Brief Behavioral Interventions for Drug Use in the Emergency Department. Amy Bohnert, PhD

Transcription

1 Brief Behaioral Interentions for Drug Use in the Emergency Department Amy Bohnert, PhD

2 Oerdose deaths are only the tip of the iceberg.

3 Outline 1. Rationale 2. SBIRT in the emergency department 3. SPOS Study oerdose risk behaiors 4. Next directions

4 Disclosures Affiliations: Uniersity of Michigan VA Center for Clinical Management Research Funding CDC (R49 CE Injury Research Center) NIH (NIDA R01 DA039159) VA (HSR&D, QUERI) Conflicts of Interest None to report

5 Your Thoughts - What are your experiences with the emergency department as a clinical setting? Why would we try to do anything about drug use there?

6 Rationale Why the Emergency Department? 1/3 of patients in the ED get an opioid Substance use is common Setting of acute treatment for oerdoses Not engaged in other care Teachable Moment

7 Your Thoughts - What are the barriers to addressing drug use in the emergency department?

8 Your Thoughts - What would be the benefit of a behaioral approach in the ED? What would be the benefit for opioid and oerdose interentions specifically?

9 Rationale Why a Behaioral Interention? Potentially low cost Upstream preention Why use this for opioid oerdose? Not all oerdose risk well-suited to naloxone as a preention approach Preent repeat oerdoses after a treated oerdose Complementary to naloxone distribution

10 SBIRT in the Emergency Department: Conflicting Eidence

11 Your Thoughts - What is your experience with SBIRT?

12 Blow et al., 2017 Addiction (HealthiER U) Design: Computer Brief Interention (BI)/Therapist BI/Control x Booster/Control (6 arm) Location: Flint, MI emergency department Sample: n=780, years old (mean=31), 44% male, 88% marijuana use problem Outcomes: 3-, 6-, and 12- month days drug use in the last 90 days, days marijuana use, weighted days drug use from Timeline Follow-Back (TLFB)

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14 Blow et al., 2017 (HealthiER U) Main Results Note no benefit of booster session(amet)

15 Bogenschutz et al., 2014 JAMA Intern Med (SMART-ED) Design: Brief interention with booster s. Screen and referral to treatment s. control (3 arm) Location: 6 U.S. Academic Hospitals Sample: n=1,285, mean age=36, 70% male, 17% heroin, 5% Rx opioid, 27% cocaine, 44% marijuana Outcomes: Days drug use in past 30 of primary drug at 3-, 6-, and 12-months Findings: No effect, also no effect for days any drug use, heay drinking, hair testing, no effects for sub-group by drug type or moderation by sex, race, and ethnicity Replicated in Merchant et al Acad Emerg Med, Guan et al., 2015 Drug Alcohol Depend

16 Saitz et al., JAMA 2014 (ASPIRE trial) Design: Brief negotiated interiew s. motiational interiew + booster s. control (3 arm) Location: Boston, MA primary care Sample: n=528, mean age 41, 70% male, 17% opioid, 19% cocaine, 63% marijuana, 12% injection drug use Outcomes: 30 day drug use oerall and by drug at 6 months Findings: No interention effects Replicated in Roy-Byrne et al., 2014 JAMA

17 Your Thoughts - What are reasons that might explain the different findings?

18 Potential Explanations of Different Findings Sample characteristics Drug type, seerity of problems Interention content Outcome measurement Location

19 SPOS: A brief behaioral interention to reduce opioid oerdose risk Bohnert ASB, Bonar EE, Cunningham R, Greenwald MK, Thomas L, Chermack S, Blow FC, Walton M. A pilot randomized clinical trial of an interention to reduce oerdose risk behaiors among emergency department patients at risk for prescription opioid oerdose. Drug Alcohol Depend, 163: 40-7, 2016.

20 Setting Location: Uniersity of Michigan Emergency Department (ED)

21 Protocol Research staff approached patients while waiting for care once in priate rooms Consent and screen ia computer tablet (Part 1) Those eligible recruited and consented for a baseline surey ia computer tablet (Part 2) Computer randomized to interention or enhanced usual care

22 Your Thoughts - How do you think that pen-and-paper s. computer tablet administration compares for assessing opioid use?

23 Eligibility Criteria Past 3 month prescription opioid misuse Positie screen on 8 items of Current Opioid Misuse Measure (COMM) Age Able to proide informed consent

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25 Sample Demographics N=204 final sample 177 (87%) followed at 6 months 64% female Age: mean 37 (SD=11) Race: 20% Black, 75% White, 5% Other

26 Chronic pain and problem opioid use both common 75% had an oerdose/serious drug eent history 56% had a chronic pain diagnosis 69% had been prescribed opioids in the prior 6 months 48% had moderate or high risk prescription opioid inolement, per ASSIST

27 Interention Brief Motiational Enhancement (ME) Interentions Non-judgmental, empathetic Focused on increasing self-efficacy, setting goals, oercoming barriers to change

28 Interention Content Outline EXPLORE Introduction and Agenda Setting Personal Strengths and Values Goals Reiew Behaioral History Reiew Oerdose History Reiew Witnessed Oerdoses GUIDE Benefits to Changing CHOOSE Strategies to Handle Risky Situations Selecting Change Goals Tools Strategic Summary

29 Behaioral targets of the interention 1. Reducing risky oerdose-related behaiors and opioid misuse 2. Improe response when witnessing an oerdose 3. Outreach to at-risk friends

30 Interention Deliery Master s leel trained therapists Computer aid to enhance fidelity and proide prompts as needed Enhanced Usual Care: pamphlets

31 Follow-up and Outcomes

32 Primary Outcomes Greater decreases in main outcomes between baseline and 6 months for the interention compared to control.

33 Regression results Poisson regression Model 1: Oerdose Risk Behaiors, n=172 IRR SE 95% CI Interention Group s. usual care , 0.87 Baseline Leel of Oerdose Risk Behaiors , 1.08 Model 5: Non-Medical Opioid Use, n=163 IRR SE 95% CI Interention Group s. usual care , 0.92 Baseline Leel of Non-Medical Opioid Use , 1.05

34 No effect on other outcomes No consistent impact on hypothesized mediators/mechanisms of: Behaioral Intention: Use as Prescribed Oerdose Symptom Knowledge Interention participants reported greater intentions to reduce or aoid using substances at 6 mo. followup compared to EUC.

35 Conclusions BI is feasible and highly acceptable to patients who are at risk for oerdose. Positie findings for behaioral outcomes.

36 Next Directions: Addressing barriers to deliering behaioral interentions R01 DA039159

37 Barriers and Solutions

38 PowerED study Recruit during an ED isit: -Recent nonmedical opioid use -Getting an opioid that day First Post- ED Contact, Randomize Interention Assess Opioid Use Enhanced Usual Care Repeat for 3 months, optimizing opioid use response ( reward ) Follow at 1-, 3- and 6-months Outcomes: -Leel of nonmedical opioid use -Secondary opioid risk behaior -ED isits RL System Decision: RL system informed by recent opioid use and baseline data -Brief Motiational Message -Extended Motiational Message -Therapist Call Back

39 Soling the opioid crisis requires: Safer Prescribing Help to those with mild opioid use problems MAT access for those with Opioid Disorders Scalable, light touch behaioral interentions