Leveraging Mobile Technology in the Delivery of Behavioral Interventions

Targeting Substance Use Disorders

Lisa A. Marsch, Ph.D.Lisa A. Marsch, Ph.D.

Director, Center for Technology and Behavioral HealthDirector, Center for Technology and Behavioral HealthDartmouth Psychiatric Research CenterDartmouth Psychiatric Research Center

Department of Psychiatry, Dartmouth CollegeDepartment of Psychiatry, Dartmouth College

AcknowledgementAcknowledgement

Research funded byResearch funded by

National Institute on Drug Abuse, National Institute on Drug Abuse, National Institutes of Health (NIH)National Institutes of Health (NIH)

P30 DA029926 P30 DA029926 NIDA “Center of Excellence” GrantNIDA “Center of Excellence” Grant

R01DA029630R01DA029630R01 DA021818R01 DA021818

R01 DA021818-01S1R01 DA021818-01S1R01DA034279-01R01DA034279-01

Affiliated with HealthSim, LLC, a small Affiliated with HealthSim, LLC, a small business that developed several business that developed several technology-based therapeutic technology-based therapeutic interventionsinterventions

AffiliationAffiliation

Implementation of Technology-Implementation of Technology-based Therapeutic Toolsbased Therapeutic Tools

• Technology-based therapeutic tools can allow for unprecedented levels of behavioral health monitoring, and provide therapeutic interventions that are as effective as science-based interventions delivered by highly trained clinicians, cost-effective, and highly acceptable to a wide variety of target populations.

•Evidence-based behavioral treatments are infrequently provided to individuals with substance use disorders.• Technology-based therapeutic tools may be deployed via

numerous flexible models and may enable entirely new models of delivering behavioral health care (e.g., treatment of substance use disorders).

•Technology-based therapeutic tools may be used along with more traditional models of intervention delivery (e.g., offered as an adjunct to substance abuse treatment).

• In a “clinician-extender” model, clinicians have the opportunity to extend their reach by offering these additional resources to their clients to support their clients outside of their direct interchange with their clinician (e.g., as a supplement to clinician-delivered therapy, pharmacological treatments, etc.)

Implementation of Technology-Implementation of Technology-based Therapeutic Toolsbased Therapeutic Tools

• Alternatively, these therapeutic tools may replace a portion of their typical interaction with clients with a technology-based intervention.

• This may allow a treatment program to treat more clients with the same number of clinicians and/or free-up clinicians to have more time to manage client crises or spend more time with clients in greatest need of more intensive care.

• These tools may also be offered as stand-alone interventions, which may be particularly relevant in rural or other settings where access to care may be limited or for individuals who do not wish to engage in traditional models of care.

Implementation of Technology-Implementation of Technology-based Therapeutic Toolsbased Therapeutic Tools

• Technology-based therapeutic tools targeting substance use and behavioral health may become increasingly important, as under U.S. healthcare reform initiatives, mental health and physical health care will be better integrated into patient medical homes (such as FQHCs).

• In this shifting paradigm of treatment delivery, clinicians in these settings will be asked to markedly increase behavioral health care offered in their care setting but may have limited time or specialty training in screening for/treating substance use disorders and other behavioral health issues.

• Technology-based assessments and interventions may be exceptionally useful in this evolving health care context.

Promise for Technology in Evolving Promise for Technology in Evolving HealthCare SystemHealthCare System

Examples of Various Models of Examples of Various Models of Deployment:Deployment:

The Therapeutic Education System (TES) The Therapeutic Education System (TES) as an Exemplaras an Exemplar

• Therapeutic Education System (TES)Therapeutic Education System (TES),, an interactive, behavioral therapy intervention for substance use disorders, grounded in the Community Reinforcement Approach (CRA) + Contingency Management Behavior Therapy + HIV Prevention

• Available on multiple platforms (including web-based desktop computers, Android smartphones, iPhones, iPads, etc.).

Partial Replacement Model in Specialty Partial Replacement Model in Specialty Addiction Treatment – Efficacy TrialAddiction Treatment – Efficacy Trial

• An NIDA-funded randomized, controlled trial (n=135) demonstrated An NIDA-funded randomized, controlled trial (n=135) demonstrated that TES was as efficacious as comparable CRA + CM therapy, that TES was as efficacious as comparable CRA + CM therapy, delivered by highly trained therapists, and better than standard delivered by highly trained therapists, and better than standard treatment in promoting objectively-verified drug abstinence among treatment in promoting objectively-verified drug abstinence among individuals in outpatient buprenorphine treatmentindividuals in outpatient buprenorphine treatment (Bickel, Marsch et (Bickel, Marsch et al., 2008).al., 2008).

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Continuous Abstinence fromOpioids and Cocaine

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• Another NIDA-funded trial (n=160; 12 month participation) Another NIDA-funded trial (n=160; 12 month participation) demonstrated that TES enhances opioid abstinence rates in demonstrated that TES enhances opioid abstinence rates in methadone maintenance treatment when a TES methadone maintenance treatment when a TES substitutessubstitutes for for a portion of standard counseling (Marsch, NIDA-supported)a portion of standard counseling (Marsch, NIDA-supported)

Partial Replacement Model in Addiction Partial Replacement Model in Addiction Specialty Treatment – Effectiveness TrialSpecialty Treatment – Effectiveness Trial

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Treatment as Usual (TAU)

TES with reduced TAU

Therapeutic Support Outside of Formal System of Care

Random assignment of 50 new intakes in MMT to: (1) standard care or (2) mobile phone/web-based psychosocial treatment for 12 weeks

The mobile intervention demonstrated good feasibility and acceptability: Participants typically maintained their mobile phones for the duration of the treatment, used the mobile program and reported high levels of acceptability of the program (e.g., how useful, how easy to use, etc.).

Qualitative data indicate that several participants reported using the mobile phone-based intervention during times of heightened risk for drug use.

Treatment Retention Mobile Psychosocial Treatment

(Chi-square = 4.7; p=.031)

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Mobile Intervention

Standard Treatment

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Objectively Measured Opioid Abstinence Mobile Psychosocial

Treatment(t (48) = -1.97; p= .055)

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Standard Treatment

MobileIntervention

Implementation Science Study- Integrating Treatment of SUDs

into Primary Care• Multiple PI with Dave Gustafson, Ph.D.

• Stepped Wedge Design evaluating a technology-based addiction/treatment recovery support system within FQHCs (SEVA)

• Focus on integrated care using personalized technology-based therapeutic support system available on mobile devices and care coordination with FQHC clinicians

• Focus on organizational and patient-level outcomes

A Focus on Translational Science A Focus on Translational Science ThroughoutThroughout

the Research & Development Process is the Research & Development Process is KeyKey

• Identifying the “community-friendliness” and dissemination potential at the outset of a intervention generation effort is critical.• Ensuring the science of behavior change and clinical considerations drive the use of technology and not letting the availability of technology drive the clinical application is critical.• Understanding the benefit to all stakeholders in a system of care is critical to successful dissemination, implementation and sustainability.

Center for Technology and Center for Technology and Behavioral HealthBehavioral Health

www.c4tbh.org