Brian D'Onofrio

IU researcher utilizing computer adaptive testing to better identify those with, and at risk for, substance use disorder

One of the largest barriers for treatment for people with substance use disorder is the fast and effective identification of those in need of interventions or preventive services in primary care centers, behavioral health agencies, emergency departments and the criminal justice system.

But the current methods of detecting the need for services are cumbersome, have low reliability, and fail to detect individuals with substance use disorders or those at great risk for developing them.

As part of the Responding to the Addictions Crisis Grand Challenge, a team, led by Brian D'Onofrio, professor of psychological and brain sciences in the College of Arts and Sciences at IU Bloomington, helped identify new ways to more quickly and accurately identify patients affected by substance use disorder and get them the help they need.

The project focused on using early identification of substance use and related problems to reduce the incidence of substance use disorder and decrease the number of overdoses.

D'Onofrio and his team used computer adaptive testing to help local clinics and health systems quickly and accurately identify patients with existing substance use disorder, predict those at great risk for substance use disorder and understand co-occurring mental health problems that must be addressed to reduce substance use disorder.

Computer adaptive testing allows health care providers to assess individuals -- measuring their level of depression, substance use problems or suicidality -- by giving them questions targeted to their specific level of severity. The testing is not only more accurate, D’Onofrio said, but faster than traditional measures.

D'Onofrio’s team ultimately implemented the computer adaptive testing with five organizations. While smaller clinics were able to utilize the tool, the research found there is still work to be done among larger health systems.

"We found that any assessments must be directly integrated into a setting’s workflow, particularly their electronic health records," D'Onofrio said. "This requires commitment of health care entities, not just local clinics."

In addition to building partnerships, D'Onofrio’s team also assessed nearly 900 patients in an Indianapolis emergency department. Research has shown that an emergency department can be an important place to intervene to stop suicide, and emergency rooms are supposed to screen for suicide among their patients.

"We found that computer adaptive testing is feasible in emergency room settings, where the standard screening test for the ER misses many people who have acute suicidal problems, as well as substance use problems," D'Onofrio said.

While the pandemic has created a speed bump for implementation, it also created opportunity as health groups, such as Riley Health Physicians, were forced to transfer to telehealth. D'Onofrio’s team was able to implement a tool and training materials for Riley that helped them assess youth before each telehealth visit, a collaboration D'Onofrio expects to expand in the future.

Mary Balle, manager of pediatric behavioral health at Riley, said computer adaptive testing allowed them to receive a lot of data quickly, data that was more reliable than current paper tests. It also can be used virtually or in-person.

"One extreme example of its success included catching a kid who not only was suicidal but had overdosed prior to our appointment," Balle said. "We didn’t know that until the screening, and we were able  to get him to the emergency department, potentially saving this kid’s life."

Trying to implement the new tool during a pandemic, and on a wider level, was difficult, Balle said. But, she is continuing to work with D'Onofrio to find ways to fully implement it and/or to tweak it to fit their needs. With a continuous rise in mental health needs among adolescents, Balle said it is valuable to have a partner like D’Onofrio who can help provide data and research-backed ideas that she otherwise would not have the time or resources to pursue.

"With my work, I'm always seeing patients," she said. "I don't always have the time or luxury to look at new ideas or all of the evidence-based practices. Working with Brian, we can discuss research, look at data and then try to apply it to a real-world scenario to see what works. Also, when we look for grants, we need data to back it up and we do not always have that. That is another area where the partnership comes into play."

D'Onofrio said he is encouraged by the work he has been able to do with local clinics, and his ultimate goal is to help behavioral health and other healthcare providers better identify people who are most at risk of, or are starting to develop, substance use disorders and refer them to treatment.