Acceptability of an Opioid Relapse Prevention Text-message Intervention for Emergency Department Patients

Feasibility of a Novel COVID-19 Telehealth Care Management Program Among Individuals Receiving Treatment for Opioid Use Disorder: Analysis of a Pilot Program

Background

The emergence of COVID-19 exacerbated the existing epidemic of opioid use disorder (OUD) across the United States due to the disruption of in-person treatment and support services. Increased use of technology including telehealth and the development of new partnerships may facilitate coordinated treatment interventions that comprehensively address the health and well-being of individuals with OUD.

Objective

The analysis of this pilot program aimed to determine the feasibility of delivering a COVID-19 telehealth care management program using SMS text messages for patients receiving OUD treatment.

Methods

Eligible individuals were identified from a statewide opioid treatment program (OTP) network. Those who screened positive for COVID-19 symptoms were invited to connect to care management through a secure SMS text message that was compliant with Health Insurance Portability and Accountability Act standards. Care management monitoring for COVID-19 was provided for a period of up to 14 days. Monitoring services consisted of daily SMS text messages from the care manager inquiring about the participant’s physical health in relation to COVID-19 symptoms by confirming their temperature, if the participant was feeling worse since the prior day, and if the participant was experiencing symptoms such as coughing or shortness of breath. If COVID-19 symptoms worsened during this observation period, the care manager was instructed to refer participants to the hospital for acute care services. The feasibility of the telehealth care management intervention was assessed by the rates of adoption in terms of program enrollment, engagement as measured by the number of SMS text message responses per participant, and retention in terms of the number of days participants remained in the program.

Results

Between January and April 2021, OTP staff members referred 21 patients with COVID-19 symptoms, and 18 (82%) agreed to be contacted by a care manager. Participants ranged in age from 27 to 65 years and primarily identified as female (n=12, 67%) and White (n=15, 83%). The majority of participants were Medicaid recipients (n=14, 78%). There were no statistically significant differences in the demographic characteristics between those enrolled and not enrolled in the program. A total of 12 (67%) patients were enrolled in the program, with 2 (11%) opting out of SMS text message communication and choosing instead to speak with a care manager verbally by telephone. The remaining 10 participants answered a median of 7 (IQR 4-10) SMS text messages and were enrolled in the program for a median of 9 (IQR 7.5-12) days. No participants were referred for acute care services or hospitalized during program enrollment.

Conclusions

These results demonstrate the feasibility of a novel telehealth intervention to monitor COVID-19 symptoms among OTP patients in treatment for OUD. Further research is needed to determine the applicability of this intervention to monitor patients with comorbid chronic conditions in addition to the acceptability among patients and providers using the SMS text messaging modality.

Promising outcomes from a cognitive behavioral therapy text-messaging intervention targeting drug use, antiretroviral therapy adherence, and HIV risk behaviors among adults living with HIV and substance use disorders

BACKGROUND

To date, no studies have reported the use of text messaging to deliver cognitive behavioral therapy (CBT) to people living with HIV and substance use disorders.

OBJECTIVE

We developed and evaluated a 12-week, CBT-based text-messaging intervention (TXT-CBT) targeting drug use and adherence to antiretroviral therapy (ART) for adults with HIV and comorbid opioid and stimulant use disorders.

MATERIALS AND METHODS

Participants were randomly assigned to receive either TXT-CBT (n = 25) or an informational pamphlet (INFO) discussing substance use and medication adherence (n = 25). ART adherence, drug use, and HIV-risk behaviors were assessed at baseline, monthly during treatment, and treatment-end, and were compared between groups using a mixed-model repeated-measures analysis. Injection drug use was examined as a moderator of outcomes.

RESULTS

Relative to the INFO group, TXT-CBT participants evidenced increased ART adherence, measured by phone-based unannounced pill counts and biochemically by viral load and CD4 count. TXT-CBT participation was also associated with reductions in opioid use and HIV risk behaviors. While reductions in cocaine use were observed in the TXT-CBT group, relative to the INFO group, other stimulant use did not change. Among people who inject drugs, TXT-CBT produced increases in ART adherence and corresponding changes in viral load, relative to injection drug users in the control condition.

CONCLUSIONS

Findings demonstrated promising preliminary evidence for the efficacy of TXT-CBT in improving ART adherence and reducing drug use and HIV-risk behaviors among people with HIV infection and comorbid opioid and stimulant use disorders.

Methods for Human-Centered eHealth Development: Narrative Scoping Review

Background

Thorough holistic development of eHealth can contribute to a good fit among the technology, its users, and the context. However, despite the availability of frameworks, not much is known about specific research activities for different aims, phases, and settings. This results in researchers having to reinvent the wheel. Consequently, there is a need to synthesize existing knowledge on research activities for participatory eHealth development processes.

Objective

The 3 main goals of this review are to create an overview of the development strategies used in studies based on the CeHRes (Center for eHealth Research) Roadmap, create an overview of the goals for which these methods can be used, and provide insight into the lessons learned about these methods.

Methods

We included eHealth development studies that were based on the phases and/or principles of the CeHRes Roadmap. This framework was selected because of its focus on participatory, iterative eHealth design in context and to limit the scope of this review. Data were extracted about the type of strategy used, rationale for using the strategy, research questions, and reported information on lessons learned. The most frequently mentioned lessons learned were summarized using a narrative, inductive approach.

Results

In the included 160 papers, a distinction was made between overarching development methods (n=10) and products (n=7). Methods are used to gather new data, whereas products can be used to synthesize previously collected data and support the collection of new data. The identified methods were focus groups, interviews, questionnaires, usability tests, literature studies, desk research, log data analyses, card sorting, Delphi studies, and experience sampling. The identified products were prototypes, requirements, stakeholder maps, values, behavior change strategies, personas, and business models. Examples of how these methods and products were applied in the development process and information about lessons learned were provided.

Conclusions

This study shows that there is a plethora of methods and products that can be used at different points in the development process and in different settings. To do justice to the complexity of eHealth development, it seems that multiple strategies should be combined. In addition, we found no evidence for an optimal single step-by-step approach to develop eHealth. Rather, researchers need to select the most suitable research methods for their research objectives, the context in which data are collected, and the characteristics of the participants. This study serves as a first step toward creating a toolkit to support researchers in applying the CeHRes Roadmap to practice. In this way, they can shape the most suitable and efficient eHealth development process.

Using mobile health technologies to test the association of cocaine use with sexual desire and risky sexual behaviors among people with and without HIV who use illicit stimulants

BACKGROUND

Cocaine use is broadly associated with risky sexual behavior potentially through elevated sexual desire. Understanding the within-person effects of cocaine on sexual desire and risky sexual behavior and the modification of HIV infection may inform primary and secondary HIV interventions.

METHODS

We conducted a mobile health (mHealth) study in a community sample of males and females with (n = 28) and without (n = 32) HIV who use illicit stimulant drugs. Participants completed ecological momentary assessments (EMAs) and daily diaries over 28 days. Mixed effects models were employed to examine the within-person association of cocaine use with sexual desire and risky sexual behavior.

RESULTS

Participants completed 3505 EMA responses, with 36 % involving recent cocaine use, including powder and/or crack cocaine. They completed 1427 daily diary responses, with cocaine use reported on 49 % of these days and sexual behavior on 21 % of these days. Sexual desire was highest in the first hour since cocaine use and gradually decreased with time. Sexual desire was lowest when participants had not used any cocaine in the past 6 h, and it correlated positively with the amount of use. Participants were more likely to have risky sexual behavior on days they used cocaine. These associations were similar for participants with and without HIV.

CONCLUSION

This study demonstrates the dynamic and proximal effects of cocaine use on sexual desire and risky sexual behavior. Our findings support the development of HIV prevention interventions that utilize mHealth technology to reduce sexual risk behavior among persons who use stimulant drugs.

Design and preliminary evaluation of a newly designed patient-friendly discharge letter - a randomized, controlled participant-blind trial

BACKGROUND

Low health literacy has been associated with poor health outcome and impaired use of healthcare services. The hospital discharge letter represents a key source of medical information for patients and can be used to address the problem of low health literacy. The aim of this project was to develop and evaluate a new, patient-directed, version of the discharge letter.

METHODS

Based upon two conventional discharge letters (CDL; one surgical and one medical letter), two new, patient-friendly discharge letters (PFDL) were designed following 5 key principles: short sentences, few abbreviations, large font size, avoidance of technical terms and no more than 4 pages length. Medical undergraduates were randomized into two blinded groups (CDL, PFDL) and asked to assess the assigned letter for the 3 domains structure, content and patient-friendliness. Subsections were rated on a 6-point Likert scale (1 = completely agree, 6 = completely disagree), the results of the survey were compared using the Mann-Whitney-U-Test with a p < 0.05 being the level of significance.

RESULTS

In total, 74 undergraduates participated in this study. PFDL (35 participants) were rated significantly better than CDL (39 participants) regarding structure (median 1 vs. 2, p = 0.005), content (1 vs. 3, p < 0.001) and patient-friendliness (2 vs. 6, p < 0.001). Of all 17 subsections, PFDL were rated significantly better in 12 cases, and never worse than CDL.

CONCLUSIONS

PFDL were rated significantly better than their CDL counterparts. Medical undergraduates were considered the ideal cohort, not being medical lays and yet unbiased regarding everyday clinical practice procedures. Further tests evaluating the impact of the PFDL on patient comprehension and health literacy are necessary.

Emergency Department-initiated Interventions for Patients With Opioid Use Disorder: A Systematic Review

OBJECTIVES

The opioid crisis has risen dramatically in North America in the new millennium, due to both illegal and prescription opioid use. While emergency departments (EDs) represent a potentially strategic setting for interventions to reduce harm from opioid use disorder (OUD), the absence of a recent synthesis of literature limits implementation and scalability. To fill this gap, we conducted a systematic review of the literature on interventions targeting OUDs initiated in EDs.

METHODS

Using an explicit search strategy (PROSPERO), the MEDLINE, CINAHL Complete, EMBASE, and EBM reviews databases were searched from 1980 to October 4, 2019. The gray literature was explored using Google Scholar. Study characteristics were abstracted independently. The methodologic quality and risk of bias were assessed.

RESULTS

Twelve of 2,270 studies met the inclusion criteria (two of high quality). In addition to the heterogeneity of the outcome measures used (retention in treatment, opioid consumption, and overdose), brief intervention and buprenorphine initiation (six of 12 studies) were the most documented with mixed effects for the former and positive short-term and confined to single ED sites effects for the latter.

CONCLUSION

Emergency departments can be an appropriate setting for initiating opioid agonist treatment, but to be sustained, it likely needs to be coupled with community-based follow-up and support to ensure longer-term retention. The scarcity of high-quality evidence on OUD interventions initiated in emergency settings highlights the need for future research.

Current reporting of usability and impact of mHealth interventions for substance use disorder: A systematic review

BACKGROUND

Connected interventions use data collected through mobile/wearable devices to trigger real-time interventions and have great potential to improve treatment for substance use disorder (SUD). This review aims to describe the current landscape, effectiveness and usability of connected interventions for SUD.

METHODS

A systematic review was conducted to identify articles evaluating connected health interventions for SUD in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Three databases (PubMed, IEEE, and Scopus) were searched over a five-year period. Included articles described a connected health intervention targeting SUD and provided outcomes data. Data were extracted using a standardized reporting tool.

RESULTS

A total of 1676 unique articles were identified during the initial search, with 32 articles included in the final analysis. Seven articles of the 32 were derived from two large studies. The most commonly studied SUD was alcohol use disorder. Sixteen articles reported at least one statistically significant result with respect to reduced craving and/or substance use. The majority of articles used ecological momentary assessment to trigger interventions, while four used biologic/physiologic data. Two articles used a wearable device. Common intervention types included craving management, coping assistance, and tailored feedback. Twenty-three articles measured usability factors, and acceptability was generally reported as high.

CONCLUSION

Identified themes included a focus on AUD, use of smart phones, use of EMA for intervention delivery, positive effects on SUD related outcomes, and overall high acceptability. Wearables that directly monitor biologic data and predictive analytics using integrated data streams represent understudied opportunities for new research.

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

Background:

The majority of individuals with Opioid Use Disorder (OUD) do not receive any formal substance use treatment. Due to limited engagement and access to traditional treatment, there is increasing evidence that patients with OUDs turn to online social platforms to access peer support and obtain health-related information about addiction and recovery. Interacting with peers before and during recovery is a key component of many evidence-based addiction recovery programs, and may improve self-efficacy and treatment engagement as well as reduce relapse. Commonly-used online social platforms are limited in utility and scalability as an adjunct to addiction treatment; lack effective content moderation (e.g., misinformed advice, maliciousness or “trolling”); and lack common security and ethical safeguards inherent to clinical care.

Methods:

This present study will develop a novel, artificial-intelligence (AI) enabled, mobile treatment delivery method that fulfills the need for a robust, secure, technology-based peer support platform to support patients with OUD. Forty adults receiving outpatient buprenorphine treatment for OUD will be asked to pilot a smartphone-based mobile peer support application, the “Marigold App”, for a duration of six weeks. The program will use (1) a prospective cohort study to obtain text message content and feasibility metrics, and (2) qualitative interviews to evaluate usability and acceptability of the mobile platform.

Anticipated findings and future directions:

The Marigold mobile platform will allow patients to access a tailored chat support group 24/7 as a complement to different forms of clinical OUD treatment. Marigold can keep groups safe and constructive by augmenting chats with AI tools capable of understanding the emotional sentiment in messages, automatically “flagging” critical or clinically relevant content. This project will demonstrate the robustness of these AI tools by adapting them to catch OUD-specific “flags” in peer messages while also examining the adoptability of the platform itself within OUD patients.