Additive Benefit in Addiction Treatment: Human and Technology-Based Patient Engagement

The World Health Organization (WHO) estimates the burden of disease related to drug and alcohol abuse disorders to be 5.4% of the global population ages 12 and above. Alcohol abuse is the most common substance use disorder (1). However, those with addictive disorders frequently abuse multiple substances. Additionally, an estimated 8 million Americans suffer from co-occurring substance abuse and mental health disorders (1). The rates of substance use disorders also vary by age. According to the National Survey on Drug Use and Health, in 2014, approximately 5% of U.S. adolescents (ages 12–17) suffered from a substance use disorder. The highest rate was for young adults (ages 18–25), at 16.3% (2). Older adults are not immune from substance use disorders. Estimates of alcohol abuse for those over age 65 range from 2% to 20%. This age cohort is at particular risk for prescription drug abuse and dependence, particularly benzodiazepines (3).

Most individuals who require treatment for substance use disorders do not receive it. Many do not access treatment because they do not feel that they need it; this is often referred to as being “in denial.” Others may avoid voluntary treatment because of their concern about embarrassment and an expectation that they will be misunderstood and judged (2). Lack of a full continuum of substance abuse treatment services is another barrier to treatment (4). Substance abuse treatment programs vary widely in the level of care (hospital, residential, outpatient, etc.), as well as therapeutic modalities (psychotherapy, social support, groups, individual, pharmaceutical tools, complementary forms of medicine, etc.) (5). Furthermore, addiction is a chronic disorder. In addition to treatment, including detoxification (if required) and achieving initial abstinence, addiction treatment must include relapse prevention. Relapse rates are estimated at 40%–60%, a rate similar to that for relapse with other chronic diseases, such as hypertension, asthma, or diabetes (2).

Individuals with substance use disorders may be legally mandated into treatment because of charges related to behavior precipitated by the addiction. In a study by Wild and colleagues (6), clients rated the extent to which treatment was sought because of coercive legal mandates (external motivation), guilt about continued substance abuse (introjected motivation), or a personal choice and commitment to the goals of the substance use disorder treatment program (identified motivation). Study findings suggested that those with coercive external motivations for seeking treatment had lower levels of treatment engagement. Identified treatment motivation positively predicted engagement in substance abuse treatment.

A consistent finding in the drug treatment literature is that successful engagement of clients in the treatment process predicts positive treatment outcomes beyond other client factors (7, 8). Development of a positive therapeutic alliance is a consistent predictor of engagement and retention in drug treatment (7). Clinicians who actively listen to their patients form a stronger doctor–patient alliance. This alliance may affect engagement in current treatment as well as future treatment decisions and future engagement with health care professionals. In addition to its bearing on patient comfort and satisfaction, doctor–patient rapport can also influence patient health behaviors; most notably, treatment adherence. This is true for both medical patients and those receiving psychological and addiction treatment (8).

The substance use treatment infrastructure is financially overburdened, labor intensive, and often suffering from unstable funding (5). It is thus incumbent upon the health care leadership to develop more efficient, cost-effective strategies to improve access to initial and continuing care in substance abuse treatment. This includes the methods of engagement of those patients who may feel coerced into treatment to optimize the likelihood of achieving and maintaining sobriety (5, 9, 10). For ongoing care, mobile communication technologies are beginning to be used to help address the shortage of services to meet the needs of people seeking long-term recovery. These technology-based services complement and extend existing modes of relapse prevention services to improve long-term outcomes for individuals struggling with substance dependence disorders (10–12).

Gustafson and colleagues (13) have described an integrated technology-based relapse-prevention system called the “Alcohol-Comprehensive Health Enhancement Support System” (ACHESS). ACHESS is a technology-based information and support system that uses the tenets of self-determination theory (SDT) (14), motivational interviewing (15), and the Marlatt relapse-prevention model (16) to help individuals coping with alcohol abuse and addiction. Consistent with SDT, the system uses relapse-prevention methods that target an individual’s inadequate coping strategies, lack of social support, and flagging motivation—all of which are associated with a heightened likelihood of relapse (13).

The Marlatt relapse-prevention model (16) is a cognitive–behavioral relapse-prevention model that targets both immediate determinants (e.g., high-risk situations, lack of adequate coping responses, decreased self-efficacy, and abstinence violation) and covert antecedents (e.g., lifestyle imbalances, urges, and cravings) that can lead to relapse. ACHESS uses mobile technology to augment, as well as in place of, individual professionals. It includes online bulletin board support groups (13). The “Ask an Expert” function allows ACHESS users to receive responses within 24 hours from an addiction specialist. ACHESS personal stories supply professionally produced text and video stories that highlight strategies to cope with challenges. Other electronic resources include medication information, an instant library, and frequently asked questions. Journaling, a computerized cognitive–behavior therapy program, and methods of quickly accessing a counselor are also supported. One of the more controversial aspects of ACHESS is the “High-Risk Patient Locator.” This application uses GPS technology to track when someone in recovery is approaching an area where he or she has traditionally obtained alcohol so he or she can be contacted to receive support to work through a high-risk situation for relapse. This is a voluntary aspect of the program (13).

Clinical Vignette

Stephanie Johnson is a 25-year-old woman who recently completed a 4-week residential treatment program for alcohol abuse disorder. Ms. Johnson lives in a small town in the rural United States. She is married and employed at a local bank. She took 4 weeks of family medical leave to receive court-mandated addiction treatment in a city 2 hours away. Ms. Johnson’s alcoholism has exacted a toll on her life: straining her marriage; resulting in the loss of her driver’s license for driving while intoxicated; precipitating sick days and loss of productivity in her job; and resulting in physical health issues, including anemia. Ms. Johnson is hoping to get healthy—to remain sober and start a family.

Four weeks earlier, Ms. Johnson’s first contact with Dr. Khan occurred via court-ordered treatment. Dr. Khan was the admissions psychiatrist on the day she arrived at the residential treatment center. Ms. Johnson entered the center angry, tearful, and with a mild tremor. She adamantly professed to having only intermittent drinking and tried to assure Dr. Khan that she “has it under control.” She didn’t understand why she needed to be “locked up.” She was particularly worried about losing her job and her deteriorating relationship with her husband. Ms. Johnson fumed, “When I get out of here, I will probably just be homeless and destitute. And all you care about is keeping this place full so you can make money!”

Dr. Khan heard the terror in Ms. Johnson’s voice, even through the insults. “Ms. Johnson, I can only imagine how frightened and upset you must be to be brought here against your will. I’m very sorry that you are in this situation.”

Ms. Johnson looked suspicious. “Sorry? Do you even know what it means to be sorry? I rear-ended an old lady and almost killed her. I have been having nightmares since. But this is the worst nightmare of all.”

Dr. Khan’s eyes softened as she listened for a long while. She finally spoke. “You have so much going wrong for you right now. It will take a while to sort it out, feel better, and decide what you want for yourself going forward. We are here to help you do that. I’m sure it doesn’t feel that way right now, though.” After completing the initial interview, assessing risk and evaluating the potential for physical withdrawal symptoms, Dr. Khan reviewed with Ms. Johnson the medication and treatment plan, the team with whom she would be working, and what to expect.

At the current appointment, Dr. Khan greeted Ms. Johnson with a warm smile. “Hello, Ms. Johnson. Do you remember me? We met when you first went into rehab. It is good to see you again,”

Ms. Johnson apologized. “I’m sorry I was so nasty to you, Dr. Khan. It was the addiction talking. You were kind to me. I know how busy everyone else here is, and I’m glad you were able to see me today.”

“No need for apologies,” Dr. Khan replied. “You have been through a lot. I look forward to working together.” Dr. Khan mused, reading through Ms. Johnson’s coconstructed plan. “Hmmm—I see you have done some good work in setting goals and priorities. And you are interested in the mobile ACHESS relapse prevention system. What have you learned about it?”

Ms. Johnson had done her homework and knew quite a bit about the technology and services provided. She was very comfortable with technology and thought that this system could be helpful in decreasing her risk of relapse. “Does this mean that I no longer get to see you or my therapist?” Ms. Johnson queried. I like apps, but I also like connecting—you know, with a real person.”

Dr. Khan had worked with other patients via the ACHESS system and found that in-person meetings were important for continuity and decreasing urgent calls for assistance. Dr. Khan took out a cellphone to give to Ms. Johnson for the ACHESS program. “I’m sure that you are more tech savvy than I, so you will be a pro in no time.” They reviewed various applications and resources. In addition, Dr. Khan described the GPS function that could track her whereabouts if she were going to a liquor store, for example. “Is this something you want? We can enable the GPS or not. It is up to you. You may want to talk to others in your support group who have used it to see if they found it helpful. Some love it, and some find it a bit intrusive.”

“What do you think, Dr. Khan?” Ms. Jones asked. “Do you think I need it?”

Dr. Khan replied, “Let’s review your triggers and motivators so that you can decide what is best for you.”

After considerable discussion, Ms. Johnson decided that she was very motivated not to relapse and that it was worth the loss of privacy to try the GPS. “Besides,” she said, “I mainly want to be home with my husband now. And get back to work, of course.”

Engaging Patients in Substance Use Treatment

In psychiatry, the therapeutic aspects of the doctor–patient relationship are crucial to effective treatment engagement and outcomes (17–19). Technology-based treatments are foreign to most clinicians. Just as psychiatrists increasingly work in interdisciplinary treatment teams, mobile technology is likely to be a more prominent aspect of long-term treatment provision for individuals suffering from addictions (11, 12). Teaching ourselves and our patients about these supports, and gaining communication skills to teach and motivate our patients to optimally utilize technology-based services, will be important to help all patients requiring access to needed chronic disease treatment.

In the vignette given earlier, Dr. Khan was able to form a therapeutic, albeit fragile, connection during the initial evaluation when Ms. Johnson was mandated for inpatient alcohol treatment. This connection helped Ms. Johnson feel less coerced and humiliated by the court order. This also helped enhance her motivation for ongoing relapse prevention treatment upon her release from the rehab center.

The use of mobile technology for a number of health-based services can augment what is available at clinics or from individual providers. Patients sometimes prefer the anonymity of the device in the journaling and rating of symptoms (13). Ensuring that we maintain the humanity that is our craft, while embracing innovations that can assist patients in longer term recovery, will be an aspect of the art of medicine that requires ongoing discussion and investigation.

The following are tips to engage the difficult-to-engage patient who has a substance use disorder:

1. Initial engagement

   1. Listen and empathize with the plight of the patient.

   2. If he or she is mandated to treatment, acknowledge how difficult that must be. You may also acknowledge that it will likely be harder to form a trusting relationship but that you are hopeful that this will happen.

   3. Self-determination theory posits that satisfaction of three fundamental needs contributes to adaptive functioning: perceived competence, feeling connected to others, and autonomous motivation (feeling internally motivated and uncoerced in one’s actions). Keeping these three fundamental needs in mind will help the clinician connect with the desires of the patient;

   4. Motivational interviewing is an excellent method of further engagement and co-constructing the patient’s priorities and methods to achieve those goals.

2. Relapse prevention

   1. Each treatment center or practitioner has a limited set of resources to assist with relapse prevention. It is important to review those resources on a regular basis, including how optimally they are being used, to ensure that the most evidence-based cost-effective modalities are implemented.

   2. Consider forming a multidisciplinary team to review resources and the costs and benefits of adding technology-assisted relapse prevention tools, as well as the human resources needed to provide more robust relapse prevention services.

   3. Engage each patient around their learning and motivational style. This will allow personalization of a relapse prevention plan and enhance ongoing engagement in treatment.

   4. Discuss with each patient openly and sensitively his or her daily routines, issues of lifestyle, culture, religion, neighborhood, and financial resources that affect quality of life and the risk and resilience factors related to relapse. For example, if family holidays include lots of wine and drinking, this may be particularly difficult for a patient who values these relationships but knows that it will be hard to abstain in these situations.

   5. Optimal team functioning is necessary to ensure that patients receive optimal care. Set up regular communication methods to review each patient’s care, including their treatment plan, and each clinician’s role. When working with very complicated patients and treatment systems, there is a high potential for “splitting” and inconsistency in implementing treatment plans. Close collaboration is essential in providing effective treatment to complicated, high-risk patients.

   6. Remain curious—about the patient, the effectiveness of various treatment modalities, and methods of collaboration. This will move the field forward and improve patient outcomes.