Methodological Strategies for Prospective Harmonization of Studies: Application to 10 Distinct Outcomes Studies of Preventive Interventions Targeting Opioid Misuse

Development of the Positive Outcomes through Supported Transition (POST) opioid preventive intervention for youth in the legal system: Study protocol for a sequential multiple assignment randomized trial

Adolescents and young adults in the legal system (AYALS) are at high risk for opioid use disorder (OUD). Effective, efficient interventions to prevent OUD that support youth as they transition to the community are needed. The Positive Outcomes through Supported Transition intervention trial is designed to identify the optimal intensity and sequence of behavioral skills and case management components for OUD prevention. This sequential, multiple assignment randomized trial addresses three research questions: 1.whether to begin with a high-intensity, broad-scope intervention (Enhanced Adolescent Community Reinforcement Approach; E-ACRA) or a lower intensity intervention (Assertive Community Support; ACS), 2. whether to continue with E-ACRA or step-down to ACS after release, and 3. whether to step-up to E-ACRA or continue ACS for youth reporting problematic substance use after release. Youth committed to state custody will be recruited prior to their release and randomized to E-ACRA or ACS. At five weeks post-release, E-ACRA participants will be re-randomized to E-ACRA or ACS. ACS participants reporting problematic substance use at five weeks will be re-randomized to E-ACRA or ACS. Primary analyses will test the effects of initial intervention (E-ACRA vs. ACS); secondary analyses will test the effects of second-stage interventions. Cost-effectiveness analysis will determine whether the additional resources deployed to E-ACRA are justified economically by the outcomes achieved. Prevention is critical for this population. High-intensity interventions can be burdensome for participants (and agencies) and costly to deliver. This study examines how best to sequence high and low intensity interventions to maximize beneficial outcomes for the most youth. This study's design was pre-registered with clinicaltrials.gov (NCT04901312).

Lifetime non-fatal overdose experiences among at-risk adolescents and young adults in the emergency department with past-year opioid use in the USA

BACKGROUND

Adolescents and young adults with risk factors for opioid misuse and opioid use disorder are at elevated risk for overdose. We examined prior non-fatal overdose experiences among at-risk adolescents/young adults to inform prevention efforts.

METHODS

Adolescents/young adults (ages 16-30) in two US emergency departments self-reporting past year opioid misuse or opioid use plus a misuse risk factor completed a baseline survey as part of an ongoing randomised controlled trial. We describe baseline factors associated with (a) overall non-fatal overdose experiences and (b) groups based on substance(s) used during the worst overdose experience.

RESULTS

Among 771 participants (27.9% male), 40.7% reported a non-fatal overdose experience. Compared with those without a prior overdose experience, those with prior overdose experience(s) were less likely to be heterosexual, and more likely to report a prior suicide attempt and greater peer substance misuse. Regarding the worst overdose experience, substance(s) included: 36.6% alcohol only, 28.0% alcohol and cannabis, 22.6% alcohol with other substance(s) and 12.7% other substance(s) only (eg, opioids). Compared with the alcohol only group, the alcohol and cannabis group were younger and less likely to be heterosexual; the alcohol with other substance(s) group were older and had greater peer substance misuse; and the other substance(s) only group were more likely to be male, receive public assistance, screen positive for anxiety and less likely to be heterosexual.

CONCLUSIONS

Among at-risk adolescents/young adults, findings support the need for tailored overdose prevention efforts based on substance(s) used, with consideration of sexuality, mental health and peer substance use.

TRIAL REGISTRATION NUMBER

NCT04550715.

Advancing Science to Prevent Firearm Violence in Communities: A Process for Harmonizing Studies to Develop Research Infrastructure

The Community Firearm Violence Prevention Network (CFVP Network), funded by the National Institutes of Health (NIH), supports a network of research projects that develop and test interventions through collaborations with community partners to prevent firearm violence, injury, and mortality. The CFVP Network presents a unique opportunity to accelerate the science of preventing firearm injuries. The data harmonization workgroup of the CFVP Network led the process of aligning studies across the three unique inaugural network projects, with particular attention to how the CFVP Network could address current gaps in the science. The goal of the data harmonization workgroup was to align study measures, assessment timelines, and data management and archival processes across projects to enable robust cross-project analyses that accelerate the science of preventing firearm injuries. To accomplish this goal, the workgroup established the infrastructure to facilitate cross-project data collection, data sharing and archiving, and analyses. Among the three inaugural network projects, the workgroup's process resulted in harmonizing two assessment timepoints (baseline and one year post-implementation) and 60 constructs (with 31 identical standardized constructs). These harmonized products provide opportunities for novel analyses across the network projects. We expect that the harmonized study infrastructure developed through this process will catalyze future research focused on preventing firearm injury, including and extending beyond CFVP Network projects. The CFVP data harmonization workgroup's process can serve as a model for future networks that seek to build the science in a particular area.

Informing evidence-based medicine for opioid use disorder using pharmacoeconomic studies

INTRODUCTION

The health and economic consequences of inadequately treated opioid use disorder (OUD) are substantial. Healthcare systems in the United States (US) and other countries are facing a growing healthcare crisis due to opioids. Although effective medications for OUD exist, relying solely on clinical information is insufficient for addressing the opioid crisis.

AREAS COVERED

In this review, the role of pharmacoeconomic studies in informing evidence-based medication treatment for OUD is discussed, with a particular emphasis on the US healthcare system, where the economic burden is significantly higher than the global average. The scope/objective of pharmacoeconomics as a distinct scientific research program is briefly defined, followed by a discussion of existing evidence informed by data from systematic reviews, in addition to a convenience sample of recently published pharmacoeconomic studies and protocols. The review also explores the need for methodological advancements in the field.

EXPERT OPINION

Despite the potential of pharmacoeconomic research in shaping evidence-based medicine for OUD, significant challenges limiting its real-world application remain. How to address these challenges are explored, including how to combine cost-effectiveness and budget impact analyses to address the needs of the healthcare system as a whole and specific stakeholders interested in adopting new OUD treatment strategies.

Theory, Measurement, and Psychometric Properties of Risk and Protective Factors for Drug Misuse Among Adolescents Living on or near the Cherokee Nation Reservation

A team of tribe-based behavioral health specialists and university-based researchers partnered to implement a cluster randomized trial for the prevention of drug misuse among adolescents attending public high schools on or near the Cherokee Nation Reservation in northeastern Oklahoma. The conceptual framework, which guided intervention and measurement design for the trial, incorporates indigenous knowledge and worldviews with empirically-based frameworks and evidence-based practices. Our goal is to serve multicultural youth, families, and schools and to provide a model of effective strategies for wide dissemination. This paper presents the conceptual model, survey design, and psychometric properties of scales to measure risk and protective factors for substance misuse. The survey includes common measures drawn from the PhenX Toolkit on substance use patterns-adolescent module, measured with standard items from the Monitoring the Future (MTF) study and items harmonized across ten NIH-funded research projects with diverse samples of youth. In our trial, brief (20-minute) self-report questionnaires were administered to 10th grade students in fall 2021 (n = 919, 87% response rate) and spring 2022 (n = 929, 89% response rate) in 20 participating high schools on or near the Cherokee Nation Reservation. The sample primarily fell into the following three categories of race/ethnicity identification: only American Indian (AI-only, 29%), AI and another race/ethnicity (AI+, 27%), and only White (35%). Results indicate that risk and protective factor scales were reliably and validly measured with 10 scales and 10 subscales. There were minimal differences between youth who identified as AI only, AI+, and White only, especially for the main scales, which provide confidence in the interpretation of trial outcomes across demographic groups. Study results may not be generalizable to AI/AN youth who live and attend school in more homogenous reservation lands, or alternatively, live in large diverse metropolitan areas.

Strengthening Prevention Systems to Address the Overdose Crisis Through the HEAL Prevention Cooperative and HEAL Preventing Opioid Use Disorder Research Program

The HEAL Prevention Cooperative (HPC), a subset of the HEAL Preventing Opioid Use Disorder (OUD) Research Program, addresses the evidence gap of interventions for populations at higher risk for opioid use initiation, escalation, and disorder. Designed to yield programs that can be scaled up for dissemination, the studies address topics critical to systematic implementation including data harmonization, intervention costs, culturally responsive services, community engagement, working across the continuum of care, and bringing interventions to market. Ideally, interventions found to be effective will be considered for adoption by community stakeholders. However, the introduction and sustained use of evidence-based approaches remain challenging across the prevention field. Using SAMHSA/CSAP's framework for describing a modern and effective prevention system (Early Action, Easy Access, Effective Delivery, and Equitable Opportunities - the 4Es), this commentary describes ways to engage states, jurisdictions, territories, tribes, and communities to apply the lessons learned and pre-position their respective prevention systems for broad-scale implementation of HPC interventions.

Prevention of Opioid Use and Disorder Among Youth Involved in the Legal System: Innovation and Implementation of Four Studies Funded by the NIDA HEAL Initiative

Youth involved in the legal system (YILS) experience rates of opioid and substance use disorders (OUD/SUDs) and overdose that is well above those in the general population. Despite the dire need, and the existing programs that focus on treatment of these problems in YILS, research on opioid initiation, and OUD prevention, including feasibility and sustainability, are severely limited. We present four studies testing interventions that, while not necessarily novel as SUD treatments, test novel structural and interpersonal strategies to prevent opioid initiation/OUD precursors: (1) ADAPT (Clinical Trial No. NCT04499079) provides real-time feedback using community-based treatment information system data to create a more effective mental health and SUD treatment cascade to prevent opioid use; (2) HOME (Clinical Trial No. NCT04135703) provides youth experiencing homelessness, including YILS, with direct access to shelter in independent living without prerequisites as an opioid initiation prevention strategy; (3) LeSA (Clinical Trial No. NCT04678960) uses the Trust-Based Relational Intervention® to equip YILS and their caregivers with self-regulatory and communication skills during the transition from secure confinement to reduce opioid initiation/re-initiation; and (4) POST (Clinical Trial No. NCT04901312) tests two interventions integrating interpersonal/drinking and drug refusal skills, case management, and goal setting among YILS in transitioning out of secure detention as opioid initiation prevention strategies. We discuss early implementation barriers and facilitators, including complexities of prevention research with YILS and adaptations due to COVID-19. We conclude by describing anticipated end products, including implementation of effective prevention interventions and integration of data from multiple projects to address larger, multi-site research questions.

Commentary: Improving the Effectiveness and Utility of the Helping to End Addiction Long-Term (HEAL) Prevention Cooperative: A Full Translational Framework

The Helping to End Addiction Long-term (HEAL) Prevention Collaborative (HPC) is designed to expedite the development of programs aimed at preventing opioid misuse and opioid use disorder (OUD) in older adolescents and young adults (ages 16-30). Funded by the National Institutes of Health Office of the Director (ODP-NIH), the HPC includes ten outcome studies that focus on distinct interventions to determine their effectiveness and real-world applicability. Also included is a coordinating center at RTI International that supports the individual projects. This commentary highlights the scientific and practical significance of this cooperative and its promise for facilitating the production and implementation of successful interventions. Attributes such as novel program designs, advanced methodologies, addressing unique characteristics of diverse populations, and real-time analysis of data and costs make this cooperative highly innovative. We note, however, that papers in this Supplemental Issue did not specifically address the persistent need to obtain stronger effect sizes than those achieved to date. Existing data captured earlier in development (< 16 years of age) are uncovering interactive neurocognitive and social-contextual mechanisms underlying the phenomena we wish to prevent. HPC projects could be guided by this information to incorporate developmentally appropriate measures of mechanisms shown previously to be influential in targeted outcomes and determine how they are impacted by specific components of their interventions. This mechanistic information can provide a roadmap for constructing interventions that are more precision-based and, thus, more likely to yield greater benefits for a larger number of recipients. Furthermore, an understanding of underlying mechanism(s) promises to shed light on the sources of heterogeneity in outcomes for further intervention refinement. It is quite possible, if not probable, that meaningful measures of underlying processes will reveal subtypes-some with very high effect sizes and others that are much lower-directly enabling program refinements to more directly target mechanisms that portend and explain less favorable outcomes. Described herein is a full-spectrum translational approach which promises to significantly boost effect sizes, a key objective that should be reached prior to scaling.