Using Smartphones to Provide Recovery Support Services

Nationwide cost estimates of 60 major illnesses place alcohol use disorders as the 2nd and
drug use disorders as the 7th most costly health problems. Both are related to higher rates
of HIV risk behaviors associated with the human immunodeficiency virus (HIV) and together
they represent 3 of the top 10 modifiable behavioral causes of mortality in the US. Studies
indicate that effective strategies for managing substance use disorders (SUD) must address
their chronic and cyclical nature, of which HIV risk is a part. For many, substance use
creates circumstances that increase HIV risk (e.g., needle use, trading sex) and for others,
substance use is a coping mechanism for the negative impact of lifestyle choices (e.g.
illegal activity, losing custody of their children, trading sex). Post-discharge monitoring,
feedback and early re-intervention have become standard practice when managing numerous
chronic conditions.10 Mobile technology has the potential to radically improve the odds of
sustained recovery by providing tools for ongoing monitoring, assessment and access to
recovery support interventions anytime and anywhere. This is particularly important for the
90% of those needing treatment that don't receive it. Therefore applying smartphone
technology to provide recovery management anytime anywhere is potentially significant.

Using their smartphone-based suite of relapse-prevention interventions , Gustafson and
colleagues11 conducted an RCT with a sample of 350 adults with alcohol use disorders
discharged from 2 residential substance abuse treatment programs and followed them for 12
months. Patients self-initiated access to the interventions 24/7; the type of interventions
ranged from being professionally supported EMIs like "ask an expert" which allowed
participants to receive personal responses to their questions from addiction experts to a
Panic Button which triggered automated reminders to the participant and, alerts to key people
(e.g., counselor, sponsor, family member) who may reach out to the participant via phone or
in person. Their system was designed to support recovery by promoting autonomous motivation,
coping competence, and relatedness.12 Relative to participants assigned to recovery support
services as usual, those receiving the support system reported significantly fewer heavy
drinking days and were more likely to be abstinent from alcohol at the end of the study.13-15
In addition, this study demonstrated that providing recovery support via smart phones is
feasible for this population.

Despite these encouraging outcomes, the full potential of providing 24/7 access to recovery
support via smartphones may not yet have been realized. For example, while participants rated
themselves on protective and risk factors weekly, opportunities to intervene "in the moments
of need" were lost if the individuals did not self-initiate use of the application, ratings
were subject to recall bias, and "teachable moments" in which participants could have
cognitively linked the risk factors to their desire or actual use were unexplored. More
frequent monitoring of current circumstances (vs. past generalized week) using methods like
Ecological Momentary Assessment (EMA) may be better suited to this context as they can
improve one's level of self-monitoring, provide additional opportunities to intervene in the
moment of risk, minimize recall bias and provide participants with the opportunity to learn
more about the relationship between current circumstances and their use.16,17 The primary
goal of the proposed trial is to examine the effect of combining more frequent
self-monitoring via EMAs and automated interventions via Ecological Momentary Interventions
(EMIs) provided by smartphone, on days of abstinence from drugs and alcohol and HIV risk
behaviors over 6 months following treatment discharge.

We will recruit a total of 400 participants in 4 cohorts of 100 people from sequential
discharges (both planned or unplanned) over 2 months starting in months 7, 19, 31, 43 and
follow them for 6 months post discharge. Using urn randomization, we will randomly assign
participants at discharge in a 2 x 2 factorial design to receive EMAs only, EMIs only,
combined EMA+EMI or control (no EMA or EMI). Post-randomization, participants assigned to the
EMA, EMI and combined EMA/EMI groups will receive a smartphone for 6 months with 450 call
minutes, 500 text messages and unlimited data plan monthly. Those in the EMA only and EMA/EMI
combined group will be asked at 6 randomly selected times each day (183 days total) to record
their past-30-minutes involvement in HIV risk behaviors and substance use, and their exposure
to internal and external risk and protective factors and rate the extent to which these
factors support their recovery, make them want to use drugs and/or alcohol. Those in the EMI
only and EMA/EMI combined group will have continuous access to a suite of smartphone based
support services (EMIs). To minimize interference with treatment, phones will be issued and
trainings will be done after discharge. To minimize potential contamination across
conditions, trainings for each condition will occur on separate days. During the month
following treatment discharge & training, participants in the three experimental groups will
return to the research office 2 times a week for research staff to check participant's
proficiency operating the phone and collect urine screens. To control for the effects of
attention, the control group will also return to the research office 2 times a week for urine
screens and a short survey on non-phone related topics. Research office visits and trainings
will be done by Protocol Monitors (not interviewers). Research Interviewers blind to
condition will conduct the discharge, 3 and 6 months post discharge interviews and urine
tests. EMA and EMI utilization data will be electronically recorded immediately via a
mobile/web application and used to track implementation.

The primary hypotheses are

H1 Random assignment to a) EMA (vs. not), b) EMI (vs. not), and c) their interaction will be
associated with more days of abstinence from drugs and alcohol over the 6 months post
discharge.

H2 Random assignment to a) EMA, b) EMI, and c) their interaction will be a associated with
fewer HIV risk behaviors over the 6 months post discharge.

H3 Days abstinent at 3 months post discharge will mediate the effects of a) EMA, b) EMI and
c) their interaction on HIV Risk behavior at 6 months post discharge.

Inclusion Criteria:

1. meet criteria for SUDs in year prior to treatment intake,

2. alcohol or other drug use during the 90 days prior to treatment,

3. discharged to the community (vs. jail or prison) from outpatient, intensive outpatient
or residential treatment,

4. age 18 or older,

5. communicate in English or Spanish, and

6. are cognitively able to provide informed consent.

Exclusion Criteria:

7. already live outside of Chicago

8. plan to live outside of Chicago in the 6 months post discharge

9. Expected to be in jail or prison or other setting that would prevent the use of
smartphones during the 6 months post discharge

10. Not able to use smartphone due to disability or health condition