CATR: What gaps can technology fill when we work with patients with substance use disorders?
Dr. Swendeman: Really, it’s about accessibility. In some ways, an in-person model where you require people to come to in-person visits could be considered a form of rationing of care. COVID-19 is creating silver-lining opportunities for telehealth to improve access, engagement, and retention in care that many colleagues are talking about. Previously you couldn’t get reimbursed or bill for telehealth services. Now there are exceptions that are being made. They seem to be temporary, but there’s tremendous excitement that we might be able to sustain some of these opportunities, which at least some patients seem to be more engaged with or appreciate.

CATR: It’s a seismic shift in how we imagine the patient-provider interaction. What do patients and providers think?
Dr. Swendeman: We’re hearing that patients like the option to do telehealth visits. Providers generally appreciate the flexibility, too, but have understandably expressed concern that we don’t know if telehealth is as effective as in-person care. Psychiatrists might say: “I’m not sure I like it as much as an in-person visit, especially for an initial visit where you can get more information than you would in a telehealth visit via nonverbal cues.” But the convenience factor benefits patients and providers alike. Demands on people’s time and attention have only become more extreme with the rise of social media and on-demand entertainment, all of which compete for people’s attention and priorities and bring technological platforms to the forefront of people’s lives. Telehealth options can harness this transformation.

CATR: What do the data show?
Dr. Swendeman: In my work with my long-term mentor Mary Jane Rotheram-Borus, we tested a one-on-one telephone intervention versus a one-on-one in-person intervention in the late 90s, targeting substance use in young people with HIV. We found that in-person visits were slightly more efficacious than telephone visits in reducing substance use and promoting safer sexual practices, but both modalities were superior to the standard-of-care control arm (Rotheram-Borus MJ et al, JAIDS 2004;37(Suppl 2):S68–S77). In interpreting these results and those of other studies, keep in mind both the individual-level patient outcomes and the broader public health impact. So, maybe we’re less efficacious on an individual level, but if we’re reaching more people on the population level, and reducing barriers to care for that population by using telehealth approaches, we might be more effective.

CATR: What are some other considerations when using telemedicine for substance use disorders?
Dr. Swendeman: Regarding confidentiality, patients may not be in a space where they are comfortable talking openly about sensitive issues like their substance use; for example, there may be family members or partners around. So, in that case, even a telephone interaction may not be as accessible or acceptable to them. Specimen collection also poses a challenge. For example, while the Substance Abuse and Mental Health Services Administration has allowed for the provision of buprenorphine to patients with opioid use disorder via telemedicine, recommendations for toxicology testing remain (www.samhsa.gov/sites/default/files/faqs-for-oud-prescribing-and-dispensing.pdf). Mail-in samples, such as urine samples or dried blood-spot testing, may be an option we’ll see in the future.

CATR: What about other electronic ways to connect with patients beyond telephone or tele-videoconferencing?
Dr. Swendeman: I’ve been involved with several projects that address substance use through text messaging, and there have actually been some interesting results. One randomized trial involved men who have sex with men and use methamphetamine (Reback CJ et al, AIDS Behav 2019;23(1):37–47). Subjects were randomly assigned to one of three arms: weekly texted self-assessments describing any recent substance use; receiving automated therapeutic text messages; or interactive conversations with peer health educators as well as the automated text messages. Our hypothesis was that the live peer health educator arm, which was much more intensive and more expensive, would have better outcomes. But as it turned out, the automated text messaging arm was more effective than the other two arms.

CATR: So you found that the less resource- and time-intensive text-messaging intervention may be more effective than involving a peer educator?
Dr. Swendeman: That was a surprising result. Automated delivery outperformed peer educator–delivered messaging. While further studies are needed, it does seem that automated text messaging is the way to go for some patients. There are many other factors that need to be considered in future research and practice, such as patient motivation and severity of the disorder, but text messaging (or direct/private messaging on smartphone apps) is a promising strategy that could also be considered as an adjunct to counseling and medication-based models.

CATR: How can we operationalize text messaging? Is there a concern that this might open the floodgates on clinicians or case managers at the other end of the phone line?
Dr. Swendeman: We were always concerned that providers would be overwhelmed with patients making requests—ie, “Oh my gosh, if I’m constantly available for patients to text me, I’m going to be buried in messages!” We haven’t found that to be the case, interestingly. But I think it can be highly variable, depending on the acuity and need of the patients. We certainly have experiences with a very small proportion of patients who initiate a higher volume of messaging and expect 24/7 access and response. In those rare cases, we have to remind them about ground rules, boundaries, and availability schedules, in addition to employing protocols using out-of-office automated responses with emergency contacts and on-shift/off-shift messages as standard procedures.

CATR: What about self-monitoring strategies that use digital platforms?
Dr. Swendeman: Self-monitoring asks patients to note internal and external factors that occur with a target behavior—like substance use. For example, a patient may be encouraged via an automated text message to report on the daily quantity of alcohol they consumed at the end of each night, and they may also be asked to comment on how they feel or their affective state. This data—linking alcohol use to affective state on a daily basis—can then be summarized and addressed in a weekly therapy session. Self-monitoring is one of the simplest things that you can implement in a smartphone app. It can be done by text messaging, or even by interactive voice response, which is what some people would call robocalling (where you get a voice call that’s automated and then you key in your responses).

CATR: How do patients feel about this form of monitoring?
Dr. Swendeman: Patients start to perceive that you are monitoring them and watching them in a way—not in a Big Brother way, but in a supportive way. I’ve had patients say things like, “I felt like you were there like a coach or a counselor; I felt like you were there with me every minute of the day,” even though no coach or counselor was monitoring the data or even sending any feedback on daily data. Patients also use it as a self-tracking tool. So, they will say things like, “I really wanted to meet my goal and I really wanted to be able to report on this next survey that I knew was coming up that I actually abstained or didn’t use today. And then I wanted to be able to share that success with you when we were able to meet again and have our session.”

CATR: Thank you for your time, Dr. Swendeman.