Online programs to provide substance abuse treatment? Phone apps that can measure someone’s blood alcohol level? Welcome to the future —in some cases, the very near future. Dr. Nunes, the deputy director for intervention studies at the Center for Technology and Behavioral Health, sheds light on technology-assisted care.
CATR: What are some of the online treatment modalities available for psychiatrists to incorporate into their substance abuse practices?
Dr. Nunes: Cognitive behavioral therapy (CBT) is the main modality available now. CBT lends itself to online treatment because it consists of a set of clearly defined techniques that can be taught in an online, multimedia format. These techniques are good adjuncts to traditional in-person psychotherapy.
CATR: What are the perks of teaching CBT online if clinicians are involved anyway?
Dr. Nunes: For one thing, it unburdens the clinician, who doesn’t need to be specifically trained in CBT and can spend the time talking to patients about their unique experiences instead of delivering content. Also, a major barrier to delivering evidence-based behavioral treatments is that it’s hard to get clinicians to deliver treatment the way the manual says to deliver it. This means the treatment delivered by clinicians often isn’t truly evidence-based. Online treatment delivers the content in a way that’s true to the manual.
CATR: What is the evidence supporting online substance abuse treatment?
Dr. Nunes: For some interventions the evidence is mixed, and as you might imagine, there are many that have never been researched. Although some may incorporate principles of evidence-based treatments like CBT, the programs themselves haven’t been tested in randomized controlled trials (RCT), and there’s no guarantee they are effective. There are a couple of programs out there with a solid evidence base, and there are two meta-analyses showing that online treatment as a whole is effective for cannabis and tobacco use disorders (Tait RJ et al, Drug Alcohol Depend 2013;133(2):295–304; Gulliver A et al, Addict Sci Clin Pract 2015;10:5).
CATR: Can you tell us about the specific programs that are evidence-based?
Dr. Nunes: There are two that I’m aware of. The first is Computer Based Training for Cognitive Behavioral Therapy, or CBT4CBT. It consists of a series of multimedia modules and is built around cognitive behavioral relapse prevention for substance use disorders. The modules teach skills such as managing cravings. For example, one skill is delaying response —this is the idea that you might really want to use drugs right now, but if you just put it off for 20 minutes, the craving will probably go away. The program includes many practical skills like this, taught through a combination of text and video. There is also a module on condom use, because substance use disorders increase the risk of STIs.
CATR: What does the research say about the effectiveness of CBT4CBT?
Dr. Nunes: There have been two RCTs. In one, among 77 individuals with any substance use disorder, participants assigned to the CBT4CBT group were significantly more likely to produce negative urine specimens for any type of drug and had longer periods of abstinence during treatment. Retention in treatment was not different between the two groups (Carroll KM et al, Am J Psychiatry 2008;165(7):881–888). In the other, among 101 cocaine-dependent participants maintained on methadone, participants assigned to CBT4CBT were more likely to have 3 or more weeks of abstinence from cocaine and had a greater reduction in cocaine use at 6 months compared with treatment as usual (Carroll KM et al, Am J Psychiatry 2014;171(4):436–444).
CATR: You mentioned there is another evidence-based intervention.
Dr. Nunes: Yes, the Therapeutic Education System, or TES. It emphasizes some of the same relapse-prevention skills as CBT4CBT, but focuses more heavily on community reinforcement approaches, such as, “What can I do to have fun without using?” It also incorporates a contingency management system.
CATR: How does that work?
Dr. Nunes: In traditional substance abuse treatment, contingency management works by rewarding patients for desired behavior, such as attending groups or producing negative urine drug screens. In TES, the principles are the same, but the computer program keeps track of the vouchers and provides a visual demonstration of the vouchers being awarded. For example, let’s say a person’s urine today was negative for drugs. The staff inputs that information into the computer, and the program keeps track of how many negative urines the person has had and how many vouchers that person earns.
CATR: What have clinical trials said about TES?
Dr. Nunes: There was a 10-site NIDA-sponsored trial including 507 participants with heterogeneous substance use disorders. In that study, TES doubled the odds of abstinence in participants who had been using within 30 days of baseline, and it increased treatment retention compared with treatment as usual (Campbell AN, Am J Psychiatry 2014;171(6):683–690).