An overview of how substance abuse professionals and researchers are using information technology to deliver substance abuse interventions to justice-invovled person who live in rural and underserved areas.

2. www.nfarattc.org

3. Agenda
Part 1: Overview of the past and current
use of technology-based interventions
for substance-use disorders.
Part 2: Description of how computers
and web-based interventions have been
used to deliver services to rural and
underserved offenders—by Tom Wilson
Counseling Center, Boise, Idaho.

4. Why Rural Offenders?

5. Approximately one quarter of the U.S.
population (62 million people) lives in
frontier/rural areas
16–20% of those individuals experience
substance dependence, mental illness, or
both conditions (NRHA, 2008)

6. Individuals residing in remote areas have
 higher mortality rates,
 higher suicide rates, and
 more severe alcohol/drug problems
(Baca et al., 2007; Goldsmith et al., 2002)

7. They have more personal, social, and geographic
barriers to accessing services.
There may be a stigma associated with treatment.
(Finfgeld-Connett & Madsen, 2008; Oser et al., 2012)

8. 3.3%
19.3 million people needed but did not receive treatment
for illicit drug or alcohol use
Did not feel
they needed
treatment
(NSDUH, 2011)
In 2011, 20.6 million people aged 12 or older met
the criteria for substance-use disorders
Felt they needed
treatment—Did not
make an effort
Felt they needed
treatment—Did
make an effort

9. Barriers to Treatment

10. Barriers include
• Travel Costs
• Transportation access
• Time Away From Work
• Child Care
• Lack of Service Providers

11. Privacy and Confidentiality
(Moyer & Finney, 2004/2005)

12. The lowest concentration of
mental health professionals was
found in frontier/rural areas
(counties with less than 10,000 people)
(Ellis et al., 2009; HRSA, 2011)

13. How could addiction treatment or
other behavioral health providers
expand their reach and overcome
barriers to serve these
populations?
(Kazdin & Blase, 2011; Perle & Neirenburg, 2013)

14. One Answer…
Telehealth Technologies

15. Telehealth Definition:
The use of telecommunications and
information technologies to provide
access to health information and services
across a geographical distance.
Technologies included in telehealth are:
• Videoconferencing
• Telephones (smart and dumb)
• Email and texting
• Web-delivered programs
• Apps
(Institute of Medicine (IOM), 2012)

16. 1879
TELEHEALTH
is not new
(Aronson, 1977; Backhaus et al., 2012; IOM, 2012; Wittson et al., 1961; Wittson & Benschoter, 1972)

17. Why Use Telehealth Technologies?
Reason #1
Most telehealth research supports that
outcomes are as good or better than in-
person strategies for behavioral health
services (mental health and substance
abuse).
(IOM, 2012)

18. Largest provider of telemental health services
using videoconferencing
(Godleski et al., 2008; Darkins et al., 2008; IOM, 2012; Deen et al., 2012; Godleski et al., 2012)

19. VA Services
 146 hospitals provided 55,000 community-based
outpatient clinic patients with 140,000 telemental
health visits
 6,700 patients received home-based telemental health
services
 25% decrease in hospitalization for receiving telemental
health services between 2006-2010
 30% reduction in admissions during the first 6 months
of care in 2011
(Darkins et al., 2008; IOM, 2012)

20. Indian Health Services (IHS)
 Serves 2 million American Indians
and Alaska Natives representing
566 federally recognized tribes
 Includes 600 hospitals, clinics, and
health stations under tribal
governance
 Implemented mobile telemedicine
services in the 1970s
 Alaska Federal Health Care Access
Network utilizes telehealth
(IOM, 2012)

21. University of Virginia’s telehealth program
has documented the avoidance of
7.2 million miles of travel
(Rheuban, 2012)

22. Annually, 10 million
patients receive
telemedicine services
(IOM, 2012)

23. Why Use Telehealth Technologies?
Reason #2: Access to
technology is widespread.
• Access to the Internet has
increased dramatically
• 90% of individuals worldwide
have access to mobile phone
services.
• Smartphone access is
expected to triple by 2019
• Internet and mobile access is
growing among traditionally
underserved populations Marsch, 2014

24. (Pew Report, 2012)

25. 85% OF AMERICAN
ADULTS HAVE MOBILE
PHONES OR TABLETS

26. 80%send and receive
text messages
(Pew Report, 2012)

27. Over HALF have gathered health
information on their phones
Almost 20% have a health app
(Pew Report, 2012)

28. Skype and
other
videochat
platforms are
free or low
cost

29. Videoconferencing Is Mainstream

30. Why Use Telehealth Technology?
Reason #3: High Customer Acceptability
.

31. Lack of Adoption by Professions
There are few published works on the use of
telehealth technologies to provide or enhance
substance-abuse services in rural areas.
(Balas & Boren, 2000; Benavides-Vaello et al., 2013; Ryan & Gross, 1943)

32. The Promise of Technology
Several research studies demonstrate that
technology-based behavioral health tools:
 Can be useful and acceptable to diverse populations
 Have an impact on health behavior and outcomes
 Can produce outcomes comparable to (and some
cases better) than providers.
(Marsch, 2014) Dartmouth Center for Technology and Behavioral Health

33. The Promise of Technology
Technology-based behavioral health tools…
 Increase quality, reach, and responsivity of care
 Can be more cost effective than in person services
 Can increase service capacity of organizations
 Can be responsive to individual's behavioral need
trajectory over time
(Marsch, 2014) Dartmouth Center for Technology and Behavioral Health

34. Examples of Technology for
Substance-Use Disorders
Decision Support Systems
- e.g., Let’s Talk About Smoking (Brunette)
Assessment
- ASI-MV (Butler)
- CHAT (Comprehensive Health Assessment
Tool for Teens) (Lord)
Brief Intervention
- Drinker’s Check-up (Hester)

35. Examples of Technology for
Substance-Use Disorders
• Treatments/Psychoeducation
Therapeutic Education System [“TES”] (Marsch,
Bickel)
Cognitive Behavior Therapy CBT4CBT (Carroll)
SHADE (Kay-Lambkin)
• Recovery Support
Addiction–Comprehensive Health Enhancement
Support System [“A-CHESS” ] (Gustafson)

36. Web-Based Screeners

37. Web-Based
Support Groups

38. Web-Based Support
Psychoeducational
Self-Help
Mutual Support

39. Virtual Reality

40. Use of computers to deliver some aspects of
psychotherapy or behavioral treatment
directly to patients through interaction with a
computer program (located on a device or
virtual learning environment [the cloud)].
(Carroll & Rounsaville, 2010)
Computer-Based Treatments

41. Using Web-Based, Substance-Abuse
Interventions With Rural
and Underserved Offenders
© 2012 Tom Wilson Counseling Center

42. Rural Nature of Idaho
Thirty-five of Idaho’s forty-four
counties are rural or frontier and
many areas have limited access to
specialty care.
While rural Idaho continues to
face challenges recruiting and
retaining medical and behavioral
professionals, telehealth and
telemedicine are playing an
increasingly important role.
(Idaho Telehealth Alliance, 2015)

43. Objectives of Web-Based Services
To expand the reach of substance-use
services to our remote, rural, or
challenged clients through technology
To help clients overcome personal, social,
and geographical barriers to substance-
use disorder services
To deliver substance-use services guided
by evidence-based practices and
principles

44. The Aim of Prevention
The aim of prevention is to:
• Deter the onset of alcohol or other
drug abuse
• Provide individuals with the
information and skills necessary to
prevent the problem.

45. Importance of Early Prevention
“…It is easier to build strong children than to
repair broken men...”
—Frederick Douglass

46. Theory of Prevention
Drug abuse can be prevented if:
 Risk factors in a population are
identified and reduced
 Protective factors are identified
and strengthened

47. ABOUT OUR
PROGRAM
Tom Wilson Counseling
Center specializes in
providing alcohol and
drug-abuse prevention
education services for
forensic (court–
ordered) clients.
Most of our clients are
low-risk offenders
charged with
substance-abuse-
related offenses and
are on diversion or
bench probation.

48. Challenges of In-Person Classes
Traditional
in-person
classes are
difficult for
offenders
who:
• Travel for work
• Have a suspended
license
• Live in rural areas
• Have child/family
obligations
• Experience
communication
problems
• Have no local SUD
provider

49. Information technology is now an
effective way to deliver health
information/content
Cost has dropped significantly due to open
source movement, cloud technology, etc.
Access to well-designed applications has increased
dramatically

50. Advantages of Online Learning
Self-paced learning can
take place anywhere,
anytime.
Accessible to virtually all
learners—regardless of
disability, location, or
learning schedule.
Providers can use creative
methods and delivery
modalities.

51. Requires computer or mobile device and
Internet access, and some computer literacy.
Some participants uncomfortable with or
distrustful of technology
Does not work well for some learning styles
or activities that require group interaction

52. Program Design
Target
Behavior:
Harmful
alcohol use
Objective:
Change
attitudes
toward
drinking
Target
Population:
Underage
Drinkers
Delivery
Medium:
Web-based
education

53. Evidence-Based Components
Motivation-
Enhancement Techniques
Stages
of
Change
Activities
Cognitive
Behavioral
Skills
Web-Based
Programs
Include:

54. Motivational Enhancement
Therapy
 Non-confrontational intervention
 Begins with self-assessment
 Personalized feedback report on pattern of use
 Feedback includes normative comparison of
results

55.  Introduce the Stages of Change
 Identify stage-specific thoughts and beliefs
 Identify activities that help an individual move
from one stage to the next

56.  What stage am I in?
 Readiness to change example
 Decisional Balance—Benefits vs. costs of
change

57. Sample Lesson Process
Read content
and answer
review
questions
Receive
feedback
If correct,
continue or
retry questions

58. Feedback Example
Your Response:
 You told us you drink 8–
14 drinks per week on
average when you drink.
 Based on your response,
you drink more than
81% of all males and
94% of all females.

59. Example of Calculation Exercise
Your typical blood
alcohol content is the
amount of alcohol in
your blood on a typical
day when you drink.
To calculate your typical
BAC (blood alcohol
content), use the online
BAC calculator provided.
Online BAC
Calculator

60. Feedback for Typical Drinking BACs
Your response:
You calculated your BACs for a
typical drinking occasion as
falling between .06 to .10.
At BAC Levels of .06 to .10,
you will have impairment of
muscle coordination and a
slower reaction time, and
disregard for personal safety.

61. Sample Lesson Page
Binge Drinking
• Is defined as 5 or more drinks on
the same occasion at least once in
the past 30 days.
• Health, social, and academic
problems occur when men drink 5
or more drinks per occasion, and
women drink 4 or more per
occasion.
• Binge drinking is the most
common pattern among underage
drinkers.
• Less than 25% of persons aged
12 or older participated in binge
drinking
Click for Review Question

62. Using Text Messaging as an
Intervention
“In a recent study, Text Messaging to Emergency
Patients Reduced Their Alcohol Consumption”
 12-week trial of receiving automated text messaging
asking about drinking
 Men who had 5 + drinks and women who had 4+
drinks received text messaging of concern about
level of use
 Asked if they would cut down.

63. Other Mediums of Delivery
2. Online Assessment
and Feedback with
“E-checkup to Go” for
university freshmen
3. Online Assessment
and Feedback with
“Brief Assessment
and Intervention for
College Students”

64. Conclusions
The tools of information and computer
technology are successfully being implemented
to remotely treat and prevent substance abuse.
The tools of technology can increase
accessibility of behavioral health services to
rural offenders through web-based delivery.
Technology-assisted services will help offenders
improve compliance—reducing the burden on
diversion and community supervision services.

65. Current Research on Outcomes

66. Recidivism Rates of Online DUI Classes
Conducted at Tom Wilson Counseling for 2010–2013
• Participants—557 (68% male, 32 % female)
• Mean age of participants: 35
• Completed DUI classes in 2010–2013 (study
4/2015)
• Cognitive-behavioral curriculum like DWC
• TWCC Recidivism rate (7.5%)
• CDBH 2008 Study of in-person DUI Program
Completers Recidivism rate (7.8%)
Preliminary Study Results 4/30/15 (Raissa Miller, Ph.D. Boise State University)
(Gender, age, and prior arrests are not predictors of subsequent arrests)

67. Tom Wilson, LCPC, CPC
514 S. Orchard Street, Suite 101
Boise, ID 83705
Office: 208.368.9909
http://www.TomWilsonCounseling.com
email: twilson@tomwilsoncounseling.com