Physical Address
304 North Cardinal St.
Dorchester Center, MA 02124
Technological Innovations in Addiction Treatment
Just for fun, check out the last five to ten years of “ 10 Breakthrough Technologies ” published in the MIT Technology Review. In most years, well over half of the discoveries in each list have clear relevance to health and health care or are communication, connectivity, and computational advances. If you allow yourself to imagine how some of these technological advances might be applied to advance the health of persons suffering from various medical conditions, including addictions and other mental disorders, the possibilities abound, and exponential progress toward reducing harm from these conditions may seem within reach. A large number of innovative applications of digital technology are now permeating the world of healthcare with the goals of improving health, extending the reach of health care, and reducing the cost of providing care.
So, why is this so important and why should this excite you? Don't we already have effective ways to identify and treat substance use disorders (SUDs) and systems designed to provide such care? Yes, we have pharmacological and behavioral interventions, and health care providers to deliver them; however, there are substantial limitations. Controlled studies show that the short- and long-term response rates for the most efficacious interventions remain well under 50% and are even lower for many SUDs. This may be because evidence-based interventions are either not readily available, not being used by providers or are not of interest to individuals with SUDs. Only 10%–20% of those with substance-use-related problems report receiving any treatment in the past year. Each of these issues must be better addressed to effectively confront the problems associated with SUDs.
Over the last 25 years, scientists in the field of addiction science have studied how to enhance outcomes, how to improve the dissemination and implementation of efficacious treatments, and how to reach a greater proportion of the population experiencing SUD. Barriers have included substandard screening for and identification of cases, limited trained personnel, the burden associated with training, poor fidelity and integrity of treatment delivery, low pay for providers, high cost to deliver the most effective interventions, difficulty in self-identifying as a person with an SUD, stigma and burden associated with seeking treatment, and lack of individualization and personalization of treatment.
The healthcare field has integrated advances in digital technology at an escalating pace to improve health behavior, healthcare delivery, and cost-effectiveness. This new area of science is often referred to as “digital health” and includes advancements in the ways mobile communications and sensing devices, software development, cloud computing, and data analytics enhance the patient experience. The progress being made in digital health offers multiple pathways that can help overcome the existing limitations to providing optimal care to patients with SUDs. This chapter will illustrate the ways in which principles and practices from this exciting new field are being tested and applied to enhance treatment for SUD. This chapter will also explore several issues that we expect will need to be addressed to maximize the opportunities offered by digital health, some of which are similar to the barriers that have impeded dissemination and implementation of evidence-based, novel interventions for behavioral health care throughout the years ( Table 5.1 ).
TABLE 5.1
Putative Benefits of Digital Health Applications for Substance Use Disorders (SUD)
Adapted from Budney AJ, Stanger C, Tilford JM, et al. Computer-assisted behavioral therapy and contingency management for cannabis use disorder. Psychol Addict Behav . 2015;29(3):501–511. https://doi.org/10.1037/adb0000078 .
|
How Can Digital Technology Enhance Care for SUDs?
Global access to digital technology has grown exponentially over the past 10 years, with some estimates suggesting that 90% of the world's population will have a mobile device by the 2020s. Of great importance to health care—and to SUD and psychiatric care in particular—is that even the most vulnerable, disadvantaged and underserved populations have high rates of access to personal digital technology devices. If effective health care can be delivered via digital health applications, such ubiquitous availability of these devices can facilitate access to care that is potentially much less burdensome to obtain (e.g., access from home), more available (e.g., received at any time of day), and less costly (e.g., provider costs reduced). Moreover, digital health tools can offer methods for engaging individuals more fully in their own health care through interactive monitoring and prompting of health behaviors in real time throughout the day when many of the most important health-related choices are made (e.g., food and drink consumption, exercise activities, medication adherence, stress management, alcohol or drug use). Individualized and daily engagement with intervention plans and actions holds promise for enhanced outcomes. Some data even suggest that interaction with a digital health device rather than with a healthcare worker may increase willingness to identify and address highly sensitive issues such as substance use, risky sexual behaviors or diseases, and other mental disorders. Digital tools could be readily available to all persons with access to digital devices and could effectively address the tremendous health disparities disadvantaged populations face worldwide with regard to access to quality care.
Digital health offers multiple potential benefits not only for the individual, but for the healthcare provider as well. Digital interventions offer greater availability of and access to evidence-based interventions in the clinic or the patient's home. For clinicians, digital screening and electronic health record (EHR) systems can provide more effective and efficient means for identifying problems, communicating within and across provider systems, and coordinating care. Moreover, digital delivery holds promise for addressing potential diminished efficacy of treatments due to the use of nonevidence-based interventions or failure to deliver evidence-based interventions with high fidelity. Utilizing digital health interventions could also greatly lower the cost of SUD treatment by reducing the time and costs associated with training personnel and delivery of effective care (e.g., Refs. ). Furthermore, technology-delivered treatment models may facilitate and expedite integration of scientific discoveries and treatment innovations, resulting in continuous enhancement of health outcomes (i.e., quality improvement).
Several articles and book chapters have explored actual and conceivable benefits of digital health and reviewed outcomes from pilot studies and controlled trials of specific digital interventions. Below, we first expound on the potential benefits of digital technology for SUD care and the multitude of clinical settings that can benefit. This discussion is followed by a brief synthesis of what the research to date has revealed about the efficacy of digital health applications in this area. We then provide examples of a few select types of digital interventions for SUDs to illustrate the progress being made and the breadth of their potential future impact. Last, we discuss challenges and barriers to adoption and implementation of the digital health applications in the SUD field.
Advantages and Value of Digital Health Technologies for SUDs
Perhaps the most obvious and important impact of digital technology on SUD is its potential to greatly extend access to evidence-based interventions. The availability of SUD treatment, state-of-the-art science-based interventions in particular, is generally poor across all segments of society and even more so in rural or disadvantaged populations and developing countries. However, mobile phone and internet access is ubiquitous even among some of the most disadvantaged and remote populations. The ability to deliver efficacious SUD interventions remotely could decrease the number of persons in need of SUD services and sharply reduce health disparities.
In addition to increased access, digital interventions hold promise for enhancing the quality of care that is delivered. Removing the human element should theoretically improve the fidelity and integrity of delivery of evidence-based care, as treatment delivered in community settings may not align closely with how the intervention was designed and thus may lose efficacy. In contrast, a digital program that has been tested in a controlled setting could be installed and made available to the patient in a format that better maintains the fidelity of the intervention.
Digital interventions allow patients the flexibility to engage with an intervention (receive care) at their convenience, potentially increasing their engagement with and commitment to their own care. Anytime access to digital interventions could facilitate opportunities for patients to expedite or enhance the learning and practice of the coping skills often involved in SUD interventions. Additionally, empirically based learning methods (e.g., fluency learning) that can be programmed into such interventions could further enhance mastery of coping skills. Offering patients the option to access care in the home environment may reduce inconsistencies in service delivery stemming from factors such as missed appointments, clinic closures, lack of transportation, or stigma.
Much attention has recently turned to the potential for “just-in-time” interventions using digital therapeutics. Research on what is being called just-in-time adaptive interventions (JITAI) is beginning to provide data on how this exciting new area of innovation in digital health may enhance treatment outcomes for SUD. JITAI models aim to leverage personal sensing technology in addition to digital mobile devices and programming to provide the right type of therapeutic assistance at the time it is most needed. Automated information about an individual's personal environment obtained via mobile sensors (e.g., from a watch or phone) or automated self-reported assessments via programmed ecological momentary assessment programs are being used to identify emotional states and environmental contexts that are high risk for substance use or relapse. The assessment then triggers an automated digital intervention or prompts the user to engage a coping skill.
Digital therapeutics have the potential to foster highly individualized or personalized care that can respond to an individual's profile of needs, preferences, culture, cognitive functioning, stage of recovery, and clinical trajectory over time. Individuals can control the pace of their treatment, and programming can readily facilitate patient choice of intervention topics, amount of practice, repetition or return to a desired topic, self-monitoring and assessment, re-examination and modification of goals, and ignoring of irrelevant topics or exercises.
Digital technology can enhance screening processes, standardization of assessment, accuracy of personal data collection, and potentially enhance assessment by extending it to the individual's environment. Most recently, digital screening models have proven helpful in increasing the efficiency and accuracy of identifying those who might benefit from SUD interventions when employed in primary care, emergency departments, pediatrics, and other non-SUD healthcare settings. Many of these systems have also used technology to more efficiently communicate screening results to providers. Systematic assessment of SUDs conducted on mobile devices or personal computers that are either patient-administered or used to guide healthcare workers can increase the probability of an SUD assessment being performed, and improve reliability and accuracy of the identification of SUDs. Digital assessment of substance use, behavior, and personal functioning in the patient's environment over time can improve accuracy and self-awareness of important treatment process variables such as identification of emotional or environmental triggers for use, or temporal relationships between substance use and positive and negative mood or consequences.
By reducing the need for SUD specialists, digital interventions and assessment platforms can extend the possibility and probability of offering care in non-SUD specialty settings such as primary care, schools, the emergency room, and pediatrics. Stand-alone, self-help SUD digital interventions can further extend care by allowing access to anyone at any time via the internet. Evidence-based self-help may be a good alternative for those who are reluctant to seek out professional help due to stigma, cost, or logistical challenges.
Finally, digital interventions may also be combined with traditional clinician-delivered care to enhance outcomes, increase efficiency, provide clinician training, and increase treatment capacity in community SUD specialty clinics. When combined with standard psychosocial approaches, digital interventions can contribute to improved outcomes by delivering essential treatment components, such as coping skills. These interventions can also address the large shortage of SUD and mental health clinicians in multiple ways. Digital therapeutics can effectively function as a partial substitute for clinician-based interventions and thus free up therapist time to devote to issues that cannot be addressed digitally. Such combination treatment models for SUD can be cost-effective and increase the availability of treatment slots.
Evidence Supporting the Positive Potential of Digital Health for SUDs
A relatively large body of data illustrates and supports the potential of applying various types of technological devices and platforms to effectively treat SUDs. This accumulation of data and knowledge progressed to the extent that a “review of reviews” was published in 2013 identifying nine meta-analytic and 13 qualitative reviews of technology-based interventions for SUDs. Much of this literature comprised examples of studies using web-based intervention programs accessed via a desktop or laptop computer to provide computerized versions of behavioral treatments that had been previously manualized for delivery by a therapist. This review of reviews concluded that “ technology-based interventions for substance use problems are efficacious, effect sizes are generally small to medium, and treatment mechanisms remain largely unknown .” One could argue that such a conclusion closely parallels the status of clinical research on much of traditional evidence-based, therapist-delivered interventions.
Several reviews have evaluated treatments delivered via mobile technologies such as smartphones and tablets, while others have focused on technology-based interventions designed to treat specific types of SUDs, such as tobacco, cannabis, or alcohol use disorders. Other reviews have synthesized data on interventions designed to address multiple types of substances. Collectively, this body of work has consistently concluded that technology-delivered treatments can be highly useful and acceptable to diverse populations; have a meaningful impact on health behavior and outcomes; produce outcomes comparable to, or better than clinicians in some settings; increase quality, reach, and personalization of care; improve cost-effectiveness; and respond to individuals' health behavior over time.
Examples of Digital Health Applications
No consensus definition exists for what comprises the increasingly broad range of technology-delivered health interventions, and the types of applications being tested and utilized to assist in SUD treatment continue to escalate. Perhaps the most developed and evaluated of these applications are software programs that “deliver” therapy via a desktop or laptop computer, tablet, or mobile phone, either through web-based connections to servers or applications housed directly on the device's hard drive. Examples of these clinical tools include: self-assessments, skills training or psychoeducation modules, automated ecological momentary assessment or intervention programs used to self-monitor target behaviors and prompt use of coping skills, text-based motivational and coping programs, and integration of social media-type support groups. In the sections below, we provide snapshots of a few of the more well-developed and tested digital health applications.
Digital Screening and Assessment
A chronic challenge facing the SUD treatment field is how to effectively identify individuals with or at-risk for developing an SUD, and once identified, how to engage them in effective interventions. Screening, brief intervention, and referral to treatment (SBIRT) models were developed to address this problem and have existed for over 20 years. While such models provide positive steps in addressing this issue, statistics indicate that 85%–90% of persons who might benefit from an SUD intervention do not receive the appropriate services, which suggests that much more progress is needed. Technology-based innovations have the potential to close this gap.
Utilization of digital self-screening and assessment tools in primary care or emergency department waiting rooms has resulted in increased rates of screening and subsequently identifying patients with SUD problems. Integrating the digital screening with a healthcare system's electronic health records (EHR) has been proposed to enhance real-time communication regarding substance use screening results to the health provider scheduled to meet with the patient. Screening results can automatically populate EHRs and clinical protocols built into EHRs can prompt provider adherence with engagement and delivery of an intervention. Such interventions could be delivered either by a provider (e.g., physician, nurse, mental health therapist, etc.) or via a digital health tool. Such models have been tested in part, and current studies that evaluate these types of models of care in primary care settings, emergency departments, and school systems are ongoing.
You're Reading a Preview
Become a Clinical Tree membership for Full access and enjoy Unlimited articles
If you are a member. Log in here