# Presentation: 085535

## Computerized CBT for Addiction

- Warren K. Bickel, Ph.D. and
- Lisa A. Marsch, Ph.D.
- University of Arkansas for Medical Sciences,
- National Development and Research Institutes,
- and HealthSim Inc.
- Supported by Grants from NIDA

## Introduction

- To produce a dramatic effect on drug abuse initiation and treatment, would likely require a substantially greater number of professionals than there currently are on the ground.
- Moreover, the costs to train and employ these professional would likely be prohibitive.

## “It would be an unsound fancy and self-contradictory to expect that things which never yet been done can be done except by means which have never yet been tried.”
						Francis Bacon
						(1561-1626)

- 						Francis Bacon
- 						(1561-1626)

**Notes:**
How can you achieve results that have never been obtained, except by methods that have never been tried

## Innovations in the Drug Abuse Field

- The Drug Abuse field has embraced both the Neuroscience and the Genetic revolutions.
- However, the field until recently all but ignored the revolution in information technologies.

## Benefits of Information Technology for the Drug Abuse Field

- Increase access to TX
- Permit more patients to be served
- Cost-effective (more effective services provided per dollar spent)
- Interventions fidelity is assured

## Opioid-Related Emergency  Room Visits

## Non-Medical Use of Opioids

- In 2004, among persons aged 12 or older, 2.4 million initiated non-medical use of prescription opioids

## Purpose

- To conduct a controlled random assignment trial comparing the efficacy of CBT delivered by computer, to CBT delivered by therapist and to standard treatment.

## Randomized Controlled Trial

- Participants: Opioid-dependent individuals randomly assigned to:
_*Therapist Delivered CRA:*_ 30 mins. 3x/wk. w/therapist & CM (Budney & Higgins, 1998)
_*Computer Assisted CRA:*_ 30 mins.3x/wk. w/computer & CM ;1 biweekly w/therapist
_*Standard Counseling:*_ 37 mins. 1/wk.  w/therapist - focus on rehabilitation & compliance with treatment program (Ball & Ross, 1991)
- All received buprenorphine maintenance treatment

## Computer-Assisted Therapy Systemfor Substance Abuse Treatment

- Individualized treatment plan for each patients
- Evidence-based program modules
- skills training, role playing, exercises, and homework
- Approx. 50 discrete, interactive modules
- Interfaced with semi-quantitative UA machine
- Therapists received electronic reports of patients’ activity and UA results
- Voucher earnings updated dependent on UA results

## Computer-Assisted Therapy Systemfor Substance Abuse Treatment(cont.)

- _x0008_Information frames relevant to a given module are systematically presented.
- Many modules employed Fluency-Based Computer-Assisted Instruction (CAI) technology
- “Read and Response Timing Parameters” are systematically altered
- A series of multiple choice questions are then presented
- Followed by a series of fill-in-the-blank questions
- Immediate feedback provided on all responses.

## Therapeutic Education System (TES)

**Therapeutic Education System (TES)**

**Flow of User Activity**

- Training Module

- Customization Program

- User asked if used drugs

- since last session

**User Log**

**-**

**In**

- Functional Analysis &

- Self

- -

- Management Planning

**If NO,**

**Proceed to Next Module**

**In Customized Plan**

**Composed of learning**

**tools including:**

- Fluency

- -

- Based CAI

- Interactive Videos

- Graphics

- Interactive Exercises

**User activity stored in**

**Database & Electronic**

**Summary Reports Sent**

**to/Viewable By Therapists**

**If First Use:**

**After First Use:**

**If YES,**

## List of Module Topics in Therapeutic Education System (TES)

** **

** **

- 1

- Training Module

- 2

- What is a Functional Analysis?

- 3

- Conducting a Functional Analysis

- 4

- Self

- -

- Management Planning

- 5

- Drug Refusal Skills Training

- 6

- Awareness of Negative Thinking

- 7

- Managing Negative Thinking

- 8

- Managing Thoughts About Using

- 9

- Managing Negative Moods and Depression

- 10

- Introduction to Problem Solving

- 11

- Effective Problem Solving

- 12

- Progressive Muscle Relaxation Training

- 13

- Receiving Criticism

- 14

- Seemingly Irrelevant Decisions

- 15

- Other Drug Use

- 16

- Coping with Thoughts About Using

- 17

- Introduction to Assertiveness

- 18

- How to Express Oneself in an Assertive Manner

- 19

- Introduction to Anger Management

- 20

- How to Become More Aware of the Feeling of Anger

- 21

- Coping with Anger

- 22

- Introduction to Relaxation Training

- 23

- Progressive Muscle Relaxation Generalization

- 24

- Introduction to Giving Criticism

- 25

- Steps for Giving Constructive Criticism

- 26

- Receiving Criticism

- 27

- Giving and Receiving Compliments

- 28

- Sharing Feelings

- 29

- Vocational Counseling

- 30

- Naltrexone

- 31

- Limited Alcohol Use

- 32

- Financial Management

- 33

- Insomnia

- 34

- Time Management

- 35

- Relationship Counseling  Part 1

- -

- 36

- Relationship Counseling  Part 2

- -

- 37

- Relationship Counseling Part 3

- -

- 38

- Alcohol and Disulfiram

- 39

- Communication Skills

- 40

- Nonverbal Communication

- 41

- Social Recreational Counseling

- 42

- Attentive Listening

- 43

- HIV and AIDS

- 44

- Sexually transmitted infections (STIs)

- 45

- Hepatitis

- 46

- Sexual transmission of HIV and STIs

- 47

- The Female Condom

- 48

- Birth control use and HIV and STIs

- 49

- Drug Use, HIV and Hepatitis

- 50

- Alcohol use and risk for HIV, STIs and hepatitis

- 51

- Getting Tested for HIV, STIs and Hepatitis

- 52

- Finding More HIV, STI and Hepatitis Information

- 53

- Negotiating Safer Sex

- 54

- Decision-Making Skills

- -

- 55

- Identifying/managing triggers for risky sex

- 56

- Identifying and Managing Triggers for Risky Drug Use

- 57

- Increasing Self-Confidence in Decision Making

- -

- 58

- Taking Responsibility for Choices

- 59

- Living with Hep C: Coping Skills

- 60

- Living with Hep C: Managing Treatment, Promoting Health

- 61

- Living with HIV: Coping skills and managing stigma

- 62

- Living with HIV: Comm. skills for disclosing HIV status

- 63

- Living with HIV: Managing treatment and medications

- 64

- Living with HIV: Drug use and Immune System

- 65

- Living with HIV: Daily routines to promote health

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## Participant Demographics

- _Therapist_

- _Computer_

-   % White

-  98

- 98

- 93

-   % Male

- 58

- 56

- 53

-   % High school education

- 71

- 67

- 69

-   % Employed full-time

- 47

- 44

- 49

-   Age (in years)

- 30.1 ±  9.2

- 26.1 ± 6.9

- 29.7 ± 8.9

-   Mean Monthly income

- 523

- 698

- 675

-   % Prior treatment

- 64

- 68

- 70

-   Years of regular use

- 5.6 ± 6.2

- 5.2 ±  4.4

- 6.4 ± 6.3

- % Injection Drug Users

- 62

- 80

- 68

-  % Cocaine Dependent

- 24

- 16

- 27

- _Characteristic_

-  by Group

- N =

- 45

- 45

- 45

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## Therapeutic Alliance

## Slide 31

**Notes:**
Computer therapy was only 20% of the time associated with computer-assisted Therapy

## Summary

- Computer-Assisted Therapy is generally as effective as comparable counselor-delivered therapy
- The computer-based intervention greatly decreases cost of treatment via reduced patient-therapist contact time
- The system enables counselors to focus on aspects of treatment they are uniquely skilled to address and enables more patients to receive treatment

## Future Directions

- This system could be used by patients in office-based buprenorphine treatment.
- This system could be adapted for use with other substance abusing populations.
- This system could be adapted for application in rural settings where this limited access to treatment