grand rounds. tbi. june, 2016 final tb
TRANSCRIPT
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Tobie Barton, MA
Using Technology to Enhance Addiction Treatment
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Neither the NFAR ATTC nor the trainer presenting today endorse or promote the use of any specific technology application mentioned in this training. All technology
applications are discussed as examples of available resources only. The NFAR ATTC does not guarantee that any of the
technologies discussed meets federal, state, or local regulations. Please consult with an attorney, your institution’s HIPAA compliance officer, and/or your local licensing agency
before utilizing any technology for clinical or recovery support purposes.
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GOAL: to expose practitioners to technology-based interventions that complement behavioral health treatment and recovery services.
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Outline
• Definition of technology-based interventions • Discuss use of technology in behavioral health
by practitioners and clients • Research-based technologies for treating SUDs • Resources • Summary
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develop and strengthen the workforce that provides
addictions treatment and recovery support services
Purpose of the ATTCs (SAMHSA FUNDED)
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ATTC Network Coordinating Office
10 Regional Centers
2012 – 2017
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National Frontier & Rural
ATTC
National American Indian & Alaska Native
ATTC National SBIRT ATTC
National Hispanic & Latino
ATTC
4 ATTC National Focus Centers
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Serve as the national subject expert and key resource to PROMOTE the awareness and implementation of telehealth technologies
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“The successful practitioner of the next century will need to master technologies in order to effectively manage the care of their patients. As the microscope allowed practitioners in an earlier era to see the microbial agents of infection… the computer will also change the patient. As patients arrive with better and more information, health care professionals may find themselves increasingly in the role of counselor and consultant”
(O’Neil & Pew, 1998, p. 18)
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People are using technology
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Use of online and mobile technologies is increasingly ubiquitous across age,
race/ethnicity, and geography.
Consumers rely on Internet and smartphone-based tools for health information and
tracking.
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Use of technology devices to deliver some aspects of psychotherapy or behavioral
treatment directly to patients via interaction with a web-based program.
(Carroll & Rounsaville, 2010)
Technology-Based Interventions
DEFINITION
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Technology can be applied to both the pharmacotherapy treatment of
substance use disorders and psychosocial treatments.
Continuum of intervention, treatment, and recovery services
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(Gainsbury & Blaszczynski, 2011)
Technology has enormous potential to provide a highly influential tool to
assist individuals in overcoming their addictions that
appropriately meets individuals’
expectations and needs.
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Technology-based interventions have the ability to:
• lower consumer threshold for initiation of treatment
• refer at-risk individuals to in-person treatment
Clarke & Yarbourough, 2013
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Technology-Based Intervention BENEFITS
• Serve as adjuncts to standard treatment • Save clinician time • Extend clinician expertise • Integrate other EBPs to provide additional
services to clients with co-morbid conditions • Provide access to web-based smoking
cessations programs or other health-related conditions
(Carroll & Rounsaville, 2010)
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Encouraging evidence suggests positive
treatment outcomes
Bickel et al., 2008; Carroll & Rounsaville, 2010)
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Substance use is a public health crisis in the rural United States and has been identified as one of the
top 10 priorities Rural Healthy People 2020
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Technology has the potential to narrow the “access gap” to behavioral health
interventions and reduce health disparities in disadvantaged and hard-to-reach populations
Gibbons et al., 2011
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Majority (90%) of persons with SUDs have not entered
treatment 20.2 million in 2013
(NSDUH, 2013)
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Technology can address barriers to accessing treatment
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Workforce & Technology
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Use of technology by clinicians
• is increasing
• presents unique clinical/business dilemmas
(NBCC Policy, 2013)
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DIGITAL TYPES
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Digital Immigrants
(Zur, 2012; Prensky, 2001)
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Digital Immigrants … people born before 1964 and who grew up in
a pre-computer world
(Zur & Zur, 2011)
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‘native speakers’ of the digital language of computers, cell phones, video games,
and the Internet (Zur, 2012; Prensky, 2001)
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Like all immigrants… as Digital Immigrants learn to adapt to their environment, they retain, to some degree, their ‘accent’ …
What is your digital accent?
(Prensky, 2001)
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Digital Immigrants Digital Natives • Prefer to talk in-person or
on the phone • Prefer to talk via chat, text, or
messaging thru social media • Don’t text or only sparingly • Text more than call • Prefer synchronous
communication • Prefer asynchronous
communication • Prefer receiving information
slowly: linearly, logically, & sequentially
• Prefer receiving information quickly & simultaneously from multiple multimedia & other sources
• Prefer reading text (i.e., books) on processing pictures, sounds & video
• Prefer processing /interacting with pictures, graphics, sounds & video before text
Comparison of Digital Types
(Zur & Zur, 2011; Rosen, 2010; Prennsky, 2001)
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Other Digital Types
Ways to sort people other than age • Attitudes • Comprehension • Relationships • Practices • Comfort with technology
(Feeney, 2010; Toledo, 2007)
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DIGITAL DIVIDE
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Younger clinicians and those with smartphones found a PTSD app
more usable than older clinicians and those without smartphones.
These variables predicted clinicians’ intentions to use the app in treatment with veterans.
(Kuhn et al., 2014)
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ORGANIZATIONS
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Agencies with annual operating budgets of greater than $10 million reported significantly fewer barriers
(Ramsey et al., 2016 )
than those with budgets of $10 million or less
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Agencies serving more than 3,000 clients per year reported significantly fewer
implementation barriers than those serving fewer clients annually.
(Ramsey et al., 2016)
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Provider resistance and lack of openness to use technology-based care approaches
may be multifaceted…
• limited awareness of established benefits • an organizational climate characterized by
skepticism or unwillingness to try new approaches
• a demand for more research on the effectiveness and safety of these tools
(Ramsey et al., 2016)
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a substantial portion of providers reported a lack
of basic knowledge about how technologies
can be used for behavioral health care
(Ramsey et al., 2016)
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How will technologies change how the provider does business?
(Muench, 2015)
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Recommendations
STAFF
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The fit of any innovation with the attitudes and values of the agency and providers
adopting it is critical to the acceptability, efficiency, and effectiveness of the
implementation process. (Ramsey et al., 2016)
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The most pressing staff concern: Is this better and easier than what I am
currently using/doing?
(Muench, 2015)
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Integration requires an understanding of staff members’ degree of comfort with technology
(Muench, 2015)
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and the time burden
(Campbell et al., 2012)
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and the selection of appropriate training to increase staff confidence in navigating
potentially foreign technologies
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Most providers will need to re-structure operations to understand how technology will
impact clinician workload… • accept e-mails or phone messages on work phones • develop on-call lists or use peer specialists to
manage alerts/requests for help and client check-ins if not automated
(Muench, 2015)
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For example, Muench and colleagues (2013) found that although 80% of providers want to be alerted
if their client is at risk of relapse, only 8% would want an immediate mobile alert.
(Muench, 2015)
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debunk fears cited by providers regarding the use of technologies
compromised client care and job replacement (Ramsey et al., 2016)
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Clinician Extenders
(Ramsey et al., 2016; Marsch, 2011)
allow providers to work at their highest level of
training and focus on the
most high-need client issues
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Digital Health Technologies will not replace clinical staff but will enhance their work
Digital Health Technologies will not replace clinical staff but will enhance their work
Digital Health Technologies will not replace clinical staff but will enhance their work
Digital Health Technologies will not replace clinical staff but will enhance their work
Digital Health Technologies will not replace clinical staff but will enhance their work
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• the ability of technology to reach enormous numbers of people (it is undeniable)
• the use of technology for treatment and recovery support offers the possibility of better care, reduced stigma, and broader reach
It’s imperative that professionals understand…
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Since patients are likely to use
technologies, it may be helpful for
practitioners to understand the
phenomena of technologies, even
if they struggle with technologies
or are doubtful about their utility.
(Myers et al., 2012)
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Client Acceptability of Technologies
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What do we know about clients? Survey of 8 urban drug treatment clinics
in Baltimore (266 patients)
Clients had access to: • Mobile Phone - 91% • Text Messaging - 79% • Internet/Email/Computer - 39-45%
(McClure, Acquanta, Harding, & Stitzer, 2012)
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(Moore et al., 2011; Muench et al., 2013; Muench, 2015)
Current evidence demonstrates that clients use and are interested in using technologies as
part of their treatment or continuing support.
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Customer Demand
57
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People with common health care concerns find each other by website
and blog search engines, and through mobile apps and Twitter tags
(Marri, et al., 2014)
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Clients’ Issues Regarding Using Technologies for Treatment and Recovery
• Make sure clients understand: ‒ technologies that may monitor them and
their locations ‒ how to use the technologies ‒ what to do in the case of emergencies and
service problems
(Muench, 2015)
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Other Technology Issues with Clients • Many clients change phone numbers or experience
disruptions in their phone service which interferes with use of technology-based interventions.
• Approximately 20% of participants had their phone service turned off at least once over the course of a 5-week study as a result of nonpayment.
• Clients sharing phones with family members/others raises issues with privacy/security and confidentiality.
• Warn clients about technology failures and that their messages might not go through.
• Determine percentage of clients that have access to smart phones before implementing technology.
(Muench, 2012; 2015)
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Given the promise of these computerized interventions, we feel encouraged that technology has become mature
enough to capture at least some aspect of psychotherapy. (Campbell & Luo)
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Videoconferencing
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The research base for telemental health-related interventions is more
than 50 years old.
(Richardson et al., 2009; Wittson et al., 1961; Wittson & Benschoter, 1972)
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Systematic Review of Videoconferencing Psychotherapy
• Patients and providers perceived a strong therapeutic alliance over videoconferencing
• Studies that compared videoconferencing to in-person psychotherapy reported similar satisfaction levels between the conditions
• High levels of satisfaction and acceptance with telemental health have been consistently demonstrated among patients across a variety of clinical populations and for a broad range of services
(Backhaus et al., 2012) (Backhaus et al.2012)
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Studies on Videoconferencing in Addiction Treatment
• Opioid Treatment-group counseling (King et al., 2009; King et al., 2014)
• Alcohol Treatment (Postel et al., 2005)
• Alcohol Treatment (Frueh et al., 2005)
• Teleconferencing Supervision (TCS) - MI (Smith et al., 2012)
(Backhaus et al., 2012)
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eGetgoing uses videoconferencing
technology to deliver therapy to patients with
opioid dependence
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Leading Technologies in Addiction Treatment
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Technology-Based Interventions have been validated recently through funded
research studies:
TES, CBT4CBT, and ACHESS
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Therapeutic Education System (TES)
An interactive, web-based psychosocial intervention for SUDs, grounded in:
Community Reinforcement Approach (CRA) + Contingency Management Behavior Therapy +
HIV Prevention
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CBT4CBT • A computer-based version of cognitive
behavioral therapy (CBT) • Designed to use in conjunction with clinical
care for current substance users • Multimedia presentation, based on
elementary level computer learning games, requires no previous computer experience
(Carroll et al., 2008; 2009; 2011; 2014; Olmstead, Ostrow, & Carroll, 2010)
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http://www.cbt4cbt.com
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ACHESS • Monitoring and alerts
• Reminders
• Autonomous motivation
• Assertive outreach
• Care coordination
• Medication reminders
• Peer & family support
• Relaxation
• Locations tracking
• Contact with professionals
• Information
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Research Studies Using Texting • weight/obesity
(Gerber et al., 2009)
• diabetes (Franklin et al., 2006; Hanauer et al., 2009)
• asthma (Neville et al., 2002)
• tobacco dependence (Rodgers et al., 2005)
• sexual health (Leach-Lemens, 2009; Lim et al., 2008)
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(Ingersoll et al., 2014)
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• Used youth to craft language • Daily self-monitoring texts, a daily wellness recovery tip,
and substance abuse education and social support resource information on weekends
• Compared with standard aftercare, texting reduced relapse risk and promoted recovery engagement
Youth-Focused Texting
Case Study
(Gonzales et al., 2014)
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TEXTING - Portable Contingency Management
1-3 text reminders about sending video
of breathalyzer results
• Vouchers earned for negative BAC tests • Thank you texts (Alessi & Petry, 2012)
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TELEPHONE RECOVERY SUPPORT
• Peer-based, volunteer supported • Check-in, issue identifier, make
connections • Builds recovery capital • Standard 12-week program, but
unlimited • Free service to anyone • Not limited by geography, more
flexible
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Telephone Continuing Care for SUDs • Telephone Monitoring and Adaptive Counseling (TMAC)
(McKay, 2004)
• Focused Continuing Care (FFC) (Betty Ford Clinic)
• Telephone Enhancement of Long Term Engagement (TELE) (Hubbard et al., 2007)
• Individual Therapeutic Brief Phone Contact (ITBPC) (Kaminer & Napolitano, 2004) ADOLESCENTS
• Telephone Case Monitoring (TCM) (McKellar et al., 2012)
• Telephone Continuing Care (TCC) (Godley et al., 2010)
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Social media networks facilitate highly interactive online communities where individuals share, co-
create, discuss and modify user-generated content
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Apps provide: • Information • Motivation • Support • Feedback
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61% of patients reported using mobile applications
Dahne & Lejuez, 2015
Few evidence-based apps exist, in contrast to the thousands of apps available that are not evidence-based or research-informed.
Majeed-Ariss, et al., 2015
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8 Strategies for Evaluating/Selecting Apps 1) Review the scientific literature 2) Search app clearinghouse websites 3) Search app stores 4) Review app descriptions, user ratings, and reviews 5) Conduct a social media query within professional
and, if available, patient networks 6) Pilot the apps 7) Elicit feedback from patients 8) Understand free apps have more privacy/security
risks (Boudreaux et al., 2014; Frank, 2015)
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Providers Using Telehealth Technologies
• Operation PAR in Florida – Web-videoconferencing and email
• Tarzana Treatment Centers in California – Web-video conferencing and email
• Heartview Foundation in North Dakota – Web-based recovery support/private social network-
Ning
• Face It Together in South Dakota – Telephone Recovery Support
(NFAR Data, 2015)
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or like this…
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Clients and consumers are already embracing TBIs and creating a patient-
centered health movement.
As the research has repeatedly revealed, TBIs are most effective when combined with human support, reinforcing how
providers will remain the foundation of care for those seeking help.
(Muench, 2015)
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How do I remember all of this…..
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SUDTECH.ORG
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Center for Technology and Behavioral Health
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New Ethical Dilemmas in the Digital Age
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Technology-Based Supervision: Extending the Reach of
Clinical Supervisors
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New Curriculum
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