Telemedicine interventions for substance-use disorder: a literature review

A randomised trial of real-time video counselling for smoking cessation among rural and remote residents

INTRODUCTION

Despite its reach, very limited evidence exists on the effectiveness of real-time video counselling for smoking cessation (e.g. via Skype). This study compared the effectiveness of real-time video counselling for smoking cessation to (a) telephone counselling; and (b) a control among rural and remote residents.

METHODS

Between 25 May 2017 and 3 March 2020, a three-arm, parallel group, randomised trial, randomised 1244 rural and remote residents from New South Wales, Australia who smoked tobacco to: video counselling (4-6 video sessions); telephone counselling (4-6 telephone calls); or a control (printed materials). The primary outcome was 7-day point prevalence abstinence at 13 months post-baseline. Secondary outcomes were point prevalence abstinence at 4 months and 7-months post-baseline, prolonged abstinence, quit attempts, anxiety and depression.

RESULTS

For the primary outcome of 7-day point prevalence abstinence at 13 months post-baseline, there was no significant difference between video counselling and telephone counselling (14.6% vs 13.3%; (OR = 1.11, 95% CI (0.75-1.64), P = 0.61) or video counselling and control (14.6% vs 13.9%; (OR = 1.06, 95% CI (0.71-1.57), P = 0.77). For secondary outcomes at 4 months post-baseline, the video counselling group had significantly higher odds than the control of 7-day point prevalence abstinence (14.3% vs 8.2%; OR = 1.88, 95% CI (1.20-2.95), P = 0.006) and 3-month prolonged abstinence (4.9% vs 2.2%; OR = 2.28, 95% CI (1.03-5.07), P = 0.04). There were no significant differences for other secondary outcomes.

DISCUSSION

Video counselling increased smoking cessation in the short-term compared to a control although strategies to improve its long-term effectiveness are needed.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, https://www.anzctr.org.au ACTRN12617000514303.

Assessing Feasibility and Barriers to Implementing a Family-Based Intervention in Opioid Treatment Programs

Families Facing the Future (FFF) is an intervention designed specifically for families with a parent in methadone treatment. FFF is unique because it addresses prevention for children and recovery for parents in a single intervention. The primary goals of the program are to prevent parents' relapse, help them cope with relapse if it occurs, and teach parenting skills in order to reduce the likelihood of substance use among their children. FFF has been implemented as an adjunct to treatment in several Opioid Treatment Programs, but has not been widely adopted due to various implementation barriers. The aims of this study, therefore, were to (1) assess the perceived feasibility of implementing FFF and (2) identify/describe barriers to implementing FFF. An online survey was used to assess implementation feasibility, while individual qualitative interviews were conducted to explore specific barriers to implementation. Data collection from a total of 40 participants (20 patients and 20 providers) was conducted from August 2022 to October 2022 at two Opioid Treatment Programs in Florida. Analyses revealed high feasibility scores, indicating that FFF was viewed by both patients and providers as a practical intervention to implement. Despite strong perceived feasibility of the intervention, qualitative findings identified several implementation barriers with respect to difficulty attending parent training sessions, aversion to in-home visits, and lack of funding (inability to provide patient incentives/bill insurance). This study provides evidence that while patients and providers view FFF as having high feasibility, significant implementation barriers exist. This paper fills a void in the literature by informing if and which modifications might be necessary to facilitate wider adoption of FFF in real-world Opioid Treatment Program settings.

Patterns & Predictors of Telehealth Utilization Among Individuals Who Use Substances: Implications for the Future of Virtual Behavioral Health Services

Telehealth dramatically expanded during the COVID-19 pandemic, but there remains a dearth of literature examining how this service modality is utilized by individuals who use substances. This study examined patterns of telehealth use and individual level sources of variation among clients receiving counseling in an outpatient substance use clinic in early 2021 (n = 370). Univariate statistics described the percentage of counseling visits delivered via telehealth. OLS regression explored individual level demographic and clinical characteristics that predicted greater telehealth utilization. Overall, more than two thirds (86%) of counseling visits were conducted via telehealth. Individuals with unstable housing or with a co-occurring serious mental illness used less telehealth. Findings suggest that while telehealth appears to be an acceptable way to deliver substance use counseling, patterns varied among vulnerable subgroups. As telehealth becomes further integrated into behavioral health services delivery, it is critical to uncover sources of this variation and identify potential solutions.

Mental Health Clinician Practices and Perspectives on Treating Adults with Co-Occurring Posttraumatic Stress and Substance Use Disorders

OBJECTIVE

Posttraumatic stress disorder (PTSD) and substance use disorders (SUD) commonly co-occur and represent a complex, challenging clinical comorbidity. Meta-analytic studies and systematic reviews suggest that trauma-focused treatments are more efficacious than non-trauma focused interventions for co-occurring PTSD/SUD. However, relatively little is known about mental health clinicians' practices or preferences for treating co-occurring PTSD/SUD. The present study aimed to describe the current clinical practices of mental health clinicians who treat PTSD and/or SUD-related conditions and to assess interest in novel integrative treatments for PTSD/SUD.

METHODS

Licensed mental health clinicians (N = 76; Mage = 39.59, SD = 8.14) who treat PTSD and/or SUD completed an anonymous online survey from April 2021 to July 2021.

RESULTS

The majority (61.8%) of clinicians reported using integrative treatments for PTSD/SUD. The most commonly used trauma-focused treatments were 1) Cognitive Processing Therapy (CPT: 71.1%) and 2) Prolonged Exposure Therapy (PE: 68.4%) for PTSD. Approximately half (51.3%) of clinicians endorsed using Relapse Prevention (RP) for SUD. The vast majority (97.4%) of clinicians were somewhat or very interested in a new integrative CPT-RP intervention, and 94.7% of clinicians believed patients would be interested in a CPT-RP intervention. In the absence of an available evidence-based integrative treatment using CPT, 84.0% of clinicians reported modifying extant treatment protocols on their own to address PTSD and SUD concurrently.

CONCLUSIONS

The findings demonstrate mental health clinician support of integrative treatments for PTSD/SUD. The most commonly used trauma-focused intervention was CPT and clinicians expressed strong interest in an integrative intervention that combines CPT and RP. Implications for future treatment development are discussed.

Telemedicine-delivered treatment for substance use disorder: A scoping review

INTRODUCTION

The COVID pandemic prompted a significant increase in the utilization of telemedicine (TM) for substance use disorder (SUD) treatment. As we transition towards a "new normal" policy, it is crucial to comprehensively understand the evidence of TM in SUD treatment. This scoping review aims to summarize existing evidence regarding TM's acceptability, quality, effectiveness, access/utilization, and cost in the context of SUD treatment in order to identify knowledge gaps and inform policy decisions regarding TM for SUDs.

METHOD

We searched studies published in 2012-2022 from PubMed, Cochrane Library, Embase, Web of Science, and other sources. Findings were synthesized using thematic analysis.

RESULTS

A total of 856 relevant articles were screened, with a final total of 42 articles included in the review. TM in SUD treatment was perceived to be generally beneficial and acceptable. TM was as effective as in-person SUD care in terms of substance use reduction and treatment retention; however, most studies lacked rigorous designs and follow-up durations were brief (≤3 months). Telephone-based TM platforms (vs video) were positively associated with older age, lower education, and no prior overdose. Providers generally consider TM to be affordable for patients, but no relevant studies were available from patient perspectives.

CONCLUSIONS

TM in SUD treatment is generally perceived to be beneficial and acceptable and as effective as in-person care, although more rigorously designed studies on effectiveness are still lacking. Access and utilization of TM may vary by platform. TM service quality and costs are the least studied and warrant further investigations.

Zoom-Based Mindfulness-Oriented Recovery Enhancement Plus Just-in-Time Mindfulness Practice Triggered by Wearable Sensors for Opioid Craving and Chronic Pain

Objective

The opioid crisis in the USA remains severe during the COVID-19 pandemic, which has reduced access to evidence-based interventions. This Stage 1 randomized controlled trial (RCT) assessed the preliminary efficacy of Zoom-based Mindfulness-Oriented Recovery Enhancement (MORE) plus Just-in-Time Adaptive Intervention (JITAI) prompts to practice mindfulness triggered by wearable sensors (MORE + JITAI).

Method

Opioid-treated chronic pain patients (n = 63) were randomized to MORE + JITAI or a Zoom-based supportive group (SG) psychotherapy control. Participants completed ecological momentary assessments (EMA) of craving and pain (co-primary outcomes), as well as positive affect, and stress at one random probe per day for 90 days. EMA probes were also triggered when a wearable sensor detected the presence of physiological stress, as indicated by changes in heart rate variability (HRV), at which time participants in MORE + JITAI were prompted by an app to engage in audio-guided mindfulness practice.

Results

EMA showed significantly greater reductions in craving, pain, and stress, and increased positive affect over time for participants in MORE + JITAI than for participants in SG. JITAI-initiated mindfulness practice was associated with significant improvements in these variables, as well as increases in HRV. Machine learning predicted JITAI-initiated mindfulness practice effectiveness with reasonable sensitivity and specificity.

Conclusions

In this pilot trial, MORE + JITAI demonstrated preliminary efficacy for reducing opioid craving and pain, two factors implicated in opioid misuse. MORE + JITAI is a promising intervention that warrants investigation in a fully powered RCT.

Preregistration

This study is registered on ClinicalTrials.gov (NCT04567043).

Treatment retention and reductions in blood alcohol concentration (BAC) during the first 90 days of a telehealth program for alcohol use disorder

Background: Alcohol use disorder (AUD) treatments, including medications, are increasingly offered via telehealth.Objective: This study characterizes 90-day treatment retention and changes in objectively measured blood alcohol concentration (BAC) in a large cohort receiving AUD telehealth.Methods: Patients received AUD treatment through Ria, a virtual (telehealth) program offering AUD treatment that is tailored to patient goals (e.g. abstinence or controlled drinking). Patients were encouraged to complete breathalyzer readings twice daily for measurement-based care. We characterized rates of 90-day treatment retention (i.e. completing a BAC reading or medical/coaching encounter on the 90^th day or later) and used growth curve analyses to model changes in daily estimated peak BAC over 90 days.Results: Of 4121 patients (51.5% women), 50.1% had 90-day treatment retention (n = 2066, 52.2% women). Most patients received prescriptions for AUD medications (84.6%) and completed encounters with medical providers (86.7%) and coaches (86.1%). Patients with 90-day retention provided 184,817 BAC readings in the first 90 days. Growth curve analyses revealed significant reductions in daily estimated peak BAC (p < .001) from a mean of 0.092 (day 1) to 0.038 (day 90). Similar magnitudes of BAC reduction were observed for men and women and for patients with abstinence and controlled drinking goals.Conclusion: Telehealth appears to be a viable approach to delivering AUD treatments in a manner that promotes drinking reductions. Telehealth approaches can yield reductions in objectively measured BAC, including for some patient subgroups that have historically faced greater stigma in AUD treatment settings, such as women and people with non-abstinence drinking goals.

Key implementation factors in telemedicine-delivered medications for opioid use disorder: a scoping review informed by normalisation process theory

Telemedicine could improve access to medications for opioid use disorder (MOUD). Telemedicine-delivered MOUD (TMOUD) has expanded substantially in response to the restrictions imposed by the COVID-19 pandemic on in-person clinical contact, yet this expansion has not happened consistently across all health systems and countries. This Review aims to understand key factors in TMOUD implementation that might explain variations in uptake. We did a scoping review using three English language databases for articles reporting on the implementation of TMOUD services. 57 peer-reviewed articles were identified, subjected to open coding and thematic analysis, and further interpreted through normalisation process theory (NPT). NPT was originally used to evaluate telehealth innovations and has been applied extensively to describe, assess, and develop the implementation potential of a broad range of complex health-care interventions. By categorising our findings according to the four core NPT constructs of coherence, cognitive participation, collective action, and reflexive monitoring, we aim to rationalise the current evidence base to show the workability of TMOUD in practice. We find that variations in TMOUD models in practice depend on organisations' attitudes towards risk, clinicians' tensions around giving up control over standard practices, organisation-level support in overcoming operational and technological challenges, and evaluation methods that might neglect a potential widening of the digital divide.

Patient evaluation of a smartphone application for telehealth care of opioid use disorder

Background

People with opioid use disorder (OUD) face barriers to entering and remaining in life-saving treatment (e.g., stigma, detrimental interactions with health care, and privacy concerns). Telehealth and related technology can reduce barriers to entering and staying in care. Patient feedback is critical to the development of these newer treatment approaches to ensure they are usable and do not inadvertently recreate treatment barriers.

Purpose

Evaluate the perceived usability of existing and planned features of a mobile application (app) that facilitates delivery of OUD treatment via telehealth.

Methods

People with current or prior experience with OUD treatment were eligible for the study. Participants (n = 31; 55% women) provided feedback on an interactive prototype demonstration via individual qualitative interviews and completed a quantitative survey on the app’s perceived usability. Descriptive statistics summarized the usability survey. We analyzed qualitative interview transcripts to elicit common themes.

Results

Participants were primarily white (77%) with a mean age of 42.2 years (range 22–69). Participants rated the six major features of the current app as helpful (median response 5 out of 5) and appreciated the flexibility of conducting a visit from a place of their choosing. Participants regarded the five proposed components of the app, such as daily affirmations and medication treatment-related reminders (e.g., pick up medication at pharmacy, medication schedule), as useful features with medians 5 out of 5, and reported they would recommend the app to others for OUD care. Participant qualitative interviews provided additional information on perceived usability of existing and proposed app features.

Conclusion

Our study suggests that an appealing, easy-to-use app—with tools and features that effectively support care—could circumvent existing barriers and foster sustained recovery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13722-022-00331-4.

Acceptability of Telehealth for Multidiagnostic Suicidal Patients in a Real-World Dialectical Behavior Therapy Clinic During the COVID-19 Pandemic

Objective: This study aimed to evaluate the acceptability of Dialectical Behavior Therapy (DBT) delivered through telehealth to complex, suicidal patients during the COVID-19 pandemic. Methods: We surveyed 163 adult participants enrolled in outpatient services at a private, free-standing DBT clinic certified by the DBT-Linehan Board of Certification for its fidelity to the treatment. Treatment satisfaction was assessed, as well as ease of telehealth over time, differences in satisfaction between patients who had previously experienced face-to-face treatment and those who had only experienced telehealth, patients' beliefs regarding the impact of telehealth on their progress, and preference for face-to-face versus telehealth services. Additionally, participants' reasons for liking and disliking telehealth were reported. Results: The average overall satisfaction rating was 82.26 (±18.71) on a 100-point scale. Factors identified as being relevant to satisfaction included increased access to care, saving time and money, and increased comfort participating in therapy from home. Factors identified as relevant to dissatisfaction included feeling less connected to therapists and other patients. The majority of participants reported that telehealth positively impacted or did not impact treatment progress. Satisfaction was significantly related to participants' perception of telehealth's impact on progress in treatment. Demographic variables were also included in the analyses, but were unrelated to satisfaction. Conclusions: Findings indicate that, from the point of view of consumer satisfaction, telehealth appears satisfactory for delivery of DBT and may play an increased role in behavioral health care postpandemic.

Digital Health Interventions for Delivery of Mental Health Care: Systematic and Comprehensive Meta-Review

BACKGROUND

The COVID-19 pandemic has shifted mental health care delivery to digital platforms, videoconferencing, and other mobile communications. However, existing reviews of digital health interventions are narrow in scope and focus on a limited number of mental health conditions.

OBJECTIVE

To address this gap, we conducted a comprehensive systematic meta-review of the literature to assess the state of digital health interventions for the treatment of mental health conditions.

METHODS

We searched MEDLINE for secondary literature published between 2010 and 2021 on the use, efficacy, and appropriateness of digital health interventions for the delivery of mental health care.

RESULTS

Of the 3022 records identified, 466 proceeded to full-text review and 304 met the criteria for inclusion in this study. A majority (52%) of research involved the treatment of substance use disorders, 29% focused on mood, anxiety, and traumatic stress disorders, and >5% for each remaining mental health conditions. Synchronous and asynchronous communication, computerized therapy, and cognitive training appear to be effective but require further examination in understudied mental health conditions. Similarly, virtual reality, mobile apps, social media platforms, and web-based forums are novel technologies that have the potential to improve mental health but require higher quality evidence.

CONCLUSIONS

Digital health interventions offer promise in the treatment of mental health conditions. In the context of the COVID-19 pandemic, digital health interventions provide a safer alternative to face-to-face treatment. However, further research on the applications of digital interventions in understudied mental health conditions is needed. Additionally, evidence is needed on the effectiveness and appropriateness of digital health tools for patients who are marginalized and may lack access to digital health interventions.

COVID-19 and opioid use disorder: Expanding treatment access in rural settings

ABSTRACT

Substance use treatment inequities among rural populations are well documented and the COVID-19 pandemic has exacerbated these inequalities, forcing healthcare providers to be creative in the delivery of treatment. Systematic reviews on the use of telehealth to treat patients with substance use disorder indicate that it is a promising alternative to in-person services. This article examines the evidence supporting the use of telehealth in treating patients with opioid use disorder and explores other promising options that can help overcome pandemic-related barriers to treatment.

Contextual challenges in police-assisted substance use referral programs: Impact of COVID-19 and Black Lives Matter movement

Background: Police assisted referral (PAR) programs provide people with substance use disorders (SUD) with a non-arrest treatment pathway, yet systemic barriers, including stigma and access to treatment services, may limit engagement. We sought to understand how the dual contextual challenges of COVID-19 and the Black Lives Matter movement have impacted PAR programs. Methods: Participants completed semi-structured interviews between July and September 2020. Transcribed interviews were analyzed qualitatively to extract emergent codes and themes. Results: Key themes included: adoption and reach of adapted remote services, and barriers to access; and questions on the role of police as health service providers, including police embeddedness in the community. COVID-related social distancing demands undermined police engagement with people with SUD. Treatment providers and advocates reported moderate success in utilizing remote interventions as workarounds. While participants acknowledged the Black Lives Matter movement's criticism of police, many saw continued value in police involvement in substance use interventions, due to their accessibility in communities and capacity for rapid response. Conclusions: PAR programs quickly adapted to a largely remote format, increasing longer-term accessibility. While Black Lives Matter had little direct impact on PAR programs, concerns about police-community relations were acknowledged. Recommendations include further police training to enhance trust and reduce stigma, and wider integration of digitally-based substance use referral options.

Veteran Perspectives on Adaptations to a VA Residential Rehabilitation Program for Substance Use Disorders During the Novel Coronavirus Pandemic

Individuals attending residential rehabilitation programs for substance misuse are particularly vulnerable to treatment disruptions spurred by the novel coronavirus disease 2019 (COVID-19) pandemic. We describe adaptations to services within a large residential rehabilitation program for under-resourced veterans, report veterans' experiences with these changes, and outline successes and challenges encountered throughout adjustment to the pandemic. Data collected from two focus groups with nine veterans engaged in this program during the pandemic highlight experiences of inconsistent communication about residential policies, interruptions to medical and addiction services, and feelings of confinement and social isolation. Overall, these findings suggest the need for health systems to support clients in taking an active role in communications, provide additional technical and social support in transitioning to virtual health services, and offer alternative means for clients to maintain social connection during a pandemic. Understanding clients' perspectives can inform strategies to promote continuity of care and enhanced care experiences.

Creating a pronation therapy team: One hospital's journey

ABSTRACT

Prone positioning is a recommended therapy for patients with COVID-19 who develop acute respiratory distress syndrome. This article describes the creation, operation, and evolution of the pronation therapy team at the author's Veterans Affairs facility.

A Retrospective Cohort Study Comparing In-Person and Telemedicine-Based Opioid Agonist Treatment in Ontario, Canada, Using Administrative Health Data

BACKGROUND

This study evaluated how telemedicine as a modality for opioid agonist treatment compares to in-person care.

METHODS

We conducted a retrospective cohort study of patients enrolled in opioid agonist treatment between January 1, 2011, and December 31, 2015, in Ontario, Canada. We compared patients who received opioid agonist treatment predominantly in person, mixed, and predominantly by telemedicine. We used a logistic regression model to evaluate mortality, a Cox proportional hazard model to assess retention, and a negative binomial regression model to evaluate emergency department visits and hospitalizations. The study was performed using administrative health data with physician billing data from the Ontario Health Insurance Plan and prescription data from the Ontario Drug Benefit databases.

RESULTS

A total of 55,924 individuals were included in the study. Receiving opioid agonist treatment by predominantly telemedicine was not associated with all-cause mortality (OR = 0.9, 95% CI: 0.8-1.0), 1-year treatment retention (OR = 1.0, 95% CI: 0.9-1.1), or opioid-related emergency department visits and hospitalizations when compared to in-person care. The rate of emergency department visits (IRR = 1.4), the rate of mental health-related emergency department visits (IRR = 1.5), and the rate of mental health-related hospitalizations per year (IRR = 1.2) was higher for patients who received opioid agonist treatment predominantly by telemedicine compared to in person.

CONCLUSION

Our findings support the conclusion that telemedicine is equal to in-person care regarding mortality opioid-related emergency department visits and retention, and is a viable option for those seeking opioid agonist treatment.

Substance Use Disorders and Telehealth in the COVID-19 Pandemic Era: A New Outlook

During the current coronavirus disease 2019 epidemic, many outpatient chemical dependency treatment programs and clinics are decreasing their number of in-person patient contacts. This has widened an already large gap between patients with substance use disorders (SUDs) who need treatment and those who have actually received treatment. For a disorder where group therapy has been the mainstay treatment option for decades, social distancing, shelter in place, and treatment discontinuation have created an urgent need for alternative approaches to addiction treatment. In an attempt to continue some care for patients in need, many medical institutions have transitioned to a virtual environment to promote safe social distancing. Although there is ample evidence to support telemedical interventions, these can be difficult to implement, especially in the SUD population. This article reviews current literature for the use of telehealth interventions in the treatment of SUDs and offers recommendations on safe and effective implementation strategies based on the current literature.

Are videoconferenced mental and behavioral health services just as good as in-person? A meta-analysis of a fast-growing practice

The use of videoconferencing technologies (VCT) is on the rise given its potential to close the gap between mental health care need and availability. Yet, little is known about the effectiveness of these services compared to those delivered in-person. A series of meta-analyses were conducted using 57 empirical studies (43 examining intervention outcomes; 14 examining assessment reliability) published over the past two decades that included a variety of populations and clinical settings. Using conventional and HLM3 meta-analytical approaches, VCT consistently produced treatment effects that were largely equivalent to in-person delivered interventions across 281 individual outcomes and 4336 clients, with female clients and those treated in medical facilities tending to respond more favorably to VCT than in-person. Results of an HLM3 model suggested assessments conducted using VCT did not appear to lead to differential decisions compared to those conducted in-person across 83 individual outcomes and 332 clients/examinees. Although aggregate findings support the use of VCT as a viable alternative to in-person service delivery of mental healthcare, several limitations in the current literature base were revealed. Most concerning was the relatively limited number of randomized controlled trials and the inconsistent (and often incomplete) reporting of methodological features and results. Recommendations for reporting the findings of telemental health research are provided.

Telepsychiatry and Outpatient Department Services

The utilization of telemedicine and telepsychiatry (TP) services in the outpatient department (OPD) has been increasing in recent years. The information about the technological, administrative, and clinical challenges is being addressed by the telemedicine and TP guidelines published by several individual nations. TP aims to address the treatment gaps, barriers for utilization, accessibility, diagnostic validity, financial implications, and individual client preferences. Utilization of TP in the OPD varies from country to country depending upon their healthcare delivery systems. It also varies in populations utilizing the TP services-urban, rural, child and adolescent, geriatric, and differently abled. TP services in the OPDs are being incorporated differentially by government organizations, insurance recognized psychiatric healthcare organizations, private psychiatric group practice deliverers, and individual, standalone psychiatric healthcare deliverers. TP may not replace the traditional in-person consultations completely. Covid-19 pandemic has hastened its utilization across several healthcare delivery systems. Healthcare organizations, clinicians, other healthcare deliverers, and end users are in the process of adapting to the new scenario. Incorporation of the big data, machine learning, artificial intelligence, virtual reality, and other technological advances in the psychiatric healthcare delivery systems into TP services in the OPDs would significantly contribute to the overall quality and efficacy of the psychiatric healthcare delivery systems in the future.

Digital Health Tools and Patients With Drug Use Disorders: Qualitative Patient Experience Study of the Electronic Case-Finding and Help Assessment Tool (eCHAT)

Background

One of the promises of digital health is to better engage patients and improve care for vulnerable populations. Patients with drug use disorders are a vulnerable population who often do not receive the care they need, both for their drug use disorders as well as their other health care needs. Appropriate primary care for patients with drug use disorders needs to be patient-centered, holistic, highly accessible, and engaging. The electronic Case-finding and Help Assessment Tool (eCHAT) was designed as a patient-centered tool for the identification and measurement of problematic health behaviors and mood states.

Objective

The aim of this study was to explore the patient experience of eCHAT at an Australian family medicine clinic for patients with drug use disorders.

Methods

A total of 12 semistructured interviews were conducted with patients, two interviews were conducted with doctors, and one focus group was conducted with patient advocates who were former patients of the clinic where the study took place. The transcripts were analyzed using inductive thematic analysis.

Results

The key themes identified from the interviews and the focus group were as follows: (1) eCHAT helped reduce stigma related to drug use in the doctor-patient consultation, (2) restricted answer options impacted the ability of patients to tell their stories, (3) patient-related response factors, (4) increased efficiency in the consultation process, and (5) divergence in level of concern around security and privacy.

Conclusions

eCHAT has the potential to help vulnerable patients in primary care to engage more with their doctors and reduce experiences of stigma. eCHAT may be a useful digital health intervention in a family medicine clinic for patients with drug use disorders. It has the potential to improve patient engagement and access to health care, which are crucial areas of need in this vulnerable population. However, it is important to clearly communicate the privacy risk of digital health tools and to implement eCHAT such that it will add value to, rather than displace, in-person consultations with the family doctor.

Business as usual? Psychological support at a distance

The impact of COVID-19 has challenged the long accepted 'norm' in delivery of psychological therapy. Public policies designed to reduce transmission have made it extremely difficult to meet with service-users safely in the traditional face-to-face context. E-therapies have existed in theory and practice since technological progress has made them possible. They can offer a host of advantages over face-to-face equivalents, including improved access, greater flexibility for service-users and professionals, and cost savings. However, despite the emerging evidence and anticipated positive value, implementation has been slower than anticipated. Concerns have been raised by service-users, clinicians, and public health organisations, identifying significant barriers to the wide spread use of e-therapies. In the current climate, many clinicians are offering e-therapies for the first time, without prior arrangement or training, as the only viable option to continue to support their clients. This paper offers a clinically relevant review of the e-therapies literature, including effectiveness and acceptability dilemmas and challenges that need to be addressed to support the safe use and growth of e-therapies in psychology services. Further research is needed to better understand what might be lost and what gained in comparison to face-to-face therapy, and for which client groups and settings it might be most effective.

Measures of Effectiveness, Efficiency, and Quality of Telemedicine in the Management of Alcohol Abuse, Addiction, and Rehabilitation: Systematic Review

Background

More than 18 million Americans are currently suffering from alcohol use disorder (AUD): a compulsive behavior of alcohol use as a result of a chronic, relapsing brain disease. With alcohol-related injuries being one of the leading causes of preventable deaths, there is a dire need to find ways to assist those suffering from alcohol dependence. There still exists a gap in knowledge as to the potential of telemedicine in improving health outcomes for those patients suffering from AUD.

Objective

The purpose of this systematic review was to evaluate the measures of effectiveness, efficiency, and quality that result from the utilization of telemedicine in the management of alcohol abuse, addiction, and rehabilitation.

Methods

This review was conducted utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The articles used in this analysis were gathered using keywords inclusive of both telemedicine and alcohol abuse, which were then searched in the Cumulative Index to Nursing and Allied Health Literature, Cochrane, and MEDLINE (PubMed) databases. A total of 22 articles were chosen for analysis.

Results

The results indicated that telemedicine reduced alcohol consumption. Other common outcomes included reduced depression (4/35, 11%), increased patient satisfaction (3/35, 9%), increase in accessibility (3/35, 9%), increased quality of life (2/35, 6%), and decreased cost (1/35, 3%). Interventions included mobile health (11/22, 50%), electronic health (6/22, 27%), telephone (3/33, 14%), and 2-way video (2/22, 9%). Studies were conducted in 3 regions: the United States (13/22, 59%), the European Union (8/22, 36%), and Australia (1/22, 5%).

Conclusions

Telemedicine was found to be an effective tool in reducing alcohol consumption and increasing patients’ accessibility to health care services or health providers. The group of articles for analysis suggested that telemedicine may be effective in reducing health care costs and improving the patient’s quality of life. Although telemedicine shows promise as an effective way to manage alcohol-related disorders, it should be further investigated before implementation.

A structured telephone-delivered intervention to reduce problem alcohol use (Ready2Change): study protocol for a parallel group randomised controlled trial

Background

Current population surveys suggest around 20% of Australians meet diagnostic criteria for an alcohol use disorder. However, only a minority seek professional help due to individual and structural barriers, such as low health literacy, stigma, geography, service operating hours and wait lists. Telephone-delivered interventions are readily accessible and ideally placed to overcome these barriers. We will conduct a randomised controlled trial (RCT) to examine the efficacy of a standalone, structured telephone-delivered intervention to reduce alcohol consumption, problem severity and related psychological distress among individuals with problem alcohol use.

Methods/design

This is a single site, parallel group, two-arm superiority RCT. We will recruit 344 participants from across Australia with problem alcohol use. After completing a baseline assessment, participants will be randomly allocated to receive either the Ready2Change (R2C) intervention (n = 172, four to six sessions of structured telephone-delivered intervention, R2C self-help resource, guidelines for alcohol consumption and stress management pamphlets) or the control condition (n = 172, four phone check-ins < 5 min, guidelines for alcohol consumption and stress management pamphlets). Telephone follow-up assessments will occur at 4–6 weeks, 3 months, 6 months and 12 months post-baseline. The primary outcome is the Alcohol Use Disorders Identification Test (AUDIT) score administered at 3 months post-baseline. Secondary outcomes include change in AUDIT score (6 and 12 months post-baseline), change in number of past-month heavy drinking days, psychological distress, health and wellbeing, quality of life, client treatment evaluation and cost effectiveness.

Discussion

This study will be one of the first RCTs conducted internationally to examine the impact of a standalone, structured telephone-delivered intervention to address problem alcohol use and associated psychological morbidity. The proposed intervention is expected to contribute to the health and wellbeing of individuals who are otherwise unlikely to seek treatment through mainstream service models, to reduce the burden on specialist services and primary care providers and to provide an accessible and proportionate response, with resulting cost savings for the health system and broader community.

Trial registration

Australian New Zealand Clinical Trials Registry, ACTRN12618000828224. Pre-registered on 16 May 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3462-9) contains supplementary material, which is available to authorized users.

Telemedicine-delivered treatment interventions for substance use disorders: A systematic review

With increased negative impacts from opioid and other substance use disorders in the US, it is important for treatments to not only be effective, but also accessible to patients. Treatment delivery via telemedicine, specifically, the use of videoconferencing, which allows real time communication between a patient and a clinician at a distant site, has been shown to be an effective approach for increasing reach and access to treatments for mental health disorders and other chronic illnesses. This systematic review identified and summarized studies examining the effectiveness of telemedicine interventions to deliver treatment for patients with substance use disorders. Out of 841 manuscripts that met our search criteria, 13 studies met the inclusion criteria. Studies covered interventions for nicotine, alcohol and opioid use disorders. They varied widely in size, quality, and in the comparison groups examined. Studies examined both delivery of psychotherapy and medication treatments. Most studies suggested telemedicine interventions were associated with high patient satisfaction and are an effective alternative, especially when access to treatment is otherwise limited. However, there were substantial methodological limitations to the research conducted to date. Further studies are needed, including larger scale randomized studies that examine different models of telemedicine that can be integrated into existing healthcare delivery settings, to increase the use of effective treatments for patients with substance use disorders.

Use of Telemedicine in Addiction Treatment: Current Practices and Organizational Implementation Characteristics

Telemedicine applications offer innovative approaches for treating and reducing the effects of substance use disorders (SUDs). This analysis assessed the interest in and use of 11 telemedicine applications in a sample of 363 SUD organizations in the United States of America. Fifty percent of the organizations expressed high rates of interest in seven of the telemedicine applications, demonstrating the appeal of telemedicine within this field. The top three self-reported telemedicine applications being used were (1) computerized screening/assessments (44.6%), (2) telephone-based recovery supports (29.5%), and (3) telephone-based therapy (28.37%). The greatest gaps between interest and use were for (1) texting appointment reminders (55.2% differential), (2) mobile apps for posttreatment recovery (46.6% differential), and (3) recovery support chats (46.6% differential). A Latent Class Analysis (LCA) of the organizations' telemedicine use behavior identified three groupings: “Innovators” that were using a range of technologies (n = 27, 7.4%); “Technology Traditionalists” that limited their use to telephone, video, and web portal technologies (n = 101, 27.8%); and “Low Tech” that had low overall technology use (n = 235, 64.7%). Future studies should build on how telemedicine could be applied in SUD settings, organizational behaviors towards its adoption, and telemedicine's effect on treatment adherence and clinical outcomes.

Test of a workforce development intervention to expand opioid use disorder treatment pharmacotherapy prescribers: protocol for a cluster randomized trial

BACKGROUND

Overdoses due to non-medical use of prescription opioids and other opiates have become the leading cause of accidental deaths in the USA. Buprenorphine and extended-release naltrexone are key evidence-based pharmacotherapies available to addiction treatment providers to address opioid use disorder (OUD) and prevent overdose deaths. Treatment organizations' efforts to provide these pharmacotherapies have, however, been stymied by limited success in recruiting providers (physicians, nurse practitioners, and physician assistants) to prescribe these medications. Historically, the addiction treatment field has not attracted physicians, and many barriers to implementing OUD pharmacotherapy exist, ranging from lack of confidence in treating OUD patients to concerns regarding reimbursement. Throughout the USA, the prevalence of OUD far exceeds the capacity of the OUD pharmacotherapy treatment system. Poor access to OUD pharmacotherapy prescribers has become a workforce development need for the addiction treatment field and a significant health issue.

METHODS

This cluster randomized controlled trial (RCT) is designed to increase buprenorphine and extended-release naltrexone treatment capacity for OUD. The implementation intervention to be tested is a bundle of OUD pharmacotherapy capacity building practices called the Prescriber Recruitment Bundle (PRB), which was developed and piloted in a previous statewide buprenorphine implementation study. For this cluster RCT, organizational sites will be recruited and then randomized into one of two arms: (1) control, with treatment as usual and access to a website with PRB resources, or (2) intervention, with organizations implementing the PRB using the Network for the Improvement of Addiction Treatment organizational change model over a 24-month intervention period and a 10-month sustainability period. The primary treatment outcomes for each organizational site are self-reported monthly counts of buprenorphine slots, extended-release naltrexone capacity, number of buprenorphine patients, and number of extended-release naltrexone patients. This trial will be conducted in Florida, Ohio, and Wisconsin, resulting in 35 sites in each arm, for a total sample size of 70 organizations.

DISCUSSION

This study addresses three issues of substantial public health significance: (1) the pressing opioid misuse epidemic, (2) the low uptake of OUD treatment pharmacotherapies, and (3) the need to increase prescriber participation in the addiction treatment workforce.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02926482.

Opioid use disorder patients' perceptions of healthcare delivery platforms

OBJECTIVES

To assess the acceptability and quality of web-based videoconferencing telemedicine consultation platform in the treatment of opioid use disorder at TrueNorth Medical Centre.

METHODS

We conducted an interview based quality improvement initiative using an investigator-designed questionnaire. The questionnaire consisted of 17 Agree/Disagree questions, measured on a 7-point Likert scale and 2 questions where patients had the ability to elaborate qualitatively on their perceptions and experiences with their telemedicine service. Content-style analysis was performed on qualitative responses.

RESULTS

The majority of patients (n=14; 47%) preferred face-to-face over telemedicine consultations. The number of patients that preferred telemedicine consultations over face-to-face consultations was lower (n=6; 20%). A notable number of patients (n=10; 33%) indicated no specific preference for either telemedicine or face-to-face consultations. Patients preferring face-to-face consultations rated their clinical outcome and patient-physician relationship following telemedicine consultations similarly as those who preferred telemedicine consultations. Patients preferring telemedicine rated their experience and overall perceptions of the service significantly higher than those preferring face-to-face consultations. Patients who preferred telemedicine consultations identified the efficient and timesaving nature of telemedicine consultations as primary advantages whereas those preferring face-to-face consultations reported lower levels of empathy from their physician during telemedicine consultations as a major disadvantage.

CONCLUSIONS

The majority of patients at TrueNorth Medical Centre viewed telemedicine consultations as an acceptable treatment modality. Patients preferring telemedicine consultations and those preferring face-to-face consultations evaluated the majority of the measured indices of care in a similar fashion.

Transitioning From Detoxification to Substance Use Disorder Treatment: Facilitators and Barriers

Although successful transitions from detoxification to substance use disorder treatment are associated with improved outcomes, many detoxification patients do not initiate treatment. This qualitative study informs detoxification and addiction treatment providers, and health systems, about how to improve detoxification to treatment transitions, by reporting detoxification providers' views of transition facilitators and barriers. The sample consisted of 30 providers from 30 Veterans Health Administration detoxification programs. Themes regarding transition facilitators and barriers emerged at the patient, program (detoxification programs, and addiction programs), and system levels. Detoxification program-level practices of discharge planning, patient education, and rapport building were reported as facilitating the transition to treatment. Six themes captured transition facilitators within addiction treatment programs: the provision of evidence-based practices, patient-centered care, care coordination, aftercare, convenience, and a well-trained and professional staff. This study expands previous literature on detoxification and addiction treatment by systematically and qualitatively examining factors that promote and hinder treatment initiation after inpatient and outpatient detoxification, from a provider perspective, in an era of health care reform and expanded substance use disorder treatment.

Usefulness of telepsychiatry: A critical evaluation of videoconferencing-based approaches

Telepsychiatry, i.e., the use of information and communication technologies to provide psychiatric services from a distance, has been around for more than half a century now. Research over this period has shown that videoconferencing-based telepsychiatry is an enabling and empowering form of service delivery, which promotes equality of access, and high levels of satisfaction among patients. The range of services offered by videoconferencing-based telepsychiatry, potential users and points of delivery of such services are theoretically limitless. Telepsychiatry has both clinical utility and non-clinical uses such as administrative, learning and research applications. A large body of accumulated evidence indicates that videoconferencing-based telepsychiatric assessments are reliable, and clinical outcomes of telepsychiatric interventions are comparable to conventional treatment among diverse patient populations, ages and diagnostic groups, and on a wide range of measures. However, on many aspects of effectiveness, the evidence base is still relatively limited and often compromised by methodological problems. The lack of cost-effectiveness data in particular, is a major hindrance, raising doubts about the continued viability of telepsychiatric services. Added to this are the vagaries of technology, negative views among clinicians, poor uptake by providers, and several legal, ethical and administrative barriers. These hamper the widespread implementation of telepsychiatry and its integration with routine care. Though further advances in technology and research are expected to solve many of these problems, the way forward would be to promote telepsychiatry as an adjunct to conventional care, and to develop hybrid models, which incorporate both traditional and telepsychiatric forms of mental health-care.

The effectiveness of telephone counselling in the treatment of illicit drug and alcohol use concerns

INTRODUCTION

Technology-assisted substance use interventions such as 'high-tech' internet-based treatments are thought to be effective; however, the relatively 'low-tech' use of telephone counselling does not yet have an established evidence base. This paper reviews the literature including articles with information on the use of telephone counselling for the treatment of illicit drug or alcohol use.

METHODS

A systematic literature search using a set of telephone counselling and substance-related terms was conducted across four electronic databases. English studies prior to June 2014 that involved the use of telephone counselling with the treatment of illicit drug or alcohol use as a primary or secondary outcome were included. Review papers, opinion pieces, letters or editorials, case studies, published abstracts, and posters were excluded. In all, 94 publications were included in the review.

RESULTS AND DISCUSSION

The literature was supportive of telephone counselling for the treatment of alcohol use in the short term; however, literature regarding illicit drug use was particularly scarce. The generalisability of findings was limited by evident methodological issues in the included studies.

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.

Just telling and selling: current limitations in the use of digital media in public health: a scoping review

OBJECTIVE

To undertake a scoping review and to map research in the area of digital media use in public health.

STUDY DESIGN

Scoping review.

METHODS

PubMed, PsycINFO, Google and major textbooks of public health communication and health psychology were searched for primary studies or systematic reviews examining the use of digital media in a health context. Searches focussed on studies published between the start of 2000 and the end of June 2013. Abstracts of reviews of public health interventions were examined with respect to target groups, health topic, intervention characteristics, media used, study design, issues of quality and ethics, and outcomes. To map this area of work fully, this information was supplemented by adding information from primary studies. Areas were identified where systematic review evidence was scarce or non-existent by comparing the final map with information from the reviews analysed.

RESULTS

221 systematic reviews related to digital media use in a public health context were included. Most reviews included studies with an experimental design and general 'at risk' target populations. Specific settings were not specified in the majority of reviews. A large variety of health topics were covered. About a quarter of reviews did not specify a health topic but were concerned with broader issues of health promotion, disease prevention, or health education. Over half of the reviews focussed on eHealth and telemedicine, and another third were concerned with mass media - social marketing. Reviews most frequently reported behaviour-related outcomes or conducted some form of content analysis or analysis of the use of particular media. Research gaps were identified relating to community-based research, participation and empowerment, active media use (especially with respect to visual media und use of specific visual methodologies), and the use of salutogenic or assets-based approaches.

CONCLUSION

The available research relating to digital media use in public health is dominated by studies relating to eHealth, telehealth or social marketing; emphasising the passive reception of messages and a focus on individual behaviour change approaches. Issues of quality and ethics need to be taken into account more consistently. Further research is needed with respect to more participatory methods, particularly those which would seek to use digital media as a means to harness individual and community assets.

The Implementation of a Telephone-Delivered Intervention for Asian American Disordered Gamblers: A Pilot Study

This report will discuss the implementation and preliminary results of a community-based telephone-delivered gambling treatment program specifically designed for Asian Americans. The intervention was implemented by the NICOS Chinese Health Coalition, a nonprofit community organization based in Northern California, overseen by the UCLA (University of California, Los Angeles) Gambling Studies Program and the California Office of Problem Gambling, and launched in December 2010. It consisted of six 1-hr long telephone-delivered sessions conducted by a mental health provider using a translated version of the Freedom from Problem Gambling Self-Help Workbook. In the current study, 6 providers completed a 30-hr training program for gambling related disorders. One-hundred and 40 callers inquired about the intervention within the first 6 months of its launch, 19 clients expressed interest in participating, and 8 enrolled into the program. The results show that the majority of clients who enrolled into the program did not report any gambling behavior after baseline and improved on self-reported measures of overall life satisfaction, gambling urges, and self-control. This study suggests that the implementation of this type of intervention is feasible at a small community-based organization and may be effective in treating gambling-related disorders for Asian American populations. The low rate of clientele enrollment is addressed and potential remedies are discussed.