Digital Clinical Trials for Substance Use Disorders in the Age of Covid-19

Application of Virtual Drug Study to New Drug Research and Development: Challenges and Opportunity

In recent years, virtual drug study, as an emerging research strategy, has become increasingly important in guiding and promoting new drug research and development. Researchers can integrate a variety of technical methods to improve the efficiency of all phases of new drug research and development, including the use of artificial intelligence, modeling and simulation for target identification, compound screening and pharmacokinetic characteristics evaluation, and the application of clinical trial simulation to carry out clinical research. This paper aims to elaborate on the application of virtual drug study in the key stages of new drug research and development and discuss the opportunities and challenges it faces in supporting new drug research and development.

Using digital technology to reduce drug-related harms: a targeted service users' perspective of the Digital Lifelines Scotland programme

BACKGROUND

Deaths due to drug overdose are an international issue, causing an estimated 128,000 global deaths in 2019. Scotland has the highest rate of drug-related deaths in Europe, with those in the most deprived areas at greater risk than those in affluent areas. There is a paucity of research on digital solutions, particularly from the perspective of those who use drugs who additionally access harm reduction and homelessness support services. The Digital Lifelines Scotland programme (DLS) provides vulnerable people who use/d drugs with digital devices to connect with services.

METHODS

This paper reports on the evaluation of the DLS from the perspective of service users who accessed services for those at risk of drug-related harms. A mixed methods approach was used including an online-survey (n = 19) and semi-structured interviews (n = 21). Survey data were analysed descriptively and interview data through inductive coding, informed by the Technology, People, Organisations and Macroenvironmental factors (TPOM) framework, to investigate the use, access, and availability of devices, and people's experiences and perceptions of them.

RESULTS

Most participants lived in social/council housing (63.2%, n = 12), many lived alone (68.4%, n = 13). They were mainly over 40 years old and lived in a city. Participants described a desire for data privacy, knowledge, and education, and placed a nascent social and personal value on digital devices. Participants pointed to the person-centred individuality of the service provision as one of the reasons to routinely engage with services. Service users experienced an increased sense of value and there was a palpable sense of community, connection and belonging developed through the programme, including interaction with services and devices.

CONCLUSIONS

This paper presents a unique perspective which documents the experiences of service users on the DLS. Participants illustrated a desire for life improvement and a collective and individual feeling of responsibility towards themselves and digital devices. Digital inclusion has the potential to provide avenues by which service users can safely and constructively access services and society to improve outcomes. This paper provides a foundation to further cultivate the insight of service users on digital solutions in this emerging area.

Preferred sources of information on diabetes prevention programmes: a population-based cross-sectional study in Poland

OBJECTIVE

This study aimed to analyse preferred sources of information on diabetes prevention programmes and to identify sociodemographic determinants influencing these preferences among adults in Poland.

DESIGN

A cross-sectional survey was carried out between 15 and 18 September 2023 using a computer-assisted web interview. A self-prepared questionnaire included 10 questions on sources of information on type 2 diabetes prevention.

PARTICIPANTS

Data were obtained from 1046 adults (18-82 years); 53.4% were females.

RESULTS

Most respondents preferred email communication (46.4%), followed by a doctor or nurse (33.5%), and a letter or leaflet directly delivered to the mailbox (25.8%) for type 2 diabetes mellitus (DM2) prevention information. Younger respondents were more likely to indicate mass media (OR=1.81, 95% CI=1.12 to 2.95, p=0.01) and digital media (OR=1.65, 95% CI=1.02 to 2.67, p=0.04) as a source of information on DM2 prevention. Those who had higher education (OR=1.51, 95% CI=1.16 to 1.96, p=0.002), as well as those with chronic diseases (OR=1.50, 95% CI=1.14 to 1.97, p=0.004), were more likely to indicate digital media. Out of 10 different variables analysed in this study, passive occupational status (OR=1.43, 95% CI=1.04 to 1.96, p=0.03) as well as having chronic diseases (OR=1.51, 95% CI=1.16 to 1.96, p=0.002) were associated with higher odds of indicating healthcare workers as a preferred source of information. Marital status, having children, place of residence, household characteristics and financial status do not significantly decide communication preferences.

CONCLUSION

Communication on DM2 prevention should be adjusted to public preferences and expectations. Tailoring interventions to different demographic groups can enhance outreach and engagement. Email emerged as a popular choice, suggesting the potential of digital communication in preventive health programmes.

Narrative review of telemedicine applications in decentralized research

Telemedicine enables critical human communication and interaction between researchers and participants in decentralized research studies. There is a need to better understand the overall scope of telemedicine applications in clinical research as the basis for further research. This narrative, nonsystematic review of the literature sought to review and discuss applications of telemedicine, in the form of synchronous videoconferencing, in clinical research. We searched PubMed to identify relevant literature published between January 1, 2013, and June 30, 2023. Two independent screeners assessed titles and abstracts for inclusion, followed by single-reviewer full-text screening, and we organized the literature into core themes through consensus discussion. We screened 1044 publications for inclusion. Forty-eight publications met our inclusion and exclusion criteria. We identified six core themes to serve as the structure for the narrative review: infrastructure and training, recruitment, informed consent, assessment, monitoring, and engagement. Telemedicine applications span all stages of clinical research from initial planning and recruitment to informed consent and data collection. While the evidence base for using telemedicine in clinical research is not well-developed, existing evidence suggests that telemedicine is a potentially powerful tool in clinical research.

The impact of the COVID-19 pandemic on ICU clinical trials: a description of one research team's experience

BACKGROUND

Disruptions to clinical trials conducted in the intensive care unit (ICU) due to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV2; coronavirus disease 2019 [COVID-19]) pandemic included fewer new trials activated and more trials stopped. While a number of ongoing, non-COVID-19 clinical trials remained open to enrollment, the direct impact of the pandemic on ICUs instilled chaos in this already challenging environment. The numerous challenges need to be reported so investigators can proactively plan and manage these myriad challenges. Thus, the purpose of this study was to describe the impact of the COVID-19 pandemic on screening and accrual for a non-COVID-19 parent clinical trial enrolling critically ill ICU patients receiving mechanical ventilatory support.

METHODS

A descriptive, retrospective design using quantitative data from detailed screening logs and qualitative observations with field notes from a parent clinical trial were used to address the objectives. The primary aims of the two-site parent clinical trial (n = 190) are to test the efficacy of self-administration of sedative therapy by mechanically ventilated ICU patients on anxiety and delirium occurrence. ICUs from two academic medical centers [names removed for blinding] plus a community hospital in Minnesota were screened daily for alert patients (Richmond Agitation Sedation Scale [RASS] - 2 to + 1), following commands, hemodynamically stable with sufficient hand grip strength to depress a push-button device. Screening data were summarized based on the primary reason patients were not enrolled (screen failures, declinations of consent). Descriptive statistics (frequencies, percentages), chi-square, and Fisher's Exact test were used to describe the data and to determine any differences among distributions of screening failures and recruitment declinations during the defined pre-pandemic (August 27, 2018-March 15, 2020, 2976 screened patients) and pandemic timeframes (March 16, 2020-February 28, 2022, 3912 screened patients). Qualitative data from varied sources such as screening logs, institutional email communications, staff field notes, and research team meeting minutes were summarized into themes.

RESULTS

Despite significantly fewer screen failures due to hypotension, cognitive impairment/dementia, coma, or chemical paralysis with 938 additional patients on the screening log, more were accrued pre-pandemic (n = 55) than during the pandemic period (n = 45); declination reasons were non-significant. Pandemic burdens experienced by study personnel, ICU care providers, and patients/families were revealed that attributed to decreased accrual.

CONCLUSIONS

While the parent clinical trial remained opened, cumulative factors adversely impacted the trial during the pandemic period with fewer patients accrued. The human toll of the pandemic on research staff, clinicians, and patients/family members demands that investigators be proactive in managing these challenges to conduct ICU clinical trials successfully, including careful oversight of human and financial resources.

TRIAL REGISTRATION

ClinicalTrials.gov NCT#02,819,141 Registered 29 June 2016.

Patient and Healthcare Professional Insights of Home- and Remote-Based Clinical Assessment: A Qualitative Study from Spain and Brazil to Determine Implications for Clinical Trials and Current Practice

INTRODUCTION

The SARS-CoV-2 virus pandemic has accelerated the growing trend towards using home- and remote-based medical testing (H/RMT). The aim of this study was to gather insights and explore the opinions of patients and healthcare professionals (HCPs) in Spain and Brazil regarding H/RMT and the impact of decentralised clinical trials.

METHODS

This qualitative study consisted of in-depth open question interviews of HCPs and patients/caregivers followed by a workshop that aimed to determine the advantages and barriers to H/RMT in general, and in the context of clinical trials.

RESULTS

There were 47 participants in the interviews (37 patients, 2 caregivers, 8 HCPs) and 32 in the validation workshops (13 patients, 7 caregivers, 12 HCPs). The main advantages for the use of H/RMT in current practice were the comfort and convenience, the ability to improve the relationship between HCPs and patients and personalise patient care, and the increased patient awareness towards their disease. Barriers to H/RMT included accessibility, digitalisation, and the training requirements for both HCPs and patients. Furthermore, according to the Brazilian participants, there is a general distrust in the logistical management of H/RMT. Patients indicated that the convenience of H/RMT did not influence their decision to participate in a clinical trial, with the main reason for participating in a clinical trial being to improve health; however, H/RMT in clinical research does aid adherence to the long-term follow-up associated with trials and provides access to patients living far from the clinical sites.

CONCLUSION

Insights from patients and HCPs suggest that the advantages of H/RMT may outweigh the barriers, and that social, cultural and geographical factors and the HCP-patient relationship are critical aspects to be considered. Moreover, the convenience of H/RMT does not appear to be a driver for participating in a clinical trial but can facilitate patient diversity and study adherence.

The impact of COVID-19 on the treatment of opioid use disorder in carceral facilities: a cross-sectional study

While the COVID-19 pandemic disrupted healthcare delivery everywhere, persons with carceral system involvement and opioid use disorder (OUD) were disproportionately impacted and vulnerable to severe COVID-associated illness. Carceral settings and community treatment programs (CTPs) rapidly developed protocols to sustain healthcare delivery while reducing risk of COVID-19 transmission. This survey study assessed changes to OUD treatment, telemedicine use, and re-entry support services among carceral and CTPs participating in the National Institute on Drug Abuse (NIDA)-funded study, Long-Acting Buprenorphine vs. Naltrexone Opioid Treatments in Criminal Justice System-Involved Adults (EXIT-CJS) study. In December 2020, carceral sites (n = 6; median pre-COVID 2020 monthly census = 3468 people) and CTPs (n = 7; median pre-COVID 2020 monthly census = 550 patients) participating in EXIT-CJS completed a cross-sectional web-based survey. The survey assessed changes pre- (January-March 2020) and post- (April-September 2020) COVID-19 in OUD treatment, telemedicine use, re-entry supports and referral practices. Compared to January-March 2020, half of carceral sites (n = 3) increased the total number of persons initiating medication for opioid use disorder (MOUD) from April-September 2020, while a third (n = 2) decreased the number of persons initiated. Most CTPs (n = 4) reported a decrease in the number of new admissions from April-September 2020, with two programs stopping or pausing MOUD programs due to COVID-19. All carceral sites with pre-COVID telemedicine use (n = 5) increased or maintained telemedicine use, and all CTPs providing MOUD (n = 6) increased telemedicine use. While expansion of telemedicine services supported MOUD service delivery, the majority of sites experienced challenges providing community support post-release, including referrals to housing, employment, and transportation services. During the COVID-19 pandemic, this small sample of carceral and CTP sites innovated to continue delivery of treatment for OUD. Expansion of telemedicine services was critical to support MOUD service delivery. Despite these innovations, sites experienced challenges providing reintegration supports for persons in the community. Pre-COVID strategies for identifying and engaging individuals while incarcerated may be less effective since the pandemic. In addition to expanding research on the most effective telemedicine practices for carceral settings, research exploring strategies to expand housing and employment support during reintegration are critical.

Virtual Infection Prevention and Control in Low- and Middle-Income Countries

COVID-19 brought new challenges and opportunities for infection prevention and control. Virtual infection prevention and control (VIPC), although nascent, is rapidly becoming a viable and necessary strategy for combatting the COVID-19 pandemic. Benefits of VIPC include extending the impact of globally scarce infectious disease providers and public health practitioners, allowing coordination between disparate professionals to more effectively combat infectious disease, and increasing access to and quality of healthcare. Although mainly applied in developed countries, VIPC may play its greatest role in low- and middle-income countries (LMICs) with fewer healthcare resources. We conducted a brief literature search of VIPC in LMICs and found that many studies describe solutions in developed countries or describe planned or theoretical solutions. Few studies describe actual VIPC implementation in LMICs, except for China. Literature from related fields, for example, virtual critical care, and from developed countries is more robust and provides a roadmap for future research on VIPC in LMICs. Further research into strategies and outcomes related to VIPC in LMICs is necessary.

Patient Engagement With a Game-Based Digital Therapeutic for the Treatment of Opioid Use Disorder: Protocol for a Randomized Controlled Open-Label, Decentralized Trial

BACKGROUND

Prescription digital therapeutics are software-based disease treatments that are regulated by the US Food and Drug Administration; the reSET-O prescription digital therapeutic was authorized in 2018 and delivers behavioral treatment for individuals receiving buprenorphine for opioid use disorder. Although reSET-O improves outcomes for individuals with opioid use disorder, most of the therapeutic content is delivered as narrative text. PEAR-008 is an investigational device based on reSET-O that uses an interactive, game-based platform to deliver similar therapeutic content designed to enhance patient engagement, which may further improve treatment outcomes.

OBJECTIVE

We aim to investigate how participants interact with the prescription digital therapeutic's new content delivery format. Secondary objectives include evaluating treatment success, symptoms of co-occurring mental health disorders, recovery capital, and skill development.

METHODS

Due to the COVID-19 pandemic, this study was redesigned using a decentralized model because it was not possible to conduct medication initiation and study visits in person, as initially intended. A decentralized, randomized controlled trial design will be utilized to compare patient engagement with PEAR-008 and that with reSET-O using both subjective and objective assessments. The study population will consist of approximately 130 individuals with opioid use disorder (based on Diagnostic and Statistical Manual of Mental Disorders 5 criteria) who have recently started buprenorphine treatment for opioid use disorder. Participants will be virtually recruited and randomly assigned to receive either PEAR-008 or reSET-O. All study sessions will be virtual, and the duration of the study is 12 weeks. The primary outcome measure of engagement is operationalized as the number of active sessions per week with either PEAR-008 or reSET-O. (An active session is any session that contains some active participation in the app, such as navigating to a different screen, engaging with a learning module, or responding to a notification.) Subjective dimensions of engagement will be assessed with participant surveys. The hypothesis is that PEAR-008 will have significantly greater participant engagement than reSET-O.

RESULTS

As of February 2021, participant enrollment is ongoing.

CONCLUSIONS

This randomized controlled trial will investigate if changing the delivery format and enhancing the content of a prescription digital therapeutic for opioid use disorder will affect how participants use and interact with the prescription digital therapeutic. The study design may serve as a useful model for conducting decentralized studies in this patient population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04542642; https://clinicaltrials.gov/ct2/show/NCT04542642.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/32759.

Conducting a pediatric randomized clinical trial during a pandemic: A shift to virtual procedures

Background/Objective

Prior to the COVID-19 pandemic, our research group initiated a pediatric practice-based randomized trial for the treatment of childhood obesity in rural communities. Approximately 6 weeks into the originally planned 10-week enrollment period, the trial was forced to pause all study activity due to the COVID-19 pandemic. This pause necessitated a substantial revision in recruitment, enrollment, and other study methods in order to complete the trial using virtual procedures. This descriptive paper outlines methods used to recruit, enroll, and manage clinical trial participants with technology to obtain informed consent, obtain height and weight measurements by video, and maintain participant engagement throughout the duration of the trial.

Methods

The study team reviewed the IRB records, protocol team meeting minutes and records, and surveyed the site teams to document the impact of the COVID-19 shift to virtual procedures on the study. The IRB approved study changes allowed for flexibility between clinical sites given variations in site resources, which was key to success of the implementation.

Results

All study sites faced a variety of logistical challenges unique to their location yet successfully recruited the required number of patients for the trial. Ultimately, virtual procedures enhanced our ability to establish relationships with participants who were previously beyond our reach, but presented several challenges and required additional resources.

Conclusion

Lessons learned from this study can assist other study groups in navigating challenges, especially when recruiting and implementing studies with rural and underserved populations or during challenging events like the pandemic.

Applications of technology in the assessment and treatment of cannabis use disorder

Cannabis use and Cannabis Use Disorder (CUD) have been increasing. There are no FDA approved medications and evidence-based psychotherapy is limited by insufficient providers, serving very few patients effectively. The lack of resources for prevention and treatment of CUD has resulted in a significant gap between the need for services and access to treatment. The creation of a scalable system to prevent, screen, refer and provide treatment for a chronic, relapsing diagnosis like CUD could be achieved through the application of technology. Many studies have utilized ecological momentary assessments (EMA) in treatment seeking and non-treatment seeking cannabis users. EMA allows for repeated, intensive, longitudinal data collection in vivo. EMA has been studied in cannabis use and its association with affect, craving, withdrawal, other substances, impulsivity, and interpersonal behaviors. EMA has the potential to serve as a valuable monitoring tool in prevention, screening, and treatment for CUD. Research has also focused on the development of internet and application-based treatments for CUD, including a currently available prescription digital therapeutic. Treatment options have expanded to more broadly incorporate telehealth as an option for CUD treatment with broad acceptance and change in regulation following the COVID-19 pandemic. While technology has limitations, including cost, privacy concerns, and issues with engagement, it will be a necessary medium to meet societal health needs as a consequence of an ever-changing cannabis regulatory landscape. Future work should focus on improving existing platforms while ethically incorporating other functions (e.g., sensors) to optimize a public and clinical health approach to CUD.

Participation of rural patients in clinical trials at a multisite academic medical center

Objective:

Clinical trials, which are mainly conducted in urban medical centers, may be less accessible to rural residents. Our aims were to assess participation and the factors associated with participation of rural residents in clinical trials.

Methods:

Using geocoding, the residential address of participants enrolled into clinical trials at Mayo Clinic locations in Arizona, Florida, and the Midwest between January 1, 2016, and December 31, 2017, was categorized as urban or rural. The distance travelled by participants and trial characteristics was compared between urban and rural participants. Ordinal logistic regression analyses were used to evaluate whether study location and risks were associated with rural participation in trials.

Results:

Among 292 trials, including 136 (47%) cancer trials, there were 2313 participants. Of these, 731 (32%) were rural participants, which is greater than the rural population in these 9 states (19%, P < 0.001). Compared to urban participants, rural participants were older (65 ± 12 years vs 64 ± 12 years, P = 0.004) and travelled further to the medical center (103 ± 104 vs 68 ± 88 miles, P < 0.001). The proportion of urban and rural participants who were remunerated was comparable. In the multivariable analysis, the proportion of rural participants was lower (P < 0.001) in Arizona (10%) and Florida (18%) than the Midwest (38%) but not significantly associated with the study-related risks.

Conclusions:

Approximately one in three clinical trial participants were rural residents versus one in five in the population. Rural residents travelled further to access clinical trials. The study-associated risks were not associated with the distribution of rural and urban participants in trials.

Comparison of Communication Channels for Large-Scale Type 2 Diabetes Risk Screening and Intervention Recruitment: Empirical Study

Background

Clinical trials have shown that type 2 diabetes (T2D) is preventable through lifestyle interventions targeting high-risk people. Nevertheless, large-scale implementation of risk identification followed by preventive interventions has proven to be challenging. Specifically, recruitment of participants into preventive interventions is an important but often overlooked part of the intervention.

Objective

This study aims to compare the reach and yield of different communication channels to engage people at increased risk of T2D to fill in a digital screening questionnaire, with emphasis on reaching those at most risk. The participants expressing their willingness to participate is the final step in the risk screening test, and we aim to determine which channels had the most participants reach this step.

Methods

We established a stepwise web-based T2D risk screening tool with automated feedback according to the T2D risk level and, for those who were eligible, an invitation to participate in the StopDia prevention intervention study conducted in a primary health care setting. The risk estimate was based on the Finnish Diabetes Risk Score; history of repeatedly measured high blood glucose concentration; or, among women, previous gestational diabetes. We used several channels to invite people to the StopDia web-based screening tool, and respondents were classified into 11 categories based on the channel through which they reported having learned about StopDia. The demographics of respondents reached via different communication channels were compared using variance analysis. Logistic regression was used to study the respondents’ likelihood of progressing through risk screening steps.

Results

A total of 33,399 persons started filling the StopDia screening tool. Of these, 86.13% (28,768/33,399) completed the test and named at least one communication channel as the source of information about StopDia. Altogether, 26,167 persons filled in sufficient information to obtain risk estimates. Of them, 53.22% (13,925/26,167) were at increased risk, 30.06% (7866/26,167) were men, and 39.77% (10,136/25,485) had low or middle education levels. Most frequently mentioned channels were workplace (n=6817), social media or the internet (n=6712), and newspapers (n=4784). The proportion of individuals at increased risk was highest among those reached via community pharmacies (415/608, 68.3%) and health care (1631/2535, 64.33%). The communication channel reaching the largest percentage of interested and eligible men (1353/3979, 34%) was relatives or friends. Health care (578/1069, 54.07%) and radio or television (225/487, 46.2%) accounted for the largest proportion of people with lower education.

Conclusions

Communication channels reaching a large number of people, such as social media and newspapers, were the most effective channels for identifying at-risk people. Personalized approaches increased the engagement of men and less-educated people. Community pharmacies and health care services reached people with a particularly high T2D risk. Thus, communication and recruitment channels should be selected and modified based on the intended target group.

International Registered Report Identifier (IRRID)

RR2-10.1186/s12889-019-6574-y