Web-based intervention enhances treatment, refocuses clinicians

While computers are replacing the need for people for many functions – computerized tax filing systems, self check-out lines at the grocery store, textile-producing machinery – will they soon be making clinicians obsolete in the addiction treatment field? Not quite, according to Aimee Campbell, PhD, assistant professor of clinical psychiatric social work in the Department of Psychiatry at Columbia University College of Physicians & Surgeons and New York State Psychiatric Institute. However, she does believe that certain types of technologies can be used as a substitute for a small portion of treatment as usual.

A recent National Institute on Drug Abuse (NIDA) study, of which Campbell was lead author, analyzed the results of treatment when the web-based Therapeutic Education System (TES) is incorporated. The TES consists of two evidence-based interventions – a web-based version of the community reinforcement approach (CRA) plus contingency management (the latter involving the offering of tangible rewards for achieving desired outcomes in treatment).

Campbell says that the two interventions are “some of the most researched and efficacious for the substance use disorders that currently exist.” The community reinforcement approach, according to a published work by the National Institute on Alcohol Abuse and Alcoholism (NIAAA), is “an alcoholism treatment approach that aims to achieve abstinence by eliminating positive reinforcement for drinking and enhancing positive reinforcement for sobriety.”

The intervention provides skills to teach, encourage and increase satisfaction with drug-free sources of reinforcement. “We’re trying to replace the reinforcement that drug use provides with some of these more positive activities and relationships,” explains Campbell.

The CRA was an appealing candidate for a technology platform for multiple reasons: one, because it is evidence-based and has extensive empirical support; and two, because despite that effectiveness, it has been relatively burdensome to implement it on an ongoing basis.

Typically, it is delivered in weekly individualized sessions over the course of several months, so the resources needed have been a barrier to its adoption. In essence, moving this intervention to a computer-assisted platform allows for the content to be consistently delivered to patients, using minimal clinician time. In turn, this means the clinician can focus more time and energy on other interventions.

“It becomes a clinician extender, if you will,” explains Campbell. “In a model such as this, the patient has access to more evidence-based treatment than could be delivered in standard community-based treatment alone.”

Previous research has shown that the CRA delivered via computer achieved comparable abstinence outcomes to the same approach delivered by trained clinicians who were being supervised.

While the CRA is a process of learning skills over time, the motivational incentives (contingency management) offers patients an immediate incentive to attend treatment as well as to maintain abstinence.

The study

In the study, a heterogeneous sample of 507 participants, in 10 outpatient substance abuse programs throughout the United States, were randomized to either 12 weeks of treatment as usual or to modified treatment as usual that included the computer-assisted TES. The study was designed for the TES to replace approximately two hours per week of treatment as usual.

The research staff entered into the system information on whether the participant was abstinent based on biological markers. Participants earned draws from a virtual fish bowl for potential prizes based on achieving abstinence from their primary substance of abuse and completing their CRA modules. The approach consists of 62 web-based modules, or individual topics.

The study, which will be published in the American Journal of Psychiatry in June, demonstrated that participants who were randomized to the TES were retained in treatment significantly longer than those in conventional treatment, and that they also showed significantly greater abstinence rates in the last month of treatment. While abstinence status at the start of treatment is typically a strong predictor of treatment outcome, this study showed that the treatment effect was more pronounced in participants who were not abstinent at study entry.

“Participants that were in TES had more than two times the odds of abstinence compared to those in treatment as usual among the non-abstinent group at study entry,” Campbell explains.

Learning curve for participants

Because of past research and experience, there were no challenges with the actual technology during the course of the study. However, Campbell notes that some of the participants were unfamiliar with computers and therefore had a slight learning curve.

The way it is set up, the TES is self-directed and begins with a training module that shows participants how the program works and how to navigate through it. For the first few topic modules, Campbell notes that a few participants experienced some challenges but soon began to grasp the concept and found it was relatively easy to work through.

Campbell’s take away from this is that there should be staff support at the beginning of implementation to work with patients who may not be at ease on the computer.

She says the study, which was conducted within NIDA’s Clinical Trials Network (CTN), helps to show that technology-based addiction treatment can serve as a useful tool in outpatient settings. Additional research is needed to determine how best to integrate these types of technologies into outpatient treatment and into clinicians’ schedules, for the most optimal enhancement of treatment outcomes, Campbell says.