More than 20 million adults struggle with a substance use disorder, according to data from the Substance Abuse and Mental Health Services Administration shared by Smita Das, MD, PhD, MPH, Clinical Assistant Professor in the Department of Psychiatry, Stanford University School of Medicine, Stanford, California, during the webinar “Advancing the Integration of Digital Therapeutics into Addiction Management Strategies: Engaging Multidisciplinary Stakeholders for Optimal Application in Practice” offered on June 24, 2019 by the North American Center for Continuing Medical Education.
Alcohol use disorder (as defined by the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition) affects 16.3 million Americans, followed by:
• Illicit drug use disorder, 6.2 million
• Marijuana use disorder, 3.5 million
• Prescription pain reliever use disorder, 1.8 million
• Cocaine use disorder, 0.9 million
• Heroin use disorder, 0.6 million
Trends in Treating Alcohol and Tobacco Dependency
Alcohol is the third-leading preventable cause of death in the United States, causing 88,000 deaths annually. Three medications are approved by the US Food and Drug Administration (FDA): naltrexone, acamprosate, and disulfiram. However, even though 6.2% of adults have alcohol use disorders, only 8.3% of them receive specialty alcohol treatment.
“Research shows that even brief psychological interventions are important and reduce alcohol intake,” said Dr Das. “It’s important to integrate motivational interviewing into practice.”
Tobacco, said Dr Das, is a “heavy hitter” that is being undertreated in the United States. It is the leading preventable cause of death and is associated with more morbidity and mortality than alcohol and all other drugs combined. Although screenings are happening in two-thirds of the exam rooms across the country, physicians are asking but not acting on the information they receive. In fact, only 21% of patients identified as current tobacco users received cessation counseling, and only 8% received cessation medications.
Medication-Assisted Treatment for Opioid Use Disorders
Medication-assisted treatment (MAT) using methadone, buprenorphine, or naltrexone can:
• Normalize brain chemistry
• Block the euphoric effects of opioids and alcohol
• Relieve physiological cravings
• Normalize body functions without negative effects
A national study of more than 120,000 people on methadone and nearly 16,000 on buprenorphine concluded that those treatments were associated with substantial reductions in the risk for all-cause and overdose-related deaths.
Theoretically, access to addiction management therapies has improved through legislation like 2008’s Mental Health Parity and Addiction Equity Act and 2010’s Affordable Care Act, said Dr Das, yet fewer than 1 million Americans with opioid use disorder (OUD) have received MAT. In fact, in a Massachusetts study, only 30% of nearly 18,000 opioid overdose survivors received any treatment for OUD.
Barriers to MAT include:
• Bureaucratic hurdles, like required training and Drug Enforcement Administration waivers to prescribe buprenorphine and lack of methadone clinics in rural areas
• Not enough resources and training given to physicians about offering treatment
• Stigma surrounding opioid use treatment
• Physicians are not consistently incentivized to treat OUD
• Lack of insurance coverage
• Lack of knowledge of where to seek treatment
• Concerns about how seeking treatment will affect employment status
Accessing treatment is difficult for incarcerated users in particular. Although 65% of inmates have substance use disorders, only 11% receive treatment while incarcerated.
“Substance use disorders are everyone’s problem, but not enough physicians are involved in treatment,” Dr Das explained. “Over half of the people with substance use disorders want help and aren’t getting it. We need to work together to own and provide treatment, even things as simple as screenings, brief interventions, and referrals.”
Emerging Treatment Technologies
According to Mario San Bartolome, MD, MBA, MRO, FASAM, National Medical Director, Substance Use Disorders at Molina Healthcare, Inc., digital therapeutics may hold the key to treating OUDs. Digital therapeutics leverage computer-based and mobile technologies to complement medical or psychological treatments. It is an additional tool to deliver evidence-based treatments in a convenient, familiar, and confidential form.
“Change is scary, but we need to provide access to care every way we can,” said Dr San Bartolome.
Digital therapeutics can improve the effectiveness of behavioral interventions like cognitive behavioral therapy (CBT) by pairing skills training to encourage behavior change using nondrug incentives that reinforce positive behaviors. This technology combines a community reinforcement approach with contingency management. The true opportunity for digital therapeutics, said Dr San Bartolome, lies in 3 areas:
• Standardization of quality and increased consistency
• Reduced variability, such as the variability inherent in face-to-face therapy that makes measurement difficult
• Optimization of the technology to personalize each patient’s tools to improve adaption
Because most Americans have a mobile phone, digital therapeutics are a unique way to reach previously underserved populations. By piercing that barrier to access, providers can deliver treatment the way it is needed by the patient, when it is needed by the patient, said Dr San Bartolome. Other benefits include:
• A fluency-based delivery method that allows patients to move through treatment at their own pace
• Reduced cost
• Increased engagement
• Longer commitment to treatment
• More positive patient experience
• Less therapist intervention time
• Reduced stigma because the solution can be done privately
A large-scale, multisite randomized controlled trial of digital therapeutics for patients with alcohol or illicit drug disorders not receiving MAT found:
• Increased treatment retention over a 12-week period
• Outcomes that were equally effective at supporting abstinence in patients abstinent at baseline as traditional treatment
• Double the odds of abstinence among patients not abstinent at baseline compared with traditional treatment
The first 2 FDA-approved digital therapeutics are 90-day reSET for substance use disorders and 84-day reSET-O, which is specifically for OUD. They are designed to support outpatient treatment therapies such as contingency management and transmucosal buprenorphine by providing CBT modules that enhance retention.
“There’s quite convincing evidence that digital therapeutics are impactful and should be embraced,” said Dr San Bartolome. “I think of treatment like a tool belt. You pick the right tool for your patient, and this is just one more tool to choose from.”
The key to adherence is completing the CBT modules. In fact, a study showed that patients who completed the recommended number of modules in the first 6 weeks were more than 3 times as likely to complete the full 12-week course of treatment, said Dr San Bartolome.
However, he said, adopting new technologies requires:
• Increased attention and accessibility
• Evidence of feasibility and effectiveness, including collecting and analyzing feedback
• Adequate resources for adoption, including developing a plan and using the principles of change management to continue to refine it
• Encouragement of organization-wide change by promoting a team effort
Other digital therapeutics tools include Addiction Comprehensive Health Enhancement Support System (A-CHESS), Computer-Based Training for Cognitive Behavioral Therapy (CBT4CBT), and virtual reality applications. Researchers are investigating the use of digital therapeutics in inpatient settings, according to Dr San Bartolome.
Das S, San Bartolome M. Advancing the integration of digital therapeutics into addiction management strategies: engaging multidisciplinary stakeholders for optimal application in practice. Webinar presented June 24, 2019.