Trends in telemedicine use in addiction treatment

Telemedicine applications (apps) that exchange health information from one location to another create new connections between treatment providers and their patients. In general health care, telemedicine is giving patients a sense that their illness is being monitored more closely, the ability to participate in their own health management, and a feeling they have not been forgotten by their doctor [1].

The addiction treatment field offers a promising setting for telemedicine use. The chronic nature of addiction disorders calls for methods for clinicians to stay connected with patients over extended periods of time. Face-to-face contacts between patients and clinicians are limited to scheduled appointments or group sessions. Counselors are not available when they’re most needed: outside the treatment setting, where patients make decisions to stay sober or not. Telemedicine extends the providers’ availability and offers patients an immediate resource.

Telemedicine can increase access to addiction treatment service by removing the barriers of geography and stigma [2]. Patients in rural areas who in the past had to drive long distances can now receive addiction services within their own homes or at a local health care provider. Through telemedicine, patients can also avoid experiencing the perceived stigma of being identified as a patient at a specialty addiction treatment provider. In practice, a variety of electronic modalities are increasing the use of telemedicine in addiction treatment and recovery. The most mature modality, telephone-based care, has been used to provide continuing care for substance use disorders (SUDs) [3]. Continuing care delivered by telephone is easy to implement and does not carry additional costs such as licensing fees or patient training. Telephone-based services have included telephone monitoring, feedback, and counseling. Study results for telephone-based continuing care are mixed, but generally show better results than traditional continuing care [4–6].

An enhanced application of telephone-based technology is interactive voice recognition (IVR) technology. In IVR, an automated telephone system provides patients with different follow-up and feedback options based on their responses to pre-established questions [7]. This technology has been tested in primary care settings with mixed therapeutic results [7, 8]. IVR tested in pilot studies in specialty treatment settings reduced post-outpatient treatment drinking days per week, but only for patients who had achieved treatment goals at time of discharge [9].

Web-based telemedicine services are accessible to many patients and are typically “asynchronous,” meaning that people can access them any time, at their convenience. Several web-based platforms and apps for SUD assessment are available [10, 11]. Overall, web-based telemedicine services have been found to be more effective at reducing alcohol consumed per week than comparison conditions [12, 13]. This is particularly true for nonstudent populations [12]. One population, subcritically injured trauma patients, has not had positive results with web-based telemedicine [14].

For web-based alcohol screening, assessment, and feedback or brief intervention, the Drinker’s Check-up (DCU) has demonstrated positive results in several clinical trials [10, 15]. The DCU (www.drinkerscheckup.com) is an integrated computerized system that includes Moderate Drinking (moderatedrinking.com), a web app for people who want to reduce their drinking, along with several other components: a) a brief screening that utilizes the Alcohol Use Disorders Identification Test (AUDIT); b) an in-depth assessment; c) a full motivational session tailored to the individual’s assessment results; and d) computerized cognitive treatment options that link to web-based mutual aid groups. Similarly, web-based, computerized, brief interventions for drug use demonstrate results similar to or better than clinician-delivered services [16].

An example of a web-based SUD treatment is the Therapeutic Education System (TES) [17]. TES consists of 65 modules based on the Community Reinforcement Approach (CRA) and includes modules on HIV/STD prevention. TES is provided in conjunction with clinician-delivered services and serves as a clinician extender. Research studies are demonstrating superior outcomes for patients using TES compared to treatment as usual. Research studies are also showing TES results comparable to those for the CRA delivered in person by highly trained clinicians [18].

Another web-based treatment approach that has been examined in research studies is Computer-Based Treatment for Cognitive Behavioral Therapy (CBT4CBT) [19]. Research studies have shown positive outcomes (similar to the TES studies) with CBT4CBT compared to treatment as usual or treatment provided solely by clinicians [17, 20].

Videoconferencing for addiction treatment or psychiatry occurs through secure portals on personal computers or dedicated telemedicine consoles. Videoconferencing is currently used in addiction services for: a) video therapy, where patients can interact with clinicians from a remote location or the privacy of their homes; b) recovery supports, where a counselor or peer-support specialist interacts with a person in recovery; and c) specialty services, where patients are placed in contact with hard-to-reach medical specialists, such as an adolescent psychiatrist or a physician who can prescribe buprenorphine. Studies in videoconferencing for addiction services have found no difference in the results or patient satisfaction of care provided in person or by video [21, 22]. Meta-analyses of videoconferencing for psychiatry services have found similar positive results [23, 24], with the notable exception that neither in-person nor video services affected outcomes for post-traumatic stress disorder patients [25].

Mobile devices (smartphones and tablets) make substance abuse treatment and recovery support available 24 h a day, 7 days a week. An early meta-analysis of mobile device use in overall health care determined that it is too early to pool effects of this technology, and that the positive effects that have been realized are primarily attributed to texting interventions within the mobile device apps [26]. Smartphones and tablets offer the same services as telephone-based, web-based, and videoconferencing services. The Addiction Comprehensive Health Enhancement Support System (A-CHESS) app has been found to reduce risky drinking days and to achieve higher abstinence rates than usual care [27]. A-CHESS has also been a useful tool for alcohol relapse prevention for patients following discharge from residential services [28]. A-CHESS is delivered through a smartphone and contains the following key features: a secure discussion board; an “ask an expert” forum; a panic button that provides supportive information; individualized reminders of reasons to not use; automatic messages requesting assistance from people identified as supportive of the patient’s recovery; a GPS-enabled function that sends a warning if a patient is approaching a previously identified high-risk location; a daily check-in assessment of substance use; and a mutual-aid meeting locator. A weekly survey of recovery risk and protection factors is also pushed through the phones, with graphs showing changes over time. Counselors have access to the daily check-in assessment and weekly survey results. Another mobile app called Location-Based Monitoring and Intervention System for Alcohol Use Disorders (LBMI-A) has reduced hazardous drinking days and drinks per day [29]. This app provides numerous features, similar to A-CHESS, for intervening with ongoing drinking, craving, connecting with supportive others, managing life problems, high-risk location alerting, and activity scheduling.

Virtual worlds are an ongoing, synchronous (or real-time) environment facilitated by networked computers that provide a “virtual” social space where people interact and are represented by avatars [29]. Avatars are graphic representations of users that users build with tools supplied in the computerized environment. Users can then control their avatars to interact with others avatars within the virtual environment. Research on virtual reality in addiction treatment that predates virtual worlds and does not allow for synchronous social interaction has established that computer-generated, 3-D environments can simulate reality effectively and provide settings for testing reactions to environmental triggers for craving [30–32].

Virtual worlds and avatars have been used in recent years to address SUDs. Companies design these virtual environments for specific treatment organizations; the resulting virtual world is protected and available only to people with an access code and a password. Services within the virtual worlds may include presentations, individual or group counseling, and a live clinician who interacts with the patients through an avatar. Thus, the virtual world allows synchronous communication between SUD patients and clinicians. To our knowledge, no research studies on the use of virtual worlds to address substance use have been completed; however, early adopters of telemedicine technology in addiction services are considering this option, even though it currently lacks an evidence base.