Online Intervention Improves Outcomes in Substance Abuse

Deborah Brauser

April 22, 2014

An Internet-based behavioral intervention may improve treatment outcomes in individuals who are dependent on drugs or alcohol, new research suggests.

A large, randomized controlled trial (RCT) of more than 500 adult outpatients seeking treatment for substance abuse showed that those who received 12 weeks of Therapeutic Education System (TES) plus individual and group counseling had a significantly greater rate of abstinence and a lower dropout rate than their counterparts who received 12 weeks of individual and group counseling (treatment as usual).

In addition, those in the TES group who tested positive for drugs or alcohol at baseline had double the abstinence rates after treatment compared with those in the treatment-as-usual group.

"The purpose of this study was to take an efficacious, computer-assisted intervention and test it in a real-world setting," lead author Aimee N. C. Campbell, PhD, assistant professor of clinical psychiatric social work at Columbia University College of Physicians and Surgeons in New York City and from the New York State Psychiatric Institute, told Medscape Medical News.

"Overall, this was a positive trial. We hypothesized that adding [TES] would improve retention and enhance abstinence outcomes. And we were excited that the trial did both of those things," added Dr. Campbell.

The study was published online April 4 in the American Journal of Psychiatry.

Problem-Solving Exercises

For the study, the investigators enrolled 507 adults (62.1% men; mean age, 34.9 years) from 10 community outpatient addiction treatment programs affiliated with the National Drug Abuse Clinical Trials Network between June 2010 and August 2011.

All participants were randomly assigned to receive either 12 weeks of TES plus treatment as usual (the TES group; n = 255) or treatment as usual only (n = 252).

TES consists of 62 computerized interactive modules covering skills for achieving and maintaining abstinence, plus prize-based motivational incentives contingent on abstinence and treatment adherence.

It is also "a web-based version of the community reinforcement approach plus contingency management," the investigators write.

Dr. Aimee Campbell

Dr. Campbell further explained that the intervention uses problem-solving exercises and concentrates on enhancing family and social relationships, as well as recreational and vocational activities.

TES was substituted "for about 2 hours of standard care per week" for the TES group vs the treatment-as-usual group.

Twice-weekly urine drug screens and breath alcohol screens were administered to all participants during the treatment phase. Also, urine was collected and screened for 10 different drugs at 3- and 6-month follow-up visits.

Both groups also filled out self-reports about any drug and alcohol use at all periods.

A total of 54.2% of the entire study group was found to be abstinent at baseline.

Bridging the Treatment Gap

Results showed a significantly higher rate of abstinence for the TES group vs the treatment-as-usual group (odds ratio [OR], 1.62; 95% confidence interval [CI], 1.12 - 2.35; P = .01).

The OR went up to 2.18 (95% CI, 1.30 - 3.68; P = .003) for the TES group members who screened positive at study entry for drug or alcohol use vs nonabstinent treatment-as-usual group members.

"Often we see people who might have greater severity of substance use disorder respond more strongly to specific interventions. That's not an uncommon finding," noted Dr. Campbell.

In addition, the overall TES group had significantly fewer dropouts vs the treatment-as-usual group (hazard ratio, 0.72; 95% CI, 0.57 - 0.92; P = .01), as well as more total and consecutive half weeks of abstinence during the trial (P = .008 and P = .001, respectively).

There were no outcome differences between the 2 treatment groups at the 3- and 6-month follow-up visits.

"The effects of contingency management interventions may diminish once the contingencies end," write the investigators.

Still, "the results support the promise of the intervention for dissemination and adoption into the addiction treatment system."

They note that Affordable Care Act legislation calls for more services to be offered for individuals with substance use disorders.

"However, both the specialty addiction and primary care systems face shortages of provider time as well as of expertise in delivery of evidence-based interventions," write the researchers.

"TES is a computerized version of two of the most effective and best-replicated treatments for substance dependence," they write, adding that it and other Internet-based interventions have the potential to bridge the gap between treatment need and treatment delivery.

Dr. Campbell noted that the study was "not able to disentangle" the unique effects of contingency management from the community-enforcement approach.

"But previous research has shown that each component contributes independently to the overall treatment effect. Still, additional research would be interesting to tease apart and quantify the effects," she said.

Parts of this study were presented at the 2013 Addiction Health Services Research Conference and at the 2013 American Academy of Addiction Psychiatry meeting. Dr. Campbell and 10 of the remaining 12 investigators report no relevant financial relationships. Of the other 2 investigators, 1 reports having received medication for research studies from Alkermes/Cephalon, Duramed Pharmaceuticals, and Reckitt-Benckiser; and the other reports having served on an advisory panel for Pfizer and as a consultant for Accenture.

Am J Psychiatry. Published online April 4, 2014. Abstract

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