergency personnel felt conflicted about the implementation of harm reduction strategies like syringe services programs, others emphasized the necessity of these services. Emergency personnel expressed frustration with barriers to treatment referral in the state and recommended immediate treatment access after overdose events. CONCLUSIONS: Findings suggest that interventions addressing trauma and burnout are necessary to support emergency personnel, while expanded harm reduction and treatment access are critical to support those who experience opioid overdose in NH.

Screening for Substance Use in Rural Primary Care: a Qualitative Study of Providers and Patients.

BACKGROUND: Substance use frequently goes undetected in primary care. Though barriers to implementing systematic screening for alcohol and drug use have been examined in urban settings, less is known about screening in rural primary care. OBJECTIVE: To identify current screening practices, barriers, facilitators, and recommendations for the implementation of substance use screening in rural federally qualified health centers (FQHCs). DESIGN: As part of a multi-phase study implementing electronic health record-integrated screening, focus groups (n = 60: all stakeholder groups) and individual interviews (n = 10 primary care providers (PCPs)) were conducted. PARTICIPANTS: Three stakeholder groups (PCPs, medical assistants (MAs), and patients) at three rural FQHCs in Maine. APPROACH: Focus groups and interviews were recorded, transcribed, and content analyzed. Themes surrounding current substance use screening practices, barriers to screening, and recommendations for implementation were identified and organized by the Knowledge to Action (KTA) Framework. KEY RESULTS: Identifying the problem: Stakeholders unanimously agreed that screening is important, and that universal screening is preferred to targeted approaches. Adapting to the local context: PCPs and MAs agreed that screening should be done annually. Views were mixed regarding the delivery of screening; patients preferred self-administered, tablet-based screening, while MAs and PCPs were divided between self-administered and face-to-face approaches. Assessing barriers: For patients, barriers to screening centered around a perceived lack of rapport with providers, which contributed to concerns about trust, judgment, and privacy. For PCPs and MAs, barriers included lack of comfort, training, and preparedness to address screening results and offer treatment. CONCLUSIONS: Though stakeholders agree on the importance of implementing universal screening, concerns about the patient-provider relationship, the consequences of disclosure, and privacy appear heightened by the rural context. Findings highlight that strong relationships with providers are critical for patients, while in-clinic resources and training are needed to increase provider comfort and preparedness to address substance use.

Towards detecting cocaine use using smartwatches in the NIDA clinical trials network: Design, rationale, and methodology.

Cocaine use in clinical trials is often measured via self-report, which can be inaccurate, or urine drug screens, which can be intrusive and burdensome. Devices that can automatically detect cocaine use and can be worn conveniently in daily life may provide several benefits. AutoSense is a wearable, physiological-monitoring suite that can detect cocaine use, but it may be limited as a method for monitoring cocaine use because it requires wearing a chestband with electrodes. This paper describes the design, rationale, and methodology of a project that seeks to build upon and extend previous work in the development of methods to detect cocaine use via wearable, unobtrusive mobile sensor technologies. To this end, a wrist-worn sensor suite (i.e., MotionSense HRV) will be developed and evaluated. Participants who use cocaine (N = 25) will be asked to wear MotionSense HRV and AutoSense for two weeks during waking hours. Drug use will be assessed via thrice-weekly urine drug screens and self-reports, and will be used to isolate periods of cocaine use that will be differentiated from other drug use. The present study will provide information on the feasibility and acceptability of using a wrist-worn device to detect cocaine use.

The influence of family and social problems on treatment outcomes of persons with co-occurring substance use disorders and PTSD.

OBJECTIVE: Family and social problems may contribute to negative recovery outcomes in patients with co-occurring substance use and psychiatric disorders, yet few studies have empirically examined this relationship. This study investigates the impact of family and social problems on treatment outcomes among patients with co-occurring substance use and posttraumatic stress disorder (PTSD). METHOD: A secondary analysis was conducted using data collected from a randomized controlled trial of an integrated therapy for patients with co-occurring substance use and PTSD. Substance use, psychiatric symptoms, and social problems were assessed. Longitudinal outcomes were analyzed using generalized estimating equations (GEE) and multiple linear regression. RESULTS: At baseline, increased family and social problems were associated with more severe substance use and psychiatric symptoms. Over time, all participants had comparable decreases in substance use and psychiatric problem severity. However, changes in family and social problem severity were predictive of PTSD symptom severity, alcohol use, and psychiatric severity at follow-up. CONCLUSIONS: For patients with co-occurring substance use and PTSD, family and social problem severity is associated with substance use and psychiatric problem severity at baseline and over time. Targeted treatment for social and family problems may be optimal.

Using a Learning Collaborative Strategy With Office-based Practices to Increase Access and Improve Quality of Care for Patients With Opioid Use Disorders.

OBJECTIVES: Rapidly escalating rates of heroin and prescription opioid use have been widely observed in rural areas across the United States. Although US Food and Drug Administration-approved medications for opioid use disorders exist, they are not routinely accessible to patients. One medication, buprenorphine, can be prescribed by waivered physicians in office-based practice settings, but practice patterns vary widely. This study explored the use of a learning collaborative method to improve the provision of buprenorphine in the state of Vermont. METHODS: We initiated a learning collaborative with 4 cohorts of physician practices (28 total practices). The learning collaborative consisted of a series of 4 face-to-face and 5 teleconference sessions over 9 months. Practices collected and reported on 8 quality-improvement data measures, which included the number of patients prescribed buprenorphine, and the percent of unstable patients seen weekly. Changes from baseline to 8 months were examined using a p-chart and logistic regression methodology. RESULTS: Physician engagement in the learning collaborative was favorable across all 4 cohorts (85.7%). On 6 of the 7 quality-improvement measures, there were improvements from baseline to 8 months. On 4 measures, these improvements were statistically significant (P < 0.001). Importantly, practice variation decreased over time on all measures. The number of patients receiving medication increased only slightly (3.4%). CONCLUSIONS: Results support the effectiveness of a learning collaborative approach to engage physicians, modestly improve patient access, and significantly reduce practice variation. The strategy is potentially generalizable to other systems and regions struggling with this important public health problem.