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A Yale doctor is using a video game to fight the opioid crisis

By Noah Smith August 11, 2021 at 11:46 a.m. EDT

As drug-related deaths have spiked across the United States in recent years, doctors seeking to curb that surge are getting an unlikely new tool: a video game. The game, titled “PlaySmart,” was developed by Lynn Fiellin and funded in part by the National Institutes of Health. A professor at the Yale School of Medicine and Yale Child Study Center, as well as the founder and director of the play2PREVENT video game development lab, Fiellin hopes that by using “PlaySmart,” she and her team will be able to collect more data related to adolescent opioid misuse and provide aid to both kids who play the game and the adults who work with those youths. “The more you know that something is dangerous, the less likely you are to do it,” Fiellin said, noting that many opioids are prescription drugs and can sometimes be found in their homes. “Kids have very inaccurate perception of risk of harm for opioids … and then there are the kids who do know it’s dangerous, but just don’t know how to say no. There is a science of negotiation — science around how to say no and still preserve your position in your peer group.”

A record number of people in the United States died from drug overdoses last year as the death toll rose by 30 percent from 2019 to over 93,000, according to the National Center for Health Statistics. Almost 70,000 deaths involved opioids. In San Francisco, more than twice as many people died from drug overdoses than covid-19, reflecting a statewide 45.9 percent increase in drug overdose deaths. While “PlaySmart” is a video game, it’s not one that’s likely to spark a massive following on YouTube or Twitch. Instead, its creators hope it can provide another avenue for treatment and prevention of drug abuse, along with the more traditional methods of intervention such as pharmaceuticals, therapy and in-school lesson plans. In addition to imparting players with information that can help them avoid drug misuse, the game also provides data to researchers — based on the players’ decisions in the game — to better inform drug awareness and prevention programs. Fiellin said another goal is to promote mental health and well-being more broadly.

“PlaySmart” is one of several games that have been funded over the past decade by the National Institutes of Health and developed by Yale University’s play2PREVENT Lab, which designs games to promote “health, wellness, education and social intelligence.” The game was made in part thanks to a grant from NIH’s Helping to End Addiction Long-term (HEAL) fund, which launched in 2018. The fund aims to help public health officials and health care providers better understand the root causes of the opioid crisis as well as research optimal treatments for opioid addiction and chronic pain.

“PlaySmart” saw promising results in its pilot study earlier this year, according to Fiellin. She reported that players showed increased knowledge about opioids as well as improved decision-making skills after playing the game.

The play2PREVENT Lab, founded in 2009, has created five video games about issues related to adolescent drug use, STI/HIV testing and prevention, and mental resilience. Akin to its other offerings, “PlaySmart” is a character-driven, cartoon choose-your-own-adventure style game where the players are placed into various situations, such as a party, and shown what happens if they make certain choices, such as kissing a person with herpes. The player is then taken through the consequences of that decision before being allowed to “go back in time” and make a different choice. The game also involves mini games that enable players to build up various skill sets, like persuasion, to better equip their characters to handle certain situations in the game.

But much like a blockbuster pharmaceutical, creating a video game, much less a good one, is a difficult, time-intensive process — especially when the goal is education and patient treatment.

“It’s really hard to translate science into entertaining media with the goal that it actually accomplishes something,” Fiellin said.

Her lab’s development process — done in partnership with Pittsburgh-based game developer Schell Games and software maker Digitalmill in Portland, Maine — takes about a year. They start with focus groups of teens and incorporate into the game the stories they hear, pervasive blind spots of focus group participants, and photos that teens give them of their rooms, clothes and more.

Beyond attempting to teach young people how to respond to difficult situations, the games have also been a source of data collection, allowing researchers to better understand what players know about opioid abuse and other high-risk behaviors. Results from the lab’s studies have been published in peer-reviewed journals including Elsevier, Oxford University’s Health Education Research and Health Promotion Practice.

Player data from “PlaySmart” will be evaluated by Fiellin and her colleagues over a two-year period where they will comb through self-reported data from participants and millions of log files generated by the game with the help of machine learning and other data specialists. Starting in September, their study will asses the gameplay of 532 adolescents between 16 and 19 years old, some of whom will play the actual game while others play different, commercial games as part of the randomized, controlled trial. The study will focus on how the game impacts players’ knowledge about the risks of opioid misuse, ability to use skills taught in the game and whether they have experimented with opioids.

“It’s the ability to use something that’s fun and engaging, and that people really like, to deliver serious health information and skills building,” she said.

Vladimir Poznyak, head of the World Health Organization’s Alcohol, Drugs and Addictive Behaviors Unit based in Geneva, shares Fiellin’s thinking that games could be an effective measure in countering the drug crisis.

“The juxtaposition between something as serious as drug overdoses with a video game can make you pause,” Poznyak said. “But it’s really taking a delivery vehicle and giving kids a dose of something healthy, helping them not die.” Poznyak added that games like Fiellin’s represent a growth area for addiction science.

FDA-approved gaming is already here, pointing to its therapeutic potential

“We know, and now it’s a very rapidly developing area of gaming, [that] different types of [video game-based] interventions have prevention and even treatment potential,” Poznyak said. Earlier this year, the FDA approved a video game to help improve children’s attention spans.

On one level, Poznyak’s view that video games can help battle addiction would seem at odds with a recent controversial stance the WHO took on gaming. In 2018, Poznyak’s unit included “gaming disorder” in its International Classification of Diseases, a decision that did not resonate well with gamers.

The WHO defines gaming disorder as “a pattern of gaming behavior (‘digital-gaming’ or ‘video-gaming’) characterized by impaired control over gaming, increasing priority given to gaming over other activities to the extent that gaming takes precedence over other interests and daily activities, and continuation or escalation of gaming despite the occurrence of negative consequences.” A diagnosis of gaming disorder requires at least a year-long pattern of behavior resulting in “significant impairment in personal, family, social, educational, occupational or other important areas of functioning.”

Poznyak said he does not see a contradiction between the therapeutic potential of some video games and the medium’s ability to trigger addiction — much like with pharmaceuticals and other drugs.

“There are many examples in the health arena when some substances, on one hand, have clearly documented beneficial properties if they’re used properly with the right indication and the right cases, and [on the other hand] the same substances can cause substance use disorders,” he said. “The treatment games are usually implemented and delivered in the context of an overall therapeutic strategy, which has controlled elements.”

Poznyak also noted that addictive games are different in nature to so-called “serious” games, like “PlaySmart.”

“The nature of games that lead to addiction is different than educational games,” he said, adding that gaming disorder is “developed in a small minority of gamers, between 1 percent to a few percent, depending on the criteria … but it’s a minority you can’t ignore.”

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Fiellin said she hopes her game finds an audience among younger people who can internalize its lessons and also engage with a preventive program, one which she says is otherwise lacking in the U.S.

“The science does not support DARE,” she said, referring to the Drug Abuse Resistance Education program. “We have really good science. We’ve shown that our games have impact and kids like playing them. One of the challenges is how to get [the game] out there.”

Even as Fiellin attempts to meet the challenge of distributing and promoting “PlaySmart,” Poznyak believes games should factor into health treatment options in the future.

“From all perspectives, gaming and all the elements of gaming are becoming more used and important in more areas of our lives,” he said. “And of course this potential and this trend should be used also for public health objectives that can bring benefits to people.”

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