Michael L. Dennis, Ph.D. Chestnut Health Systems, Normal, IL...Chestnut Health Systems, Normal, IL Wednesday June 14, 2017 ... (TCC) for 3 months • The TCC group were significantly

TECHNOLOGY ASSISTED CARE INSUBSTANCE USE TREATMENT

AND RECOVERYMichael L. Dennis, Ph.D.

Chestnut Health Systems, Normal, IL

Wednesday June 14, 2017Haymarket’s 23rd Annual Summer

Institute on Addictions, Elmhurst, IL

Chronicity and Hope• Substance use disorders (SUD) are a chronic condition that typically lasts for decades and have a high risk of relapse.

• Yet over two thirds of the people with SUD eventually enter recovery.

• Treatment reduces the time to sustained recovery, but it takes 3 to 4 episodes of treatment before half the people are able to sustain remission.

• This is actually equal to or better than many other major chronic medical and mental conditions.

Source: Dennis, M., & Scott, C. K. (2007). Managing addiction as a chronic condition. Addiction Science & Clinical Practice, 4(1), 45

The Challenge• Unfortunately, less than 1 in 10 people with SUD access treatment, half drop out in less than 90 days, and half relapse within the 90 days after discharge.

• Since the turn of the century there has been a growing move to use technology (phones, pc, internet, smartphones, other devices) to reduce the barriers to entering and staying in treatment, enhance treatment and for providing recovery support.

• Technology has also been used to improve capacity, consistency, quality, effectiveness and cost‐effectiveness of care.Source: Dennis, M., & Scott, C. K. (2007). Managing addiction as a chronic

condition. Addiction Science & Clinical Practice, 4(1), 45

Workshop Objectives1. Review advances in technology and

technology assisted care in substance use treatment and recovery support;

2. Examine evidence on their acceptability and effectiveness with actual clients;

3. Identify existing resources that participants can access immediately; and

4. Identify some of the limits of what is available and look at where we are going.

Review advances in technology and technology assisted care in substance use treatment and recovery support

Examples of Technology Used to Make Care More Accessible and Efficient, and Effective• Telephones, cell phones, smartphones• Computers, Laptops, and e‐readers• Internet, streaming and mobile applications• Electronic health records• Clinical decision making and machine learning

Each can be used to help with gaining access, scheduling appointments, communications counseling, recovery support, skill building, and increasing patient engagement

Growth in Mobile Phones

0%10%20%30%40%50%60%70%80%90%100%

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

Cellphone(95%)Smartphone(77%)

Source: http://www.pewinternet.org/fact‐sheet/mobile/ , https://www.cdc.gov/nchs/data/nhis/earlyrelease/wireless201705.pdf

In addition to numbers, smartphones have gone from PDA (Palm, blackberry) to being handheld computers

Of the 56% of people in 2016 with

landlines, 48% also have cellphones

Correlates of Smartphone Ownership in 2016

Source: http://www.pewinternet.org/fact‐sheet/mobile/

95%

96%

94%

94%

94%

98%

100%

99%

97%

80%

0%20%40%60%80%100%

Total

Men

Wom

en

White

Black

Hispanic

Ages 18‐29

30‐49

50‐64

65+

Cellphone OnlySmartphone

• Little relationship to gender or race (very different than PC)

• Does go down with age

Correlates of Smartphone Ownership in 2016 (continued)


92%

92%

96%

97%

92%

95%

96%

99%

95%

96%

94%

0%20%40%60%80%100%

Less th

an H.S.

High

scho

ol

Some college

College gradu

ate

Less th

an $30

,000

$30,00

0‐$4

9,99

9

$50,00

0‐$7

4,99

9

$75,00

0+

Urban

Subu

rban

Rural

Cellphone OnlySmartphone

• Smartphone ownership goes up with education and income, and

• is lower in rural areas

Comparison with Trends for Other Devices

0%10%20%30%40%50%60%70%80%90%100%

2008

2009

2010

2011

2012

2013

2014

2015

2016

Desktop/laptop(78%)

Tablet(51%)

E‐reader(22%)


Internet Usage in the U.S.: 2016

• 88% of us use the internet• 85% access it by a mobile device• The most common uses include

–News–Social networking–Music/video streaming–Accessing health information


Internet as a diagnostic tool

Source: http://www.pewinternet.org/2013/02/12/the‐internet‐and‐health/

Internet for Self Tracking


Internet for Self Tracking


…And the above numbers were from 2012 and have likely grown further in the past 5 years

How many of you…1. Have looked up health information on the

internet? 2. Looked up information on health care providers? 3. Have a health application on your computer, tablet

or phone? 4. Have refilled a prescription on‐line, made an

appointment?5. Have accessed your health care providers patient

portal?6. Wanted to communicate with your health care

provider on‐line, including text or email?


Examine evidence on technology assisted care’s acceptability and effectiveness with actual clients

7 Reviews and formal meta analyzes across studies have found that…• Technology based prevention treatment and recovery support services as adjuncts can improve treatment satisfaction and outcomes

• Can work as well or slightly better than traditional human delivery of services

• Meta analyses of EMI across multiple platforms (e.g., SMS, IVR, smartphones) and health outcomes have generally found positive effects.

• Similar results for the limited number of smartphone studies to date. Sources: In notes

Telephone Continuing Care Experiment• 104 Adult patients being discharged from residential treatment were randomized to usual continuing care vs telephone continuing care (TCC) for 3 months

• The TCC group were significantly more likely to have:– Higher rates of initiating continuing care– More sessions of continuing care– Fewer symptoms of substance use disorders– High treatment satisfaction

• The TCC group also expressed high satisfaction with the 20 min calls and 72% would like them to have to continued

Source: Godley, M. D., Coleman‐Cowger, V. H., Titus, J. C., Funk, R. R., & Orndorff, M. G. (2010). A randomized controlled trial of telephone continuing care. Journal of substance abuse treatment, 38(1), 74‐82.

CBT4CBT Experiment• 77 patients randomized to standard treatment vs. standard treatment plus 6 more modules of Computerized CBT

• CBT4CBT group were significantly more likely to have:– Clean urines– Longer continuous periods of abstinence– High treatment satisfaction

• No significant difference on total days in treatment or total days of abstinence

• Completion of CBT4CBT modules was correlated with treatment involvement and outcomes

Source: Campbell, A.M., Nunes, E.V., Miele, G.M., Matthews, A.., Polsky, D., Ghitza, U., Turrigiano, E., VanVeldhuisen, P., Chapdelaine, R., Froias, A., Stitzer, M.L.,Carroll, (2014). Internet‐delivered treatment for substance abuse: A multisite randomized controlled trial. American Journal of Psychiatry, 171,6, 683‐690

ACHESS Smartphone Experiment• 349 adult patients at residential discharge randomized to continuing care as usual vs. that plus the Addiction Comprehensive Health Enhancement Support System (ACHESS) smartphone application

• ACHESS patients used the application and average 56 times per week over 8 months

• ACHESS group were significantly more likely to have:– fewer days of risky drinking – Longer continuous periods of abstinence

• No significant difference on total days of abstinence• The frequency of using the ACHESS application was correlated with better outcomes

Source: Gustafson DH, McTavish FM, Chih M‐Y, et al. A smartphone application to support recovery from alcoholism: A randomized clinical trial. JAMA Psychiatry. 2014;71(5):566‐572.

Combining EMA and EMI• 29 adolescents being discharged from residential adolescents being asked to self monitor via ecological momentary assessments (EMAs) 6 times a day and provided 24/7 access to ecological momentary interventions (EMIs) related to relapse prevention for 6 weeks

• 5580 EMA observations (87% completion) and 24,563 EMI (average of 84 EMI per person week).

• Demonstrated ability to use the EMA to predict time to relapse.

• Demonstrated that use of EMI was associated with reducing this risk.

Source: Dennis, M. L., Scott, C. K., Funk, R. R., & Nicholson, L. (2015). A pilot study to examine the feasibility and potential effectiveness of using smartphones to provide recovery support for adolescents. Substance abuse, 36(4), 486‐492.

Substance Use in the Next 7 Days by EMA Observation Risk Group


Smartphone Recovery Support Services (mean of 84 per week)

40

22

11

11

0 10 20 30 40 50

Recovery Support

Recovery Motivation

Relaxation

Social Networking

Times Per Week

Most popular were within cohort discussion groups, and texting within group


Substance Use in the Next 7 Daysby EMI Utilization within 1 Hour

43%32%

0%

20%

40%

60%

80%

100%

% Usin

g in th

e Next 7

Days

EMI Utilization within 1 hour of EMA0‐1 Times 2+ Times

* OR=0.62, p<.05


Substance Use by Risk and EMI Utilization within 1 Hour

96%

51%

33%

93%

43%

21%

0%

20%

40%

60%

80%

100%

Current use(O=94;OR=.55)

Unrecognized Risk(O=1552;OR=.69)

Recognized Risk(O=1994;OR=.54)

% Usin

g in Next 7

Days

0‐1 Times 2+ Times *p<.05

Effect was largest and use was lowest for youth who were recognizing risk and using EMI


Identify existing resources that participants can access immediately

Technology Assisted Care (TAC)• Brief Intervention: Targeted a places with limited behavioral health that may do a lot of screening / referral sources such as primary care, FQHC, CMHC, probation/parole

• Clinician Extender: Administered as an adjunct to treatment where clinicians prescribe modules as home work to enhance intervention; phone, text or portal to fill in down time.

• Stand Alone Treatment: Comprehensive services (up to 65 modules) delivered over a structured period of time as an alternative to regular treatment due to access issues, schedule or preference

Source: http://sudtech.org/curriculum/

TAC Consideration• Self directed websites are often administered by a third party – will likely want a business associate agreement.

• To allow staff access and control, typically purchase a license agreement for so many clients and provide them with individual id and passwords – need to ensure that the patient portal is compliant with HIPAA and HITECH

• Applications vary in in the amount of person information they collect (e.g., names, date of birth) and their ability to preload it from your records – need to assess ability to integrate with your electronic records system

Source: http://sudtech.org/curriculum/

Technology Assisted Care for Substance Use Disorders at WWW.SUDTECH.ORG

Some Key Resources for Evidence Based Practices that are available NOW

Computer‐Based Training for Cognitive Behavioral Therapy at www.CBT4CBT.com

Addiction Comprehensive Health Enhancement Support System (ACHESS) at www.chessmobilehealth.comGlobal Appraisal of Individual Needs (GAIN) Coordinating Center at www.gaincc.org

Therapeutic Education System (TES)• TES is an interactive, web‐based psychosocial intervention

for SUDs, grounded in: Community Reinforcement Approach (CRA) + Contingency Management Behavior Therapy + HIV Prevention

• Self‐directed, evidence‐based program includes skills training, interactive exercises, and homework

• Audio component accompanies all module content• Electronic reports of patient activity available• Contingency Management Component tracks earnings of

incentives dependent on some defined outcome (e.g., urine results confirming abstinence)

• New content can be readily added• Uses incentive procedures including a virtual “fishbowl”

using intermittent schedule of reinforcement based on abstinence, and module completion

• Currently enroll through an existing treatment program or private practice.

Source: WWW.SUDTECH.ORG

TES Consists of 65 interactive, multimedia modules including• Conducting a functional analysis• Effective problem solving• Drug refusal skills training• Managing negative thinking• Steps for giving constructive criticism• Giving and receiving complements• Communication skills• Sharing feelings• HIV and AIDS• Drug use, HIV and Hepatitis• Increasing self‐confidence in decision makingSource: WWW.SUDTECH.ORG

Computer‐Based Training for Cognitive Behavioral Therapy (CBT4CBT)

• CBT4CBT is a web‐based program that teaches a variety of CBT skills that are specific for helping people to reduce substance abuse.

• CBT4CBT is a self‐guided web‐based program with 7 one hour modules that uses movies and examples to teach skills.

• Typically take one module per week, they can be done in any order.


Source: www.CBT4CBT.com

CBT4CBT includes modules on

• Understanding patterns of substance use, • Learning to recognize and deal with craving, • Addressing thoughts about substance use that can set you up to use,

• How to effectively say ‘No’ to offers of alcohol or drugs, and

• how to be more aware of patterns of thinking and decision making that can lead to drug use.

Source: www.CBT4CBT.com

Addiction Comprehensive Health Enhancement Support System (ACHESS)• ACHESS is a smartphone based relapse‐prevention

program designed to improve continuing care. • It is grounded in self‐determination theory and seeks to

satisfying three fundamental needs contributes to adaptive functioning: perceived competence, a feeling of relatedness, and autonomous motivation.

• It is also based on relapse prevention to address high risk situations, lack of coping responses, and craving.

• ACHESS also has a counselor dashboard for interacting with patients


Source: www.chessmobilehealth.com

ACHESS features include:• resources to cope with pressures to relapse such as cravings, withdrawal symptoms, and high‐risk situations (competence);

• providing opportunities to give and receive social support to persevere (relatedness); and

• developing and maintaining autonomous motivation to prevent relapse (autonomy).

• GPS alerts when approaching a high risk area,• Medication and appointment reminders• Daily and weekly surveys• Recovery management plansSource: www.chessmobilehealth.com

GAIN features include:• The Global Appraisal of Individual Needs (GAIN) is a family of

standardized instruments that include clinical decision support to help clinicians with diagnosis, treatment planning, placement and program evaluation

• They can each generate narrative and tabular reports that can used with patients, other staff and other providers

• The cloud based system is also designed so that it can be a component of a n electronic medical record system

• The GAIN has been used by collect 711,000 assessments by 14,500 staff in over 4700 agencies in all 50 states of the U.S., 10 provinces of Canada and 11 other countries.

• It has over 450 publications and publically available psychometrics on over 100,000 adults, young adults and adolescents.

• It has been recognized and recommended as a standardized assessment tool by multiple federal, states, tribal and private agencies.

Source: www.gaincc.org

Range of GAIN Instruments• a 5 minute screener for general populations that can

accurately identify 90% of the diagnoses related to internalizing or externalizing mental health disorders, alcohol or other drug disorders, and crime or violence , accurately rule out 90% that do not have them, and be used to measure change.

• a 25 minute quick assessment for indicated populations that incorporates above plus additional screeners for work, school,, health, stress, risk behaviors, life satisfaction, health care utilization and costs, as well as motivational interviewing to

• a 1‐2 hour full bio‐psychosocial assessment tool for intake to substance use and co‐occurring substance use/mental health programs across levels of care and ages that incorporates the above but also measures more detailed scales and information in each area, as well as HIV risk behaviors, psychosocial stress, lifetime history of problems./utilization, more detailed diagnoses, triggers for treatment planning recommendations and placement.

Source: www.gaincc.org

Source: https://store.samhsa.gov/product/TIP‐60‐Using‐Technology‐Based‐Therapeutic‐Tools‐in‐Behavioral‐Health‐Services/SMA15‐4924

• Highlights the importance of using technology‐based assessments and interventions in behavioral health treatment services.

• Discusses how technology reduces barriers to accessing care.

• Literature review through 2014

Source: http://store.samhsa.gov/apps/mat/

• Information on treatment approaches and medications approved by the U.S. Food and Drug Administration for use in the treatment of opioid use disorders.

• A buprenorphine prescribing guide, which includes information on the Drug Addiction Treatment Act of 2000 waiver process and patient limits

• Clinical support tools , such as treatment guidelines, ICD‐10 coding , and recommendations for working with special populations, access to critical help lines and SAMHSA treatment locators

National Frontier and Rural ATTC

Source: http://www.nfarattc.org/resources/

Identify some of the limits of what is available and look at where we are going

Some Current Limits of These Systems• Most of the evidence based systems are currently only available through a SUD treatment program or private practice and not yet accessible directly by individuals

• Tend to mimic treatment or continuing care with a duration of 3 months or less and may not be as useful for longer term support with out further development of new models of care and/or recovery support

• While relatively inexpensive, it is not always clear how to bill for it as an adjunct to treatment.

Real Security Concerns• 64% of Americans have personally experienced a major data breach and Tend to mimic treatment or continuing care with a duration of 3 months or less and may not be as useful for longer term support

• 41% have had fraudulent credit card charges• 35% have received notices that sensitive information has been compromised

• 15% say someone has take over their email• 13% say someone has take over their social media• 6% say someone tried to steal their tax return

Source: PEW Research http://www.pewinternet.org/2017/01/26/americans‐and‐cybersecurity/

Trust to Protect Their Data

Source: PEW Research http://www.pewinternet.org/2017/01/26/americans‐and‐cybersecurity/

Where are we going• More user friendly applications to help with screening

and referral that can be used by community partners (e.g., first responders, teachers, health care providers) and/or even directly by individuals

• More user friendly electronic health records (EHR) that better follow workflow, integrate information between providers and with patient portals, and have more useful dash boards to help manage care from different perspectives

• More user and mobile friendly patient portals to improve access, scheduling, communications and even coordinate providing direct services

• Updates to make websites more mobile friendly

Next Generation of Patient Portals• Focus on patient activation/engagement in treatment

and recovery support • User and mobile friendly with better management of

views based on what people what to do, like: – View Clinical Summaries – Health and Behavior Tracking– Access to patient education and resources– Secure electronic messaging – Timeline access to health care information– Reminders about appointments and preventive care (including relapse prevention)

– Links to adjunct and continuing care services• Intuitive search and indexing (vs current data dump you

have to manually dig through)

Source: https://www.healthit.gov/sites/default/files/nlc_how_to_optimizepatientportals_for_patientengagement.pdf

QUESTIONS?• Comments on this presentation can be addressed to Michael Dennis at [email protected] or 309‐451‐7801

• A copy of this presentation is publicly available at https://chestnut.box.com/v/2017‐06‐14‐Haymarket

Documents

Michael L. Dennis, Ph.D. Chestnut Health Systems, Normal, IL...Chestnut Health Systems, Normal, IL Wednesday June 14, 2017 ... (TCC) for 3 months • The TCC group were significantly