ED-SMART: Emergency Department-Substance use screening, Motivational interviewing and Active Referral Targeting substance use disorder and overdose prevention

About This Grant

ABSTRACT Millions of Americans engage in substance use (SU), which poses myriad adverse health effects including risk for overdose. Consistent with RFA-CE-25-149, there is a critical need to develop, implement, rigorously evaluate, and scale feasible and efficacious approaches to Screening, Brief Intervention, and Referral for Prevention for individuals engaging in at-risk SU (SBIRP). Emergency departments (EDs) provide a unique opportunity to access the general population including young, diverse, and disadvantaged individuals to provide SU SBIRP who otherwise cannot or do not access other care and services. This proposal seeks to leverage the ED setting for an SBIRP approach paired with a subsequent telehealth-delivered motivational interviewing (MI) prevention program to avert the development of substance use disorders (SUD) in populations engaged in at-risk SU. We aim to: 1) Evaluate the efficacy of Emergency Department- Substance use screening, Motivational interviewing and Active Referral Targeting substance use disorder and overdose prevention (ED-SMART) for patients with at-risk SU. Using an established, ED-based at-risk SU screening approach, we will enroll a sample of consenting participants with at-risk SU use via recommended measures (N=650) in a two-arm RCT comparing (i) a brief, single session, ED-delivered MI intervention plus referral for 5, monthly, brief telehealth MI sessions to (ii) an SU informational control condition. Assessments will occur at baseline (prior to randomization) and at 1- and 6-months post- baseline. We hypothesize that ED-SMART will have greater reductions in SU (primary outcome) relative to control at 6 months. We will secondarily evaluate: (i) incidence of positive screen for SUD, (ii) changes from baseline in proportion with positive biological toxicology assays for SU, (iii) self-reported healthcare utilization, and (iv) frequency of fatal and non-fatal overdose. 2) Characterize ED-SMART feasibility, acceptability, and processes in preparation for future clinical implementation. We will (i) measure intervention dose, (ii) conduct time and motion observations of resource requirements for intervention delivery (ED and telehealth), and (iii) engage (n=30) patients (both completing ED-SMART and declining AIM 1 study), and (n=50) ED nurses, physicians, and administrators in planning for a future effectiveness- implementation hybrid trial. Using mixed-methods guided by Consolidated Framework for Implementation Research constructs, we will evaluate perceived feasibility, acceptability, and organizational readiness after sharing AIM 1 efficacy results and develop an operational plan for clinical ED-SMART implementation. Should ED-SMART not demonstrate efficacy, participants will also engage in a rigorous assessment of possible alternative intervention targets. This high impact research promises to launch a new paradigm in emergency care and overdose and SUD prevention. At scale, innovations to optimize and implement ED- SMART in the ED could provide meaningful reductions in the prevalence of SUD and overdoses.