Computer-Assisted Therapy for Addiction

1. Computer-Assisted Therapy for Addiction Thanks to: Warren K. Bickel, Ph.D. and Lisa A. Marsch, Ph.D. University of Arkansas for Medical Sciences, National Development and Research Institutes, HealthSim Inc., and the Atlantic Health Sciences Corporation Steering Committee: Sue Haley-La Joie, Eve Wiseman, Kelly Evans, Cynthia Boyd, Kelly Lawson, Melanie Richards, Cathy Boudreau, Pam Matthews, Lisa Henderson

2. Presentation Overview(Eve Wiseman, Melanie Richards, Kelly Lawson) The original research supporting computer-assisted therapy for addictions The clinical demonstration project (treatment NOT research) approved for New Brunswick How the New Brunswick project differs from the original research How effectiveness of the computer-assisted intervention will be measured in New Brunswick Summarizing the presentation (press release) Questions / other innovative approaches

3. Benefits of Information Technology for the Drug Abuse Field Increase access to TREATMENT Permit more persons to be served (without having to go to a specialized treatment facility) Cost-effective (more effective services provided per dollar spent) Intervention fidelity is assured

4. Randomized Controlled Trial (the original research) Participants: Opioid-dependent individuals randomly assigned to: Therapist Delivered Community Reinforcement Approach (CRA): 30 mins. 3x/wk. w/therapist & Contingency Management (CM) (Budney & Higgins, 1998) Computer Assisted CRA: 30 mins.3x/wk. w/computer & CM ;1 biweekly w/therapist Standard Counseling: 37 mins. 1/wk. w/therapist - focus on rehabilitation & compliance with treatment program (Ball & Ross, 1991) All received buprenorphine maintenance treatment Bickel, W. K., Marsch, L. A., Buchhalter, A. R., & Badger, G. J. (2008). Computerized Behavior Therapy for Opioid-Dependent Outpatients: A Randomized Controlled Trial. Experimental and Clinical Psychopharmacology, 16, 132�143

5. Computer-Assisted Therapy Systemfor Substance Abuse Treatment Individualized treatment plan for each participant Evidence-based program modules skills training, role playing, exercises, and homework Approx. 50 discrete, interactive modules Interfaced with semi-quantitative urine drug abuse screening machine Therapists received electronic reports of computer activity and drug abuse screen results Voucher earnings updated dependent on drug abuse screen results

8. Examples (content of modules) a functional analysis of recent drug use (to identify the various risk factor(s) for the drug use, and the consequences of the drug use) learning to effectively identify, analyze, and solve problems strategies for refusing drug offers what �triggers� are, how they can influence behavior choices around drug use, and how to manage those triggers in order to reduce risk identify thoughts or feelings that can lead to using drugs, and ways he or she could manage these thoughts or feelings to prevent drug use actions one can take to effectively cope with thoughts about using drugs

9. More examples Seemingly Irrelevant Decisions, which may appear to have nothing to do with drug use, may actually lead one closer to being faced with a choice about drug use if not handled effectively. Decision Making Skills (SODAS technique) Situation Option Disadvantages Advantages Solutions Kifer, R. E., Lewis, M. A., Green, D. R., & Phillips, E. L. (1974). Training predelinquent youths and their parents to negotiate conflict situations. Journal of Applied Behavior Analysis, 7, 357�364. Increasing Self Confidence in Decision Making -clarifying personal values and goals and enhancing situational self confidence

15. Computer therapy was only 20% of the time associated with computer-assisted TherapyComputer therapy was only 20% of the time associated with computer-assisted Therapy

16. Summary of original research Computer-Assisted Therapy is generally as effective as comparable counselor-delivered therapy The computer-based intervention greatly decreases cost of treatment via reduced client-therapist contact time The system enables counselors to focus on aspects of treatment they are uniquely skilled to address and enables more persons to receive treatment

17. Clinical Demonstration Projectin New Brunswick (NB) Campobello Island (a small island situated off north east coast of Maine) accessible by bridge from Lubec, Maine, or by Car Ferry from the NB mainland ferry services accessible leaving Deer Island, NB from late June to mid September only, limiting direct access to and from the rest of Canada to less than 3 months of the year

18. Campobello Island Needs Assessment Survey Findings Addictions (Use of Drugs/Alcohol) was identified by Island residents as one of the highest challenges facing their community (36.2%), identifying a presence of �rampant unchallenged drug abuse,� and �[lack of] drugs and alcohol prevention for children and adults.� Isolation and distance from health services (25.6%), �Lack of Medical/Social Resources� (12.4%) and �no health education� were also identified by residents as disconcerting. In addition, 70.2% of respondents (N=450) identified access to addiction services as 'fair or poor', and 57.1% (N=450) identified being 'dissatisfied' or 'very dissatisfied' with this (Harrop 2008).

19. Hypotheses 1. Computer-assisted therapy will be as effective as comparable counselor-delivered therapy. 2. The computer-based intervention will greatly decrease the cost of treatment via reduced client-therapist contact time 3. The system will enable counselors to focus on aspects of treatment they are uniquely skilled to address. 4. The system will enable more persons to receive treatment.

20. Modified intervention (versus research by Bickel and Marsh) The original research linked rewards to urine drug test results, done multiple times during the week. This intensity of follow-up will not be easily attainable, or possibly even necessary, for the New Brunswick participant group. Instead, for this group we propose having an option to link reward vouchers to number of completed modules per week and to completed biweekly "live� sessions with the over-seeing therapist. Bonus vouchers, of higher value will be awarded for random negative drug screens.

21. Reinforcement in the Workplace[an aside] Employment-based abstinence reinforcement as a maintenance intervention for the treatment of cocaine dependence: a randomized controlled trial Authors: DeFulio, Anthony;�Donlin, Wendy D.;�Wong, Conrad J.;�Silverman, Kenneth Source: Addiction, Volume 104,�Number 9, September 2009 , pp. 1530-1538(9) Abstinence-contingent employment participants received 1 year of employment-based contingency management, in which access to employment was contingent upon provision of drug-free urine samples under routine and then random drug testing. If a participant provided drug-positive urine or failed to provide a mandatory sample, then that participant received a temporary reduction in pay and could not work until urinalysis confirmed recent abstinence. During the 1 year of employment, abstinence-contingent employment participants provided significantly more cocaine-negative urine samples than employment-only participants �Employment-based abstinence reinforcement that includes random drug testing is effective as a long-term maintenance intervention, and is among the most promising treatments for drug dependence. Work-places could serve as therapeutic agents in the treatment of drug dependence by arranging long-term employment-based contingency management programs.

22. Modified intervention (continued) Participants will be required to complete 10 modules before they are eligible for the rewards system, intended to serve as a probationary period. Following this, incremental vouchers will be awarded for the following 10 modules, and increased for the final 12 modules, for a total of 32 core modules completed. Biweekly contact with the supervisory therapist will be available by telephone, if face-to-face contact is not feasible.

23. Summary of modifications Inclusion criteria � not limited to opioid dependent persons receiving an opioid agonist medication Random, infrequent testing for substances Probationary period prior to receiving rewards Much smaller total reinforcement possible and much less linkage to negative drug screens Telephone contact with supervising therapist, if face-to-face contact not feasible

24. Monitoring outcomes A Determinants of Health Questionnaire will be administered with each participant during the early stages of implementation. This questionnaire was developed for the purposes of program evaluation as well as for the potential of publishing data results. This questionnaire will also serve the purposes of obtaining Baseline Information, as a Measurement Tool, and to continually Evaluate and Improve computerized therapeutic programs and related services.

25. Determinants of Health Income / social status Social support Education / literacy Employment Social environment Physical environment Personal health or coping skills Medical problems Health service Gender issues Culture

26. Clinical Demonstration Project Summary The Computer-Assisted Therapy model in NB will connect participant with therapist, using technology within the modular program, with the goals of: addressing resident concerns regarding use of drugs and alcohol as well as lack of access to mental health and addiction services (Harrop, 2008) working toward closing the needs gap on Campobello Island adding improvements to the overall health of their residents. This Computer-Assisted Therapy initiative for Addictions will be piloted on Campobello Island for one full year, beginning June 2009.

29. Draft press release In June of 2009, Ridgewood Addiction Services initiated a year-long clinical demonstration project using computer-assisted treatment, an effective treatment for persons with addictions according to research studies from the United States. Individuals in remote locations of New Brunswick, starting with Campobello Island and expanding to other locations as resources allow, can be screened regarding access to an interactive educational intervention that is available through computer-assisted treatment.

30. Draft press release, continued (1) To qualify, clients must be from the Saint John catchment area, be voluntary, be physically / mentally / emotionally capable of participating, have sufficient time free of mind-altering substances to participate, have basic computer skills or willingness to learn basic computer skills, and be interested in learning ways to reduce use of alcohol and/or drugs as well as ways to reduce other risky behaviours. Contact 506-674-4357 for more information.

31. Draft press release, continued (2) Therapists from the Atlantic Health Sciences Corporation oversee the computerized modular program, which facilitates development in areas such as stress management, problem solving, assertiveness, managing thoughts about using substances, managing negative thinking, refusing offers of drugs, and appropriately giving and receiving criticism. Computer-assisted treatment is web-based yet confidential, as it is password-protected.

32. Questions