Edward V. Nunes, MD
Dr. Nunes is a professor of psychiatry at Columbia University and principal investigator of the Greater New York Node of the National Institute on Drug Abuse (NIDA) Clinical Trials Network.
Dr. Nunes has disclosed that he has no relevant financial or other interests in any commercial companies pertaining to this educational activity.
CATR: What are some of the online treatment modalities available for psychiatrists to incorporate into their substance abuse practices?
Dr. Nunes: Cognitive behavioral therapy (CBT) is the main modality available now. CBT lends itself to online treatment because it consists of a set of clearly defined techniques that can be taught in an online, multimedia format. These techniques are good adjuncts to traditional in-person psychotherapy.
CATR: What are the perks of teaching CBT online if clinicians are involved anyway?
Dr. Nunes: For one thing, it unburdens the clinician, who doesn’t need to be specifically trained in CBT and can spend the time talking to patients about their unique experiences instead of delivering content. Also, a major barrier to delivering evidence-based behavioral treatments is that it’s hard to get clinicians to deliver treatment the way the manual says to deliver it. This means the treatment delivered by clinicians often isn’t truly evidence-based. Online treatment delivers the content in a way that’s true to the manual.
CATR: What is the evidence supporting online substance abuse treatment?
Dr. Nunes: For some interventions the evidence is mixed, and as you might imagine, there are many that have never been researched. Although some may incorporate principles of evidence-based treatments like CBT, the programs themselves haven’t been tested in randomized controlled trials (RCT), and there’s no guarantee they are effective. There are a couple of programs out there with a solid evidence base, and there are two meta-analyses showing that online treatment as a whole is effective for cannabis and tobacco use disorders (Tait RJ et al, Drug Alcohol Depend 2013;133(2):295–304; Gulliver A et al, Addict Sci Clin Pract 2015;10:5).
CATR: Can you tell us about the specific programs that are evidence-based?
Dr. Nunes: There are two that I’m aware of. The first is Computer Based Training for Cognitive Behavioral Therapy, or CBT4CBT. It consists of a series of multimedia modules and is built around cognitive behavioral relapse prevention for substance use disorders. The modules teach skills such as managing cravings. For example, one skill is delaying response—this is the idea that you might really want to use drugs right now, but if you just put it off for 20 minutes, the craving will probably go away. The program includes many practical skills like this, taught through a combination of text and video. There is also a module on condom use, because substance use disorders increase the risk of STIs.
CATR: What does the research say about the effectiveness of CBT4CBT?
Dr. Nunes: There have been two RCTs. In one, among 77 individuals with any substance use disorder, participants assigned to the CBT4CBT group were significantly more likely to produce negative urine specimens for any type of drug and had longer periods of abstinence during treatment. Retention in treatment was not different between the two groups (Carroll KM et al, Am J Psychiatry 2008;165(7):881–888). In the other, among 101 cocaine-dependent participants maintained on methadone, participants assigned to CBT4CBT were more likely to have 3 or more weeks of abstinence from cocaine and had a greater reduction in cocaine use at 6 months compared with treatment as usual (Carroll KM et al, Am J Psychiatry 2014;171(4):436–444).
CATR: You mentioned there is another evidence-based intervention.
Dr. Nunes: Yes, the Therapeutic Education System, or TES. It emphasizes some of the same relapse-prevention skills as CBT4CBT, but focuses more heavily on community reinforcement approaches, such as, “What can I do to have fun without using?” It also incorporates a contingency management system.
CATR: How does that work?
Dr. Nunes: In traditional substance abuse treatment, contingency management works by rewarding patients for desired behavior, such as attending groups or producing negative urine drug screens. In TES, the principles are the same, but the computer program keeps track of the vouchers and provides a visual demonstration of the vouchers being awarded. For example, let’s say a person’s urine today was negative for drugs. The staff inputs that information into the computer, and the program keeps track of how many negative urines the person has had and how many vouchers that person earns.
CATR: What have clinical trials said about TES?
Dr. Nunes: There was a 10-site NIDA-sponsored trial including 507 participants with heterogeneous substance use disorders. In that study, TES doubled the odds of abstinence in participants who had been using within 30 days of baseline, and it increased treatment retention compared with treatment as usual (Campbell AN, Am J Psychiatry 2014;171(6):683–690).
CATR: Impressive. What does it all look like when the patient goes to the computer?
Dr. Nunes: CBT4CBT has seven modules. Each takes about 30 minutes to go through, and they have nicely filmed vignettes with high production value. TES has about 40 modules; each takes about 10 or 15 minutes, and you can pick and choose modules for your patients. If someone is having a lot of trouble getting along with people, you can say, “I think you should go and do the three modules on relationships between now and next week, and then we’ll talk about them.” There are quizzes all the way through on the modules, and the patient has to get a quiz right before moving on. It’s to make sure the patient is paying attention.
CATR: Are there any pitfalls of online treatment that patients or psychiatrists should keep in mind?
Dr. Nunes: To my knowledge, studies haven’t identified a downside clinically. Of course, in a self-guided online program, there’s always the question of whether the patient is really learning what the program is trying to teach or just going through the motions. I think the solution is for the therapist to talk to the patient: “Did you do that module about drug refusal skills? What did you learn? How could you apply it?”
CATR: What about privacy? Should we be concerned about the security of the information?
CATR: What about cost?
Dr. Nunes: Cost is a major consideration for online treatment programs. The major online programs that are evidence-based are not free, and programs that run on a tight budget may not be able to afford them. Insurance doesn’t usually cover them, and for many programs, there really isn’t an infrastructure to bill for online treatment as part of their larger programmatic offerings. You can currently license TES for something like $10,000 a year for use with an unlimited number of patients. It’s not a ton of money, but it’s also not nothing, particularly for treatment programs running on limited budgets. My understanding is that TES can now be licensed on a patient-by-patient basis.
CATR: Do you know of any free, evidence-based online treatments for substance abuse that psychiatrists can recommend to their patients right now?
Dr. Nunes: Unfortunately, I’m not aware of anything for alcohol or drug use disorders. For depression, there is a free online program out of Australia called MoodGym (https://moodgym.anu.edu.au/welcome/faq#what). And the American Cancer Society, on its website, has very useful computer-delivered cognitive behavioral strategies for making a nicotine cigarette quit attempt. But for substance use disorders, we just don’t have that kind of penetrance yet in terms of moving from the research sphere to real-world accessibility.
CATR: Overall, do you think that computer technology provides a viable alternative to face-to-face substance abuse treatment?
Dr. Nunes: I don’t think so. My feeling is that right now, online and other computerized forms of treatment are best used as a clinician extender within a traditional treatment program.
CATR: Why do you feel the human element remains important?
Dr. Nunes: Homework with in-person feedback is an important part of substance abuse counseling. For example, I might ask you to walk through a neighborhood where you used to use drugs, knowing that you’ll probably experience some craving. I’ll ask you to use certain relapse prevention skills, then come back and tell me how they worked. That’s something that the computer isn’t anywhere near to being able to do yet. It’s a bit like learning how to play tennis: You can watch tennis videos and then go hit a ball around, but you really need a coach to tell you, “Look, here’s what you need to do with your grip.”
CATR: What about apps for smartphones? I understand there are some innovative uses of that technology.
Dr. Nunes: There are some very promising apps that are under development, none of which are available to the general public yet. For example, there is a text-based app that will ask a patient, “How many drinks have you had in the past 24 hours?” After a certain number of days, it will produce a graph of how many drinks the patient has had, and this can be incorporated into motivational interviewing with a clinician. Another app will watch patients take their medicine every day using the smartphone’s camera and create a report for the clinician detailing how many days they took it. So it’s an adherence monitor. And then there is one that uses your smartphone’s GPS capability—so that if you go to an area you’ve defined as a drug market, for example, it will send you a text message saying, “Hey, you’re going over to the wrong side of town. Why don’t you turn around and go back?” This is called geofencing—trying to fence off certain areas virtually.
CATR: That’s amazing! Are there any other smartphone apps on the horizon?
Dr. Nunes: There are already smartphone-based alcohol monitors available online. These allow users to provide breath samples to the phone and transmit the results to specified recipients. The phone’s camera also transmits an image of the patient giving the sample along with a time stamp, verifying the person’s identity. I also have some colleagues who are developing a smartphone-based app where you attach a little cup to it and spit into it and it tests the saliva. So as a clinician, you can actually monitor somebody’s blood levels of drug or alcohol and confirm the person’s abstinence or non-abstinence without the patient having to come into the clinic and give a urine test. I think that pretty much covers the bases in terms of what’s under development.
CATR: Anything other than apps and online programs? The world of technology is pretty vast.
Dr. Nunes: I should mention that there are a number of text messaging interventions in development. For example, they might be set up in such a way that a person gets a text message saying, “Please indicate how many drinks you have had in the past 24 hours.” It’s kind of neat in this age of Twitter. People like getting little bits of messaging.
CATR: Fascinating technology in the pipeline. Thank you, Dr. Nunes.