Addiction treatment experts say there’s a huge need to expand high-quality outpatient care, including medication-assisted treatment, to Americans with opioid and other substance use disorders. After inpatient care, however, patients often can’t access or don’t stay connected to outpatient therapy, which contributes to a very high relapse rate.
There are also too few outpatient centers offering medication-assisted treatment, or MAT, and a shortage of clinicians trained in evidence-based substance-use disorder therapies. So there’s growing interest in empirically validated, mobile app-based therapeutic tools that allow providers to offer therapy, skills training and support to their patients in between face-to-face visits.
Clinical trials of some digital tools have shown promising results in at least temporarily reducing relapse rates and keeping patients engaged in outpatient treatment. But use of these mobile apps is at a very early stage.
The first prescription digital therapeutic products receiving Food and Drug Administration market clearance for patients with substance-use and opioid-use disorder are re-Set and re-Set-O, developed by Pear Therapeutics and distributed by Sandoz. Another, similar product that has research support is A-Chess, which Geisinger Health System started using last fall at three of its medication-assisted treatment centers in Pennsylvania.
Re-Set, for patients with addiction to alcohol and substances other than opioids, and re-Set-O, for those with opioid-use disorder, are 12-week online programs available by prescription, to be used in conjunction with outpatient treatment. Patients download the software to their smartphones and key in their access code.
Every four days, they are prompted to complete an assessment of whether they’ve used, along with their triggers and cravings. They also go through four cognitive behavioral therapy lessons a week, on issues like drug refusal skills, followed by quizzes. Re-Set-O includes lessons related to compliance with anti-withdrawal buprenorphine treatment.
The third component is motivational incentives. When patients complete a lesson and test negatively in a urine drug screen, they receive a congratulatory message or gift card. The pleasure they get from that offsets the negative reinforcing effect of substance use, said Dr. Yuri Maricich, chief medical officer at Pear Therapeutics.
Re-Set and re-Set-O give clinicians data from their patients’ responses, enabling them to focus on those issues during in-person sessions.
Dr. Martin Frost, an addiction medicine specialist in Conshohocken, Pa., has used the Pear Therapeutics tools with a dozen patients since November and found them valuable.
The digital dashboard allows him and his colleagues to track each patient’s progress and discuss roadblocks. He and one patient, using the lesson on relapse prevention, pinpointed her triggers after her brief relapse on opioids.
Another of Frost’s substance-use disorder patients, Katie Burlingame of Villanova, Pa., who works as a nanny, said using re-Set-O has helped her avoid negative thinking.
“When I’m feeling down in the dumps, that’s when I do a therapy session,” said Burlingame, who has been sober for more than five years but was feeling in a “lull” in her recovery. “If the kids are napping, I’ll read through a module and take the quiz at the end. It’s all on my phone and I love it.” It’s covered by her private insurance.
The A-Chess smartphone app, now being used by Geisinger’s MAT clinics, offers opioid-use disorder patients regular check-ins, appointment and medication reminders, and surveys. Providers receive notifications of patient trends such as increased drug cravings. Patients receive interventional content when A-Chess flags a risk of relapse, such as visiting a high-risk location.
Residential addiction treatment centers are eyeing digital tools to improve continuity of care after patients leave their facilities. Leslie Henshaw, a partner at private equity firm Deerfield Management, which owns Recovery Centers of America, said her company is evaluating nearly 20 different tools, including ones that link patients to outpatient resources.
“You can do great with patients for the 28 days they’re in your building,” she said. “But they pack their bag, and a huge percentage of the time patients don’t follow through on finding an outpatient therapist. This allows people to use their cellphone to get those visits scheduled.”
But there are several challenges holding digital therapeutics back, said Brian Kalis, managing director of digital health at Accenture. These include figuring out a reimbursement model, distinguishing tools that are rigorously tested from those with less testing, overcoming legal and regulatory barriers, and fitting the treatment into providers’ workflow.
Yet digital therapeutics hold great promise, he said. “The ability to get simple access 24/7 fits better with the reality of addiction than meeting in a one-person setting. It provides privacy, anonymity and convenience.”