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Articles   |    
Internet-Delivered Treatment for Substance Abuse: A Multisite Randomized Controlled Trial
Aimee N.C. Campbell, Ph.D.; Edward V. Nunes, M.D.; Abigail G. Matthews, Ph.D.; Maxine Stitzer, Ph.D.; Gloria M. Miele, Ph.D.; Daniel Polsky, Ph.D.; Eva Turrigiano, M.S.; Scott Walters, Ph.D.; Erin A. McClure, Ph.D.; Tiffany L. Kyle, Ph.D.; Aimee Wahle, M.S.; Paul Van Veldhuisen, Ph.D.; Bruce Goldman, L.C.S.W.; Dean Babcock, L.C.S.W.; Patricia Quinn Stabile, L.C.S.W.; Theresa Winhusen, Ph.D.; Udi E. Ghitza, Ph.D.
Am J Psychiatry 2014;171:683-690. doi:10.1176/appi.ajp.2014.13081055
View Author and Article Information

Dr. Nunes has received medication for research studies from Alkermes/Cephalon, Duramed Pharmaceuticals, and Reckitt-Benckiser. Dr. Polsky has served on an advisory panel for Pfizer and as a consultant for Accenture. The other authors report no financial relationships with commercial interests.

Supported by grants from the National Drug Abuse Treatment Clinical Trials Network, National Institute on Drug Abuse (NIDA): U10 DA013035 (to Dr. Nunes and John Rotrosen), U10 DA015831 (to Kathleen M. Carroll and Roger D. Weiss), U10 DA013034 (Dr. Stitzer and Robert P. Schwartz), U10 DA013720 (to José Szapocznik and Lisa R. Metsch), U10 DA013732 (to Eugene C. Somoza), U10 DA020024 (to Madhukar H. Trivedi), U10 DA013714 (to Dennis M. Donovan and John Roll), U10 DA015815 (to James L. Sorensen and Dennis McCarty), and K24 DA022412 (to Dr. Nunes).

Dr. Lisa Marsch, president of HealthSim, Inc., the privately owned company that developed the Therapeutic Education System, provided scientific consultation on this study but did not take part in the conduct of the trial, data analysis and interpretation, or manuscript development.

Clinicaltrials.gov identifier: NCT01104805.

From New York State Psychiatric Institute, New York; Department of Psychiatry, Columbia University, New York; Department of Psychiatry and Behavioral Health, St. Luke’s Roosevelt Hospital Center, New York; EMMES Corporation, Rockville, Md.; Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore; School of Medicine, University of Pennsylvania, Philadelphia; School of Public Health, University of North Texas Health Science Center, Fort Worth; Clinical Neuroscience Division, Medical University of South Carolina, Charleston; Center for Drug-Free Living, Orlando, Fla.; North Shore Long Island Jewish Health System, Zucker Hillside Hospital, Glen Oaks, N.Y.; Midtown Community Mental Health Center, Indianapolis; HARBEL Prevention and Recovery Center, Baltimore; Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati; Center for the Clinical Trials Network, National Institute on Drug Abuse, Bethesda, Md.

Presented in part at the Addiction Health Services Research Conference, Portland, Ore., Oct. 23–25, 2013, and at the 24th annual meeting of the American Academy of Addiction Psychiatry, Scottsdale, Ariz., December 5–8, 2013.

Address correspondence to Dr. Campbell (anc2002@columbia.edu).

Copyright © 2014 by the American Psychiatric Association

Received August 08, 2013; Revised January 02, 2014; February 04, 2014; Accepted February 13, 2014.

Abstract

Objective  Computer-delivered interventions have the potential to improve access to quality addiction treatment care. The objective of this study was to evaluate the effectiveness of the Therapeutic Education System (TES), an Internet-delivered behavioral intervention that includes motivational incentives, as a clinician-extender in the treatment of substance use disorders.

Method  Adult men and women (N=507) entering 10 outpatient addiction treatment programs were randomly assigned to receive 12 weeks of either treatment as usual (N=252) or treatment as usual plus TES, with the intervention substituting for about 2 hours of standard care per week (N=255). TES consists of 62 computerized interactive modules covering skills for achieving and maintaining abstinence, plus prize-based motivational incentives contingent on abstinence and treatment adherence. Treatment as usual consisted of individual and group counseling at the participating programs. The primary outcome measures were abstinence from drugs and heavy drinking (measured by twice-weekly urine drug screens and self-report) and time to dropout from treatment.

Results  Compared with patients in the treatment-as-usual group, those in the TES group had a lower dropout rate (hazard ratio=0.72, 95% CI=0.57, 0.92) and a greater abstinence rate (odds ratio=1.62, 95% CI=1.12, 2.35). This effect was more pronounced among patients who had a positive urine drug or breath alcohol screen at study entry (N=228) (odds ratio=2.18, 95% CI=1.30, 3.68).

Conclusions  Internet-delivered interventions such as TES have the potential to expand access and improve addiction treatment outcomes. Additional research is needed to assess effectiveness in non-specialty clinical settings and to differentiate the effects of the community reinforcement approach and contingency management components of TES.

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FIGURE 1. Abstinence by Treatment Half Week and at Follow-Ups Among Participants in Outpatient Addiction Treatment Programs Receiving Treatment as Usual or Treatment as Usual Plus TES, an Internet-Delivered Behavioral Intervention for Substance Abuse, by Abstinence at Baseline/Study Entry

FIGURE 2. Kaplan-Meier Plot of Time to Treatment Program Dropout Among Participants in Outpatient Addiction Treatment Programs Receiving Treatment as Usual or Treatment as Usual Plus TES, an Internet-Delivered Behavioral Intervention for Substance Abuse
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TABLE 1.Baseline Demographic and Clinical Characteristics of Participants in Outpatient Addiction Treatment Programs Receiving Treatment as Usual or Treatment as Usual Plus TES, an Internet-Delivered Behavioral Intervention for Substance Abusea
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a There were no significant differences between groups on any variable.

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b Gender was not reported by one participant.

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c Race was not reported by two participants.

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d Ethnicity was not reported by four participants.

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e Dependence was assessed using the DSM-IV Checklist, a semistructured interviewer-administered measure that provides a current (past-year) substance use dependence diagnosis based on DSM-IV-TR criteria (modified from reference 26).

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TABLE 2.Logistic Regression Model of Abstinence From Drug Use or Heavy Drinking Among Participants in Outpatient Addiction Treatment Programs Receiving Treatment as Usual or Treatment as Usual Plus TES, an Internet-Delivered Behavioral Intervention for Substance Abuse (N=507)
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a Odds ratios reflect the last 4 weeks (weeks 9–12) of the treatment phase.

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b Odds ratios for each site compared with the referent site ranged from 1.02 (95% CI=0.55, 1.90) to 0.31 (95% CI=0.17, 0.58), indicating that the odds of abstinence varied across sites.

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c After fitting model 1, including the main effects of treatment and stratification factors, each of the stratum-by-treatment interactions was tested using a significance threshold of 0.10. Only the abstinence at baseline/study entry by treatment interaction (p=0.068) met the threshold, and the effects of treatment (TES versus treatment as usual) are therefore shown separately in the nonabstinent and abstinent strata.

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