Virtual reality at the point of care to increase uptake of MOUD in the ED

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PROJECT SUMMARY Despite the widespread efforts to curb the opioid epidemic, the number of drug overdose deaths increased by nearly 30% from 2019 to 2020, of which approximately 75% involved an opioid. NIH and SAMHSA have directed significant funds towards improving access to increase the numbers of persons with opioid use disorder (OUD) receiving treatment. However, the treatment gap continues to grow, with only a small minority of eligible patients taking opioid agonist therapy (OAT). Although curbing the epidemic will require efforts across multiple sectors, an immediate goal is to increase adoption of strategies already proven to be effective. Initiating buprenorphine in the emergency department (ED) is an important low threshold strategy to improve access, yet it remains grossly underutilized. Interventions aimed at decreasing system and provider level barriers have not increased uptake. Therefore, increasing ED-initiated buprenorphine rates will likely not be realized unless patient level barriers (i.e., preferences) are explicitly addressed. The objective of this proposal is to develop and test a novel approach using virtual reality (VR) to increase uptake of buprenorphine in the ED. We hypothesize that participating in an immersive VR experience may be more effective than currently available counseling approaches and decision aids based on the superior ability of VR to activate emotional responses compared to other media or motivational approaches. Our intervention is based on the Emotion- Imbued Choice model which describes the multiple effects of emotion on decision making and behavior. For example, positive affect enhances flexibility and willingness to examine alternative options, and activation of positive affect is a consistent finding of VR exposure in health-related applications. During the R21 phase we will employ a stakeholder-centered and user experience iterative design approach to develop and optimize an immersive VR experience designed to motivate patients with moderate to severe OUD to agree to treatment with buprenorphine while in the ED. During the R33 phase, we will conduct a parallel, 2-arm, randomized controlled feasibility trial. The data generated from the feasibility trial will determine the feasibility of performing a definitive full-scale randomized controlled trial (RCT) to ascertain whether VR- Choice increases the rate of ED-initiated buprenorphine compared to TAU. Eligible participants will be randomized 1:1 to VR-Choice or treatment as usual (TAU). We hypothesize that this feasibility RCT will meet prespecified process criteria justifying a full-scale RCT. The five process indicators are average number of eligible patients randomized per month, baseline measure completion, proportion randomized to the VR-Choice arm completing the VR program, proportion in VR-Choice arm developing VR-related symptoms, and acceptability of VR-Choice. Each of these process indicators will be evaluated by preset “Stop” and “Go” thresholds. We will conclude that a full-scale RCT is not feasible if one or more process criteria meet the Stop threshold.