Efficacy of automated telephone continuing care following outpatient therapy for alcohol dependence

Interactive voice response (IVR) for tobacco cessation: a systematic review

OBJECTIVE

To summarise the uses, outcomes and implementation of interactive voice response (IVR) as a tobacco cessation intervention.

DATA SOURCES

A systematic review was conducted. Searches were performed on 3 May 2023. The strategies used keywords such as "tobacco cessation", "smoking reduction" and "interactive voice recording". Ovid MEDLINE ALL, Embase, APA PsycINFO, CINAHL, Cochrane Library and Web of Science were searched. Grey literature searches were also conducted.

STUDY SELECTION

Titles and abstracts were assessed by two independent reviewers. Studies were included if IVR was an intervention for tobacco cessation for adults; any outcomes were reported and study design was comparative. Any abstract included by either reviewer proceeded to full-text review. Full texts were reviewed by two independent reviewers.

DATA EXTRACTION

Data were independently extracted by two reviewers using a standardised form. The Risk of Bias Tool for Randomised Trials and the Risk of Bias in Non-Randomised Studies of Interventions tools were used to assess study quality.

DATA SYNTHESIS

Of 308 identified abstracts, 20 moderate-quality to low-quality studies were included. IVR was used standalone or adjunctly as a treatment, follow-up or risk-assessment tool across populations including general smokers, hospitalised patients, quitline users, perinatal women, patients with cancer and veteran smokers. Effective studies found that IVR was delivered more frequently with shorter follow-up times. Significant gaps in the literature include a lack of population diversity, limited implementation settings and delivery schedules, and limited patient and provider perspectives.

CONCLUSIONS

While the evidence is weak, IVR appears to be a promising intervention for tobacco cessation. However, pilot programmes and research addressing literature gaps are necessary.

Digital approaches to continuing care

PURPOSE OF REVIEW

To provide an update of studies on the effectiveness of digital and telephonic approaches to providing remote continuing care for substance use disorders.

RECENT FINDINGS

Effective continuing care can be provided via smartphone apps, text messaging, interactive voice response, and structured telephone counseling. The remote continuing care interventions with the strongest evidence of efficacy are the Addiction Comprehensive Health Enhancement Support System app and Telephone Monitoring and Counseling. Positive effects for these intervention on drinking outcomes in patients with alcohol use disorders were replicated in a recent randomized controlled study.

SUMMARY

Continuing care is widely believed to be an important component of treatment for substance use disorders, especially for sustaining positive outcomes. However, many individuals do not attend clinic-based continuing care, due to a variety of reasons, including competing work and family responsibilities, disabilities, transportation challenges, and recently the COVID-19 pandemic. Remote continuing care, provided via smartphone apps, text messaging, and various telephonic approaches, has been shown to be effective, and could be used to provide continuing care to patients who would otherwise not receive it. Further work is needed to determine how to effectively combine more traditional continuing care with newer digitized and telephonic approaches.

A holistic perspective on continuing care for substance use and dependence: Results and implications from an in-depth study of a Norwegian continuing care establishment

This article explores, systematically and in depth, users’ perceptions of participating in a Norwegian non-profit establishment that provides a continuing care programme for substance use and dependence. Identified results are linked to a holistic system perspective, where human, technology, and organisation (HTO), as well as external environment, are viewed as intertwined. At the establishment level, i.e., where the continuing care programme is delivered, we find that a clear holistic and user-oriented profile – comprising combined interventions including physical and social activities – can create a safe and stable environment that exerts a positive mental and physical influence on the user and thereby promotes abstinence from substances. However, our results suggest that the internal environment needs to connect more strongly with the external environment, such as a substance-free network, close family, and working life. At the establishment level, we conclude that there is a need to develop an explicit strategy and practice for collaborating with the external environment, built on systemisation and application of individual users’ insights into the design of the current interventions. Further research should explore the presence and absence of interplays between elements of human, technology, and organisation and the external environment, and the associated consequences for intervention processes and users’ health outcomes. Our holistic system model, empirically informed by data from a Norwegian context, can represent a starting point for such endeavours. The holistic system model also constitutes an original and novel contribution to research on continuing care interventions.

Telehealth for Substance Use Disorders: A Rapid Review for the 2021 U.S. Department of Veterans Affairs and U.S. Department of Defense Guidelines for Management of Substance Use Disorders

BACKGROUND

Approximately 20.4 million Americans met criteria for a substance use disorder (SUD) in 2019; however, only about 12.2% of persons with an SUD receive specialty care. Telehealth offers alternatives to traditional forms of substance use treatment.

PURPOSE

To synthesize recent findings on the efficacy of telehealth for SUDs.

DATA SOURCES

MEDLINE, Embase, PubMed, and the Cochrane Library from January 2015 through August 2021 (English language only).

STUDY SELECTION

Randomized controlled trials (RCTs) of adults with a diagnosis of SUD based on the Diagnostic and Statistical Manual of Mental Disorders or International Classification of Diseases.

DATA EXTRACTION

One investigator abstracted data and assessed study quality, and a second checked for accuracy.

DATA SYNTHESIS

This rapid review synthesized evidence from 17 RCTs. Evidence is very uncertain that telehealth provided as videoconference therapy (1 RCT) or web-based cognitive behavioral therapy (CBT) (3 RCTs) has similar effects to in-person therapy for improving abstinence from alcohol or cannabis. Low-strength evidence suggests that web-based CBT has similar effects for improving abstinence in multiple SUDs (2 RCTs). Low-strength evidence suggests that adding supportive text messaging to follow-up care improves abstinence and amount of alcohol per day (2 RCTs) but does not improve emergency department visits or frequency of consumption (2 RCTs). Enhanced telephone monitoring likely reduces readmissions for SUD detoxification compared with usual follow-up alone (1 RCT) but does not reduce days of substance use (low-strength evidence).

LIMITATION

Narrative synthesis, heterogeneity of telehealth interventions, no assessment of publication bias, and study methodology.

CONCLUSION

Evidence is very uncertain that telehealth is similar to in-person care for SUD outcomes. Limited evidence suggests some benefit of adding telehealth to usual SUD care.

PRIMARY FUNDING SOURCE

U.S. Department of Veterans Affairs Veterans Health Administration.

Impact of Continuing Care on Recovery From Substance Use Disorder

Continuing care is widely believed to be an important component of effective treatment for substance use disorder, particularly for those individuals with greater problem severity. The purpose of this review was to examine the research literature on continuing care for alcohol and drug use disorders, including studies that addressed efficacy, moderators, mechanisms of action, and economic impact. This narrative review first considered findings from prior reviews (published through 2014), followed by a more detailed examination of studies published more recently. The review found that research has generally supported the efficacy of continuing care for both adolescents and adults, but the picture is complex. Reviews find relatively small effects when results from individual studies are combined. However, continuing care of longer duration that includes more active efforts to keep patients engaged may produce more consistently positive results. Moreover, patients at higher risk for relapse may benefit to a greater degree from continuing care. Several newer approaches for the provision of continuing care show promise. These include incentives for abstinence and automated mobile health interventions to augment more conventional counselor-delivered interventions. Primary care can be used to provide medications for opioid and alcohol use disorders over extended periods, although more research is needed to determine the optimal mix of behavioral treatments and other psychosocial services in this setting. Regardless of the intervention selected for use, the status of most patients will change and evolve over time, and interventions need to include provisions to assess patients on a regular basis and to change or adapt treatment when warranted.

A randomized clinical trial of the Recovery Line among methadone treatment patients with ongoing illicit drug use

BACKGROUND

Relapse, drug use, and treatment dropout are common challenges facing patients receiving methadone. Though effective, multiple barriers to face-to-face counseling exist. The Recovery Line (RL), an automated, self-management system based on Cognitive Behavioral Therapy, is a phone-based adjunctive treatment that provides low cost, consistent delivery and immediate therapeutic availability 24 h a day.

METHODS

The current study was a 12-week randomized clinical efficacy trial of treatment-as-usual (TAU) only or RL + TAU for methadone treatment patients with continued illicit drug use (N = 82). Previous small trial phases evaluated methods to increase participant engagement and use of the RL and were incorporated into the current RL version. Primary outcomes were days of self-reported illicit drug abstinence and urine screens negative for illicit drugs.

RESULTS

Days of self-reported illicit drug abstinence improved for patients in RL + TAU but not in TAU. Percent of urine screens negative for illicit drugs, coping skills efficacy, and retention in methadone treatment did not differ by condition. Patients in RL + TAU attended more substance use disorder treatment and self-help group sessions during treatment than those in TAU. RL system use was generally low and more system use was correlated with abstinence outcomes.

CONCLUSIONS

Although the RL did not impact urine screen outcomes, it increases self-reported abstinence. Additional methods to increase patient engagement with automated, self-management systems for substance use disorder are needed.

Novel approaches to alcohol rehabilitation: Modification of stress-responsive brain regions through environmental enrichment

Relapse remains the most prominent hurdle to successful rehabilitation from alcoholism. The neural mechanisms underlying relapse are complex, but our understanding of the brain regions involved, the anatomical circuitry and the modulation of specific nuclei in the context of stress and cue-induced relapse have improved significantly in recent years. In particular, stress is now recognised as a significant trigger for relapse, adding to the well-established impact of chronic stress to escalate alcohol consumption. It is therefore unsurprising that the stress-responsive regions of the brain have also been implicated in alcohol relapse, such as the nucleus accumbens, amygdala and the hypothalamus. Environmental enrichment is a robust experimental paradigm which provides a non-pharmacological tool to alter stress response and, separately, alcohol-seeking behaviour and symptoms of withdrawal. In this review, we examine and consolidate the preclinical evidence that alcohol seeking behaviour and stress-induced relapse are modulated by environmental enrichment, and these are primarily mediated by modification of neural activity within the key nodes of the addiction circuitry. Finally, we discuss the limited clinical evidence that stress-reducing approaches such as mindfulness could potentially serve as adjunctive therapy in the treatment of alcoholism. This article is part of the Special Issue entitled "Neurobiology of Environmental Enrichment".

Interactive voice response interventions targeting behaviour change: a systematic literature review with meta-analysis and meta-regression

OBJECTIVE

A number of promising automated behaviour change interventions have been developed using advanced phone technology. This paper reviewed the effectiveness of interactive voice response (IVR)-based interventions designed to promote changes in specific health behaviours.

METHODS

A systematic literature review of papers published between January 1990 and September 2017 in MEDLINE, CINAHL, Embase, PsycINFO, SCOPUS and the Cochrane Central Register of Controlled Trials (CENTRAL) was conducted. From the total of 2546 papers identified, 15 randomised control trials (RCTs) met the eligibility criteria and were included in a random effects meta-analysis. Meta-regression analysis was used to explore whether behaviour change techniques (BCTs) that were used in the interventions were associated with intervention effectiveness.

RESULTS

Meta-analysis of 15 RCTs showed that IVR-based interventions had small but significant effects on promoting medication adherence (OR=1.527, 95% CI 1.207 to 1.932, k=9, p=0.000) and physical activity (Hedges' g=0.254, 95% CI 0.068 to 0.439, k=3, p=0.007). No effects were found for alcohol (Hedges' g=-0.077, 95% CI -0.162 to 0.007, k=4, p=0.073) or diet (Hedges' g=0.130, 95% CI -0.088 to 0.347, k=2, p=0.242). In the medication adherence studies, multivariable meta-regression including six BCTs explained 100% of the observed variance in effect size, but only the BCT 'information about health consequences' was significantly associated with effect size (β=0.690, SE=0.199, 95% CI 0.29 to 1.08, p=0.000).

CONCLUSION

IVR-based interventions appear promising in changing specific health behaviours, such as medication adherence and physical activity. However, more studies are needed to elucidate further the combination of active components of IVR interventions that make them effective and test their feasibility and effectiveness using robust designs and objective outcome measures.

Customized recommendations and reminder text messages for automated, computer-based treatment during methadone

The Recovery Line is an automated, computer-based intervention based on cognitive behavioral therapy (CBT) designed to provide real-time assistance by phone for patients in methadone maintenance. Preliminary efficacy findings were promising, however, as with other computer-based systems for substance use disorder, patient system use was less than recommended. Development and evaluation of system functions to increase patient engagement and use is needed. Thus, we conducted two randomized trials to evaluate system functions designed to increase patient use of the Recovery Line among methadone-maintained patients with continued illicit drug use. In Trial 1 (n = 60), patients received customized, system use recommendations or no recommendations on each Recovery Line call. Ratings of system usability were higher for customized recommendations (CR), but number of calls and total call time did not differ by condition. Trial 2 evaluated characteristics of reminder messages (message frame and reminder latency). Participants (N = 67) received gain- and loss-frame reminder messages, and were randomly assigned to immediate, short, or long term message latency. Although message framing had no effect, gender interacted with latency condition such that females did not differ by message latency, while males had significantly greater total contact time in the short latency conditions. Number of calls differed by condition over time such that the shorter latencies led to greater calls initially, but dissipated over time. Overall the study indicates that computer-based self-management systems can be adapted to increase patient engagement and use. (PsycINFO Database Record

Automated telephone interventions for problematic alcohol use in clinical and population samples: a randomized controlled trial

Objective

The primary objective was to evaluate 6-month outcomes for brief and extensive automated telephony interventions targeting problematic alcohol use, in comparison to an assessment-only control group. The secondary objective was to compare levels of problematic alcohol use (hazardous, harmful or probable dependence), gender and age among study participants from clinical psychiatric and addiction outpatient settings and from population-based telephone helpline users and Internet help-seeker samples.

Results

The Alcohol Use Disorders Identification Test (AUDIT) was used for screening of problematic alcohol use and 6-month follow-up assessment. A total of 248 of help-seekers with at least hazardous use (AUDIT scores of ≥ 6/≥ 8 for women/men) were recruited from clinical and general population settings. Minor recruitment group differences were identified with respect to AUDIT scores and age at baseline. One hundred and sixty persons (64.5%) did not complete the follow-up assessment. The attrition group had a higher proportion of probable dependence (71% vs. 56%; p = 0.025), and higher scores on the total AUDIT, and its subscales for alcohol consumption and alcohol problems. At follow up, within-group problem levels had declined across all three groups, but there were no significant between-group differences.

Trial registration ClinicalTrials.gov NCT01958359, Registered October 9, 2013. Retrospectively registered

Blending Face-to-Face and Internet-Based Interventions for the Treatment of Mental Disorders in Adults: Systematic Review

Background

Many studies have provided evidence for the effectiveness of Internet-based stand-alone interventions for mental disorders. A newer form of intervention combines the strengths of face-to-face (f2f) and Internet approaches (blended interventions).

Objective

The aim of this review was to provide an overview of (1) the different formats of blended treatments for adults, (2) the stage of treatment in which these are applied, (3) their objective in combining face-to-face and Internet-based approaches, and (4) their effectiveness.

Methods

Studies on blended concepts were identified through systematic searches in the MEDLINE, PsycINFO, Cochrane, and PubMed databases. Keywords included terms indicating face-to-face interventions (“inpatient,” “outpatient,” “face-to-face,” or “residential treatment”), which were combined with terms indicating Internet treatment (“internet,” “online,” or “web”) and terms indicating mental disorders (“mental health,” “depression,” “anxiety,” or “substance abuse”). We focused on three of the most common mental disorders (depression, anxiety, and substance abuse).

Results

We identified 64 publications describing 44 studies, 27 of which were randomized controlled trials (RCTs). Results suggest that, compared with stand-alone face-to-face therapy, blended therapy may save clinician time, lead to lower dropout rates and greater abstinence rates of patients with substance abuse, or help maintain initially achieved changes within psychotherapy in the long-term effects of inpatient therapy. However, there is a lack of comparative outcome studies investigating the superiority of the outcomes of blended treatments in comparison with classic face-to-face or Internet-based treatments, as well as of studies identifying the optimal ratio of face-to-face and Internet sessions.

Conclusions

Several studies have shown that, for common mental health disorders, blended interventions are feasible and can be more effective compared with no treatment controls. However, more RCTs on effectiveness and cost-effectiveness of blended treatments, especially compared with nonblended treatments are necessary.

Effect of short-term heart rate variability biofeedback on long-term abstinence in alcohol dependent patients - a one-year follow-up

BACKGROUND

A randomized controlled study (RCT) recently showed that short-term heart rate variability (HRV) biofeedback in addition to standard rehabilitation care for alcohol dependence can reduce craving, anxiety and improve cardiovascular autonomic function. In this one-year follow-up study we aimed to explore whether completion of 2-week HRV-Biofeedback training is associated with long-term abstinence. Furthermore, we sought to identify potential predictors of post-treatment abstinence.

METHODS

We conducted a survey on abstinence in patients with alcohol dependence 1 year after completion of an RCT comparing HRV-biofeedback in addition to inpatient rehabilitation treatment alone (controls). Abstinence rates were compared and analysed for association with demographic data as well as psychometric and autonomic cardiac assessment before and after completion of the biofeedback training using bivariate and multivariate regression analyses.

RESULTS

Out of 48 patients who participated in the RCT, 27 patients (9 females, ages 42.9 ± 8.6, mean ± SD) completed our one-year follow-up. When including in the analysis only patients who completed follow-up, the rate of abstinence tended to be higher in patients who underwent HRV-biofeedback 1 year earlier compared to those who received rehabilitative treatment alone (66.7% vs 50%, p = ns). This non-significant trend was also observed in the intention-to-treat analysis where patients who did not participate in the follow-up were assumed to have relapsed (46,7% biofeedback vs. 33.3% controls, p = ns). Neither cardiac autonomic function nor psychometric variables were associated with abstinence 1 year after HRV-biofeedback.

CONCLUSION

Our follow-up study provide a first indication of possible increase in long-term abstinence after HRV-biofeedback for alcohol dependence in addition to rehabilitation.

TRIAL REGISTRATION

The original randomized controlled trial was registered in the German Clinical Trials Register ( DRKS00004618 ). This one-year follow-up survey has not been registered.

Treatment of Cannabis Use Disorder: Current Science and Future Outlook

Cannabis is the most commonly used illicit substance in the United States. Rates of cannabis use and cannabis use disorder (CUD) have increased in the past decade, paralleling changes in the legal and political climate favoring legalization. Almost 20 million people 12 years or older report past-month cannabis use, and 8 million report daily or near-daily use. Concurrently, the perception that cannabis use poses a significant risk of negative consequences has decreased. Contrary to this perception, heavy cannabis use is associated with cognitive impairment, increased risk for psychotic disorders and other mental health problems, lower education attainment, and unemployment. Clinical trials of various treatments for CUD have likewise increased, focusing primarily on psychotherapy treatments, specifically motivational enhancement therapy, cognitive behavioral therapy, and contingency management. Their findings suggest that a combination of these three modalities produces the best abstinence outcomes, although abstinence rates remain modest and decline after treatment. More recently, pharmacotherapy trials have been conducted as adjunctive interventions to psychosocial treatment. N-acetylcysteine and gabapentin are two of the most promising medications, although no pharmacologic treatment has emerged as clearly efficacious. In this review, we provide a detailed summary of clinical trials that evaluated psychotherapy and pharmacotherapy for treating CUD and discuss emerging areas of clinical research and cannabis-specific barriers to treatment.

A Randomized Controlled Trial of Brief Intervention by Interactive Voice Response

Aims

To determine the effect of an Interactive Voice Response (IVR) brief intervention (BI) to reduce alcohol consumption among adults seeking primary care.

Methods

Patients (N = 1855) with unhealthy drinking were recruited from eight academic internal medicine and family medicine clinics and randomized to IVR-BI (n = 938) versus No IVR-BI control (n = 917). Daily alcohol consumption was assessed at baseline, 3- and 6-months using the Timeline Followback.

Results

The IVR-BI was completed by 95% of the 938 patients randomized to that condition, and 62% of them indicated a willingness to consider a change in their drinking. Participants in both conditions significantly reduced consumption over time, but changes were not different between groups. Regardless of condition, participants with alcohol use disorder (AUD) showed significant decreases in drinking outcomes. No significant changes were observed in patients without AUD, regardless of condition.

Conclusion

Although the IVR intervention was well accepted by patients, there was no evidence that IVR-BI was superior to No IVR-BI for reducing drinking in the subsequent 6 months. Because both the design and the intervention tested were novel, we cannot say definitively why this particular eHealth treatment lacked efficacy. It could be useful to evaluate the effect of the pre-randomization assessment alone on change in drinking. The high treatment engagement rate and successful implementation protocol are strengths, and can be adopted for future trials.

Short summary

We examined the efficacy of a novel BI for patient self-administration by automated telephone. Alcohol consumption decreased over time but there were no between-group changes in consumption. Regardless of treatment condition, participants with alcohol use disorder (AUD) showed significant reduction in drinking but participants without AUD showed no change.

Automated telephone communication systems for preventive healthcare and management of long-term conditions

BACKGROUND

Automated telephone communication systems (ATCS) can deliver voice messages and collect health-related information from patients using either their telephone's touch-tone keypad or voice recognition software. ATCS can supplement or replace telephone contact between health professionals and patients. There are four different types of ATCS: unidirectional (one-way, non-interactive voice communication), interactive voice response (IVR) systems, ATCS with additional functions such as access to an expert to request advice (ATCS Plus) and multimodal ATCS, where the calls are delivered as part of a multicomponent intervention.

OBJECTIVES

To assess the effects of ATCS for preventing disease and managing long-term conditions on behavioural change, clinical, process, cognitive, patient-centred and adverse outcomes.

SEARCH METHODS

We searched 10 electronic databases (the Cochrane Central Register of Controlled Trials; MEDLINE; Embase; PsycINFO; CINAHL; Global Health; WHOLIS; LILACS; Web of Science; and ASSIA); three grey literature sources (Dissertation Abstracts, Index to Theses, Australasian Digital Theses); and two trial registries (www.controlled-trials.com; www.clinicaltrials.gov) for papers published between 1980 and June 2015.

SELECTION CRITERIA

Randomised, cluster- and quasi-randomised trials, interrupted time series and controlled before-and-after studies comparing ATCS interventions, with any control or another ATCS type were eligible for inclusion. Studies in all settings, for all consumers/carers, in any preventive healthcare or long term condition management role were eligible.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods to select and extract data and to appraise eligible studies.

MAIN RESULTS

We included 132 trials (N = 4,669,689). Studies spanned across several clinical areas, assessing many comparisons based on evaluation of different ATCS types and variable comparison groups. Forty-one studies evaluated ATCS for delivering preventive healthcare, 84 for managing long-term conditions, and seven studies for appointment reminders. We downgraded our certainty in the evidence primarily because of the risk of bias for many outcomes. We judged the risk of bias arising from allocation processes to be low for just over half the studies and unclear for the remainder. We considered most studies to be at unclear risk of performance or detection bias due to blinding, while only 16% of studies were at low risk. We generally judged the risk of bias due to missing data and selective outcome reporting to be unclear.For preventive healthcare, ATCS (ATCS Plus, IVR, unidirectional) probably increase immunisation uptake in children (risk ratio (RR) 1.25, 95% confidence interval (CI) 1.18 to 1.32; 5 studies, N = 10,454; moderate certainty) and to a lesser extent in adolescents (RR 1.06, 95% CI 1.02 to 1.11; 2 studies, N = 5725; moderate certainty). The effects of ATCS in adults are unclear (RR 2.18, 95% CI 0.53 to 9.02; 2 studies, N = 1743; very low certainty).For screening, multimodal ATCS increase uptake of screening for breast cancer (RR 2.17, 95% CI 1.55 to 3.04; 2 studies, N = 462; high certainty) and colorectal cancer (CRC) (RR 2.19, 95% CI 1.88 to 2.55; 3 studies, N = 1013; high certainty) versus usual care. It may also increase osteoporosis screening. ATCS Plus interventions probably slightly increase cervical cancer screening (moderate certainty), but effects on osteoporosis screening are uncertain. IVR systems probably increase CRC screening at 6 months (RR 1.36, 95% CI 1.25 to 1.48; 2 studies, N = 16,915; moderate certainty) but not at 9 to 12 months, with probably little or no effect of IVR (RR 1.05, 95% CI 0.99, 1.11; 2 studies, 2599 participants; moderate certainty) or unidirectional ATCS on breast cancer screening.Appointment reminders delivered through IVR or unidirectional ATCS may improve attendance rates compared with no calls (low certainty). For long-term management, medication or laboratory test adherence provided the most general evidence across conditions (25 studies, data not combined). Multimodal ATCS versus usual care showed conflicting effects (positive and uncertain) on medication adherence. ATCS Plus probably slightly (versus control; moderate certainty) or probably (versus usual care; moderate certainty) improves medication adherence but may have little effect on adherence to tests (versus control). IVR probably slightly improves medication adherence versus control (moderate certainty). Compared with usual care, IVR probably improves test adherence and slightly increases medication adherence up to six months but has little or no effect at longer time points (moderate certainty). Unidirectional ATCS, compared with control, may have little effect or slightly improve medication adherence (low certainty). The evidence suggested little or no consistent effect of any ATCS type on clinical outcomes (blood pressure control, blood lipids, asthma control, therapeutic coverage) related to adherence, but only a small number of studies contributed clinical outcome data.The above results focus on areas with the most general findings across conditions. In condition-specific areas, the effects of ATCS varied, including by the type of ATCS intervention in use.Multimodal ATCS probably decrease both cancer pain and chronic pain as well as depression (moderate certainty), but other ATCS types were less effective. Depending on the type of intervention, ATCS may have small effects on outcomes for physical activity, weight management, alcohol consumption, and diabetes mellitus. ATCS have little or no effect on outcomes related to heart failure, hypertension, mental health or smoking cessation, and there is insufficient evidence to determine their effects for preventing alcohol/substance misuse or managing illicit drug addiction, asthma, chronic obstructive pulmonary disease, HIV/AIDS, hypercholesterolaemia, obstructive sleep apnoea, spinal cord dysfunction or psychological stress in carers.Only four trials (3%) reported adverse events, and it was unclear whether these were related to the interventions.

AUTHORS' CONCLUSIONS

ATCS interventions can change patients' health behaviours, improve clinical outcomes and increase healthcare uptake with positive effects in several important areas including immunisation, screening, appointment attendance, and adherence to medications or tests. The decision to integrate ATCS interventions in routine healthcare delivery should reflect variations in the certainty of the evidence available and the size of effects across different conditions, together with the varied nature of ATCS interventions assessed. Future research should investigate both the content of ATCS interventions and the mode of delivery; users' experiences, particularly with regard to acceptability; and clarify which ATCS types are most effective and cost-effective.

Trends in telemedicine use in addiction treatment

Introduction

Telemedicine use in addiction treatment and recovery services is limited. Yet, because it removes barriers of time and distance, telemedicine offers great potential for enhancing treatment and recovery for people with substance use disorders (SUDs). Telemedicine also offers clinicians ways to increase contact with SUD patients during and after treatment.

Case description

A project conducted from February 2013 to June 2014 investigated the adoption of telemedicine services among purchasers of addiction treatment in five states and one county. The project assessed purchasers’ interest in and perceived facilitators and barriers to implementing one or more of the following telemedicine modalities: telephone-based care, web-based screening, web-based treatment, videoconferencing, smartphone mobile applications (apps), and virtual worlds.

Discussion and evaluation

Purchasers expressed the most interest in implementing videoconferencing and smartphone mobile devices. The anticipated facilitators for implementing a telemedicine app included funding available to pay for the telemedicine service, local examples of success, influential champions at the payer and treatment agencies, and meeting a pressing need. The greatest barriers identified were: costs associated with implementation, lack of reimbursement for telemedicine services, providers’ unfamiliarity with technology, lack of implementation models, and confidentiality regulations. This paper discusses why the project participants selected or rejected different telemedicine modalities and the policy implications that purchasers and regulators of addiction treatment services should consider for expanding their use of telemedicine.

Conclusions

This analysis provides initial observations into how telemedicine is being implemented in addiction services in five states and one county. The project demonstrated that despite the considerable interest in telemedicine, implementation challenges exist. Future studies should broaden the sample analyzed and track technology implementation longitudinally to help the research and practitioner communities develop a greater understanding of technology implementation trends and practices.