Web-based and Mobile Health Interventions?
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Original Paper
Overcoming Addictions, a Web-Based Application, and SMART Recovery, an Online and In-Person Mutual Help Group for Problem Drinkers, Part 1: Three-Month Outcomes of a Randomized Controlled Trial
Reid K Hester1, PhD (Clin. Psycho.); Kathryn L Lenberg2, MPH, PhD (Clin. Psycho.); William Campbell3, MS(Psycho); Harold D Delaney3, PhD(Psych)
1Behavior Therapy Associates, LLC, Research Division, Albuquerque, NM, United States
2Presbyterian Medical Group, Integrated Behavioral Health, Albuquerque, NM, United States
3Psychology Department, The University of New Mexico, Albuquerque, NM, United States
Reid K Hester, PhD (Clin. Psycho.)
Behavior Therapy Associates, LLC
Research Division
9426 Indian School Rd NE Ste 1
Albuquerque, NM, 87111
United States
Phone: 1 505 345 6100
Fax: 1 505 345 4531
Email:
ABSTRACT
Background: Overcoming Addictions (OA) is an abstinence-oriented, cognitive behavioral, Web application based on the program of SMART Recovery. SMART Recovery is an organization that has adapted empirically supported treatment strategies for use in a mutual help framework with in-person meetings, online meetings, a forum, and other resources.Objective: To evaluate the effectiveness of OA and SMART Recovery (SR) with problem drinkers who were new to SMART Recovery. Our experimental hypotheses were: (1) all groups will reduce their drinking and alcohol/drug-related consequences at follow-up compared to their baseline levels, (2) the OA condition will reduce their drinking and alcohol/drug-related consequences more than the control group (SR), and (3) the OA+SR condition will reduce their drinking and alcohol/drug-related consequences more than the control group (SR only).
Methods: We recruited 189 heavy problem drinkers primarily through SMART Recovery?s website and in-person meetings throughout the United States. We randomly assigned participants to (1) OA alone, (2) OA+attend SMART Recovery (SR) meetings (OA+SR), or (3) attend SR only. Baseline and follow-ups were conducted via GoToMeeting sessions with a Research Assistant (RA) and the study participant. We interviewed significant others to corroborate the participant?s self-report. Primary outcome measures included percent days abstinent (PDA), mean drinks per drinking day (DDD), and alcohol/drug-related consequences.
Results: The intent-to-treat analysis of the 3-month outcomes supported the first hypothesis but not the others. Participants in all groups significantly increased their percent days abstinent from 44% to 72% (P<.001), decreased their mean drinks per drinking day from 8.0 to 4.6 (P<.001), and decreased their alcohol/drug-related problems (P<.001). Actual use relationships were found for the OA groups, between SR online meetings and improvement in PDA (r=.261, P=.033). In addition in the OA groups, the number of total sessions of support (including SR & other meetings, counselor visits) was significantly related to PDA (r=.306, P=012) and amount of improvement in alcohol-related problems (r=.305, P=.012). In the SR only group, the number of face-to-face meetings was significantly related to all three dependent variables, and predicted increased PDA (r=.358, P=.003), fewer mean DDD (r=-.250, P=.039), and fewer alcohol-related problems (r=-.244, P=.045), as well as to the amount of improvement in all three of these variables. Six-month follow-ups have been completed, and the results are currently being analyzed.
Conclusions: These results support our first experimental hypothesis but not the second or third. All groups significantly increased their PDA and decreased both their mean DDD and their alcohol-related problems, which indicates that both interventions being investigated were equally effective in helping people recover from their problem drinking.
Trial Registration: Clinicaltrials.gov NCT01389297; http://clinicaltrials.gov/ct2/show/NCT01389297 (Archived by WebCite at http://www.webcitation.org/6Hh5JC7Yw).
(J Med Internet Res 2013;15(7):e134)
doi:10.2196/jmir.2565
KEYWORDS
addictions; cognitive-behavioral program; Web application; SMART Recovery; mutual self-help groups
Online Interventions for People With Alcohol and Drug Problems
In the past decade, there has been a marked rise in the number of online resources available to individuals with alcohol and drug problems, and evidence has steadily mounted to support their use [1-3]. One frequently recognized benefit of this trend is that individuals who might not otherwise seek treatment will consider an online intervention [4]. The Internet also makes interventions available to drinkers who?whether due to physical infirmity, geographic isolation, or lack of resources?might have difficulty accessing traditional treatment services. As online interventions have become more prevalent, people have used these interventions on a scale that would overwhelm conventional resources [5].
Online interventions are used in a variety of contexts, from clinical settings to college dorms to free access on the Internet. They may be presented as stand-alone treatments, as the first step in a stepped model of care, as an adjunct to traditional care, or as a hybrid [2,5,6]. The form and content of these Web-based interventions vary widely, from simple text-based adaptations of brief screening instruments that take a minute or two to complete, to multisession, multimedia, interactive interventions that extend over several hour-long sessions [7-9].
Alternative Protocols
While the predominant paradigm for conceptualizing addictive behaviors in the United States is the 12-step model (eg, Alcoholics Anonymous, Narcotics Anonymous, etc), a significant proportion of individuals who are looking for help with their addictions reject 12-step programs for a variety of reasons [10]. At least some of these individuals are interested in viable alternative recovery options, often preferring approaches that provide them with more flexibility in how they define and address their addictive behavior(s). SMART Recovery (Self-Management And Recovery Training) [11] provides such individuals with a protocol that, like a 12-step program, employs the use of an interactive group component (either in person or through the use of Web-based chat rooms and a forum) while using the framework of the 4-point program (described below). However, SMART Recovery fundamentally differs from the 12-step model in that (1) ?participants learn tools for addiction recovery based on the latest scientific research?, (2) it avoids labeling (eg, ?alcoholic? or ?addict? unless individuals themselves accept that label), and (3) it does not conceptualize addiction as a disease per se (but is accepting of members? views of addiction as a disease) [12]. Anecdotal evidence from SMART Recovery meetings indicates that these aspects of the program draw participants to SMART Recovery (A.T. Horvath, personal communication, 12/2/08).
The Overcoming Addictions Web Application
The Overcoming Addictions Web Application (OA) is an abstinence-focused, cognitive-behavioral Web application [13] that we developed for SMART Recovery [11] that is based on its protocol. The program has parallel but separate modules for alcohol, marijuana, opioids, stimulants, and compulsive gambling. The interactive exercises in OA include tasks that focus on the 4-point program of SMART Recovery as well as additional activities to enhance motivation for change; track urges over time (with feedback); practice mindfulness exercises for preventing relapse [14], set goals, and make Change Plans [15]. Most other online interventions are brief interventions designed to increase users? motivation for change. OA is unusual in the realm of online interventions in that it focuses on the action stage of change.
To evaluate the effectiveness of OA and SMART Recovery, we conducted a randomized clinical trial (trial registration NCT01389297). Our experimental hypotheses were that (1) all groups will reduce their drinking and alcohol/drug-related consequences at follow-up compared to their baseline levels, (2) the OA condition will reduce their drinking and alcohol/drug-related consequences more than the control group (SR), and (3) the OA+SR condition will reduce their drinking and alcohol/drug-related consequences more than the control group (SR only).
Description of the Intervention: SMART Recovery
SMART Recovery?s protocol for change combines motivational enhancement with cognitive-behavioral principles and strategies for behavior change. Its 4-point program focuses on (1) building and maintaining motivation, (2) dealing with urges, (3) managing thoughts, feelings, and behaviors, and (4) cultivating a lifestyle balance (of short- and long-term rewards) to prevent relapse.
SMART Recovery?s program uses a common set of strategies to address all addictive behaviors. Their rationale for this is based on two aspects of addiction: (1) common etiological factors in both the development and maintenance of addictive behaviors (eg, affect regulation) [16], and (2) the broad applicability of cognitive-behavioral and motivational strategies that are supported by outcome research across addiction treatments [17]. For instance, alcohol, drugs, and compulsive behaviors like gambling produce powerfully reinforcing changes in affective states, at least on a short-term basis [18]. Identifying these immediate positive consequences is an important step in developing more adaptive alternatives.
SMART Recovery?s menu of cognitive-behavioral and motivational strategies has been adapted from treatment interventions and it ?evolves as scientific knowledge in addiction recovery evolves? [11]. Its elements are designed to help members address issues ranging from basic motivation for change to qualitative lifestyle changes intended to reduce the appeal of, and engagement in, harmful addictive behaviors.
SMART Recovery has a large and active online presence. In 2012, their website had, on average, 69,786 visits per month and 991 new subscribers on their online forum each month. The message boards now have over 50,000 registered users (a 130% increase in the last 2 years) (S Alwood, personal communication, 1/22/13). In addition to their online presence, they have over 800 in-person support groups worldwide [19].
Description of the Intervention: Overcoming Addictions
OA is an action stage program designed to help users learn how to achieve and maintain abstinence. It is a self-directed and interactive Web application developed to be used either as a stand-alone intervention, an adjunct to attending SMART Recovery meetings, or as an adjunct to professional therapy for addictions (see Multimedia Appendix 1). Participants could access OA anywhere or anytime they had an Internet connection. Reviewers wishing to access the program can contact the senior author for a reviewer?s access login.
The OA program contains and extends the elements of the 4-point program of SMART Recovery. Prior to registering, a user can read an overview of the program and its relationship to SMART Recovery. During registration, users provide a first name, gender, email address which is also their login username, and password. Once registration is completed, the program creates a new record in its database and personalizes content for that user (eg, Welcome back, John). The user is then taken to a homepage that lists all of the program?s exercises and materials that are grouped by focus. The user can access any module of the program in any order that he or she chooses (see Figure 1 for a screenshot of a user?s home page).
The first module, Getting Started gives an overview of the program, provides a discussion of the Stages of Change [20], and suggests exercises based on the individual?s perceived stage.
The second module, Building and Maintaining Motivation for Change, contains a values exercise, a decisional balance exercise that asks users to weigh the pros and cons of changing, and a cost-benefit analysis exercise that is designed to elicit ?change talk? from the user (see Multimedia Appendixes 2-5).
The third module, Dealing with Urges and Cravings, begins with a brief discussion of urges and their relationship to sobriety and lapses/relapses. It teaches users to self-monitor their urges to use, noting the date, time, intensity, and duration of the urge, the trigger to the urge, how they handled the urge, and their reactions to how they handled it. Users are able to print out a page of self-monitoring cards so that they can easily collect these data as urges happen during their day. Later, when users enter their self-monitoring data, they are provided with graphic feedback about the frequency, intensity, and duration of their urges over time. This feedback can help users see whether they?re making progress in experiencing fewer urges over time. If a user is not experiencing a gradual decline in the frequency, intensity, or duration of urges over time, the program suggests they consider additional or alternative urge-coping strategies. The module also contains the urge-coping strategies recommended by SMART Recovery, empirically supported mindfulness/relaxation exercises, and a section on medications that can help reduce urges and cravings.
In addition, exercises are available to help users identify and manage the triggers that precede urges. Identifying triggers is similar to the first step in a functional analysis of drinking behaviors [21], and users are encouraged to develop plans for managing the triggers they personally identify. It is a complex module because triggers range from simple (eg, wanting to drink more with some friends than others) to complex (eg, negative mood coupled with poor coping skills). For each domain of triggers, the program presents strategies that others have found to be helpful.
The fourth module is Self-Managing Thoughts, Behaviors, and Feelings. There are three exercises in this module: (1) the ?ABCs? of Rational Emotive Behavior Therapy (REBT) [22], (2) unconditional self-acceptance, and (3) problem solving. The ABCs of REBT section has multiple subcomponents: dysfunctional beliefs, coping statements, changing one?s self-talk to change one?s feelings, and the process of analyzing and correcting dysfunctional beliefs that produce negative affect [23] (see Multimedia Appendix 6).
The fifth module is Lifestyle Balance for Preventing Relapse. This module has five components: regaining one?s health, relaxation, goal setting, social and recreational activities, and other relapse prevention strategies. The section on regaining one?s health focuses on eating and sleeping well, and exercising. The section on relaxation training targets both those with high levels of trait anxiety as well as those sensitive to situation specific anxiety (eg, when experiencing urges to drink/use). The goal-setting component focuses on setting short-term goals that are specific, measurable, achievable, realistic, and timed (eg, once a day). The section on social and recreational activities helps individuals consider and sample enjoyable and rewarding prosocial activities that are compatible with their goals and values and that make a sober life more rewarding than drinking, using drugs, or engaging in other addictive behaviors. The section on relapse prevention strategies presents relapse as a learning experience (eg, the Abstinence Violation Effect [24]) and offers some additional strategies that have not been covered in the other modules.
The appearance of the site is pleasant and uncluttered. Content is delivered via text, embedded videos and audio files, links to other sites, pop-up windows, and graphic feedback charts. The site is structured in the hybrid style, meaning that all content is available from a central matrix homepage. Once users choose a content area, their exploration of the content is constrained by tunnels that direct them through the various exercises. At the conclusion of an exercise, users have the option of continuing to the next recommended activity, or they may return to the homepage.
Like most computer-delivered interventions, users are free to access as much program content, in any order, and whenever they choose. Their use is supported by a customizable SMS (short message service) text messaging and email system that prompts them to log onto the program, reminds them of their plans for managing triggers, reiterates their reasons for staying sober, or presents motivational thoughts. These personalized messages can be delivered daily at user-defined times.
Source: http://www.jmir.org/2013/7/e134/
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