Using SMART Design to Identify an Effective and Cost-Beneficial Approach to Preventing OUD in Justice-Involved Youth

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SUMMARY/ABSTRACT Youth involved in legal systems (YILS) are a vulnerable population with high rates of substance use and overdose. Due to forced abstinence and consequent lower tolerance rates, the risk of overdose is 50 times higher for incarcerated persons than the general population in the first two weeks after release. Nationally, commensurate with the rise in frequency of illicitly produced fentanyl and other synthetic opioids, adolescent overdose risk is increasing dramatically. Risk factors are also changing. Previously, prior use of highly potent opioids and opioid or polysubstance use disorder were critical risk factors for adolescent/young adult overdose. Currently only one in three youth that fatally overdoses has used opioids previously. In the Washington State Department of Children, Youth, and Families Juvenile Rehabilitation (DCYF JR) system almost 1 in 3 youth in our state-run facilities qualify as having opioid use disorder, and 58% of youth screened for substance use disorders indicate that they have overdosed non-fatally at some point in the past. We seek to conduct a mixed methods study to triangulate identification of modifiable overdose risk factors for YILS, develop strategies to measure this risk, and develop and test a multilevel intervention to reduce this risk. We anticipate that a combination of education, proven harm reduction strategies, and strategies to increase behavioral motivation will be the most effective way to reduce overdose risk amongst incarcerated youth. Although this proposal is focused on a specific high-risk population (incarcerated youth), we will develop overdose prevention strategies that can be replicated in other populations, addressing one of our nation's most critical public health concerns. In Aim 1 we will conduct qualitative individual semi-structured interviews with youth with exposure to overdose (20-30); internal stakeholders such as staff and medical personnel (10-15); and external stakeholders with research or policy expertise (5-10). In Aim 2 we will conduct a cross-sectional assessment of administrative DCYF JR data to identify modifiable risk reduction factors associated with prior overdose event. In Aim 3 we will develop multilevel preventive intervention data from prior aims. We anticipate including educational campaigns/initiatives, naloxone and fentanyl test strip distribution, motivational interviewing to develop overdose prevention goals and enhance motivation to carry out these goals, and text messaging reminder components. We will test specific components of the intervention in need of refinement with 20 DCYF JR youth, in anticipation of a future randomized controlled trial (RCT). Finally, we will explore data linkages between DCYF JR and other administrative data systems to determine if it is possible to predict which system(s) youth experiencing fatal or near fatal overdose are most likely to have interacted with in the 2 months prior to the overdose event. This proposal is aligned with NIDA's HEAL initiative and strategic plan and will reduce overdose risk among our nation's most vulnerable youth.