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

PROJECT SUMMARY
Non-prescription opiate use in adolescents and young adults is epidemic in our country and overdose-related
fatalities are rising. Adolescents and young adults in justice settings (AYAJS) have some of the highest rates of
opioid use disorder (OUD), with national rates approaching 20%. The majority of AYAJS engage in problematic
non-opioid substance use, which is a critical risk factor for OUD. Non-opioid substance use disorders (SUDs)
and OUD, in turn, are two of the most important predictors of subsequent re-involvement in juvenile or criminal
justice systems. Seattle Children’s Hospital (SCH), University of Washington (UW), and Washington State
Juvenile Rehabilitation (WSJR) will collaboratively evaluate OUD prevention interventions of varying intensities
based on the Adolescent Community Reinforcement Approach with Assertive Continuing Care (ACRA/ACC).
Multiple studies have established effectiveness of ACRA/ACC in reducing SUD; however none have evaluated
it as an OUD prevention strategy. SUD is incredibly common and costly among AYAJS; thus ACRA/ACC-
based approaches are likely to be effective and cost-beneficial OUD prevention strategies for this group.
However, we need to determine the optimal intensity of an ACRA/ACC-based OUD prevention intervention for
AYAJS with and without non-opioid SUD, as these groups are likely to have differing prevention needs. We will
use Sequential Multiple Assignment Randomized Trial (SMART) to construct high-quality adaptive
interventions (AIs) containing ACRA/ACC-based OUD prevention strategies of different intensity levels among
SUD and non-SUD youth. In our 2-year UG3 phase, we will collaboratively plan for a SMART experiment, i.e.:
finalize infrastructure, recruitment, intervention, and data collection procedures; and create infrastructure for
sustainable future implementation of effective interventions after the UH3 full trial (UG3 Aim 1). We will conduct
a pilot with 40 AYAJS to assess feasibility of protocols and procedures, recruitment, engagement, and
retention strategies in anticipation of full trial (UG3 Aim 2). In our 3-year UH3 phase, we will conduct a SMART
trial with 430 AYAJS aged 16-25 from all WSJR institutions to evaluate ACRA/ACC-based OUD prevention
interventions of various intensity levels among SUD and non-SUD youth (UH3 Aim 1). We will administer self-
report electronic surveys at baseline, 1, 3 & 6 months to collect cost and outcomes data on primary outcomes
(initiation and escalation of use measured by number of days and frequency of use of any substances) and
secondary outcomes (number of days/frequency of use of specific substances including opioids, others); we
will use administrative data to measure recidivism. Our UH3 Aim 2 will be to conduct comprehensive cost
analyses to estimate the resources required to implement our ACRA-based interventions. Our proposal is
responsive to the RFA, innovative in its degree of partnership with WSJR as well as in its rigorous and
pragmatic SMART design. It is also high impact in that it is highly likely to prevent OUD for one of the most
vulnerable youth populations in our country.

Grant Number: 4UH3DA050189-03
NIH Institute/Center: NIH
Principal Investigator: KYM AHRENS