New Hampshire’s efforts to expand substance-abuse treatment have been complicated by a shortage of addiction specialists. Newly licensed therapists barely outnumber those who leave the profession every year.
But there's strong evidence that digital technology can bridge the skills gap in outpatient therapy, improve outcomes and lower the cost of care.
Computer-based behavioral health programs date back to the early 1990s, but their use to treat substance abuse is still relatively new. The most thoroughly studied model - and perhaps the most promising - is the Therapeutic Education System, or TES, which was developed by Dartmouth psychiatry professor Lisa Marsch.
Comprised of 65 interactive “modules,” TES is a web-based, multi-media version of the Community Reinforcement Approach, a type of behavioral therapy that has been studied extensively for substance-abuse disorders. Community reinforcement leverages patients’ relationships at home, at work and with friends to promote behavior change and reduce the risk of relapse.
TES takes the therapeutic components of community reinforcement and delivers them on a mobile, web-based platform. It’s doesn’t necessarily replace traditional clinicians. But it can help busy practices treat more clients, manage heavy caseloads and free up clinician time for patients who need more intensive treatment.
“There are lots of ways to think about the deployment of these tools, but I really think of them as clinician extenders,” Marsch says. “The idea is, this is an additional resource in the toolbox of the clinician that they can offer to increase the reach and quality and cost-effectiveness of the care.”
Marsch is considered a pioneer in technology-assisted addiction treatment. The half-dozen or so randomized clinical trials of TES, all funded by the National Institute on Drug Abuse, are the bedrock of a rapidly evolving field of behavioral health.
The first study of TES, in 2008, involved 135 people receiving buprenorphine, a drug used to treat opioid addiction. The participants were randomly assigned to three treatment groups: one met three times a week with therapists trained in the community reinforcement approach; a second followed the approach using TES, meeting every other week with a therapist; the third group received a half-hour of standard individual counseling per week.
After 23 weeks, abstinence rates, as measured by continuous weeks of clean urine screens, were about the same for the therapist-only and TES groups. Those two groups, however, “produced significantly greater weeks” of abstinence compared to the group that received standard outpatient therapy.
Subsequent research has been just as encouraging. A 2013 study of patients in an outpatient methadone program found TES can roughly double abstinence rates. And a large multi-site study a year later found that substituting traditional counseling with a few hours of TES produced lower relapse rates and kept patients in treatment longer.
Marsch and colleagues' study of TES in prison populations reported lower rates of re-incarceration, illegal drug use and HIV infection after release. Her research has also shown that people who have tried and failed treatment numerous times benefited from TES, reporting longer periods of abstinence than a control group that received standard therapy.
Marsch joined Dartmouth in 2011 to lead the college’s Center for Technology and Behavioral Health, which has received more than $10 million in federal grants to develop and evaluate ways to deliver behavioral health care via technology.
She says researchers still need to apply technology-assisted care to other evidence-based addiction therapies, in a wider variety of clinical settings. The results could make it easier to provide treatment in primary care and make it more available in rural and remote areas.
And provide "just in time" support to people in crisis, wherever they happen to be.
“This is something that can be available 24/7,” she says. “That’s really helpful because if you feel like you’re going to relapse at two in the morning, you might not have anyone to help you navigate that. But you could literally have in your pocket access to a therapeutic resource.”
For more information, visit sudtech.org, a collaboration of the National Institute on Drug Abuse and the Substance Abuse and Mental Health Services Administration. The site includes videos, training and research findings on TES and other technology-assisted treatments currently being tested.