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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
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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.


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.



National Drug Intelligence Center:  Economic Impact of Illicit Drug Use on American Society .  Washington, DC,  U.S. Department of Justice, 2011
Bouchery  EE;  Harwood  HJ;  Sacks  JJ;  Simon  CJ;  Brewer  RD:  Economic costs of excessive alcohol consumption in the US, 2006.  Am J Prev Med 2011; 41:516–524
Substance Abuse and Mental Health Services Administration:  Results From the 2011 National Survey on Drug Use and Health: Summary of National Findings. NSDUH Series H-44, HHS Publication No (SMA) 12-4713 .  Rockville, Md,  Substance Abuse and Mental Health Services Administration, 2012
Campbell  ANC;  Nunes  EV;  Miele  GM;  Matthews  A;  Polsky  D;  Ghitza  UE;  Turrigiano  E;  Bailey  GL;  VanVeldhuisen  P;  Chapdelaine  R;  Froias  A;  Stitzer  ML;  Carroll  KM;  Winhusen  T;  Clingerman  S;  Perez  L;  McClure  E;  Goldman  B;  Crowell  AR:  Design and methodological considerations of an effectiveness trial of a computer-assisted intervention: an example from the NIDA Clinical Trials Network.  Contemp Clin Trials 2012; 33:386–395
Fichman  RG;  Kemerer  C:  The illusory diffusion of innovation: an examination of assimilation gaps.  Inf Syst Res 1999; 10:255–275
Martino  S;  Ball  SA;  Nich  C;  Frankforter  TL;  Carroll  KM:  Informal discussions in substance abuse treatment sessions.  J Subst Abuse Treat 2009; 36:366–375
Bennett  GG;  Glasgow  RE:  The delivery of public health interventions via the Internet: actualizing their potential.  Annu Rev Public Health 2009; 30:273–292
Carroll  KM;  Rounsaville  BJ:  Computer-assisted therapy in psychiatry: be brave: it’s a new world.  Curr Psychiatry Rep 2010; 12:426–432
Moore  BA;  Fazzino  T;  Garnet  B;  Cutter  CJ;  Barry  DT:  Computer-based interventions for drug use disorders: a systematic review.  J Subst Abuse Treat 2011; 40:215–223
Bewick  BM;  Trusler  K;  Barkham  M;  Hill  AJ;  Cahill  J;  Mulhern  B:  The effectiveness of web-based interventions designed to decrease alcohol consumption: a systematic review.  Prev Med 2008; 47:17–26
Kiluk  BD;  Sugarman  DE;  Nich  C;  Gibbons  CJ;  Martino  S;  Rounsaville  BJ;  Carroll  KM:  A methodological analysis of randomized clinical trials of computer-assisted therapies for psychiatric disorders: toward improved standards for an emerging field.  Am J Psychiatry 2011; 168:790–799
Bickel  WK;  Marsch  LA;  Buchhalter  AR;  Badger  GJ:  Computerized behavior therapy for opioid-dependent outpatients: a randomized controlled trial.  Exp Clin Psychopharmacol 2008; 16:132–143
Carroll  KM;  Ball  SA;  Martino  S;  Nich  C;  Babuscio  TA;  Nuro  KF;  Gordon  MA;  Portnoy  GA;  Rounsaville  BJ:  Computer-assisted delivery of cognitive-behavioral therapy for addiction: a randomized trial of CBT4CBT.  Am J Psychiatry 2008; 165:881–888
Kay-Lambkin  FJ;  Baker  AL;  Lewin  TJ;  Carr  VJ:  Computer-based psychological treatment for comorbid depression and problematic alcohol and/or cannabis use: a randomized controlled trial of clinical efficacy.  Addiction 2009; 104:378–388
Higgins  ST;  Budney  AJ;  Bickel  WK;  Foerg  FE;  Donham  R;  Badger  GJ:  Incentives improve outcome in outpatient behavioral treatment of cocaine dependence.  Arch Gen Psychiatry 1994; 51:568–576
Higgins  ST;  Sigmon  SC;  Wong  CJ;  Heil  SH;  Badger  GJ;  Donham  R;  Dantona  RL;  Anthony  S:  Community reinforcement therapy for cocaine-dependent outpatients.  Arch Gen Psychiatry 2003; 60:1043–1052
Petry  NM;  Peirce  JM;  Stitzer  ML;  Blaine  J;  Roll  JM;  Cohen  A;  Obert  J;  Killeen  T;  Saladin  ME;  Cowell  M;  Kirby  KC;  Sterling  R;  Royer-Malvestuto  C;  Hamilton  J;  Booth  RE;  Macdonald  M;  Liebert  M;  Rader  L;  Burns  R;  DiMaria  J;  Copersino  M;  Stabile  PQ;  Kolodner  K;  Li  R:  Effect of prize-based incentives on outcomes in stimulant abusers in outpatient psychosocial treatment programs: a National Drug Abuse Treatment Clinical Trials Network study.  Arch Gen Psychiatry 2005; 62:1148–1156
Stitzer  ML;  Petry  NM;  Peirce  JM:  Motivational incentives research in the National Drug Abuse Treatment Clinical Trials Network.  J Subst Abuse Treat 2010; 38(suppl 1):S61–S69
Kampman  KM;  Volpicelli  JR;  Mulvaney  F;  Rukstalis  M;  Alterman  AI;  Pettinati  H;  Weinrieb  RM;  O’Brien  CP:  Cocaine withdrawal severity and urine toxicology results from treatment entry predict outcome in medication trials for cocaine dependence.  Addict Behav 2002; 27:251–260
Nunes  EV;  Pavlicova  M;  Hu  MC;  Campbell  AN;  Miele  G;  Hien  D;  Klein  DF:  Baseline matters: the importance of covariation for baseline severity in the analysis of clinical trials.  Am J Drug Alcohol Abuse 2011; 37:446–452
Budney  AJ;  Higgins  ST:  Therapy Manuals for Drug Addiction: A Community Reinforcement Plus Vouchers Approach: Treating Cocaine Addiction .  Rockville, Md,  National Institute on Drug Abuse, 1998
Sobell  LC;  Sobell  MB:  Timeline follow-back: a technique for assessing self-reported alcohol consumption, in  Measuring Alcohol Consumption: Psychosocial and Biological Methods . Edited by Allen  J;  Litten  RZ.  Totowa, NJ,  Humana Press, 1992
Liang  K-Y;  Zeger  S:  Longitudinal data analysis using generalized linear models.  Biometrika 1986; 73:13–22
Cox  DR:  Regression models and life tables.  J R Statistical Society 1972; 34(Series B):187–220
Schoenfeld  D:  Partial residuals for the proportional hazards regression model.  Biometrika 1982; 69:239–241
Hudziak  JJ;  Helzer  JE;  Wetzel  MW;  Kessel  KB;  McGee  B;  Janca  A;  Przybeck  T:  The use of the DSM-III-R Checklist for initial diagnostic assessments.  Compr Psychiatry 1993; 34:375–383
Lamb  S;  Greenlick  MR;  McCarty  D (eds):  Bridging the Gap Between Practice and Research: Forging Partnerships With Community-Based Drug and Alcohol Treatment .  Washington, DC,  National Academy Press, 1998
Buck  JA:  The looming expansion and transformation of public substance abuse treatment under the Affordable Care Act.  Health Aff (Millwood) 2011; 30:1402–1410
Office of National Drug Control Policy: Substance Abuse and the Affordable Care Act. http://www.whitehouse.gov/ondcp/healthcare
McLellan  AT;  Carise  D;  Kleber  HD:  Can the national addiction treatment infrastructure support the public’s demand for quality care? J Subst Abuse Treat 2003; 25:117–121
Nunes  EV;  Ball  SA;  Booth  RE;  Brigham  G;  Calsyn  DA;  Carroll  K;  Feaster  DJ;  Hien  D;  Hubbard  RL;  Ling  W;  Petry  NM;  Rotrosen  J;  Selzer  J;  Stitzer  M;  Tross  S;  Wakim  P;  Winhusen  T;  Woody  G:  Multisite effectiveness trials of treatments for substance abuse and co-occurring problems: have we chosen the best designs? J Subst Abuse Treat 2010; 38(suppl 1):S97–S112
Chaple  M;  Sacks  S;  McKendrick  K;  Marsch  LA;  Belenko  S;  Leukefeld  C;  Prendergast  M;  French  M:  Feasibility of a computerized intervention for offenders with substance use disorders: a research note.  J Exp Criminol 2013 (online only)
Knapp  WP;  Soares  BG;  Farrel  M;  Lima  MS:  Psychosocial interventions for cocaine and psychostimulant amphetamines related disorders.  Cochrane Database Syst Rev 2007; 3:CD003023
Marsch  LA;  Guarino  H;  Acosta  M;  Aponte-Melendez  Y;  Cleland  C;  Grabinski  M;  Brady  R;  Edwards  J:  Web-based behavioral treatment for substance use disorders as a partial replacement of standard methadone maintenance treatment.  J Subst Abuse Treat 2014; 46:43–51
Roozen  HG;  Boulogne  JJ;  van Tulder  MW;  van den Brink  W;  De Jong  CA;  Kerkhof  AJ:  A systematic review of the effectiveness of the community reinforcement approach in alcohol, cocaine, and opioid addiction.  Drug Alcohol Depend 2004; 74:1–13
Carroll  KM;  Ball  SA;  Martino  S;  Nich  C;  Babuscio  TA;  Rounsaville  BJ:  Enduring effects of a computer-assisted training program for cognitive behavioral therapy: a 6-month follow-up of CBT4CBT.  Drug Alcohol Depend 2009; 100:178–181
Magill  M;  Ray  LA:  Cognitive-behavioral treatment with adult alcohol and illicit drug users: a meta-analysis of randomized controlled trials.  J Stud Alcohol Drugs 2009; 70:516–527
McLellan  AT:  Have we evaluated addiction treatment correctly? Implications from a chronic care perspective.  Addiction 2002; 97:249–252
Campbell  ANC;  Nunes  EV;  McClure  EA;  Hu  MC;  Turrigiano  E;  Goldman  B;  Stabile  PQ:  Characteristics of an outpatient treatment sample by primary substance of abuse.  J Addict Med 2013; 7:363–371
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