Using MedSMA℞T Families for Opioid Safety Education: Emergency Department Staff Perspective

Recent studies have shown that fatal opioid overdoses are increasing. However, nonfatal opioid overdoses have remained stable in pediatric patients over recent years.¹ Rates of high-dosage and long-duration prescriptions have decreased for adolescents and young adults but have increased in young children.² In a study examining adolescents visiting emergency departments (EDs), a significant and sudden rise in opioid prescriptions was discovered starting at age 18. This sharp increase in prescribing was linked to an elevated risk of long-term negative outcomes related to opioid use.³ 

One well-known adverse childhood experience is being exposed to substance use in the household. This experience is linked to worse outcomes as an adult when compared with adolescents who did not have this childhood experience.¹ The availability of opioid analgesics and the rise in their abuse likely led to a rise in the number of opioid overdose deaths in adolescents.⁴ Use of prescribed opioids for both therapeutic and nontherapeutic purposes during adolescence is a risk factor for opioid misuse later in life^5–7 and is associated with an increase in substance-related morbidity.⁸ Unfortunately, adolescents who use prescription opioids before 12th grade are also at significant risk of misusing opioids later in life.^9,10 On surveys of clinicians, 64% do not have a standardized protocol for prescribing pain management medications to adolescents, less than half of pediatric providers screen their adolescent patients for substance use, and only 30% offer an educational intervention, which often has a brief impact.^11,12 

Adolescents have inadequate knowledge about opioid use and safety.^13–18 With easy access to prescribed opioids and a lack of understanding or awareness of safe practices related to opioid medications, adolescents are at high risk for prescription opioid misuse.^14,19 However, adolescents can be taught to avoid harmful health-related behaviors, especially if they are provided with evidence that correlates dangerous behaviors to potentially unsafe outcomes.¹⁴ Research indicates adolescents are willing to practice correct opioid use if provided with the information in a way they can understand, such as tailored prescription opioid education.^20,21 They prefer digital opioid education sources such as videos, websites, and serious games,²² although they often also turn to Google or other search engines and online videos for information about opioids currently.^15,16 In one study, about 80% of adolescents surveyed were receptive to the use of an educational game to improve opioid safety knowledge.²³ Adolescents also turn to family members, particularly parents, and health care professionals, such as doctors, nurses, or pharmacists for opioid information.^15,16 Unfortunately, parents often model inappropriate prescription opioid use in the home, suggesting that opioid education for family members is a key piece in adolescent opioid misuse.^8,9,15 

MedSMA℞T Families is a digital health intervention that combines the game MedSMA℞T: Adventures in PharmaCity, which is a serious game that aims to improve adolescent opioid safety knowledge with a digital personalized family medication safety plan (FMSP) (Figure 1) to promote communication between adolescents and their families about safe prescription opioid use.^24,25 This intervention targets several key factors in preventing unsafe opioid use by teaching adolescents and their parents while considering youth preferences for education. Implementation of MedSMA℞T Families in the ED setting provides health care staff with an effective tool for improving patient care by addressing their opioid knowledge gaps and promoting positive health behaviors in the home. MedSMA℞T Families is a digital health intervention grounded in human factors engineering. The intervention focuses on increasing communication among families and improving opioid safety in adolescents. Participants play as “Shan,” the anthropomorphized sheep, who has been prescribed opioids after breaking an arm.²⁴ 

The objective of this study is to understand the ED staff’s perceptions on implementing the MedSMA℞T Families intervention in the ED setting and surveying ED staff to assess the feasibility of gameplay in the ED.

This project was approved by the local institutional review board. To be eligible, participants needed to be employed at the BerbeeWalsh Department of Emergency Medicine at the University of Wisconsin-Madison University Hospital. Eligible participants were able to speak, read, and understand English and had access to a computer, tablet, or mobile phone with videoconferencing ability. The general ED staff recruitment flyer was posted in high-traffic locations throughout the department. ED research coordinators (EDRCs) pitched the study at preshift huddles and handed out flyers. EDRCs approached any ED staff with direct patient engagement (nurse, physician, physician’s assistant, etc). The study team followed up with ED staff no more than 3 times via email to schedule a virtual (Zoom) meeting session.

A sociotechnical systems approach to the patient journey is the Systems Engineering Initiative for Patient Safety (SEIPS) 3.0 model.²⁶ It views the patient journey as a temporal sequence of work systems that interact with one another. These work systems are always responding to and adapting to changes in the external environment, including new rules and regulations, new technology, the addition of a patient portal, or improved clinical decision support. Additionally, they adjust to modifications in the management style and the structure of the job within the socio-organizational context. The SEIPS 3.0 model has 5 main components including “tools & technologies,” “care team,” “physical environment,” “tasks,” and “organizational conditions.” To define each component, “tools & technologies” refer to objects that people use to do work or that assist in doing work. “Care team” is a local context where patients interact with various care team members, caregivers, and clinicians. The “physical environment belongs” to the workplace and environmental elements such as lights, noise, and distractions that impact the work process. “Tasks” are specific actions within a larger work process, and lastly, “organizational conditions” represent structures external to a person that organize time, resources, and activities.²⁶ 

The MedSMA℞T game: Adventures in PharmaCity was developed by the Collaborative Research on MEdication use & family health (CRoME) laboratory and the university team. It is a task-guided game divided into 5 levels. Level 1 is focused on teaching the player about safe storage of opioids. Level 2 enhances the game storyline by adding a real-life scene about being in pain and forgetting there was an important assignment due that day. Level 3 focuses on teaching the player not to take others’ pain medication and the negative consequences of taking someone else’s medications. Level 4 focuses on teaching the player not to share their medication with others and what Narcan® (a medicine that rapidly reverses an opioid overdose) is used for. Level 5 shows the player the correct way to dispose of opioid medications.

The FMSP is the next tool in the MedSMA℞T Families intervention, which facilitates communication between adolescents and parents regarding medication safety. It provides a space to document medication and family information, dosage and instructions, medication schedule, benefits, potential side effects, drug-drug interactions, food-drug interactions, and proper storage and disposal techniques.²⁵ 

The development of questions was informed by using 2 specific implementation frameworks. One framework was RE-AIM (reach, effectiveness, adoption, implementation, maintenance),²⁷ a widely used metric, that evaluates 5 areas of public health impact. For this project, the 5 areas are: reach (ability to provide intervention to those at risk), effectiveness (benefit of intervention), adoption (ability of organization to take up intervention), implementation (fidelity of program), and maintenance (ability of participants and organizations to keep intervention going). This framework helped develop questions around implementation in the ED setting as well as perceived efficacy. The second theoretical framework involved in question development was EPIS (exploration, preparation, implementation, sustainability) because it facilitates a dynamic approach to implementation that considers stakeholder needs and experiences throughout the process. It allows for the examination of the change process at multiple levels over time, leading to effective implementation and long-term sustainment.²⁸ Throughout the 4 phases, the EPIS framework takes into consideration both the outer and inner context to identify all relevant factors for implementation success. The outer context describes factors external to the organization, such as patient characteristics and patient advocacy. The inner context describes characteristics within the organization, such as the ED structure, culture, resources, and readiness for change and the characteristics of ED staff. Questions were also informed by user experience testing wherein participants were asked about their likes and dislikes of the game as well as suggested improvements. The questions concentrated on how implementation is carried out, individuals’ perceptions, and recommendations for enhancement. The interview guide is presented in the Supplemental Materials.

The data collection took place from November 2022 to March 2023. Similar to a previous study on pharmacists’ perspectives of MedSMA℞T, data saturation was reached at 20 participants; however, data collection continued until 23 participants were reached to ensure that no new information or themes emerged from the data set, indicating that the data had been fully explored. During the virtual meeting sessions, ED staff played the game for 30 minutes while being observed by a member of the research team. They then responded to a survey that focused on overall perceptions of the MedSMA℞T game, the FMSP, game design, educational accuracy, and barriers related to implementation. Participants were interviewed in a 45-minute semistructured follow-up session. Observation during gameplay was for the purpose of intervening in the event of a technological error and documenting any issues during gameplay. Gameplay and interviews were recorded via Zoom. Demographic characteristics of participants were also collected (Table 1). The interviews were transcribed verbatim by a professional from audio recordings.

Qualitative data were analyzed using a standard, semantic inductive approach to explore factors related to ED staff’s perspectives on the implementation and design of the game. This method provides adaptability in exploring and identifying patterns linked to implementation and iterative design based on the feedback provided by participants. One research team member analyzed the survey data using descriptive statistics (Supplemental Table 1), which contains results from the survey questions. Also, each transcript was independently coded using inductive thematic analyses via NVivo 14. The team member was familiarized with the data, generated preliminary codes, and held meetings with the principal investigator to discuss and refine codes and finalize the master codebook. Once the verbatim transcripts had been coded, they were exported and collated to elucidate prevalent themes. The principal investigator reviewed codes and their prevalence, which were used to identify major themes and subthemes from the data set.

A total of 23 ED staff with various roles were recruited, including 8 nurses, 3 attending physicians, 3 physician assistants, 2 medicine residents, 2 nurse residents, 2 technicians, 1 pharmacist, 1 social worker, and 1 ED research coordinator supervisor. ED staff played the game for an average of 22 minutes. To expand on different components of the SEIPS 3.0 model and considering “tools and technologies,” it was reported that creative scenes and scenarios in the game are well-structured and educate patients on required actions with expired opioids, dropping off opioids at pharmacies, and safety concerns when having kids at home. Surveyed staff also reported that it is user-friendly, more interactive, fun, personalized, adapted to the patient, and age-appropriate for adolescents compared with the educational materials used in the ED currently. Constructive feedback included adapting the game to all medications, game availability as a phone app, shortening the game, and translation to other commonly used languages among non-English speaking patients such as Spanish and Hmong. Additionally, it was reported that the FMSP is a good resource for families at home because it provides detailed information regarding safe opioid use, disposal, and storage that is often missed in patient education in the ED and opens the door for conversations with adolescents about opioid safety. Color coding additions to the different sections of the FMSP and simplifying jargon were recommended as future alterations. Regarding the “care team” component of the SEIPS 3.0 model, the game did allow for nursing staff to be more engaged with the plan of care, although it was suggested that child life specialists might be more appropriate staff to introduce and deliver the game to patients because they are equipped with more technology resources.

The majority of staff were willing to implement the game in the ED. Moreover, staff buy-in, staff training, allocated electronic resources, and having a thorough understanding of the game’s goal, impact, and value were recognized as important factors within the “organizational conditions” for the implementation of the game. Regarding the “physical environment” component of the model, the space, busyness, loudness, workplace time constraints, and allocated resources in the ED were perceived as challenges to game implementation. Lastly, waiting room gameplay was believed to be the most efficient setting of game implementation after an opioid prescription is likely to be prescribed. Keeping electronic resources in the ED and having the care team walk patients through the game were discussed as part of the “tasks” component of the SEIPS 3.0 model.

Table 2 includes main themes, subthemes, and related verbatim quotes for each component of the SEIPS 3.0 model.

Previous studies on adolescents’ and parents’ views regarding the MedSMA℞T game showed that both adolescents and parents considered the MedSMA℞T game more interactive than conventional educational materials. They appreciated the game’s graphics, characters, and technology-driven format. However, some difficulties, such as the slow pace of gameplay, were noted. Additionally, participants thought that the game increased their awareness about safe opioid practices, such as proper storage and safe disposal. Furthermore, they regarded the FMSP as a valuable resource for starting conversations about opioids between adolescents and their parents and was perceived as a useful resource for promoting safe medication practices.

A previous study on pharmacists’ views on the MedSMA℞T intervention for educating youth about opioid safety indicated that pharmacists viewed the game as a useful and effective educational tool. They emphasized the significance of interactive gameplay for active learning and recalling information.²⁹ Moreover, a previous study on pharmacists’ perceptions of the FMSP indicated that it could facilitate interactive opioid discussions between adolescents and families. According to pharmacists, the FMSP could promote customized medication consultations and improve safety communications about opioids.³⁰ This is the first study to explore the perceptions of ED staff regarding the implementation of the MedSMA℞T Families intervention in the ED to educate adolescents and their families on safe opioid use. MedSMA℞T Families was deemed by ED staff to be an interactive and fun serious game with engaging dialogues among cartoon-like characters and realistic events to enhance learning outcomes. The option of trial and error for making different decisions throughout the game and using understandable language for kids was appreciated by the ED team. The ED staff’s perspective corroborated findings in earlier studies, which indicated that playing serious games supports cognitive development in young patients and their decision-making abilities regarding drug safety and substance use.^29,31 

Additionally, ED staff identified potential facilitators and barriers to implementation in an ED setting. Overall, implementation was deemed feasible and impactful, and the ED staff were willing to complete the tasks necessary to engage patients in gameplay. A primary barrier identified to implementation was the time constraint and adding more work to an already busy workplace. Another important consideration is the lack of mobile compatibility and the requirement for technology resources in the ED settings in this study. Adaptations to the length of gameplay or the ability to play the game at home using a quick response code could ameliorate this concern, as suggested by some staff members. Staff also suggested increasing staff buy-in by providing game announcements and advertisements and introducing its benefits and uses to ED management to improve gameplay.

In conclusion, these opinions are consistent with prior research that indicates serious educational games foster greater engagement, retention, and interest among adolescents as compared with traditional learning resources.³² 

The adoption of MedSMA℞T Families is reinforced by positive impressions of ED staff, an interactive design, clear learning goals, and a unique and creative approach to involve adolescents. Although these elements support implementation in ED settings, there are implementation barriers that still exist. There is a lack of literature on the implementation and sustainment of serious game interventions in the ED setting for adolescents, and our study addresses this gap by providing valuable insights and strong support from the ED staff for the implementation of the game in the ED setting. There are no studies that have been published that involve ED staff in the preimplantation phase of serious game creation. Developing pilot programs for this intervention requires the early involvement of ED staff and an understanding of their perspectives on implementation. This study has aided in anticipating future implementation barriers in other EDs by collating and reporting the perceptions of our ED staff. Further steps include characterizing children’s and parents’ perspectives on the MedSMA℞T game and the FMSP who are prescribed opioids in the ED to better understand the perceptions of the end users of this intervention in the ED setting where this intervention can be implemented.

As staff interviews were recorded via Zoom, ED staff could have been more likely to respond in a socially desirable manner. However, interviews were conducted until reaching data saturation, indicating that our sample size was sufficient to achieve the aims of this study. Another limitation is that all the ED staff surveyed were from one academic ED, which may not represent the sentiments of all the EDs across the United States. Given the unique characteristics of ED settings and their vital role in the intervention implementation, further research using a more diverse sample of ED settings is warranted to gain organizational-related information and adaptations.

ED staff play an integral role in the health care system and contribute novel and valuable insights into how the MedSMA℞T Families intervention can be efficiently implemented in ED settings. The MedSMA℞T game is one of the first serious games to target opioid medication safety education for adolescents and families in an ED. Similar to other existing serious games for health, the MedSMA℞T game has the potential to engage, interact, and better retain the attention of younger patients. Future research and game refinement are necessary for the efficient implementation of the intervention.

ED

emergency department

SEIPS

Systems Engineering Initiative for Patient SafSety

FMSP

family medication safety plan

EDRC

emergency department research coordinators

RE-AIM

reach, effectiveness, adoption, implementation, maintenance

EPIS

exploration, preparation, implementation, sustainment

Thank you to Tyler J. McCarthy for helping with the data collection.