It felt like a hug.
“That’s how one young adult patient in recovery described fentanyl to us,” remembers addiction medicine specialist Lynn Fiellin, M.D. She and her team at Yale University School of Medicine in New Haven, Connecticut, are trying to understand awareness surrounding opioid use among adolescents and young adults. A key research strategy is seeing the world through their eyes.
“What are they thinking and feeling?” Understanding risk perception, Fiellin explains, is an important component to designing effective prevention interventions. To that end, the researchers are developing a set of serious, yet highly engaging videogames to help youth consider outcomes of risky behavior in advance. The goal is for simulated experiences to guide healthier choices in real-life scenarios and prevent risky behaviors like drug use and unprotected sex.
This innovative research is part of the Helping to End Addiction Long-termSM Initiative, or NIH HEAL InitiativeSM’s new strategies to prevent and treat opioid addiction.
Focus on Prevention
Like many other health providers who see patients with substance use disorders, Fiellin is board-certified in addiction medicine, which is a specialty area of internal medicine. She is active in research: to develop, test, and implement the best approaches for helping her patients and other individuals struggling to find lasting recovery. Until about 10 years ago, Fiellin’s research focused primarily on opioid use disorder in adults – but at that point, she saw a need to reach back earlier into the lives of her patients.
“I kept hearing stories from adolescence,” she recalls, referring to her patients’ experiences growing up that led them to start having struggles with addiction. These observations prompted Fiellin to acquire a sharpened focus on teens and young adults, a population that can get lost between pediatric and adult medical care.
“How can we help teens and young adults find a healthy path going forward, so they never need to deal with addiction?” is the main goal of this research, she describes. Other research, including some of Fiellin’s past studies, had already looked at ways to target the teen years to prevent other serious health conditions, like HIV.
She considered the best way to get into the heads of this young population was to talk to them about their experiences – and then reach them through a comfortable and familiar platform: videogames.
Serious Prevention Through Play
All prevention strategies that aim to influence human behavior must satisfy one critical goal: They must make sense in the context of an individual’s life and take into account the real-time challenges and opportunities people face every day.
Fiellin and her Yale team run a research lab called play2PREVENT™, or the p2P Lab (watch a brief video about it), which is part of the Yale Center for Health & Learning Games, also founded by Fiellin. Their scientific approach involves developing videogame interventions that will be both effective and entertaining, but for a serious purpose. The p2P Lab uses videogame play to teach youth skills so they can take charge of their own lives – including recognizing and managing risk.
The games visit a range of scenarios common to this population, including drug and alcohol use, sexual risk behaviors, driving under the influence, cheating in school, bullying, and others – “the environment teens live in” as Fiellin describes it.
The videogame approach is not unlike good storytelling, using characters and vivid imagery to guide individuals through real-life experiences. It then goes a step further to prepare players to make healthy decisions in their own lives at school and at home. The researchers work closely with other researchers, educators, commercial game developers, and community-based organizations.
Perhaps the most important part of the research team are the people who will play the games – teens and young adults – both those who have never used opioids and those in recovery. The research relies heavily on these individuals who participate in extensive focus-group testing of videogame concepts, content, and usability.
“We ask them to vet everything we create such that the stories come from their eyes and their voice,” Fiellin says, recalling what she heard first-hand about the perception of fentanyl as a comforting hug instead of as a potentially lethal substance.
For such individuals, Fiellin’s HEAL Initiative research is building PlaySmart, a videogame focused on preventing opioid misuse in adolescents between the ages of 16 and 19. In addition to development of the game itself, this research funds a randomized controlled trial to test how effective it is among Connecticut youth as well as implementation research done in partnership with school-based health centers and the national School-Based Health Alliance.
PlaySmart – which offers up to 6 hours of game play – is structured around 5 sections that encompass teen life: Risk, Refusal Power, Social Media, Stress, and Future Sense. Game players navigate through stories such as “Grandma’s Pills,” “Trading Wisdom,” and “A Friend in Need,” about snooping in the family medicine cabinet, managing pain from a wisdom-tooth extraction, and going to a party. Other content offers the opportunity to find help for mental health challenges that can co-occur with substance misuse.
A key strategy built into the game, Fiellin explains, is the ability to “go back in time and make safer choices about opioids” in the safe environment of a videogame at school, at home, or even at a friend’s house.
The opportunity to develop PlaySmart enabled Fiellin to combine her research interests about opioid misuse and prevention, more of which is needed: “There really isn’t a good option for effective, engaging evidence-based interventions around opioid misuse in adolescents.”
PlaySmart, which is in the final stages of development and user testing, will be the newest offering from the p2P Lab. Other games already tested and in use across the country to address risky behaviors have been developed with support from both NIH and the CVS Health Foundation.
An earlier game, smokeSCREEN, targets children between 10 and 16 and focuses on smoking and vaping prevention – engaging players in simulated experiences where they can see the potential outcomes of decisions: both good and bad ones. Research results from use of this game are encouraging. For example, children who played smokeSCREEN had significantly increased perception and knowledge about e-cigarette risk: The team measured a 25% increase in the number of children who, after playing the game, understood that nicotine is the addictive component in e-cigarettes.
“It’s just flavored air,” students told Fiellin before playing smokeSCREEN. “There was no understanding of nicotine, or the addictive nature of nicotine, or the other potential toxins within electronic cigarettes.”
“Doctors prescribe pain medications. They’re in my family’s medicine cabinet. They must be safe,” Fiellin says of similar confusion surrounding use of prescription opioids. Many teens don’t adequately perceive the risk.
The PlaySmart game is now ready for pilot testing among a small group of teens and young adults – aiming to get more input from the people who will use the game. Over the next few months, the team will work with game developers to finalize content. In fall 2021, the group plans to begin a randomized controlled trial with 532 teens in 10 school-based health centers in Connecticut as well as more broadly across the nation. Ultimately, the research will involve students in 2,600 school-based health centers – where the game can be implemented right away if it proves to be effective and popular.
Beyond educational settings, other potential venues for distribution of PlaySmart and other p2P Lab videogames include insurers who offer health and wellness tools to members and their families. But Fiellin and her team are realistic about what they are trying to do and laser-focused on outcomes.
“This is not Grand Theft Auto – that’s not our competition,” she says, but adding that the vast majority of teens play videogames by choice. Health-promotion videogames might offer an alternative to hearing a health teacher teach about substance use in a classroom setting.
PlaySmart is web-based and can be played on any available device, including a computer or tablet. The free smokeSCREEN game has been downloaded 40,000 times.
Fiellin believes that user-focused research is incredibly important, especially to help solve a problem like opioid misuse and its significant health ramifications for individuals, families, and communities.
“As scientists and providers, our brains can be the content experts in terms of the facts and the data,” she says, “but in terms of the perspective, and really how kids want to see this, it has to come from them.”