JMIR Publications

ABSTRACT

Background:

Drug overdose mortality continues to increase, now driven by fentanyl. Prevention tools, such as naloxone and medications to treat opioid use disorder, are not sufficient to control overdose rates, and additional strategies are urgently needed.

Objective:

We sought to adapt a behavioral intervention (REBOOT), that had been successfully piloted in San Francisco, California, to the setting of Boston, Massachusetts, and the era of fentanyl for a full efficacy trial (NCT03838510).

Methods:

We used the ADAPT-ITT framework for intervention adaptation. We first identified opioid overdose survivors who were actively using opioids as the population of interest and REBOOT counseling as the intervention to be adapted. We then performed theater testing and elicited feedback with two focus groups (n=10) in Boston in 2018. All focus group participants had used opioids that were not prescribed to them in the past year and had experienced an opioid overdose during their lifetime. We incorporated focus group findings into our initial draft of the adapted REBOOT intervention. The adapted intervention was then reviewed by three topical experts, whose feedback was integrated into a subsequent draft. Finally, we trained study staff on the intervention, and made final refinements based on internal piloting. This paper describes the overall ADAPT-ITT process for intervention adaptation, as well as a qualitative analysis of the focus groups that were conducted. Two authors (VMM and JA) independently reviewed the focus group transcripts and coded them for salient and common themes using the constant comparison method, meeting to discuss any discrepancies until consensus was reached. Codes and themes were then mapped onto the REBOOT counseling steps.

Results:

Focus group findings contributed to substantial changes in the counseling intervention to better address fentanyl overdose risk. Focus group participants described the widespread prevalence of fentanyl, and said that, while they tried to avoid it, avoidance was becoming impossible. Using alone and lower opioid tolerance were identified as contributors to overdose risk. Slow or tester shots were acceptable and considered effective to reduce risk. Naloxone was considered an effective reversal strategy. While calling emergency services was not ruled out, participants described techniques to prevent the arrival of police on the scene. Expert review and internal piloting improved the intervention manual through increased participant-centeredness and improved clarity and usability.

Conclusions:

We successfully completed the ADAPT-ITT approach for an overdose prevention intervention, utilizing theater testing with people who use opioids to incorporate the perspectives of people who use drugs into a substance use intervention. In the current crisis, overdose prevention strategies must be adapted to the context of fentanyl and innovative strategies must be deployed, including behavioral interventions. Clinical Trial: NCT03838510