Lisa A. Marsch (Center for Technology and Behavioral Health, Dartmouth College, US)
Leveraging Mobile Technologyin the Delivery of Behavioral Interventions Targeting Substance Use Disorders Lisa A. Marsch, Ph.D. Director, Center for Technology and Behavioral Health Dartmouth Psychiatric Research Center Department of Psychiatry, Dartmouth College
Acknowledgement Research funded byNational Institute on Drug Abuse,National Institutes of Health (NIH) P30 DA029926NIDA “Center of Excellence” Grant R01DA029630 R01 DA021818 R01 DA021818-01S1 R01DA034279-01
AffiliationAffiliated with HealthSim, LLC, a smallbusiness that developed several technology-based therapeutic interventions
Implementation of Technology- based Therapeutic Tools• Technology-based therapeutic tools can allow for unprecedented levels of behavioral health monitoring, and provide therapeutic interventions that are as effective as science-based interventions delivered by highly trained clinicians, cost-effective, and highly acceptable to a wide variety of target populations.•Evidence-based behavioral treatments are infrequently provided toindividuals with substance use disorders.• Technology-based therapeutic tools may be deployed via numerous flexible models and may enable entirely new models of delivering behavioral health care (e.g., treatment of substance use disorders).
Implementation of Technology- based Therapeutic Tools•Technology-based therapeutic tools may be used along with moretraditional models of intervention delivery (e.g., offered as anadjunct to substance abuse treatment).• In a “clinician-extender” model, clinicians have the opportunity to extend their reach by offering these additional resources to their clients to support their clients outside of their direct interchange with their clinician (e.g., as a supplement to clinician-delivered therapy, pharmacological treatments, etc.)
Implementation of Technology- based Therapeutic Tools• Alternatively, these therapeutic tools may replace a portion of their typical interaction with clients with a technology-based intervention.• This may allow a treatment program to treat more clients with the same number of clinicians and/or free-up clinicians to have more time to manage client crises or spend more time with clients in greatest need of more intensive care.• These tools may also be offered as stand-alone interventions, which may be particularly relevant in rural or other settings where access to care may be limited or for individuals who do not wish to engage in traditional models of care.
Promise for Technology in Evolving HealthCare System• Technology-based therapeutic tools targeting substance use and behavioral health may become increasingly important, as under U.S. healthcare reform initiatives, mental health and physical health care will be better integrated into patient medical homes (such as FQHCs).• In this shifting paradigm of treatment delivery, clinicians in these settings will be asked to markedly increase behavioral health care offered in their care setting but may have limited time or specialty training in screening for/treating substance use disorders and other behavioral health issues.• Technology-based assessments and interventions may be exceptionally useful in this evolving health care context.
Examples of Various Models of Deployment: The Therapeutic Education System (TES) as an Exemplar• Therapeutic Education System (TES), an interactive, behavioral therapy intervention for substance use disorders, grounded in the Community Reinforcement Approach (CRA) + Contingency Management Behavior Therapy + HIV Prevention• Available on multiple platforms (including web-based desktop computers, Android smartphones, iPhones, iPads, etc.).
Partial Replacement Model in Specialty Addiction Treatment – Efficacy Trial• An NIDA-funded randomized, controlled trial (n=135) demonstrated that TES was as efficacious as comparable CRA + CM therapy, delivered by highly trained therapists, and better than standard treatment in promoting objectively-verified drug abstinence among individuals in outpatient buprenorphine treatment (Bickel, Marsch et al., 2008). 12 Standard Therapist 10 a a Computer 8 Treatment Weeks b 6 4 2 0 Continuous Abstinence from Opioids and Cocaine
Partial Replacement Model in AddictionSpecialty Treatment – Effectiveness Trial• Another NIDA-funded trial (n=160; 12 month participation) demonstrated that TES enhances opioid abstinence rates in methadone maintenance treatment when a TES substitutes for a portion of standard counseling (Marsch, NIDA-supported) 70% 60% Opioid Abstinent Percent Weeks 50% 40% 30% 20% 10% 0% TES with Treatment reduced TAU as Usual (TAU)
Therapeutic Support Outside of Formal System of CareRandom assignment of 50 new intakes in MMT to: (1) standard care or (2)mobile phone/web-based psychosocial treatment for 12 weeksThe mobile intervention demonstrated good feasibility and acceptability:Participants typically maintained their mobile phones for the duration of thetreatment, used the mobile program and reported high levels ofacceptability of the program (e.g., how useful, how easy to use, etc.).Qualitative data indicate that several participants reported using the mobilephone-based intervention during times of heightened risk for drug use.
Objectively Measured OpioidAbstinence Mobile Psychosocial 7 Treatment (t (48) = -1.97; p= .055) 6 5 4 3 2 1 0 Standard Mobile Intervention Treatment
Implementation Science Study- Integrating Treatment of SUDs into Primary Care• Multiple PI with Dave Gustafson, Ph.D.• Stepped Wedge Design evaluating a technology-based addiction/treatment recovery support system within FQHCs (SEVA)• Focus on integrated care using personalized technology-based therapeutic support system available on mobile devices and care coordination with FQHC clinicians• Focus on organizational and patient-level outcomes
A Focus on Translational Science Throughoutthe Research & Development Process is Key• Identifying the “community-friendliness” and dissemination potential at the outset of a intervention generation effort is critical.• Ensuring the science of behavior change and clinical considerations drive the use of technology and not letting the availability of technology drive the clinical application is critical.• Understanding the benefit to all stakeholders in a system of care is critical to successful dissemination, implementation and sustainability.
Center for Technology and Behavioral Health www.c4tbh.org