There is no way to meet the need for substance abuse treatment through the current healthcare system. The number of people who need treatment for drug and alcohol abuse is far greater than the number of clinicians available to treat them. In more rural areas, patients might have to spend a lot of time traveling great distances to appointments, which can be difficult to do while working or taking care of a family. And, the cost and stigma of treatment can get in the way of getting help. Moreover, even if people do get to substance abuse treatment, they often do not receive the most effective ones. As illicit drug use increases in the United States, new ways to deliver treatment are urgently needed.
Computer-guided treatments are one way to overcome the hurdles of access to evidence-based treatments, including travel and scheduling, cost, and stigma. Additionally, using computers to treat one’s own substance abuse can be empowering, giving a sense of "I did it on my own."
How well do computer-guided treatments work compared to live counseling?
Researchers from Yale University recently developed and studied the "Computer-based Training for Cognitive-behavioral Therapy" (or "CBT4CBT") web-based substance abuse treatment as a fully standalone intervention. CBT4CBT provides cognitive behavioral therapy (CBT) — an evidence-based treatment for substance abuse. The treatment is completely computer-guided, and does not involve interacting with a counselor or other healthcare professional. It combines online games and video vignettes with actors to teach how to manage one’s own substance use. Specifically, CBT4CBT covers: how to understand and change patterns of substance use; dealing with cravings; refusing offers of alcohol and drugs; problem-solving; noticing thoughts about drugs and alcohol and how to change them; and strengthening decision-making abilities.
Earlier research has shown that CBT4CBT can be an excellent complement to make live treatment with a counselor more effective and efficient. Recently, the research team conducted the first comparison of any standalone web-based treatment for substance abuse to "treatment as usual" — and data suggest that it may be better.
The study on CBT4CBT
The Yale team recruited 137 people seeking substance use treatment from the Connecticut Mental Health Center in New Haven; 49% African American, 34% Caucasian, and 8% Latino or Latina. Substances used were marijuana, cocaine, alcohol, opioids, and PCP. It was a real-world sample in that most participants used more than one illicit drug and most also used alcohol.
One-third of the participants were randomized to use CBT4CBT, with 10-minute in-person weekly checkups to evaluate their overall functioning, their safety, and their use of the online program. One-third of participants were enrolled in "treatment as usual," which was either group or individual therapy, and covered topics including motivational interviewing, life skills, relapse prevention, harm reduction, mindfulness, and others. The other third were assigned to in-person CBT with a therapist who delivered the same type of content as the CBT4CBT online program.
The researchers found that drug use (measured by urine tests — which corresponded closely with self-reported use) in the CBT4CBT group was significantly less than treatment as usual, and remained lower over six months of follow-up. Persons who received live CBT had the same level of drug use as the treatment as usual group after six months. They also found that participants in the online treatment learned the CBT concepts the best, and had the highest level of satisfaction and lowest dropout rate of any of the three study conditions. Overall, after treatment the percentage of days abstinent from any drug use was 75% for the CBT4CBT group, vs. 67% of days abstinent for the treatment as usual group and 61% for the live CBT group. The study did not enroll a large enough number of participants to conduct a head-to-head comparison of CBT4CBT and live CBT. That may come later, and the results could inform how to conduct live CBT more effectively.
Getting access to computer-guided CBT
Computer-guided CBT for substance abuse should be studied further should be studied further, with different populations and in different settings, the next real challenge is to disseminate it widely across the US and beyond. According to its website, the CBT4CBT program is not yet available to the public, outside of clinical trials.
Building computer-guided treatment programs is often easier than building companies to deliver them. Barriers include acceptance by institutions, payment by insurance companies, liability, FDA approval, and resistance from healthcare providers — as well as coming up with viable business models. But if these obstacles can be overcome, the world could benefit from a highly effective and accessible treatment for drug and alcohol abuse.
Randomized Clinical Trial of Computerized and Clinician-Delivered CBT in Comparison With Standard Outpatient Treatment for Substance Use Disorders: Primary Within-Treatment and Follow-Up Outcomes. American Journal of Psychiatry, May 2018.
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