Web-based Intervention Increases Abstinence in Individuals Using Stimulants, But Not Opioids

Web-based treatments for substance use disorder (SUD) are gaining support in the addiction field due to their ability to reach people beyond traditional service settings.

One such treatment, the Therapeutic Education System (TES), was shown to improve abstinence rates when substituted for two hours per week of regular in-person counseling.

WHAT PROBLEM DOES THIS STUDY ADDRESS?

The Therapeutic Education System (TES) is a self-directed intervention for substance use disorders (SUDs) based on a particular addiction treatment known as the Community Reinforcement Approach and comprised of interactive, multimedia modules.

This study explores if the use of this web-based treatment has differential effects for individuals who primarily use different substance (stimulants, alcohol, marijuana, and opioids).

HOW WAS THIS STUDY CONDUCTED?

This study used data from a prior study testing the effectiveness of the Theraputic Education randomized controlled trial testing the effectiveness of Theraputic Education System (TES combined with treatment as usual (TAU; i.e., in-person counseling) to TAU without TES.

Participants (N = 507) were recruited from ten outpatient treatment centers and received treatment for 12 weeks. Those randomly assigned to the TES group received 62 self-guided cognitive behavioral therapy modules instead of 2 hours of in-person counseling each week. TES also had a contingency management (CM) component where participants could earn over $100 dollars for completing modules and over $450 for remaining abstinent throughout the study.

Participants reported their primary substance as follows:

cannabis 22.5% (n = 114)
stimulants 33.7% (n = 171)
opioids 21.3% (n = 108)
alcohol 20.5% (n = 104)
other substances 2% (n = 10)

“Other substances” was not included due to small sample size, resulting in a final sample of 497 for the present analysis.

Outcomes included:

a) abstinence (self-report and negative urine sample) during the last 4 weeks of the 12-week study, which was measured twice per week (measured 8 times during the last 4 weeks)

b) treatment retention, defined as the proportion of participants remaining in the program at week 12

WHAT DID THIS STUDY FIND?

The majority of participants were male (62%), White (53%), single (61%), under or unemployed (59%), and had a high school diploma or equivalent (61%). The figure below shows the abstinence rates during the last 4 weeks of the treatment period measured dichotomously for those abstinent across the entire 4 week period versus those who were not.

In an analysis that adjusted for baseline levels of abstinence and time, there was a significant effect favoring TES for the stimulant group only. For this group, the odds of abstinence were almost 4 times higher for TES than TAU. It is interesting that participants who primarily used opioids in the TAU group experienced higher rates of abstinence than TES, though this difference was not statistically significant. Treatment condition and primary substance were not associated with treatment retention.

Abstinence Rates By Primary Substance & Intervention

This study showed that a web-based intervention combined with in-person counseling produces significantly better results for individuals who primarily use stimulants than TAU. Results appeared also to be potentially promising among individuals who reported alcohol or cannabis as their primary substance. However, the advantage of TES for these participants did not reach statistical significance perhaps because of small sample sizes.

WHY IS THIS STUDY IMPORTANT

This study is important for determining if TES is more or less effective for certain groups of individuals. If effects are different by primary substance used, it may inform tailored clinical recommendations based on one’s substance of choice.

Individuals who reported opioids as their primary substance did not experience the same benefits from this web-based treatment as participants who used other drugs.

As the authors point out, these individuals may require more treatment such as medication in addition to psychosocial counseling. A different study of opioid-dependent patients in methadone treatment found that TES in place of a portion of standard treatment resulted in greater rates of opioid abstinence, and another study of opioid-dependent patients receiving buprenorphine found comparable abstinence rates for TES versus in-person CRA plus CM, suggesting that TES may be effective for patients with opioid use disorder if used in conjunction with medication-assisted treatment.

Individuals reporting stimulants as their primary substance were the only group where TES performed significantly better than TAU. This is consistent with prior research showing that CM can enhance the effect of CBT for individuals using cocaine (see here for a summary from a previous RRI Recovery Research Review). However, effects tend to wear off after the treatment phase when the possibility of reward is removed. Given the lack of follow-up data, it is unknown if this is the case with current study as well.

Individuals reporting stimulants as their primary substance were the only group where TES performed significantly better than TAU. This is consistent with prior research.

LIMITATIONS

This study did not have enough participants to test if one group benefited more from TES than another. For example, TES was more effective than TAU for individuals reporting stimulants as their primary substance, but it is unknown if TES was better for these individuals than individuals reporting alcohol as their primary drug.
Since TES includes rewards for abstinence through CM, it is also impossible to separate the effects of the CM component from the effects of the web-based treatment modules. It may be that either alone may be produce the kinds of effects observed here and future research could dismantle the contribution of each specific component of the TES intervention to see which elements may be carrying the effect; or whether, indeed, all components are needed.

NEXT STEPS

Future research should focus on determining for which specific populations TES and other web-based interventions are effective. Potential subgroups include young adults or people with co-occurring disorders. Also, cost-effectiveness studies could be conducted to investigate the increased value of providing TES and similar interventions.

BOTTOM LINE

For individuals & families seeking recovery: If the primary substance is opioids, a web-based treatment with a cognitive-behavioral approach like TES may not improve on your standard treatment. TES may be more suitable for individuals with other drugs of choice such as stimulants.
For scientists: Web-based interventions like TES are effective for some subgroups but this sample had insufficient power to determine if these groups performed better than one another.
For policy makers: TES appears to be an effective adjunct to standard treatment and can help expand treatment beyond the clinical setting. These kinds of interventions may also be cost-effective and help expand the reach of interventions to impact more individuals suffering from SUD.
For treatment professionals and treatment systems: Patients who use opioids are a difficult population to treat and the addition of a web-based treatment did not add benefit to face-to-face counseling in this study.

CITATIONS

Cochran, G., Stitzer, M., Campbell, A. N., Hu, M. C., Vandrey, R., & Nunes, E. V. (2015). Web-based treatment for substance use disorders: differential effects by primary substance. Addict Behav, 45, 191-194. doi:10.1016/j.addbeh.2015.02.002