Saskatchewan DTFP Project to Review Current Research Literature on Web-Based Interventions for Risky Alcohol and other Drug Use

Summary

Prepared by

David Brown PhD

Pathways Research

May 2014

Background

Challenge

There is an emerging body of evidence that the identification and provision of subsequent treatment of depression can be augmented by web-based technologies in ways that are efficacious and cost-effective. The evidence comes from projects within Canada, including the online therapy project led by Dr. Heather Hadjistavropoulos at the University of Regina in Saskatchewan, as well as from large scale implementation in Australia.

However, similar technologies to augment identification and provision of subsequent treatment of alcohol and other drug use problems have not been as widely implemented or tested. The potential cost-savings and increased capacity to help a larger segment of the population are significant. Online and related technologies might be used by individuals as either stand-alone self-help tools for self-screening and self-directed behavioral change, or used to support formal treatment processes.

Objectives

In order to determine next steps in this area, the Saskatchewan Ministry of Health commissioned this brief study with the support of Health Canada’s Drug Treatment Funding Program. The study aims to provide an overview of what has been learned about the use of online tools in the area of substance use, to gauge the perceived potential for implementing such tools in Canada, and to make recommendations regarding useful next steps.

Methods Used

Literature Search

Terms related to technology and substance abuse in various combinations were searched in PubMed. Fifty articles were located dating back to 2006. Articles were sorted based on relevance and forward and backward searches from identified papers were conducted to find related articles. Google Scholar and Research Gate were used to locate new articles identified from the initial article search. A grey area search was conducted to find programs that are not in the academic and professional literature that have been created or are being used.

We located 9 review articles and 29 single study articles that met the criteria of technology-based interventions for substance abuse (see Appendix 1). The reviews and single studies vary in which types of substances and technologies they include and how they define a technology-based intervention. The articles encompass computer-based interventions, web-based phone programs, interactive voice response phone programs, text-message programs, smartphone apps, video-conferencing, and tablet programs.

Survey of Experts

An online survey was conducted with a sample of experts from across Canada in the area of problem substance use screening and treatment. A snow-ball sampling process was used. Initially, approximately 20 individuals were invited to participate. These individuals were also asked to share the invitation with any of their peers whom they felt might offer useful insights. The sampling processes yielded 28 respondents. (see Appendix 2)

Scan for Examples

In addition to reviewing the research literature and consulting with Canadian experts, we conducted a scan for examples of web-based resources for augmenting substance use problem screening and interventions (see Appendix 3).

Summary of Findings

Literature Overview

Research conducted on computer-based interventions for alcohol orother drug problems show that these therapies can be effective. Some studies concluded that these therapies are as effective as traditional in-person treatment and others showed that these treatments are more effective than in-person treatment (GainsburyBlaszcynski 2011, Moore 2011, Tait & Christensen 2010). Studies showed that these effects can last through follow-up of 6 and 12 months (Kypri 2008, Riper 2009, Klein 2012, Carroll 2008).

One study found that more intensive technology-based interventions are more efficacious than briefer technology-based interventions (Litvin 2013). Another study found that minimal contact interventions, with fewer sessions and that can be accessed from home, may be as effective as high-cost, labour-intensive interventions (Rooke 2010).

One study found that technology-based interventions for marijuana are effective but less so than in-person interventions (Tait). Another showed that interventions to reduce marijuana use may be affective if they are applied and reinforced through interpersonal aspects of treamtent (Shrier 2013).

A computer-screening program in an emergency department had very good results with 98% of interviews completed without being interrupted by other clinical care activities (Murphy 2013).

Interactive Voice Response telephone programs were found to be effective for alcohol and drug use patients as follow-up care and reduced their use compared to those not using the program (Tucker 2012, Moore 2013).

However, technology-based brief alcohol interventions may not be as effective in cases of concurrent substance use and mental health problems (Cucciare 2013).

Computer-based interventions showed high levels of client satisfaction and had levels of engagement and retention similar to those in therapist-provided treatment (Moore 2011).This can potentially improve treatment response by promoting client satisfaction (Newman 2011).

Patients had a preference for receiving information about reducing substances using newer technologies rather than traditional formats (Choo 2012).The most commonly cited reasons for this preference being 24-hour availability, ease of access to a computer, anonymity and privacy, not having to attend face-to-face meetings and counselor credentials (White 2010, Newman 2011, King 2009).

Only 10-20% of risky or problem drinkers seek or engage treatment (Riper 2009). This is the case even though concern about the harm of alcohol in those with risky alcohol use who have never sought treatment was comparable to that of traditional treatment-seekers. An opportunity may therefore exist to use technology for engaging those who do not usually seek help (Liberman & Huang 2008).

Technology-based interventions could be especially useful for groups less likely to access traditional alcohol-related services, such as women, young people, and at-risk users. Traditional substance use treatment programs have gender-specific barriers and do not adequately meet the needs of women. These barriers include lack of childcare, lack of family treatment, and discomfort in male-dominated groups. (Liberman & Huang 2008) Women and parents were more likely to access technology-based interventions. (VanDeMark 2010, White 2010)

Attrition levels with internet-based treatments were often high and in one review ranged from 22% to 65% (Newman 2011).Individuals will often drop out or discontinue using technology-based interventions that are not highly engaging or that lack the ability to freely explore and access all available content at any time with clear therapeutic goals (Litvin 2013).

To make the best use of technology-based interventions, clients should be allowed to set the pace of their treatment and they should be able to determine when and how long to engage in the assigned intervention (Neman 2011).

Internet-based treatments should take advantage of the potential for highly tailored, unlimited, constantly available content that adapts and responds in a dynamic, iterative manner to fluctuations in individuals’ environmental and social contexts and emotional and physiological states (Litvin 2013).

Patients and clients have voiced concerns and need reassurances about the confidentiality of technology-based interactions. It is important that patients perceive and are reassured of the security and privacy of technology-based interventions (Newman 2011, Choo 2012).

Consultation with Experts

Of the 28 respondents 13 (just under half) were aware of web-based screening or assessment tools for AOD issues currently used in Canada. Only four (4) respondents were aware of plans or opportunities in Canada to set up web-based screening or assessment tools for AOD issues. Eighty-five percent were not aware of any.

The majority of respondents were not aware of any web-based tools available for individuals to do cognitive or behavioral change work relating to AOD currently being used in Canada. The majority of respondents were not aware of any plans or opportunities in Canada to set up web-based tools for individuals to do cognitive or behavior change work relating to AOD issues.

When asked to comment on the importance of development technology-supported approaches, all who commented (22) felt it was important and also described it as helpful, valuable, useful, and beneficial. The following themes emerged from their comments on strengths:

  • Respondents indicated that such tools will be helpful to provide information, allow for self-reflection and ‘open doors’ to treatment for individuals. They will be a valuable, easily accessible resource for health care providers and professionals to use in a variety of settings.
  • It was felt that tools for addictions would likely be successful due to the success of web based mental health tools in Australia. One person commented that all information online is American and/or not regulated or appropriate.
  • One respondent commented that many people may prefer to work with web-based tools and use the internet as a first place to seek information on challenges they are facing. Respondents felt this would be particularly beneficial for youth and those not situated, do not have resources in their community or are not prepared to meet face to face.
  • Respondents like the idea of mobile applications, supports with someone live attached to them 24/7 (e.g. moderated online support groups), and using strength based language for both addictions and co-occurring disorders.
  • Respondents felt that web-based screening is “a promising practice” and “important strategy” to identify and contribute to moderate to high risk drinkers considering change and taking action. Someone felt this should be promoted as society’s cultural norms around alcohol are changing in favor of risky drinking. Another indicated there is research to support web based tools helps people be linked into assistance for highly stigmatized behaviour of drinking when pregnant.
  • One respondent commented that the computer will likely replace face to face clinical experiences in the future and feels this is worthy of investigation and research. This respondent commented on these tools will make things easier for the client (or potential client), ease clinical administrative paperwork and steer/guide clinical decision making and will be a huge improvement.
  • Evidence supports that these are an important part of an overall strategy. Web-based tools with normative feedback are as effective as face-to-face interventions. This means that this is potentially a very important population health strategy.

The following themes emerged from respondent comments on potential barriers:

  • In developing the tool it must be a quality tool that is simple, relatively short and not too complicated so it is easily accessible to everyone. It should include different versions (e.g. a computer, iPad, smartphone app). Localized pathways to care would need to be established for the referral and treatment that might be needed as a follow-up to the screening.
  • Barriers identified include lack of evidence of effectiveness, cost, language diversity, privacy, access to the internet, perceived lack of time to use the resource, interpretation of the instruments, and awareness and ability to get information out to potential users (e.g. LRADG and inconsistent messaging with risks for alcohol and chronic disease (cancer).
  • Some concerns raised for service providers include fear of change, the ability for agencies to have permission to set up these tools, lack of follow-up support in the community to support moderate to high-risk drinkers and lack of knowledge/time among primary healthcare professionals to value web-based screening and face-to-face brief intervention for alcohol.
  • Negative stigma in Mental Health and Addictions regarding addictions. Most believe that if the Mental Health problems go away then there is no need to address addictions. Proper assessment of what needs to happen first.

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