Automated Addictions Treatment

Contribution by-Brent R. Coyle, M.D.

The financial, personal, familial and societal consequences of addictions are enormous
and many of the ultimate causes of morbidity and mortality globally, ultimately have
their origins in addictions. (Mokdad, Marks, Stroup, & Gerberding, 2004; Murray, et al.,
2007; Services, 2000) The Internet has also contributed its own problems with the ready
availability of illegal drugs and other addictive substances online and the potential of
addiction to the technologies themselves. (Kwon, Chung, & Lee, 2009) This reality,
combined with sobering low success and abstinence rates discourages and fatigues the
most enthusiastic of caretakers. (Leukefeld & Tims, 1989; Maddux & Desmond, 1986)

Despite the overwhelming and life-threatening urgency of these issues, meaningful

screening and intervention for smoking cessation, alcohol and drug problems, even diet
and exercise, eating disorders and a wide variety of other “addictive” disorders has
traditionally been a resource consuming and, perhaps, less than exciting task for most
providers. Relatively few physicians or other providers develop or sustain passion for
routinely and effectively dealing with these ominous threats to our health. (Ockene &
Ockene, 1996) Arguably, the time required to engage and maintain individuals in a
comprehensive plan for major life change is simply beyond the human realities and pace
of modern medicine. Other populations, most importantly, rural and underprivileged
ones, continue to have highly limited treatment options without innovative solutions.
(Danaher, Hart, McKay, & Severson, 2007; Finfgeld-Connett & Madsen, 2008)

Complex and challenging tasks are perhaps best suited to technology, therefore if
automated treatment could be applied to this core problem in medicine, this contribution
could be of unprecedented impact. (Balmford, Borland, Li, & Ferretter, 2009) There have
been dreams and musings for the vast potential for technology to meaningfully impact
these challenges since moments after the capability existed, however the actual practical
development, then empirical study and further refinement of these applications has been a
challenging journey. (Bewick, Trusler, Barkham, et al., 2008)

This is an overview of the opportunities, either existent or theoretically possible, in

technical and automated ways (and therefore typically also with potential global impact
using the power of the Internet. The transtheoretical model of change has become a
touchstone for the understanding of addictions treatment and is, therefore, a useful way to
organize this discussion as well. (Prochaska & Velicer, 1997; Sutton, 2001)

_______________________________________________________________________
Correspondence to: Brent R. Coyle, M.D., c/o My Therapy Session, Inc. www.MyTherapySession.com
P.O. Box 6185, Maryville, TN 37802, USA; email: bcoyle@mytherapysession.com.

Dr. Brent Coyle is a board-certified psychiatrist and the founder and developer of
MyTherapySession.com, an innovative resource for emotional health wellness. Through the use of
web-based assessment tools and stepwise video learning modules with reflective journal prompts and
selected (optional) spiritually sensitive observations, both consumers and healthcare providers can
more efficiently and effectively address a variety of essential mental health concerns, including weight
management, stress, anxiety and depression, self-esteem and goal setting, comprehensive addictions
treatment, eating disorders, overcoming guilt and shame, and many more.
 2 Brent R. Coyle, M.D.

Precontemplation (Screening and Prevention)

The essence of the first stage of any behavioral change is to engender an awareness of a
potential problem and develop the beginnings of insight and motivation for doing
something about it. Computer technologies have already captured the attention of the
world, a crucial first step. Furthermore, intuitively, catching illness at its earliest stages
will be most efficacious; therefore it is significant that adolescents may be particularly
open to these new approaches.(An, et al., 2008; Bewick, Trusler, Mulhern, Barkham, &
Hill, 2008; Hallett, Maycock, Kypri, Howat, & McManus, 2009; Newton, Andrews,
Teesson, & Vogl, 2009; Newton, Vogl, Teesson, & Andrews, 2009; Vogl, et al., 2009)

The web, with its multiple search engines and “viral” presence is quickly becoming the
primary global source of medical information. (Inc, 2007) A number of screening tools
are now immediately available at the moment of slightest insight or motivation, and make
the “intake” process for intervention easy and even fun using colorful and “personalized”
feedback to the inquisitive. (Cunningham, Hodgins, Toneatto, Rai, & Cordingley, 2009;
Cunningham & Van Mierlo, 2009; Cunningham & van Mierlo, 2009; Health, 2009;
Linke, McCambridge, Khadjesari, Wallace, & Murray, 2008)

In light of addiction’s insidious onset and sense of invincibility (perhaps partially due to
the effects of the drugs themselves), a powerful force is needed to capture the attention of
the impaired individual. (Lieberman & Huang, 2008; Lieberman & Massey, 2008)
Motivational interviewing techniques along with personalized and gripping comparative
and financial consequence data seem to be capturing the public’s attention. (Hettema,
Steele, & Miller, 2005; Madson, Loignon, & Lane, 2009) The anonymity found in
technical approaches may be particularly important for males and, at least partially, may
circumvent the social obligation, delay and perhaps, shaming nature of face-to-face
encounters.

Efficiencies are increasing being found by collecting pieces of history directly from
potential “patients” then providing personalized feedback. Alternatively, clinicians are
then poised for confirming and answering questions with greatly improved efficiency
over gathering the information in traditional ways. (Bickel, Marsch, Buchhalter, &
Badger, 2008; Kay-Lambkin, Baker, Lewin, & Carr, 2009; Kessler, et al., 2009)

Confidence for dealing with addictive disorders often lies in issues slightly outside the
realm of addiction treatment per se. For example, we humans have a tremendous
tendency to ignore problems if we don’t feel like there is anything we can do about them.
Repeated failure, for example, in smoking cessation often leads individuals to minimize
nicotine’s poisoning effects on health. Opportunities then to “weave in” such things as
self-esteem and goal setting, depression and anger management, pain issues, even trauma
or abuse themes may then, intuitively lead to greater determination and strength for
dealing with recalcitrant addictive problems. (Kay-Lambkin, et al., 2009) While the
addition of such complexity has typically frustrated the human care delivery system,
computerized systems handle complex tasks with patience, determination and ease.
 3 Brent R. Coyle, M.D.

Contemplation
The considerations of the pros and cons of major behavioral change and the ultimate goal
of emerging from the reflective process with a conviction that one has a problem and is
going to do something about it, offers opportunities for technology as well. This is a
challenging phase and not too surprisingly may require a human touch. The literature
seems to suggest that fully automated systems are certainly having a powerful impact but
adding even small amounts of human component may result in nearly the same outcome
as fully interpersonal therapies with only a small fraction of the time, space and expense.
(Bickel, et al., 2008; Kay-Lambkin, et al., 2009)

Another unique and quickly evolving opportunity exists within “social networking” and
other technical means for bringing users together in their pursuits. This is powerfully
present in gaming and other online “communities” already. Collaborative approaches to
addictive education and rehabilitation are therefore virtually unlimited. Additionally,
once an individual responds to treatment, they often wish to share what they have learned
with others. This not only helps the “teacher” of the material solidify their own gains but
enlists in an army of willing and often, enthusiastic individuals ready to make it their
life’s altruistic work to help others.

Preparation
Because the preliminary precontemplation and contemplation phases are difficult and
time consuming, it is often tempting for human therapeutic systems to jump to
preparation content. Automated systems have already impacted our treatment
communities toward targeting the appropriate stage of change and we finally are
beginning to realize that failure to do so typically results in frustration for both parties.
The “patience” of computerized approaches to apply variable learning speeds and
methods is well known and perfectly applied to these sensitive and vulnerable areas of
personal growth.

The multimodal technical world offers unique challenges and opportunities. While simple
written material carries impact and is unlimited (Carroll, et al., 2008; Carroll, et al.,
2009), adding even brief physician or other authority advice has been clearly found to be
more helpful and enduring. (Finfgeld-Connett, 2006; Gilbert, Nazareth, Sutton, Morris, &
Godfrey, 2008; Ockene & Ockene, 1996; Thompson, Schwankovsky, & Pitts, 1993) The
quickly evolving video image capabilities are astounding. Not only can physicians be
digitally called up for advice and coaching, but images might also be altered for greatest
cultural receptivity and impact. Multiple languages for these interventions might be then
developed once techniques are clearly found to be efficacious, etc.

Partnership again plays a vital consultative role during this active learning stage. Partners
are much more likely to have the time and inclination to help troubled individuals
understand the necessary components of effective management. Virtual reality offers
further vivification of this theme of personalization and even the potential for virtual
partnership. These techniques can then be applied to relapse management education, for
 4 Brent R. Coyle, M.D.

example, reenacting various high-risk social situations then can be presented and woven
into triggers, unwelcome exposures to drugs/alcohol, etc. (Cho, et al., 2008; Lieberman,
2006)

The power of sounds and especially music might be predicted to have the greatest impact
since these are such powerful influences on addictions already. Technologies will be
required to sort and “prescribe” healing verses destructive aims however.

Finally, numerous practical management issues can be accomplished via the Internet.
From simply using the convenience of it to find and coordinate meeting attendance, to
mutual encouragement with e-mail, “texting”, videoconferencing, etc., the Internet has
already become a centrally powerful tool in continuous use and evolution.

Action
Emerging from preparation with information and determination to change one’s lifestyle
is best accomplished with a specific date and perhaps time for adoption of a new way of
being. Computers are perfectly suited to track progress and keep us accountable with
reminders, cues, etc. and connect individuals in accountability and support.

Maintenance/Management of relapse
Again, the multiple ways of putting people together with technology first come to mind
but the ability to step back and rebuild a “program” through an “evolving plan”, as
quickly as possible, channeling any shame or guilt into even more determined action is
crucial. Computers are also particularly good, (in contrast to real-life counselors) at non-
judgmentally redirecting interest and motivation.

Research Opportunities and Cautions

A related but extraordinarily important issue is technology’s way of solving paralyzing
limitations in psychotherapy and psychoeducational research. Standardization of content
delivery has been a long-standing problem but an even greater limitation was the
measurement of effectiveness. Outcome measures can now be applied routinely and used
to dynamically alter intervention for greatest impact. The financial support for conducting
outcomes research in these modalities has paled in comparison to the deep pockets of the
pharmaceutical industry and therefore has lagged behind and been understandably
devalued.

Another aspect of cost is worthy of reflection. A subtle but important message is

conveyed by making automated psychotherapeutic and psychoeducational interventions
available at no cost. Patients have been found to improve more when drugs and even
placebos cost more. A drink or drug has a monetary “value”. When interventions are
offered for free, there is a powerful subliminal message that the treatment is not nearly as
“valuable” as the drug/addiction itself. (Gordon, Akers, Severson, Danaher, & Boles,
2006; Hester & Squires, 2008; Waber, Shiv, Carmon, & Ariely, 2008)
 5 Brent R. Coyle, M.D.

Conclusion
We are clearly in an exciting time that is changing at a mind-splitting pace. While new
opportunities can be expected to produce a certain number of deleterious ends, one would
hope and pray that we would find it in our humanity to apply our technologies abundantly
toward healing ends.

Bibliography

An, L. C., Klatt, C., Perry, C. L., Lein, E. B., Hennrikus, D. J., Pallonen, U. E., et al.
(2008). The RealU online cessation intervention for college smokers: a
randomized controlled trial. Prev Med, 47(2), 194-199.
Balmford, J., Borland, R., Li, L., & Ferretter, I. (2009). Usage of an Internet smoking
cessation resource: the Australian QuitCoach. Drug Alcohol Rev, 28(1), 66-72.
Bewick, B. M., Trusler, K., Barkham, M., Hill, A. J., Cahill, J., & Mulhern, B. (2008).
The effectiveness of web-based interventions designed to decrease alcohol
consumption--a systematic review. Prev Med, 47(1), 17-26.
Bewick, B. M., Trusler, K., Mulhern, B., Barkham, M., & Hill, A. J. (2008). The
feasibility and effectiveness of a web-based personalised feedback and social
norms alcohol intervention in UK university students: a randomised control trial.
Addict Behav, 33(9), 1192-1198.
Bickel, W. K., Marsch, L. A., Buchhalter, A. R., & Badger, G. J. (2008). Computerized
behavior therapy for opioid-dependent outpatients: a randomized controlled trial.
Exp Clin Psychopharmacol, 16(2), 132-143.
Carroll, K. M., Ball, S. A., Martino, S., Nich, C., Babuscio, T. A., Nuro, K. F., et al.
(2008). Computer-assisted delivery of cognitive-behavioral therapy for addiction:
a randomized trial of CBT4CBT. Am J Psychiatry, 165(7), 881-888.
Carroll, K. M., Ball, S. A., Martino, S., Nich, C., Babuscio, T. A., & Rounsaville, B. J.
(2009). Enduring effects of a computer-assisted training program for cognitive
behavioral therapy: a 6-month follow-up of CBT4CBT. Drug Alcohol Depend,
100(1-2), 178-181.
Cho, S., Ku, J., Park, J., Han, K., Lee, H., Choi, Y. K., et al. (2008). Development and
verification of an alcohol craving-induction tool using virtual reality: craving
characteristics in social pressure situation. Cyberpsychol Behav, 11(3), 302-309.
Cunningham, J. A., Hodgins, D. C., Toneatto, T., Rai, A., & Cordingley, J. (2009). Pilot
study of a personalized feedback intervention for problem gamblers. Behav Ther,
40(3), 219-224.
Cunningham, J. A., & Van Mierlo, T. (2009). Methodological issues in the evaluation of
Internet-based interventions for problem drinking. Drug Alcohol Rev, 28(1), 12-
17.
 6 Brent R. Coyle, M.D.

Cunningham, J. A., & van Mierlo, T. (2009). The check your cannabis screener: a new
online personalized feedback tool. Open Med Inform J, 3, 27-31.
Danaher, B. G., Hart, L. G., McKay, H. G., & Severson, H. H. (2007). Measuring
participant rurality in Web-based interventions. BMC Public Health, 7, 228.
Finfgeld-Connett, D. (2006). Web-based treatment for problem drinking. J Psychosoc
Nurs Ment Health Serv, 44(9), 20-27.
Finfgeld-Connett, D., & Madsen, R. (2008). Web-based treatment of alcohol problems
among rural women. J Psychosoc Nurs Ment Health Serv, 46(9), 46-53.
Gilbert, H., Nazareth, I., Sutton, S., Morris, R., & Godfrey, C. (2008). Effectiveness of
computer-tailored Smoking Cessation Advice in Primary Care (ESCAPE): a
Randomised Trial. Trials, 9, 23.
Gordon, J. S., Akers, L., Severson, H. H., Danaher, B. G., & Boles, S. M. (2006).
Successful participant recruitment strategies for an online smokeless tobacco
cessation program. Nicotine Tob Res, 8 Suppl 1, S35-41.
Hallett, J., Maycock, B., Kypri, K., Howat, P., & McManus, A. (2009). Development of a
Web-based alcohol intervention for university students: processes and challenges.
Drug Alcohol Rev, 28(1), 31-39.
Health, N. I. o. (2009). Rethinking Drinking, from
http://rethinkingdrinking.niaaa.nih.gov/
Hester, R. K., & Squires, D. D. (2008). Web-based norms for the Drinker Inventory of
Consequences from the Drinker's Checkup. J Subst Abuse Treat, 35(3), 322-327.
Hettema, J., Steele, J., & Miller, W. R. (2005). Motivational interviewing. Annu Rev Clin
Psychol, 1, 91-111.
Inc, H. I. (2007). Harris Poll Shows Number of "Cyberchondriacs" – Adults Who Have
Ever Gone Online for Health Information– Increases to an Estimated 160 Million
Nationwide, from
http://www.harrisinteractive.com/harris_poll/printerfriend/index.asp?PID=792
Kay-Lambkin, F. J., Baker, A. L., Lewin, T. J., & Carr, V. J. (2009). Computer-based
psychological treatment for comorbid depression and problematic alcohol and/or
cannabis use: a randomized controlled trial of clinical efficacy. Addiction, 104(3),
378-388.
Kessler, D., Lewis, G., Kaur, S., Wiles, N., King, M., Weich, S., et al. (2009). Therapist-
delivered internet psychotherapy for depression in primary care: a randomised
controlled trial. Lancet, 374(9690), 628-634.
Kwon, J. H., Chung, C. S., & Lee, J. (2009). The Effects of Escape from Self and
Interpersonal Relationship on the Pathological Use of Internet Games. Community
Ment Health J.
Leukefeld, C. G., & Tims, F. M. (1989). Relapse and recovery in drug abuse: research
and practice. Int J Addict, 24(3), 189-201.
Lieberman, D. Z. (2006). Effects of a personified guide on adherence to an online
program for alcohol abusers. Cyberpsychol Behav, 9(5), 603-607.
Lieberman, D. Z., & Huang, S. W. (2008). A technological approach to reaching a hidden
population of problem drinkers. Psychiatr Serv, 59(3), 297-303.
 7 Brent R. Coyle, M.D.

Lieberman, D. Z., & Massey, S. H. (2008). Pathways to change: the effect of a Web
application on treatment interest. Am J Addict, 17(4), 265-270.
Linke, S., McCambridge, J., Khadjesari, Z., Wallace, P., & Murray, E. (2008).
Development of a psychologically enhanced interactive online intervention for
hazardous drinking. Alcohol Alcohol, 43(6), 669-674.
Maddux, J. F., & Desmond, D. P. (1986). Relapse and recovery in substance abuse
careers. NIDA Res Monogr, 72, 49-71.
Madson, M. B., Loignon, A. C., & Lane, C. (2009). Training in motivational
interviewing: a systematic review. J Subst Abuse Treat, 36(1), 101-109.
Mokdad, A. H., Marks, J. S., Stroup, D. F., & Gerberding, J. L. (2004). Actual causes of
death in the United States, 2000. JAMA, 291(10), 1238-1245.
Murray, E., McCambridge, J., Khadjesari, Z., White, I. R., Thompson, S. G., Godfrey, C.,
et al. (2007). The DYD-RCT protocol: an on-line randomised controlled trial of
an interactive computer-based intervention compared with a standard information
website to reduce alcohol consumption among hazardous drinkers. BMC Public
Health, 7, 306.
Newton, N. C., Andrews, G., Teesson, M., & Vogl, L. E. (2009). Delivering prevention
for alcohol and cannabis using the internet: a cluster randomised controlled trial.
Prev Med, 48(6), 579-584.
Newton, N. C., Vogl, L. E., Teesson, M., & Andrews, G. (2009). CLIMATE Schools:
alcohol module: cross-validation of a school-based prevention programme for
alcohol misuse. Aust N Z J Psychiatry, 43(3), 201-207.
Ockene, I. S., & Ockene, J. K. (1996). Barriers to lifestyle change, and the need to
develop an integrated approach to prevention. Cardiol Clin, 14(1), 159-169.
Prochaska, J. O., & Velicer, W. F. (1997). The transtheoretical model of health behavior
change. Am J Health Promot, 12(1), 38-48.
Services, D. o. H. a. H. (2000). 10th Special Report to the US Congress on Alcohol and
Health.
Sutton, S. (2001). Back to the drawing board? A review of applications of the
transtheoretical model to substance use. Addiction, 96(1), 175-186.
Thompson, S. C., Schwankovsky, L., & Pitts, J. (1993). Counselling patients to make
lifestyle changes: the role of physician self-efficacy, training and beliefs about
causes. Fam Pract, 10(1), 70-75.
Vogl, L., Teesson, M., Andrews, G., Bird, K., Steadman, B., & Dillon, P. (2009). A
computerized harm minimization prevention program for alcohol misuse and
related harms: randomized controlled trial. Addiction, 104(4), 564-575.
Waber, R. L., Shiv, B., Carmon, Z., & Ariely, D. (2008). Commercial features of placebo
and therapeutic efficacy. JAMA, 299(9), 1016-1017.