5/27/16

1. Tobie Barton, MA
Using Technology to Enhance
Addiction Treatment

2. Neither the NFAR ATTC nor the trainer presenting today
endorse or promote the use of any specific technology
application mentioned in this training. All technology
applications are discussed as examples of available resources
only. The NFAR ATTC does not guarantee that any of the
technologies discussed meets federal, state, or local
regulations. Please consult with an attorney, your institution’s
HIPAA compliance officer, and/or your local licensing agency
before utilizing any technology for clinical or recovery support
purposes.

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

4. Outline
• Definition of technology-based interventions
• Discuss use of technology in behavioral health
by practitioners and clients
• Research-based technologies for treating SUDs
• Resources
• Summary

5. develop and strengthen
the workforce that provides
addictions treatment and recovery
support services
Purpose of the ATTCs (SAMHSA FUNDED)

6. ATTC Network
Coordinating Office
10 Regional Centers
2012 – 2017

7. National
Frontier & Rural
ATTC
National
American Indian & Alaska Native
ATTC National
SBIRT
ATTC
National
Hispanic & Latino
ATTC
4 ATTC National Focus Centers

8. Serveas the national subject expert
and key resource to PROMOTE the awareness
and implementation of telehealth technologies

9. “The successful practitioner of the
next century will need to master
technologies in order to effectively
manage the care of their patients. As
the microscope allowed practitioners
in an earlier era to see the microbial
agents of infection… the computer
will also change the patient. As
patients arrive with better and more
information, health care professionals
may find themselves increasingly in
the role of counselor and consultant”
(O’Neil & Pew, 1998, p. 18)

10. People are using technology

11. Use of online and mobile technologies is
increasingly ubiquitous across age,
race/ethnicity, and geography.
Consumers rely on Internet and smartphone-
based tools for health information and
tracking.

12. Use of technology devices to deliver some
aspects of psychotherapy or behavioral
treatment directly to patients via
interaction with a web-based program.
(Carroll & Rounsaville, 2010)
Technology-Based Interventions
DEFINITION

13. Technology can be applied to both
the pharmacotherapy treatment of
substance use disorders and
psychosocial treatments.
Continuum of intervention, treatment, and recovery services

14. (Gainsbury & Blaszczynski, 2011)
Technology has
enormous potential
to provide a highly
influential tool to
assist individuals in
overcoming their
addictions that
appropriately meets
individuals’
expectations and
needs.

15. Technology-based interventions
have the ability to:
• lower consumer threshold for
initiation of treatment
• refer at-risk individuals to in-
person treatment
Clarke & Yarbourough, 2013

16. Technology-Based Intervention
BENEFITS
• Serve as adjuncts to standard treatment
• Save clinician time
• Extend clinician expertise
• Integrate other EBPs to provide additional
services to clients with co-morbid conditions
• Provide access to web-based smoking
cessations programs or other health-related
conditions
(Carroll & Rounsaville, 2010)

17. Encouraging evidence
suggests positive
treatment outcomes
Bickel et al., 2008; Carroll & Rounsaville, 2010)

18. Substance use is a public health
crisis in the rural United States and
has been identified as one of the
top 10 priorities
Rural Healthy People 2020

19. Technology has the potential to narrow the
“access gap” to behavioral health
interventions and reduce health disparities in
disadvantaged and hard-to-reach populations
Gibbons et al., 2011

20. Majority (90%) of persons
with SUDs have not entered
treatment
20.2 million in 2013
(NSDUH, 2013)

21. Technology can address barriers to
accessing treatment

22. Workforce & Technology

23. Use of technology
by clinicians
• is increasing
• presents unique
clinical/business
dilemmas
(NBCC Policy, 2013)

24. DIGITAL TYPES

25. Digital Immigrants
(Zur, 2012; Prensky, 2001)

26. Digital Immigrants
… people born before 1964 and who grew up in
a pre-computer world
(Zur & Zur, 2011)

27. ‘native speakers’ of the digital language
of computers, cell phones, video games,
and the Internet
(Zur, 2012; Prensky, 2001)

28. Like all immigrants… as Digital Immigrants
learn to adapt to their environment, they
retain, to some degree, their ‘accent’ …
What is your
digital accent?
(Prensky, 2001)

29. Digital Immigrants Digital Natives
• Prefer to talk in-person or
on the phone
• Prefer to talk via chat, text, or
messaging thru social media
• Don’t text or only sparingly • Text more than call
• Prefer synchronous
communication
• Prefer asynchronous
communication
• Prefer receiving information
slowly: linearly, logically, &
sequentially
• Prefer receiving information quickly
& simultaneously from multiple
multimedia & other sources
• Prefer reading text (i.e.,
books) on processing
pictures, sounds & video
• Prefer processing /interacting with
pictures, graphics, sounds & video
before text
Comparison of Digital Types
(Zur & Zur, 2011; Rosen, 2010; Prennsky, 2001)

30. Other Digital Types
Ways to sort people other than age
• Attitudes
• Comprehension
• Relationships
• Practices
• Comfort with technology
(Feeney, 2010; Toledo, 2007)

31. DIGITAL DIVIDE

32. Younger clinicians and those with
smartphones found a PTSD app
more usable than older clinicians
and those without smartphones.
These variables predicted
clinicians’ intentions to use the
app in treatment with veterans.
(Kuhn et al., 2014)

34. ORGANIZATIONS

35. Agencies with annual operating budgets of
greater than $10 million reported
significantly fewer barriers
(Ramsey et al., 2016 )
than those with budgets of $10 million or less

36. Agencies serving more than 3,000 clients per
year reported significantly fewer
implementation barriers than those serving
fewer clients annually. (Ramsey et al., 2016)

37. Provider resistance and lack of openness
to use technology-based care approaches
may be multifaceted…
• limited awareness of established benefits
• an organizational climate characterized by
skepticism or unwillingness to try new
approaches
• a demand for more research on the
effectiveness and safety of these tools
(Ramsey et al., 2016)

38. a substantial portion of
providers reported a lack
of basic knowledge
about how technologies
can be used for
behavioral health care
(Ramsey et al., 2016)

39. How will technologies change how the
provider does business?
(Muench, 2015)

40. Recommendations
STAFF

41. The fitof any innovation with the attitudes
and values of the agency and providers
adopting it is critical to the acceptability,
efficiency, and effectiveness of the
implementation process.
(Ramsey et al., 2016)

42. The most pressing staff concern:
Is this better and easier than what I am
currently using/doing?
(Muench, 2015)

43. Integration
requires an
understanding of
staff members’
degree of
comfort with
technology
(Muench, 2015)

44. and the time burden
(Campbell et al., 2012)

45. and the selection of appropriate training
to increase staff confidence in navigating
potentially foreign technologies

46. Most providers will need to re-structure
operations to understand how technology will
impact clinician workload…
• accept e-mails or phone messages on work phones
• develop on-call lists or use peer specialists to
manage alerts/requests for help and client check-
ins if not automated
(Muench, 2015)

47. For example, Muench and colleagues (2013) found
that although 80% of providers want to be alerted
if their client is at risk of relapse, only 8% would
want an immediate mobile alert.
(Muench, 2015)

48. debunk fears cited by providers regarding
the use of technologies
compromised client care and job replacement
(Ramsey et al., 2016)

49. Clinician
Extenders
(Ramsey et al., 2016; Marsch, 2011)
allow providers
to work at their
highest level of
training and
focus on the
most high-need
client issues

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

51. • the ability of technology to reach enormous
numbers of people (it is undeniable)
• the use of technology for treatment and
recovery support offers the possibility of
better care, reduced stigma, and broader
reach
It’s imperative that professionals
understand…

52. Since patients are likely to use
technologies, it may be helpful for
practitioners to understand the
phenomena of technologies, even
if they struggle with technologies
or are doubtful about their utility.
(Myers et al., 2012)

54. Client Acceptability of Technologies

55. What do we know about clients?
Survey of 8 urban drug treatment clinics
in Baltimore (266 patients)
Clients had access to:
• Mobile Phone - 91%
• Text Messaging - 79%
• Internet/Email/Computer - 39-45%
(McClure, Acquanta, Harding, & Stitzer, 2012)

56. (Moore et al., 2011; Muench et al., 2013; Muench, 2015)
Current evidence demonstrates that clients use
and are interested in using technologies as
part of their treatment or continuing support.

57. Customer
Demand
57

58. People with common health care
concerns find each other by website
and blog search engines, and through
mobile apps and Twitter tags
(Marri, et al., 2014)

59. Clients’ Issues Regarding Using
Technologies for Treatment and Recovery
• Make sure clients understand:
‒ technologies that may monitor them and
their locations
‒ how to use the technologies
‒ what to do in the case of emergencies and
service problems
(Muench, 2015)

60. Other Technology Issues with Clients
• Many clients change phone numbers or experience
disruptions in their phone service which interferes with use
of technology-based interventions.
• Approximately 20% of participants had their phone service
turned off at least once over the course of a 5-week study
as a result of nonpayment.
• Clients sharing phones with family members/others raises
issues with privacy/security and confidentiality.
• Warn clients about technology failures and that their
messages might not go through.
• Determine percentage of clients that have access to smart
phones before implementing technology.
(Muench, 2012; 2015)

61. Given the promise of these computerized interventions, we
feel encouraged that technology has become mature
enough to capture at least some aspect of psychotherapy.
(Campbell & Luo)

62. Videoconferencing

63. The research base for telemental
health-related interventions is more
than 50 years old.
(Richardson et al., 2009; Wittson et al., 1961; Wittson & Benschoter, 1972)

65. Systematic Review of
Videoconferencing Psychotherapy
• Patients and providers perceived a strong
therapeutic alliance over videoconferencing
• Studies that compared videoconferencing to in-
person psychotherapy reported similar
satisfaction levels between the conditions
• High levels of satisfaction and acceptance with
telemental health have been consistently
demonstrated among patients across a variety of
clinical populations and for a broad range of
services
(Backhaus et al., 2012)(Backhaus et al.2012)

66. Studies on Videoconferencing in
Addiction Treatment
• Opioid Treatment-group counseling
(King et al., 2009; King et al., 2014)
• Alcohol Treatment
(Postel et al., 2005)
• Alcohol Treatment
(Frueh et al., 2005)
• Teleconferencing Supervision (TCS) - MI
(Smith et al., 2012)
(Backhaus et al., 2012)

67. eGetgoing
uses videoconferencing
technology to deliver
therapy to patients with
opioid dependence

69. Leading Technologies in
Addiction Treatment

70. Technology-Based Interventions have
been validated recently through funded
research studies:
TES, CBT4CBT, and ACHESS

71. Therapeutic Education System (TES)
An interactive, web-based psychosocial
intervention for SUDs, grounded in:
Community Reinforcement Approach (CRA) +
Contingency Management Behavior Therapy +
HIV Prevention

72. What Do People Say About TES?
72

73. CBT4CBT
• A computer-based version of cognitive
behavioral therapy (CBT)
• Designed to use in conjunction with clinical
care for current substance users
• Multimedia presentation, based on
elementary level computer learning games,
requires no previous computer experience
(Carroll et al., 2008; 2009; 2011; 2014; Olmstead, Ostrow, & Carroll, 2010)

74. http://www.cbt4cbt.com

75. ACHESS
• Monitoring and alerts
• Reminders
• Autonomous motivation
• Assertive outreach
• Care coordination
• Medication reminders
• Peer & family support
• Relaxation
• Locations tracking
• Contact with professionals
• Information

76. Research Studies Using Texting
• weight/obesity
(Gerber et al., 2009)
• diabetes
(Franklin et al., 2006; Hanauer et al., 2009)
• asthma
(Neville et al., 2002)
• tobacco dependence
(Rodgers et al., 2005)
• sexual health
(Leach-Lemens, 2009; Lim et al., 2008)

77. (Ingersoll et al., 2014)

78. • Used youth to craft language
• Daily self-monitoring texts, a daily wellness recovery tip,
and substance abuse education and social support
resource information on weekends
• Compared with standard aftercare, texting reduced
relapse risk and promoted recovery engagement
Youth-Focused
Texting
Case Study
(Gonzales et al., 2014)

79. TEXTING - Portable Contingency
Management
1-3 text reminders
about sending video
of breathalyzer results
• Vouchers earned for negative BAC tests
• Thank you texts (Alessi & Petry, 2012)

80. TELEPHONE
RECOVERY
SUPPORT
• Peer-based, volunteer supported
• Check-in, issue identifier, make
connections
• Builds recovery capital
• Standard 12-week program, but
unlimited
• Free service to anyone
• Not limited by geography, more
flexible

81. Telephone Continuing Care for SUDs
• Telephone Monitoring and Adaptive Counseling (TMAC)
(McKay, 2004)
• Focused Continuing Care (FFC) (Betty Ford Clinic)
• Telephone Enhancement of Long Term Engagement (TELE)
(Hubbard et al., 2007)
• Individual Therapeutic Brief Phone Contact (ITBPC)
(Kaminer & Napolitano, 2004) ADOLESCENTS
• Telephone Case Monitoring (TCM)
(McKellar et al., 2012)
• Telephone Continuing Care (TCC)
(Godley et al., 2010)

82. Social media networks facilitate highly interactive
online communities where individuals share, co-
create, discuss and modify user-generated content

84. Apps provide:
• Information
• Motivation
• Support
• Feedback

85. 61%of patients reported using
mobile applications
Dahne & Lejuez, 2015
Few evidence-based apps exist, in contrast to the
thousands of apps available that are not
evidence-based or research-informed.
Majeed-Ariss, et al., 2015

86. 8Strategies for Evaluating/Selecting Apps
1) Review the scientific literature
2) Search app clearinghouse websites
3) Search app stores
4) Review app descriptions, user ratings, and reviews
5) Conduct a social media query within professional
and, if available, patient networks
6) Pilot the apps
7) Elicit feedback from patients
8) Understand free apps have more privacy/security
risks
(Boudreaux et al., 2014; Frank, 2015)

88. Providers Using Telehealth Technologies
• Operation PAR in Florida
– Web-videoconferencing and email
• Tarzana Treatment Centers in California
– Web-video conferencing and email
• Heartview Foundation in North Dakota
– Web-based recovery support/private social network-
Ning
• Face It Together in South Dakota
– Telephone Recovery Support
(NFAR Data, 2015)

91. or like this…

92. Clients and consumers are already
embracing TBIs and creating a patient-
centered health movement.
As the research has repeatedly revealed,
TBIs are most effective when combined
with human support, reinforcing how
providers will remain the foundation of
care for those seeking help.
(Muench, 2015)

93. How do I remember
all of this…..

96. SUDTECH.ORG

97. Center for Technology and Behavioral Health

100. New Ethical Dilemmas in the Digital Age

101. Technology-Based Supervision:
Extending the Reach of
Clinical Supervisors

103. New Curriculum