Smartphone apps offer support for SUD

In 2005, the University of Wisconsin received a grant from the Robert Wood Johnson Foundation to bring together technology experts and addiction treatment professionals to brainstorm ways technology could impact the addiction treatment field. Ideas ranged from functional MRIs to nanotechnology to virtual training modules. The idea that drew the most interest and led to follow-up funding, however, was an application for mobile technology.

Soon, in the nascent days of the iPhone, the researchers began work on a smartphone application, the Addiction-Comprehensive Health Enhancement Support System (A-CHESS), designed to provide continuing care for patients with alcohol use disorders. A-CHESS provides monitoring, information, counselor communication and support services to patients. In a randomized clinical trial, its use reduced the number of risky drinking days by 57 percent.

“Throughout the clinical trial, when we would talk to clinicians or give a demo to providers and patients, they would ask where they could get it,” says Andrew Isham, an associate researcher. “Even before the results were in, we knew there was demand for something like this.”

Ten years after that first meeting, A-CHESS is being deployed at clinical sites across the country for alcohol and other substance use disorders. Today, many other developers and treatment organizations are experimenting with smartphone apps to help people connect with peers and clinicians and find support material. Hazelden Betty Ford Foundation and Elements Behavioral Health are among the larger treatment centers offering apps.

It doesn’t happen in a vacuum

Last year DCCCA Inc., an addictions treatment and behavioral health provider based in Lawrence, Kan., started researching applications and technology to incorporate into its treatment programs.

“We are challenged in terms of tools clients can use when they are done with their treatment with us,” says Sandra Dixon, director of behavioral health services. “Over 50 percent of clients told us they have smartphones, and most have access to the Internet.”

Dixon had met with representatives of a technology company that had apps focused on depression and anxiety and was just starting to work on a substance use module.

“Substance use doesn’t happen in a vacuum,” Dixon says.

Many people also deal with depression, anxiety, trauma or chronic pain. The DCCCA team decided to participate in piloting the substance use module and now offers it from the first day a person enters a program.

“We get clients comfortable using the app with our staff so that when they leave us, it is not something new they have to learn; it is part of their recovery process,” Dixon says.

Some apps set up virtual support groups, she adds, but the organization chose to focus on the app for trauma and chronic pain. The app also could be linked to its EHR in the future.

“We are beginning to work on shared functionality that will allow us to expand how we use it and document it in our medical record,” she says.

Dixon and her team coach clients to decide whether the technology is going to be helpful.

 “We encourage folks to be self-directed in their recovery and use technology if that is what works for them,” she says. “But we are really picky about what we introduce. We want to do the vetting. If we are going to put our name on it, we want a level of confidence that it is going to be helpful. When someone is new in recovery, they could latch on to lots and lots of stuff that may not be supportive of what they are trying to do.”

Comprehensive support network

Patrick Dulin, an associate professor in the Department of Psychology at the University of Alaska-Anchorage, has focused his research on technology-based interventions for substance use disorders. With funding from the National Institute of Alcohol Abuse and Alcoholism, he piloted a smartphone app with tools related to managing alcohol craving, monitoring consumption and identifying triggers to drinking.

The system leads users through an intervention set similar to what people would experience during in-person counseling, Dulin says. It would ask about sources of social support, dealing with cravings, coming up with other non-drinking-related activities as well as provide in-the-moment tools to help clients if they were down or bored.

Users go through a seven-module process in which they also identify people they can count on for support when they need it. It not only identifies the people, places and things that serve as triggers, it also sends information to share with others about how to deal with someone with an alcohol problem.

“So it helps provide a comprehensive support network,” he says.

Many of the 28 participants in the six-week pilot demonstrated significant reductions in hazardous alcohol use while using the system (56 percent of days spent hazardously drinking at baseline vs. 25 percent while using the app) and drinks per day diminished by 52 percent, according to the research paper published on the project.

Dulin has refined the product and a publicly available app called “Step Away” is free on iTunes. He is looking to do a longer-term clinical trial.

“The new system we have created is designed to be used for as long as the user would like,” he says. “The pilot had a limited amount of funding, but we found in the study that people who were pretty substantially dependent on alcohol and scored in the moderate to severe range of alcohol dependency had a good outcome.”

Dulin is working on submitting a grant proposal to look at effectiveness over a one-year time period and to study the population it is most helpful for. He also is in conversations with drug courts.

“They are pretty interested in something that would help their participants stay on track,” he says.

Building on the promise

In 2011, the promise of the A-CHESS clinical trial led to another three-year-long project called the CHESS Health Education Consortium, which consisted of 15 agencies willing to buy licenses to use it with 100 patients and 10 counselors each.

“Even though we didn’t have a commercialized version, we could scale up the prototype, so we could learn more about implementation,” says Isham, who also is director of research and development at Chess Mobile Health, which is commercializing the solution. The consortium studied how A-CHESS fits into the real world. For instance, each clinic had to decide how connected and responsive they wanted to be to clients in a 24 hour day. For many users, peer group support through the app proved more important than contacting clinicians, he adds.

One of the members of that consortium was Loyola Recovery Foundation, which was led at the time by Christopher Wilkins. Loyola ran integrated crisis detox services within the Veterans Administration system in upstate New York, and studied the veterans who returned to detox for the third time in 18 months, Wilkins says.

“We didn’t have a tool to monitor the recovery status of the person after discharge from detox,” he says.

Loyola adopted A-CHESS because of its randomized clinical trial, and in a research study found that rehospitalization rates among its cohort fell by almost 70 percent.

The platform also provides a picture of probability of relapse, according to Wilkins. “Then you can intervene in a variety of ways depending on the severity of the rising risk,” he says.

In fact, Wilkins eventually stepped down from his position at Loyola to lead Chess Mobile Health, the public benefit corporation that is commercializing the platform. The State of Oklahoma has contracted to use it with its young adult population, he says.

FDA regulation

Until recently there had been some uncertainty about how the Food & Drug Administration (FDA) was going to regulate mobile medical apps. But the FDA recently renewed its guidance about which mobile health apps require regulatory approval. Basically, for an app to require approval, it has to be considered a medical device or turn the mobile phone into a control for a medical device such as a blood glucose reader. Because most apps offer information and communication, they are not considered medical devices. However, the FDA says it reserves the right to exercise enforcement discretion over them.

Wilkins says that the first level of analysis for clinicians evaluating an app is to look for research.  But he adds that providers must gather their own feedback about what works and what doesn’t.

“Too often the addiction treatment field rigidly predetermines what people need,” he says. “People are going to be our greatest teachers about how they build social relationships and coping competencies and protection for themselves through the use of mobile applications. We’ve got to hear their voices and learn.”

Some apps to assist in addiction recovery 

This is by no means an exhaustive list of apps, but those listed are free for clients to download.

Cassava — Developed by Elements Behavioral Health, includes a personal journal component and a database of more than 140,000 recovery support meetings, including 12-Step and non-12 Step alternatives.

Steps Away — Allows users to locate a 12-Step meeting anywhere in the world.

Friend of Bill — Keeps track of the user’s sobriety in months, days, hours and minutes, plus  350 Alcoholics Anonymous slogans for inspiration.

Quit That — Compatible with Apple Watch, the app tracks anything a user wants to “quit” such as coffee, smoking or video games.

Addicaid — Helps find meetings and track progress.

Sobertool — Questions lead users to messages to help maintain recovery and avoid relapse.

What’s Your Experience?

Send us your list of favorite—or not so favorite—recovery apps and we might share your ideas with our readers.

David Raths is a freelance writer based in Pennsylvania.