grand rounds. tbi. june, 2016 final tb

Tobie Barton, MA

Using Technology to Enhance Addiction Treatment

Neither the NFAR ATTC nor the trainer presenting today endorse or promote the use of any specific technology application mentioned in this training. All technology

applications are discussed as examples of available resources only. The NFAR ATTC does not guarantee that any of the

technologies discussed meets federal, state, or local regulations. Please consult with an attorney, your institution’s HIPAA compliance officer, and/or your local licensing agency

before utilizing any technology for clinical or recovery support purposes.

GOAL: to expose practitioners to technology-based interventions that complement behavioral health treatment and recovery services.

Outline

• Definition of technology-based interventions • Discuss use of technology in behavioral health

by practitioners and clients • Research-based technologies for treating SUDs • Resources • Summary

develop and strengthen the workforce that provides

addictions treatment and recovery support services

Purpose of the ATTCs (SAMHSA FUNDED)

ATTC Network Coordinating Office

10 Regional Centers

2012 – 2017

National Frontier & Rural

ATTC

National American Indian & Alaska Native

ATTC National SBIRT ATTC

National Hispanic & Latino

ATTC

4 ATTC National Focus Centers

Serve as the national subject expert and key resource to PROMOTE the awareness and implementation of telehealth technologies

“The successful practitioner of the next century will need to master technologies in order to effectively manage the care of their patients. As the microscope allowed practitioners in an earlier era to see the microbial agents of infection… the computer will also change the patient. As patients arrive with better and more information, health care professionals may find themselves increasingly in the role of counselor and consultant”

(O’Neil & Pew, 1998, p. 18)

People are using technology

Use of online and mobile technologies is increasingly ubiquitous across age,

race/ethnicity, and geography.

Consumers rely on Internet and smartphone-based tools for health information and

tracking.

Use of technology devices to deliver some aspects of psychotherapy or behavioral

treatment directly to patients via interaction with a web-based program.

(Carroll & Rounsaville, 2010)

Technology-Based Interventions

DEFINITION

Technology can be applied to both the pharmacotherapy treatment of

substance use disorders and psychosocial treatments.

Continuum of intervention, treatment, and recovery services

(Gainsbury & Blaszczynski, 2011)

Technology has enormous potential to provide a highly influential tool to

assist individuals in overcoming their addictions that

appropriately meets individuals’

expectations and needs.

Technology-based interventions have the ability to:

• lower consumer threshold for initiation of treatment

• refer at-risk individuals to in-person treatment

Clarke & Yarbourough, 2013

Technology-Based Intervention BENEFITS

• Serve as adjuncts to standard treatment • Save clinician time • Extend clinician expertise • Integrate other EBPs to provide additional

services to clients with co-morbid conditions • Provide access to web-based smoking

cessations programs or other health-related conditions

(Carroll & Rounsaville, 2010)

Encouraging evidence suggests positive

treatment outcomes

Bickel et al., 2008; Carroll & Rounsaville, 2010)

Substance use is a public health crisis in the rural United States and has been identified as one of the

top 10 priorities Rural Healthy People 2020

Technology has the potential to narrow the “access gap” to behavioral health

interventions and reduce health disparities in disadvantaged and hard-to-reach populations

Gibbons et al., 2011

Majority (90%) of persons with SUDs have not entered

treatment 20.2 million in 2013

(NSDUH, 2013)

Technology can address barriers to accessing treatment

Workforce & Technology

Use of technology by clinicians

• is increasing

• presents unique clinical/business dilemmas

(NBCC Policy, 2013)

DIGITAL TYPES

Digital Immigrants

(Zur, 2012; Prensky, 2001)

Digital Immigrants … people born before 1964 and who grew up in

a pre-computer world

(Zur & Zur, 2011)

‘native speakers’ of the digital language of computers, cell phones, video games,

and the Internet (Zur, 2012; Prensky, 2001)

Like all immigrants… as Digital Immigrants learn to adapt to their environment, they retain, to some degree, their ‘accent’ …

What is your digital accent?

(Prensky, 2001)

Digital Immigrants Digital Natives • Prefer to talk in-person or

on the phone • Prefer to talk via chat, text, or

messaging thru social media • Don’t text or only sparingly • Text more than call • Prefer synchronous

communication • Prefer asynchronous

communication • Prefer receiving information

slowly: linearly, logically, & sequentially

• Prefer receiving information quickly & simultaneously from multiple multimedia & other sources

• Prefer reading text (i.e., books) on processing pictures, sounds & video

• Prefer processing /interacting with pictures, graphics, sounds & video before text

Comparison of Digital Types

(Zur & Zur, 2011; Rosen, 2010; Prennsky, 2001)

Other Digital Types

Ways to sort people other than age • Attitudes • Comprehension • Relationships • Practices • Comfort with technology

(Feeney, 2010; Toledo, 2007)

DIGITAL DIVIDE

Younger clinicians and those with smartphones found a PTSD app

more usable than older clinicians and those without smartphones.

These variables predicted clinicians’ intentions to use the app in treatment with veterans.

(Kuhn et al., 2014)

ORGANIZATIONS

Agencies with annual operating budgets of greater than $10 million reported significantly fewer barriers

(Ramsey et al., 2016 )

than those with budgets of $10 million or less

Agencies serving more than 3,000 clients per year reported significantly fewer

implementation barriers than those serving fewer clients annually.

(Ramsey et al., 2016)

Provider resistance and lack of openness to use technology-based care approaches

may be multifaceted…

• limited awareness of established benefits • an organizational climate characterized by

skepticism or unwillingness to try new approaches

• a demand for more research on the effectiveness and safety of these tools

(Ramsey et al., 2016)

a substantial portion of providers reported a lack

of basic knowledge about how technologies

can be used for behavioral health care

(Ramsey et al., 2016)

How will technologies change how the provider does business?

(Muench, 2015)

Recommendations

STAFF

The fit of any innovation with the attitudes and values of the agency and providers

adopting it is critical to the acceptability, efficiency, and effectiveness of the

implementation process. (Ramsey et al., 2016)

The most pressing staff concern: Is this better and easier than what I am

currently using/doing?

(Muench, 2015)

Integration requires an understanding of staff members’ degree of comfort with technology

(Muench, 2015)

and the time burden

(Campbell et al., 2012)

and the selection of appropriate training to increase staff confidence in navigating

potentially foreign technologies

Most providers will need to re-structure operations to understand how technology will

impact clinician workload… • accept e-mails or phone messages on work phones • develop on-call lists or use peer specialists to

manage alerts/requests for help and client check-ins if not automated

(Muench, 2015)

For example, Muench and colleagues (2013) found that although 80% of providers want to be alerted

if their client is at risk of relapse, only 8% would want an immediate mobile alert.

(Muench, 2015)

debunk fears cited by providers regarding the use of technologies

compromised client care and job replacement (Ramsey et al., 2016)

Clinician Extenders

(Ramsey et al., 2016; Marsch, 2011)

allow providers to work at their highest level of

training and focus on the

most high-need client issues

Digital Health Technologies will not replace clinical staff but will enhance their work

Digital Health Technologies will not replace clinical staff but will enhance their work

Digital Health Technologies will not replace clinical staff but will enhance their work

Digital Health Technologies will not replace clinical staff but will enhance their work

Digital Health Technologies will not replace clinical staff but will enhance their work

• the ability of technology to reach enormous numbers of people (it is undeniable)

• the use of technology for treatment and recovery support offers the possibility of better care, reduced stigma, and broader reach

It’s imperative that professionals understand…

Since patients are likely to use

technologies, it may be helpful for

practitioners to understand the

phenomena of technologies, even

if they struggle with technologies

or are doubtful about their utility.

(Myers et al., 2012)

Client Acceptability of Technologies

What do we know about clients? Survey of 8 urban drug treatment clinics

in Baltimore (266 patients)

Clients had access to: • Mobile Phone - 91% • Text Messaging - 79% • Internet/Email/Computer - 39-45%

(McClure, Acquanta, Harding, & Stitzer, 2012)

(Moore et al., 2011; Muench et al., 2013; Muench, 2015)

Current evidence demonstrates that clients use and are interested in using technologies as

part of their treatment or continuing support.

Customer Demand

57

People with common health care concerns find each other by website

and blog search engines, and through mobile apps and Twitter tags

(Marri, et al., 2014)

Clients’ Issues Regarding Using Technologies for Treatment and Recovery

• Make sure clients understand: ‒ technologies that may monitor them and

their locations ‒ how to use the technologies ‒ what to do in the case of emergencies and

service problems

(Muench, 2015)

Other Technology Issues with Clients • Many clients change phone numbers or experience

disruptions in their phone service which interferes with use of technology-based interventions.

• Approximately 20% of participants had their phone service turned off at least once over the course of a 5-week study as a result of nonpayment.

• Clients sharing phones with family members/others raises issues with privacy/security and confidentiality.

• Warn clients about technology failures and that their messages might not go through.

• Determine percentage of clients that have access to smart phones before implementing technology.

(Muench, 2012; 2015)

Given the promise of these computerized interventions, we feel encouraged that technology has become mature

enough to capture at least some aspect of psychotherapy. (Campbell & Luo)

Videoconferencing

The research base for telemental health-related interventions is more

than 50 years old.

(Richardson et al., 2009; Wittson et al., 1961; Wittson & Benschoter, 1972)

Systematic Review of Videoconferencing Psychotherapy

• Patients and providers perceived a strong therapeutic alliance over videoconferencing

• Studies that compared videoconferencing to in-person psychotherapy reported similar satisfaction levels between the conditions

• High levels of satisfaction and acceptance with telemental health have been consistently demonstrated among patients across a variety of clinical populations and for a broad range of services

(Backhaus et al., 2012) (Backhaus et al.2012)

Studies on Videoconferencing in Addiction Treatment

• Opioid Treatment-group counseling (King et al., 2009; King et al., 2014)

• Alcohol Treatment (Postel et al., 2005)

• Alcohol Treatment (Frueh et al., 2005)

• Teleconferencing Supervision (TCS) - MI (Smith et al., 2012)

(Backhaus et al., 2012)

eGetgoing uses videoconferencing

technology to deliver therapy to patients with

opioid dependence

Leading Technologies in Addiction Treatment

Technology-Based Interventions have been validated recently through funded

research studies:

TES, CBT4CBT, and ACHESS

Therapeutic Education System (TES)

An interactive, web-based psychosocial intervention for SUDs, grounded in:

Community Reinforcement Approach (CRA) + Contingency Management Behavior Therapy +

HIV Prevention

What Do People Say About TES?

72

CBT4CBT • A computer-based version of cognitive

behavioral therapy (CBT) • Designed to use in conjunction with clinical

care for current substance users • Multimedia presentation, based on

elementary level computer learning games, requires no previous computer experience

(Carroll et al., 2008; 2009; 2011; 2014; Olmstead, Ostrow, & Carroll, 2010)

http://www.cbt4cbt.com

ACHESS • Monitoring and alerts

• Reminders

• Autonomous motivation

• Assertive outreach

• Care coordination

• Medication reminders

• Peer & family support

• Relaxation

• Locations tracking

• Contact with professionals

• Information

Research Studies Using Texting • weight/obesity

(Gerber et al., 2009)

• diabetes (Franklin et al., 2006; Hanauer et al., 2009)

• asthma (Neville et al., 2002)

• tobacco dependence (Rodgers et al., 2005)

• sexual health (Leach-Lemens, 2009; Lim et al., 2008)

(Ingersoll et al., 2014)

• Used youth to craft language • Daily self-monitoring texts, a daily wellness recovery tip,

and substance abuse education and social support resource information on weekends

• Compared with standard aftercare, texting reduced relapse risk and promoted recovery engagement

Youth-Focused Texting

Case Study

(Gonzales et al., 2014)

TEXTING - Portable Contingency Management

1-3 text reminders about sending video

of breathalyzer results

• Vouchers earned for negative BAC tests • Thank you texts (Alessi & Petry, 2012)

TELEPHONE RECOVERY SUPPORT

• Peer-based, volunteer supported • Check-in, issue identifier, make

connections • Builds recovery capital • Standard 12-week program, but

unlimited • Free service to anyone • Not limited by geography, more

flexible

Telephone Continuing Care for SUDs • Telephone Monitoring and Adaptive Counseling (TMAC)

(McKay, 2004)

• Focused Continuing Care (FFC) (Betty Ford Clinic)

• Telephone Enhancement of Long Term Engagement (TELE) (Hubbard et al., 2007)

• Individual Therapeutic Brief Phone Contact (ITBPC) (Kaminer & Napolitano, 2004) ADOLESCENTS

• Telephone Case Monitoring (TCM) (McKellar et al., 2012)

• Telephone Continuing Care (TCC) (Godley et al., 2010)

Social media networks facilitate highly interactive online communities where individuals share, co-

create, discuss and modify user-generated content

Apps provide: • Information • Motivation • Support • Feedback

61% of patients reported using mobile applications

Dahne & Lejuez, 2015

Few evidence-based apps exist, in contrast to the thousands of apps available that are not evidence-based or research-informed.

Majeed-Ariss, et al., 2015

8 Strategies for Evaluating/Selecting Apps 1) Review the scientific literature 2) Search app clearinghouse websites 3) Search app stores 4) Review app descriptions, user ratings, and reviews 5) Conduct a social media query within professional

and, if available, patient networks 6) Pilot the apps 7) Elicit feedback from patients 8) Understand free apps have more privacy/security

risks (Boudreaux et al., 2014; Frank, 2015)

Providers Using Telehealth Technologies

• Operation PAR in Florida – Web-videoconferencing and email

• Tarzana Treatment Centers in California – Web-video conferencing and email

• Heartview Foundation in North Dakota – Web-based recovery support/private social network-

Ning

• Face It Together in South Dakota – Telephone Recovery Support

(NFAR Data, 2015)

or like this…

Clients and consumers are already embracing TBIs and creating a patient-

centered health movement.

As the research has repeatedly revealed, TBIs are most effective when combined with human support, reinforcing how

providers will remain the foundation of care for those seeking help.

(Muench, 2015)

How do I remember all of this…..

SUDTECH.ORG

Center for Technology and Behavioral Health

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Technology-Based Supervision: Extending the Reach of

Clinical Supervisors

New Curriculum