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).