July 2014

Technology-assisted Care for Substance Use Disorders

Wendy Hausotter, MPH
NWATTC Research Assistant

“Science and technology multiply around us. To an increasing extent they dictate the languages in which we speak and think. Either we use those languages, or we remain mute.”    ― J.G. Ballard

The innovative collaboration between NIDA and SAMHSA, known as the “Blending Initiative,” has once again produced cutting-edge information and tools for behavioral health practitioners—the latest focusing on technology-assisted care for substance use disorders. This article highlights some of the information and tools available on the new blending “product,” a resource hub called SUDTECH.ORG.

What does technology-assisted care mean?  Basically, it is adding technology-based elements to a practitioners “toolkit” as a supplement and complement to their treatment repertoire. Technology-based care is a rapidly evolving field and can take many different forms and formats, including audio, video, animations and/or other forms of multimedia; may use information from medical records or physiological data capture devices, etc.; and may be interactively customized, or tailored, to an individual user’s needs (Aronson, Marsch, & Acosta, 2013). How often is technology used to deliver psychotherapy or behavioral treatment to patients?  To date, more than 100 different computer-assisted therapy programs have been developed for a range of mental disorders and behavioral health problems (Klein et al., 2012; Moore et al., 2011). Treatment practices administered via technology-based interventions include: Cognitive Behavioral Therapy, Community Reinforcement Approach (CRA), Contingency Management, Motivational Enhancement, Motivational Interviewing, Screening, Brief Intervention and Relapse Prevention.

Technology-assisted care has applications in many settings and can be viewed in many ways; for example, as part of brief intervention—particularly in settings where SUD treatment services are limited (e.g., primary care settings)—and as a “clinician extender,” i.e., when used as an adjunct to treatment whereby clinicians “prescribe” it to enhance therapeutic intervention. The good news is that, in general, technology-based behavioral health interventions have been shown to be well accepted, efficacious, and cost effective, especially when compared to standard care (Aronson, Marsch, and Acosta, 2013).

What are the potential benefits of technology-assisted care?

Aside from the obvious benefit of helping to close the treatment gap (19.3 million people needed but did not receive treatment for illicit drug or alcohol use—SAMHSA, 2011), current research on this topic suggests that technology-assisted care has specific benefits for clients and treatment providers. Technology-assisted care:

  • Allows for on-demand access to therapeutic support outside of formal care settings anytime/anywhere
  • Transcends geographical boundaries
  • Facilitates linkages to services in the community
  • Could increase receptivity to care by serving as a “foot in the door" for clients who are uneasy about seeking SUD treatment (Rummel and Joyce, 2010)
  • Enables anonymity (Marsch 2012)
  • Could improve access to evidence-based practices (EBPs), thereby enhancing their reach (Marsch 2013), and helps ensure that an EBP is implemented with fidelity, thereby improving the chances of achieving positive outcomes.

The benefits for treatment providers, based on current research, include:

  • May allow for providing more treatment and treating more clients with the same number of clinicians
  • Frees up clinicians to spend more time with those with the greatest need for more intensive care
  • Helps clinicians more effectively manage high patient caseloads
  • Allows for provision of automated and tailored information

(Moyer & Finney, 2004/2005; Fotheringham et al., 2000)

Two examples of technology-assisted care models and outcomes 

Therapeutic Education System (TES) is an interactive, web-based psychosocial intervention for SUDs grounded in: Community Reinforcement Approach (CRA), Cognitive Behavioral Therapy (CBT), and Contingency Management (CM). The specific features of TES include:

  • 65 interactive, multimedia modules that focus on: Substance Use/Abuse(e.g., drug refusal skills, coping with thoughts about using, identifying/managing triggers); Risk Reduction for HIV, AIDS & STIs (e.g., drug use, HIV and hepatitis, identifying/managing triggers for risky sexual behaviors); Cognitive and Emotional Regulation ( e.g., managing negative thinking, anger management)  and Psychosocial Functioning  (e.g., effective problem solving, communication skills)
  • Self-directed, evidence-based programs with skills training, interactive exercises, and homework
  • Audio components that accompany all module content
  • Electronic reports of patient activity
  • A contingency management component that tracks earnings of incentives dependent on some defined outcome (e.g., urine results confirming abstinence)
  • Rewards-prize based incentives, intermittent schedule of reinforcement based on abstinence, module completion

A NIDA Clinical Trials Network’s multi-site trial evaluated the effectiveness of TES. The trial involved 10 sites and 507 participants and showed the following (Campbell et al 2014):

  • TES doubled the odds of abstinence among clients who tested positive for substances
  • Improved retention (48% of TES clients stayed in treatment for 12 months compared to 40% of treatment as usual
  • Findings suggest that TES can be substituted for a portion of face-to-face counseling and produce better outcomes (i.e., abstinence and retention)

Findings from other studies include:

  • In outpatients with opioid dependence, computer-assisted CRA with vouchers produced similar abstinence weeks and longer continuous abstinence than therapist-administered CRA with vouchers and reduced therapist time (Bickel et al., 2008)
  • TES was an effective adjunct to HIV prevention education for youth in substance abuse treatment; TES plus counseling produced greater 12 month abstinence than counseling alone (Marsch et al., 2011)
  • In a prison population TES was as effective as standard treatment in reducing drug use, HIV risk and self-reported criminal behavior at 3- and 6-months post release, and greater reported treatment satisfaction and completion (Chaple et al., 2013)

Computer-Based Training for Cognitive Behavioral Therapy (CBT4CBT) is a web-based program that teaches a variety of skills to help people reduce substance abuse. Training lessons include understanding patterns of substance use, learning to recognize and deal with craving, addressing thoughts about substance use that can set a person up to use, how to effectively say ‘No’ to offers of alcohol or drugs, and how to be more aware of patterns of thinking and decision making that can lead to drug use. The seven training modules use a range of formats and techniques including graphic illustrations, games, videotaped examples, questions to consider, verbal instructions, audio voiceovers, interactive assessments, and practice exercises. The overall approach is to make the experience engaging and interactive. Each module or content area takes about one hour to complete and users typically complete one module per week. Users can choose the order of topics they wish, and work at their own pace for completion.

Outcomes for CBT4CBT include (Carroll et al., 2008; 2009; 2011; 2014; Olmstead, Ostrow, & Carroll, 2010) a randomized controlled trial of 77 individuals seeking outpatient treatment:

  • Participants assigned to the CBT4CBT condition submitted significantly more urine specimens that were negative for any type of drugs, especially cocaine and tended to have longer continuous periods of abstinence during treatment.

In a randomized controlled trial of 101 cocaine-dependent individuals maintained on methadone, participants:

  • Were significantly more likely to attain three or more consecutive weeks of abstinence from cocaine;
  • Had significantly more negative urines for all drugs but only among those who completed the eight-week trial, and
  • Had greater reduction in cocaine use at 6 months follow up, showing durability of the intervention.

Moving forward

Promising technology-assisted treatments exist for alcohol, tobacco, gambling, and illicit substance use. Moving forward, it behooves clinicians and administrators to think through how they can use these new technologies in clinical treatment. Now and in the future, behavioral health professionals have the opportunity to “view technology as a powerful partner in improving quality and productivity of behavioral healthcare” (Marsch & Gustafson, 2013). The resources below can help you move along that path.

Technology-Assisted Care for Substance Use Disorders website http://sudtech.org/ This site is a collaborative “Blending” product from the NIDA/SAMHSA Blending Initiative that provides information, videos, training, and other resource information for implementing technology assisted treatments/care to improve the quality and reach of treatment services for persons with substance use disorders. The site includes curricula, research studies and links, video interviews with practitioners who use technology-assisted care, information on administrative and other considerations for implementing this type of approach, program models, and much more.

The 2014 Addiction Treatment Technology Summit will be held in Chicago, Illinois on August 26-27, 2014. Hosted by the National Frontier and Rural ATTC, the goal of the summit is to increase knowledge and awareness regarding technology-based substance use disorder interventions to promote the utilization of telehealth technologies in delivering addiction treatment and recovery services. Leading addiction treatment researchers will present their findings on technology-based interventions to addiction treatment providers, followed by breakout discussion groups regarding implementation strategies. Registration is free.

The National Frontier and Rurall ATTC sponsors Telehealth Tuesdays

There will also be a Treatment Improvement Protocol (TIP) on this topic (Using Technology-Based Therapeutic Tools in Behavioral Health Services) coming in the near future.

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