Willingness to use a wearable device capable of detecting and reversing overdose among people who use opioids in Philadelphia

Overdose Detection Among High-Risk Opioid Users Via a Wearable Chest Sensor in a Supervised Injecting Facility: Protocol for an Observational Study

BACKGROUND

Opioid overdose is a global health crisis, affecting over 27 million individuals worldwide, with more than 100,000 drug overdose deaths in the United States in 2022-2023. This protocol outlines the development of the PneumoWave chest biosensor, a wearable device being designed to detect respiratory depression in real time through chest motion measurement, intending to enhance early intervention and thereby reduce fatalities.

OBJECTIVE

The study aims to (1) differentiate opioid-induced respiratory depression (OIRD) from nonfatal opioid use patterns to develop and refine an overdose detection algorithm and (2) examine participants' acceptability of the chest biosensor.

METHODS

The study adopts an observational design over a 6-month period. The biosensor, a small device, will be worn by consenting participants during injecting events to capture chest motion data. Safe injecting facilities (SIF) in Melbourne, Victoria (site 1), and Sydney, New South Wales (site 2), which are legally sanctioned spaces where individuals can use preobtained illicit drugs under medical supervision. Each site is anticipated to recruit up to 100 participants who inject opioids and attend the SIF. Participants will wear the biosensor during supervised injecting events at both sites. The biosensor will attempt to capture data on an anticipated 40 adverse drug events. The biosensor's ability to detect OIRD will be compared to the staff-identified events that use standard protocols for managing overdoses. Measurements will include (1) chest wall movement measured by the biosensor, securely streamed to a cloud, and analyzed to refine an overdose detection algorithm and (2) acute events or potential overdose identified by site staff. Acceptability will be measured by a feedback questionnaire as many times as the participant is willing to throughout the study.

RESULTS

As of April 2024, a total of 47 participants have been enrolled and data from 1145 injecting events have already been collected, including 10 overdose events. This consists of 17 females and 30 males with an average age of 45 years. Data analysis is ongoing.

CONCLUSIONS

This protocol establishes a foundation for advancing wearable technology in opioid overdose prevention within SIFs. The study will provide chest wall movement data and associated overdose data that will be used to train an algorithm that allows the biosensor to detect an overdose. The study will contribute crucial insights into OIRD, emphasizing the biosensor's potential step forward in real-time intervention strategies.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/57367.

Users' Acceptability and Perceived Efficacy of mHealth for Opioid Use Disorder: Scoping Review

BACKGROUND

The opioid crisis continues to pose significant challenges to global public health, necessitating the development of novel interventions to support individuals in managing their substance use and preventing overdose-related deaths. Mobile health (mHealth), as a promising platform for addressing opioid use disorder, requires a comprehensive understanding of user perspectives to minimize barriers to care and optimize the benefits of mHealth interventions.

OBJECTIVE

This study aims to synthesize qualitative insights into opioid users' acceptability and perceived efficacy of mHealth and wearable technologies for opioid use disorder.

METHODS

A scoping review of PubMed (MEDLINE) and Google Scholar databases was conducted to identify research on opioid user perspectives concerning mHealth-assisted interventions, including wearable sensors, SMS text messaging, and app-based technology.

RESULTS

Overall, users demonstrate a high willingness to engage with mHealth interventions to prevent overdose-related deaths and manage opioid use. Users perceive mHealth as an opportunity to access care and desire the involvement of trusted health care professionals in these technologies. User comfort with wearing opioid sensors emerged as a significant factor. Personally tailored content, social support, and encouragement are preferred by users. Privacy concerns and limited access to technology pose barriers to care.

CONCLUSIONS

To maximize benefits and minimize risks for users, it is crucial to implement robust privacy measures, provide comprehensive user training, integrate behavior change techniques, offer professional and peer support, deliver tailored messages, incorporate behavior change theories, assess readiness for change, design stigma-reducing apps, use visual elements, and conduct user-focused research for effective opioid management in mHealth interventions. mHealth demonstrates considerable potential as a tool for addressing opioid use disorder and preventing overdose-related deaths, given the high acceptability and perceived benefits reported by users.

What impacts the acceptability of wearable devices that detect opioid overdose in people who use opioids? A qualitative study

INTRODUCTION

Drug-related deaths involving an opioid are at all-time highs across the United Kingdom. Current overdose antidotes (naloxone) require events to be witnessed and recognised for reversal. Wearable technologies have potential for remote overdose detection or response but their acceptability among people who use opioids (PWUO) is not well understood. This study explored facilitators and barriers to wearable technology acceptability to PWUO.

METHODS

Twenty-four participants (79% male, average age 46 years) with current (n = 15) and past (n = 9) illicit heroin use and 54% (n = 13) who were engaged in opioid substitution therapy participated in semi-structured interviews (n = 7) and three focus groups (n = 17) in London and Nottingham from March to June 2022. Participants evaluated real devices, discussing characteristics, engagement factors, target populations, implementation strategies and preferences. Conversations were recorded, transcribed and thematically analysed.

RESULTS

Three themes emerged: device-, person- and environment-specific factors impacting acceptability. Facilitators included inconspicuousness under the device theme and targeting subpopulations of PWUO at the individual theme. Barriers included affordability of devices and limited technology access within the environment theme. Trust in device accuracy for high and overdose differentiation was a crucial facilitator, while trust between technology and PWUO was a significant environmental barrier.

DISCUSSION AND CONCLUSIONS

Determinants of acceptability can be categorised into device, person and environmental factors. PWUO, on the whole, require devices that are inconspicuous, comfortable, accessible, easy to use, controlled by trustworthy organisations and highly accurate. Device developers must consider how the type of end-user and their environment moderate acceptability of the device.

Electronic harm reduction interventions for drug overdose monitoring and prevention: A scoping review

BACKGROUND

Novel strategies are required to address rising overdose deaths across the globe. We sought to identify the breadth and depth of the existing evidence around electronic harm reduction (e-harm reduction) interventions that aimed to reduce the harms associated with substance use.

METHODS

We conducted a scoping review according to the PRISMA-ScR and PRISMA for Searching guidelines. A health sciences librarian systematically searched seven health databases from inception until January 20, 2023. Citation chaining and reference lists of included studies were searched to identify additional articles. Two reviewers independently screened, extracted and charted the data. Additionally, we conducted a gray literature search and environmental scan to supplement the findings.

RESULTS

A total of 51 studies met the criteria for inclusion (30 peer-reviewed articles and 21 non-peer reviewed). Most peer-reviewed studies were conducted in Western countries (USA = 23, Canada = 3, Europe = 3, China = 1) and among adult samples (adult = 27, youth/adults =1, unspecified = 2). Study designs were predominantly quantitative (n = 24), with a minority using qualitative (n = 4) or mixed methods (n = 2). Most e-harm reduction interventions were harm reduction (n = 15), followed by education (n = 6), treatment (n = 2), and combined/other approaches (n = 7). Interventions utilized web-based/mobile applications (n = 15), telephone/telehealth (n = 10), and other technology (n = 5).

CONCLUSIONS

While e-harm reduction technology is promising, further research is required to establish the efficacy and effectiveness of these novel interventions.

Digital Biomarker Applications Across the Spectrum of Opioid Use Disorder

Opioid use disorder (OUD) is one of the most pressing public health problems of the past decade, with over eighty thousand overdose related deaths in 2021 alone. Digital technologies to measure and respond to disease states encompass both on- and off-body sensors. Such devices can be used to detect and monitor end-user physiologic or behavioral measurements (i.e. digital biomarkers) that correlate with events of interest, health, or pathology. Recent work has demonstrated the potential of digital biomarkers to be used as a tools in the prevention, risk mitigation, and treatment of opioid use disorder (OUD). Multiple physiologic adaptations occur over the course of opioid use, and represent potential targets for digital biomarker based monitoring strategies. This review explores the current evidence (and potential) for digital biomarkers monitoring across the spectrum of opioid use. Technologies to detect opioid administration, withdrawal, hyperalgesia and overdose will be reviewed. Driven by empirically derived algorithms, these technologies have important implications for supporting the safe prescribing of opioids, reducing harm in active opioid users, and supporting those in recovery from OUD.

Reducing opioid related deaths for individuals who are at high risk of death from overdose: a co-production study with people housed within prison and hostel accommodation during Covid-19

Background

A record number of Opioid-related deaths occurred in Northern Ireland in 2021 and it is acknowledged that the Covid-19 pandemic compounded drugs related deaths crisis. This co-production study set out to refine the design of a wearable device for Opioid users to detect and subsequently prevent a potential overdose situation.

Method

Purposive sampling was used to recruit people who had substance use disorders and were living in a hostel and prison during the Covid-19 pandemic. Principles of co-production influenced the study, which encompassed a focus group phase and a wearable phase. The initial phase included three focus groups with participants who inject Opioids and one focus group with workers from a street injector support service. During the wearable phase, the participant group tested the feasibility of the wearable technology in a controlled environment. This included testing the transferability of data from the device to a backend server on the cloud.

Results

All focus group participants expressed an interest in the wearable technology when it was presented to them and agreed, that in principle, such a device would be extremely beneficial to help reduce the risk of overdose within the active drug using community. Participants outlined factors which would help or hinder the design of this proposed device and their decision to wear it, if it were readily available to them. Findings from wearable phase indicated that it was feasible to use a wearable device for monitoring Opioid users' biomarkers remotely. The provision of information regarding the specific functionality of the device was considered key and could be disseminated via front line services. The data acquisition and transfer process would not be a barrier for future research.

Conclusion

Understanding the benefit and disadvantages of technologies such as a wearable device to prevent Opioid-related deaths will be critical for mitigating the risk of overdose for people who use Heroin. It was also clear that this would be particularly relevant during Covid-19 lock-down periods, when the effects of the pandemic further exacerbated the isolation and solitude experienced by people who use Heroin.

The acceptability of overdose alert and response technologies: introducing the TPOM-ODART framework

BACKGROUND

Opioids were implicated in approximately 88,000 fatal overdoses (OD) globally. However, in principle all opioid OD are reversible with the timely administration of naloxone hydrochloride. Despite the widespread availability of naloxone among people who use opioids (PWUO), many who suffer fatal OD use alone, without others present to administer the reversal agent. Recognising this key aspect of the challenge calls for innovations, a number of technological approaches have emerged which aim to connect OD victims with naloxone. However, the acceptability of OD response technologies to PWUO is of key concern.

METHODS

Drawing on the Technology People Organisations Macroenvironment (TPOM) framework, this study sought to integrate acceptability-related findings in this space with primary research data from PWUO, affected family members and service providers to understand the factors involved in harm reduction technology acceptability. A qualitative study using a focus group methodology was conducted. The participant groups were people with lived experience of problem opioid use, affected family members and service providers. Data analysis followed a multi-stage approach to thematic analysis and utilised both inductive and deductive methods.

RESULTS

Thirty individuals participated in one of six focus groups between November 2021 and September 2022. The analysis generated six major themes, three of which are reported in this article-selected for their close relevance to PWUO and their importance to developers of digital technologies for this group. 'Trust-in technologies, systems and people' was a major theme and was closely linked to data security, privacy and confidentiality. 'Balancing harm reduction, safety and ambivalence' reflects the delicate balance technological solutions must achieve to be acceptable to PWUO. Lastly, 'readiness-a double bind' encapsulates the perception shared across participant groups, that those at the highest risk, may be the least able to engage with interventions.

CONCLUSION

Effective digital strategies to prevent fatal OD must be sensitive to the complex relationships between technological, social/human, organisational and wider macroenvironmental factors which can enable or impede intervention delivery. Trust, readiness and performance are central to technology acceptability for PWUO. An augmented TPOM was developed (the TPOM-ODART).

A scoping review of mHealth technologies for opioid overdose prevention, detection and response

ISSUES

Opioid overdose kills over 100,000 people each year globally. Mobile health (mHealth) technologies and devices, including wearables, with the capacity to prevent, detect or respond to opioid overdose exist in early form, or could be re-purposed or designed. These technologies may particularly help those who use alone. For technologies to be successful, they must be effective and acceptable to the at-risk population. The aim of this scoping review is to identify published studies on mHealth technologies that attempt to prevent, detect or respond to opioid overdose.

APPROACH

A systematic scoping review of literature was conducted up to October 2022. APA PsychInfo, Embase, Web of Science and Medline databases were searched.

INCLUSION CRITERIA

articles had to report on (i) mHealth technologies that deal with (ii) opioid (iii) overdose.

KEY FINDINGS

A total of 348 records were identified, with 14 studies eligible for this review across four domains: (i) technologies that require intervention/response from others (four); (ii) devices that use biometric data to detect overdose (five); (iii) devices that automatically respond to an overdose with administration of an antidote (three); (iv) acceptability/willingness to use overdose-related technologies/devices (five).

IMPLICATIONS

There are multiple routes in which these technologies may be deployed, but several factors impact acceptability (e.g., discretion or size) and accuracy of detection (e.g., sensitive parameter/threshold with low false positive rate).

CONCLUSION

mHealth technologies for opioid overdose may play a crucial role in responding to the ongoing global opioid crises. This scoping review identifies vital research that will determine the future success of these technologies.

Overdose Alert and Response Technologies: State-of-the-art Review

BACKGROUND

Drug overdose deaths, particularly from opioids, are a major global burden, with 128,000 deaths estimated in 2019. Opioid overdoses can be reversed through the timely administration of naloxone but only if responders are able to administer it. There is an emerging body of research and development in technologies that can detect the early signs of an overdose and facilitate timely responses.

OBJECTIVE

Our aim was to identify and classify overdose-specific digital technologies being developed, implemented, and evaluated.

METHODS

We conducted a "state-of-the-art review." A systematic search was conducted in MEDLINE, Embase, Web of Science, Scopus, ACM, IEEE Xplore, and SciELO. We also searched references from articles and scanned the gray literature. The search included terms related to telehealth and digital technologies, drugs, and overdose and papers published since 2010. We classified our findings by type of technology and its function, year of publication, country of study, study design, and theme. We performed a thematic analysis to classify the papers according to the main subject.

RESULTS

Included in the selection were 17 original research papers, 2 proof-of-concept studies, 4 reviews, 3 US government grant registries, and 6 commercial devices that had not been named in peer-reviewed literature. All articles were published between 2017 and 2022, with a marked increase since 2019. All were based in or referred to the United States or Canada and concerned opioid overdose. In total, 39% (9/23) of the papers either evaluated or described devices designed to monitor vital signs and prompt an alert once a certain threshold indicating a potential overdose has been reached. A total of 43% (10/23) of the papers focused on technologies to alert potential responders to overdoses and facilitate response. In total, 48% (11/23) of the papers and 67% (4/6) of the commercial devices described combined alert and response devices. Sensors monitor a range of vital signs, such as oxygen saturation level, respiratory rate, or movement. Response devices are mostly smartphone apps enabling responders to arrive earlier to an overdose site. Closed-loop devices that can detect an overdose through a sensor and automatically administer naloxone without any external intervention are still in the experimental or proof-of-concept phase. The studies were grouped into 4 themes: acceptability (7/23, 30%), efficacy or effectiveness (5/23, 22%), device use and decision-making (3/23, 13%), and description of devices (6/23, 26%).

CONCLUSIONS

There has been increasing interest in the research and application of these technologies in recent years. Literature suggests willingness to use these devices by people who use drugs and affected communities. More real-life studies are needed to test the effectiveness of these technologies to adapt them to the different settings and populations that might benefit from them.

Overdose Detection Technologies to Reduce Solitary Overdose Deaths: A Literature Review

Drug overdoses were a leading cause of injury and death in the United States in 2021. Solitary drug use and solitary overdose deaths have remained persistent challenges warranting additional attention throughout the overdose epidemic. The goal of this narrative review is to describe recent global innovations in overdose detection technologies (ODT) enabling rapid responses to overdose events, especially for people who use drugs alone. We found that only a small number of technologies designed to assist in overdose detection and response are currently commercially available, though several are in the early stages of development. Research, development, and scale-up of practical, cost-effective ODTs remains a public health imperative. Equipping places where people live, learn, work, worship, and play with the necessary tools to detect and prevent overdose deaths could complement ongoing overdose prevention efforts.

Safety in solitude? Competing risks and drivers of solitary drug use among women who inject drugs and implications for overdose detection

BACKGROUND AND AIMS

Solitary drug use (SDU) can amplify risks of fatal overdose. We examined competing risks and drivers of SDU, as well as harm reduction strategies implemented during SDU episodes, among women who inject drugs (WWID).

DESIGN

A cross-sectional qualitative study, including telephone and face-to-face in-depth interviews.

SETTING

Baltimore City, MD, USA.

PARTICIPANTS

Twenty-seven WWID (mean age = 39 years, 67% white, 74% injected drugs daily) recruited via outreach and street intercept (April-September 2021).

MEASUREMENTS

Interviews explored the physical (i.e. indoor/private, outdoor/public) and social (i.e. alone, accompanied) risk environments in which drug use occurred. Guided by the principles of emergent design, we used thematic analysis to interrogate textual data, illuminating women's preferences/motivations for SDU and strategies for minimizing overdose risks when using alone.

FINDINGS

Many participants reported experiences with SDU, despite expressed preferences for accompanied drug use. SDU motivations clustered around three primary drivers: (1) avoiding opioid withdrawal, (2) preferences for privacy when using drugs and (3) safety concerns, including threats of violence. Participants nevertheless acknowledged the dangers of SDU and, at times, took steps to mitigate overdose risk, including naloxone possession, communicating to peers when using alone ('spotting') and using drugs in public spaces.

CONCLUSIONS

WWID appear to engage frequently in SDU due to constraints of the physical and social environments in which they use drugs. They express a preference for accompanied drug use in most cases and report implementing strategies to mitigate their overdose risk, especially when using drugs alone.

Perceptions on wearable sensor-based interventions for monitoring of opioid therapy: A qualitative study

Prescription opioid use is a risk factor for the development of opioid use disorder. Digital solutions, including wearable sensors, represent a promising opportunity for health monitoring, risk stratification and harm reduction in this treatment space. However, data on their usability and acceptability in individuals using opioids is limited. To address this gap, factors that impact usability and acceptability of wearable sensor-based opioid detection were qualitatively studied in participants enrolled in a wearable sensor-based opioid monitoring research study. At the conclusion of the monitoring period, participants were invited to take part in semi-structured interviews developed based on the technology acceptance model. Thematic analysis was conducted first using deductive, then inductive coding strategies. Forty-four participants completed the interview; approximately half were female. Major emergent themes include sensor usability, change in behavior and thought process related to sensor use, perceived usefulness in sensor-based monitoring, and willingness to have opioid use patterns monitored. Overall acceptance for sensor-based monitoring was high. Aesthetics, simplicity, and seamless functioning were all reported as key to usability. Perceived behavior changes related to monitoring were infrequent while perceived usefulness in monitoring was frequently projected onto others, requiring careful consideration regarding intervention development and targeting. Specifically, care must be taken to avoid stigma associated with opioid use and implied misuse. The design of sensor systems targeted for opioid use must also consider the physical, social, and cognitive alterations inherent in the respective disease processes compared to routine daily life.

Treatment of opioid overdose: current approaches and recent advances

BACKGROUND

The USA has recently entered the third decade of the opioid epidemic. Opioid overdose deaths reached a new record of over 74,000 in a 12-month period ending April 2021. Naloxone is the primary opioid overdose reversal agent, but concern has been raised that naloxone is not efficacious against the pervasive illicit high potency opioids (i.e., fentanyl and fentanyl analogs).

METHODS

This narrative review provides a brief overview of naloxone, including its history and pharmacology, and the evidence regarding naloxone efficacy against fentanyl and fentanyl analogs. We also highlight current advances in overdose treatments and technologies that have been tested in humans.

RESULTS AND CONCLUSIONS

The argument that naloxone is not efficacious against fentanyl and fentanyl analogs rests on case studies, retrospective analyses of community outbreaks, pharmacokinetics, and pharmacodynamics. No well-controlled studies have been conducted to test this argument, and the current literature provides limited evidence to suggest that naloxone is ineffective against fentanyl or fentanyl analog overdose. Rather a central concern for treating fentanyl/fentanyl analog overdose is the rapidity of overdose onset and the narrow window for treatment. It is also difficult to determine if other non-opioid substances are contributing to a drug overdose, for which naloxone is not an effective treatment. Alternative pharmacological approaches that are currently being studied in humans include other opioid receptor antagonists (e.g., nalmefene), respiratory stimulants, and buprenorphine. None of these approaches target polysubstance overdose and only one novel approach (a wearable naloxone delivery device) would address the narrow treatment window.

Wearable biosensors have the potential to monitor physiological changes associated with opioid overdose among people who use drugs: A proof-of-concept study in a real-world setting

INTRODUCTION

Wearable biosensors have the potential to monitor physiological change associated with opioid overdose among people who use drugs.

METHODS

We enrolled 16 individuals who reported ≥ 4 daily opioid use events within the previous 30 day. Each was assigned a wearable biosensor that measured respiratory rate (RR) and actigraphy every 15 s for 5 days and also completed a daily interview assessing drug use. We describe the volume of RR data collected, how it varied by participant characteristics and drug use over time using repeated measures one-way ANOVA, episodes of acute respiratory depression (≤5 breaths/minute), and self-reported overdose experiences.

RESULTS

We captured 1626.4 h of RR data, an average of 21.7 daily hours/participant over follow-up. Individuals with longer injection careers and those engaging in polydrug use captured significantly fewer total hours of respiratory data over follow-up compared to those with shorter injections careers (94.7 vs. 119.9 h, p = 0.04) and injecting fentanyl exclusively (98.7 vs. 119.5 h, p = 0.008), respectively. There were 385 drug use events reported over follow-up. There were no episodes of acute respiratory depression which corresponded with participant reports of overdose experiences.

DISCUSSION

Our preliminary findings suggest that using a wearable biosensor to monitor physiological changes associated with opioid use was feasible. However, more sensitive biosensors that facilitate triangulation of multiple physiological data points and larger studies of longer duration are needed.

Closed-loop wearable naloxone injector system

Overdoses from non-medical use of opioids can lead to hypoxemic/hypercarbic respiratory failure, cardiac arrest, and death when left untreated. Opioid toxicity is readily reversed with naloxone, a competitive antagonist that can restore respiration. However, there remains a critical need for technologies to administer naloxone in the event of unwitnessed overdose events. We report a closed-loop wearable injector system that measures respiration and apneic motion associated with an opioid overdose event using a pair of on-body accelerometers, and administers naloxone subcutaneously upon detection of an apnea. Our proof-of-concept system has been evaluated in two environments: (i) an approved supervised injection facility (SIF) where people self-inject opioids under medical supervision and (ii) a hospital environment where we simulate opioid-induced apneas in healthy participants. In the SIF (n = 25), our system identified breathing rate and post-injection respiratory depression accurately when compared to a respiratory belt. In the hospital, our algorithm identified simulated apneic events and successfully injected participants with 1.2 mg of naloxone. Naloxone delivery was verified by intravenous blood draw post-injection for all participants. A closed-loop naloxone injector system has the potential to complement existing evidence-based harm reduction strategies and, in the absence of bystanders, help make opioid toxicity events functionally witnessed and in turn more likely to be successfully resuscitated.