Potential roles for new communication technologies in treatment of addiction

Mobile, Remote, and Individual Focused: Comparing Breath Carbon Monoxide Readings and Abstinence Between Smartphone-Enabled and Stand-Alone Monitors

INTRODUCTION

Newly available, smartphone-enabled carbon monoxide (CO) monitors are lower in cost than traditional stand-alone monitors and represent a marked advancement for smoking research. New products are promising, but data are needed to compare breath CO readings between smartphone-enabled and stand-alone monitors. The purpose of this study was to (1) determine the agreement between the mobile iCO (Bedfont Scientific Ltd) with two other monitors from the same manufacturer (Micro+ pro and Micro+ basic) and (2) determine optimal, monitor-specific, cotinine-confirmed abstinence cutoff values.

METHODS

Adult (≥18) smokers (n = 26) and nonsmokers (n = 21) provided three breath CO samples (using three different monitors) in each of 10 sessions, and urine cotinine was measured for gold standard determination of abstinence. CO comparisons (N = 437) were analyzed using regression-based Bland-Altman Analysis of Agreement; receiver operating characteristics curves were used to determine optimal abstinence cutoffs.

RESULTS

Bland-Altman analyses indicated that the iCO monitor provided higher CO results than both Micro+ monitors. Sensitivity and specificity analyses showed that the optimal CO cutoff for determining abstinence was <3 ppm for the Micro+ pro (88% sensitivity, 93% specificity) and Micro+ basic (83% sensitivity, 98% specificity), but was higher for the iCO (<6 ppm; 73% sensitivity, 100% specificity).

CONCLUSIONS

Relative to both Micro+ monitors, the smartphone-enabled iCO provided systematically higher CO values and required a higher cutoff to reliably determine smoking abstinence. This does not indicate that CO values obtained using the iCO are not valid; instead, these results suggest that monitor-specific abstinence cutoffs are needed to ensure accurate bioverification of smoking status.

IMPLICATIONS

Results from this study indicate that CO values from the smartphone-enabled iCO should not be used interchangeably with the stand-alone Micro+ pro and Micro+ basic, particularly when lower CO values (<10 ppm) are critical (ie, determination of abstinence vs confirming smoking status for study inclusion). Optimal CO cutoffs recommended for determining abstinence on Micro+ and iCO monitors are at <3 and <6 ppm, respectively.

A systematic review of technology-based psychotherapeutic interventions for decreasing cannabis use in patients with psychosis

Persistent use of cannabis in persons with psychosis is associated with poor symptomatic and functional outcomes and increased healthcare costs. Face-to-face psychological interventions (e.g., Cognitive Behavioral Therapy- [CBT], Motivation Enhancement Therapy- [MET]) are widely used in treating problematic cannabis use. We aimed to comprehensively review the efficacy of technology-based psychological interventions (TBPIs) in decreasing cannabis use, the design of TBPIs, and TBPI-related preferences in individuals with psychosis. For the systematic review, we searched six major databases from their inception to November 27, 2019. We included empirical articles of quantitative and qualitative methodologies related to TBPIs in individuals with psychosis and cannabis misuse and used narrative synthesis to report results. Only eight articles were found showing that technology-based motivational and psycho-education interventions and cognitive enhancement therapy were minimally efficient in achieving cannabis abstinence or decreasing frequency of use. Qualitative exploratory methods and participatory action research were used to elicit patient and clinician preferences and TBPIs were tailored accordingly to improve cannabis use related outcomes. Research on TBPIs in individuals with psychosis and cannabis misuse is in its early phases. A significant research effort is needed for the development of adapted interventions for CUD to capitalize on the potential of web-based applications.

The utility and impact of the addiction comprehensive health enhancement support system (ACHESS) on substance abuse treatment adherence among youth in an intensive outpatient program

Youth experiencing substance use disorders often are susceptible to relapse because traditional support systems can be expensive, geographically dispersed, operated on limited schedules and lacking in peer support. The continuity of care offered via the digital Addiction Comprehensive Health Enhancement Support System (ACHESS) system holds promise in preventing relapse because of its portability and capability to foster virtually anytime/anywhere, cost-effective access to supportive interventions. The aim of this mixed-methods study was to evaluate the utility and impact of ACHESS on treatment adherence among youth with substance use disorders in an intensive outpatient program in the US Midwest. Data on 28 clients using ACHESS during 2016-17 were compared to retrospective data on 28 carefully-matched others treated without ACHESS during 2014-16. Fifty-four percent of the study group successfully completed treatment as opposed to 42.9% of those in the comparison group. Staff focus group findings highlighted how some features of ACHESS were effectively integrated into the care model and appeared to positively impact outcomes, while other elements of the application offered little utility. We suggest further study of ACHESS among larger samples of youth with substance use disorders in intensive outpatient programs to assess its efficacy in supporting adherence to treatment.

Information and Communication Technologies Interest, Access, and Use: Cross-Sectional Survey of a Community Sample of Urban, Predominantly Black Women

Background

Information and communication technologies (ICT) offer the potential for delivering health care interventions to low socioeconomic populations who often face barriers in accessing health care. However, most studies on ICT for health education and interventions have been conducted in clinical settings.

Objective

The aim of this study was to examine access to and use of mobile phones and computers, as well as interest in, using ICT for receipt of behavioral health information among a community sample of urban, predominately black, women with low socioeconomic status.

Methods

Participants (N=220) were recruited from hair salons and social service centers and completed audio-computer assisted self-interviews.

Results

The majority of the participants (212/220, 96.3%) reported use of a cell phone at least weekly, of which 89.1% (189/212) used smartphones and 62.3% (137/220) reported computer use at least weekly. Of the women included in the study, 51.9% (107/206) reported using a cell phone and 39.4% (74/188) reported using a computer to access health and/or safety information at least weekly. Approximately half of the women expressed an interest in receiving information about stress management (51%-56%) or alcohol and health (45%-46%) via ICT. Smartphone ownership was associated with younger age (odds ratio [OR] 0.92, 95% CI 0.87-0.97) and employment (OR 5.12, 95% CI 1.05-24.95). Accessing health and safety information weekly by phone was associated with younger age (OR 0.96, 95% CI 0.94-0.99) and inversely associated with higher income (OR 0.42, 95% CI 0.20-0.92).

Conclusions

Our findings suggest that ICT use, particularly smartphone use, is pervasive among predominantly black women with low socioeconomic status in urban, nonclinical settings. These results show that ICT is a promising modality for delivering health information to this population. Further exploration of the acceptability, feasibility, and effectiveness of using ICT to disseminate behavioral health education and intervention is warranted.

Using nominal group technique among clinical providers to identify barriers and prioritize solutions to scaling up opioid agonist therapies in Ukraine

BACKGROUND

Opioid agonist therapies (OAT) like methadone and buprenorphine maintenance treatment remain markedly under-scaled in Ukraine despite adequate funding. Clinicians and administrators were assembled as part of an implementation science strategy to scale-up OAT using the Network for Improvement of Addiction Treatment (NIATx) approach.

METHODS

Nominal Group Technique (NGT), a key ingredient of the NIATx toolkit, was directed by three trained coaches within a learning collaborative of 18 OAT clinicians and administrators to identify barriers to increase OAT capacity at the regional "oblast" level, develop solutions, and prioritize local change projects. NGT findings were supplemented from detailed notes collected during the NGT discussion.

RESULTS

The top three identified barriers included: (1) Strict regulations and inflexible policies dictating distribution and dispensing of OAT; (2) No systematic approach to assessing OAT needs on regional or local level; and (3) Limited funding and financing mechanisms combined with a lack of local/regional control over funding for OAT treatment services.

CONCLUSIONS

NGT provides a rapid strategy for individuals at multiple levels to work collaboratively to identify and address structural barriers to OAT scale-up. This technique creates a transparent process to address and prioritize complex issues. Targeting these priorities allowed leaders at the regional and national level to advocate collectively for approaches to minimize obstacles and create policies to improve OAT services.

Decision support in addiction: The development of an e-health tool to assess and prevent risk of fatal overdose. The ORION Project

BACKGROUND AND OBJECTIVE

The application of e-health technology to the field of substance use disorders is at a relatively early stage, and methodological quality is still variable. Few have explored the extent of utilization of communication technology in exploring risk perception by patients enrolled in substance abuse services. The Overdose RIsk InfOrmatioN (ORION) project is a European Commission funded programme, aimed to develop and pilot an e-health psycho-educational tool to provide information to drug using individuals about the risks of suffering a drug overdose.

METHODS

In this article, we report on phase 1 (risk estimation), phase 2 (design), and phase 3 (feasibility) of the ORION project.

RESULTS

The development of ORION e-health tool underlined the importance of an evidence-based intervention aimed in obtaining reliable evaluation of risk. The ORION tool supported a decision making process aimed at influencing the substance users' self-efficacy and the degree to which the substance users' understand risk factors. Therefore, its innovative power consisted in translating risks combination into a clear estimation for the user who will then appear more likely to be interested in his/her risk perception.

CONCLUSION

Exploratory field testing and validation confirmed the next stage of evaluation, namely, collection of routine patient samples in study clinics. The associations between risk perception of overdose, engagement with the ORION tool and willingness to alter overdose risk factors, in a clinical setting across various EU member states will further confirm the ORION tool's generalisability and effectiveness.

A Smartphone Application Supporting Recovery from Heroin Addiction: Perspectives of Patients and Providers in China, Taiwan, and the USA

Smartphone-based interventions are increasingly used to support self-monitoring, self-management, and treatment and medication compliance in order to improve overall functioning and well-being. In attempting to develop a smartphone application (S-Health) that assists heroin-dependent patients in recovery, a series of focus groups (72 patients, 22 providers) were conducted in China, Taiwan, and the USA to obtain their perspectives on its acceptance and potential adoption. Data were analyzed according to the Diffusion of Innovation (DOI) theory of characteristics important to the adoption of innovation. Important to Relative Advantage, USA participants cited S-Health's potential ability to overcome logistical barriers, while those in China and Taiwan valued its potential to supplement currently limited services. In terms of Compatibility, participants across sites reported recovery needs and goals that such an application could be helpful in supporting; however, its utility during strong craving was questioned in China and Taiwan. Important factors relevant to Complexity included concerns about smartphone access and familiarity, individualization of content, and particularly in China and Taiwan, participants wanted assurance of privacy and security. The study results suggest a general acceptance, but also indicate cultural variations in access to therapeutic and other social support systems, legal repercussions of substance use, societal perceptions of addiction, and the role of family and other social support in recovery. Taking these factors into consideration is likely to increase diffusion as well as effectiveness of these smartphone-based interventions.

A Pilot Test of a Mobile App for Drug Court Participants

The U.S. criminal justice system refers more people to substance abuse treatment than any other system. Low treatment completion rates and high relapse rates among addicted offenders highlight the need for better substance use disorder treatment and recovery tools. Mobile health applications (apps) may fill that need by providing continuous support. In this pilot test, 30 participants in a Massachusetts drug court program used A-CHESS, a mobile app for recovery support and relapse prevention, over a four-month period. Over the course of the study period, participants opened A-CHESS on average of 62% of the days that they had the app. Social networking tools were the most utilized services. The study results suggest that drug court participants will make regular use of a recovery support app.

This pilot study sought to find out if addicted offenders in a drug court program would use a mobile application to support and manage their recovery.

Identifying Drug (Cocaine) Intake Events from Acute Physiological Response in the Presence of Free-living Physical Activity

A variety of health and behavioral states can potentially be inferred from physiological measurements that can now be collected in the natural free-living environment. The major challenge, however, is to develop computational models for automated detection of health events that can work reliably in the natural field environment. In this paper, we develop a physiologically-informed model to automatically detect drug (cocaine) use events in the free-living environment of participants from their electrocardiogram (ECG) measurements. The key to reliably detecting drug use events in the field is to incorporate the knowledge of autonomic nervous system (ANS) behavior in the model development so as to decompose the activation effect of cocaine from the natural recovery behavior of the parasympathetic nervous system (after an episode of physical activity). We collect 89 days of data from 9 active drug users in two residential lab environments and 922 days of data from 42 active drug users in the field environment, for a total of 11,283 hours. We develop a model that tracks the natural recovery by the parasympathetic nervous system and then estimates the dampening caused to the recovery by the activation of the sympathetic nervous system due to cocaine. We develop efficient methods to screen and clean the ECG time series data and extract candidate windows to assess for potential drug use. We then apply our model on the recovery segments from these windows. Our model achieves 100% true positive rate while keeping the false positive rate to 0.87/day over (9+ hours/day of) lab data and to 1.13/day over (11+ hours/day of) field data.

New developments in behavioral treatments for substance use disorders

After decades of defining which behavioral treatments are effective for treating addictions, the focus has shifted to exploring how these treatments work, how best to disseminate and implement them in the community, and what underlying factors can be manipulated in order to increase the rates of treatment success. These pursuits have led to advances in our understanding of the mechanisms of treatment effects, the incorporation of technology into the delivery of current treatments and development of novel applications to support relapse prevention, as well as the inclusion of neurocognitive approaches to target the automatic and higher-order processes underlying addictive behaviors. Although such advances have the promise of leading to better treatments for more individuals, there is still much work required for these promises to be realized. The following review will highlight some of these recent developments and provide a glimpse into the future of behavioral treatments.

Technology-based interventions for the treatment and recovery management of substance use disorders: a JSAT special issue

A growing line of research has highlighted the promising role that interactive web and mobile technologies may play in improving the effectiveness, cost-effectiveness, and reach of efforts to assess, prevent, treat, and support the recovery management of substance use disorders and other risk behavior. Manuscripts in this special issue of the Journal of Substance Abuse Treatment focus on the application of technology to the delivery of interventions for the treatment and recovery management of substance use disorders. These manuscripts are intended to highlight the diversity and current state of the science of empirically-supported innovations in this area of intervention delivery. The included manuscripts range from experimental evaluations of a variety of types of technology-based interventions (brief interventions, behavior therapy, medication adherence tools, and HIV prevention interventions) and technology platforms (mobile, Web, videoconferencing, and telephone-based interactive voice response), for an array of populations (adults, adolescents, criminal justice populations, and post-partum women), in a number of different settings (addiction specialty treatment programs, schools, emergency rooms, and criminal justice settings). They additionally reflect a variety of experimental research designs, including those focused on the design, development, and clinical evaluation of these technology-based therapeutic tools, as well as research focused on models for their successful implementation and sustained use.

Advances in the psychosocial treatment of addiction: the role of technology in the delivery of evidence-based psychosocial treatment

The clinical community has a growing array of psychosocial interventions with a strong evidence base available for the treatment of SUDs. Considerable opportunity exists for leveraging technology in the delivery of evidence-based interventions to promote widespread reach and impact of evidence-based care. Data from this line of research to date are promising, and underscore the potential public health impact of technology-based therapeutic tools. To fully realize the potential of technology-delivered interventions, several areas of inquiry remain important. First, scientifically sound strategies should be explored to ensure technology-based interventions are optimally designed to produce maximal behavior change. Second, efficient and effective methods should be identified to integrate technology-based interventions into systems of care in a manner that is most responsive to the needs of individual users. Third, payment, privacy, and regulatory systems should be refined and extended to go beyond electronic medical records and telehealth/distance care models, and support the deployment of technology-based systems to enhance the quality, efficiency and cost-effectiveness of care. Fourth, the mechanisms underlying behavior change derived from technology-based treatments should be explicated, including new mechanisms that may be tapped via novel, technology-based tools. Such work will be critical in isolating mechanisms that are useful in predicting treatment response, and in ensuring that key ingredients are present in technology-based interventions as they are made widely available.