Fall 2024 Issue

Substance Use Disorder
By Sue Coyle, MSW
Social Work Today
Vol. 24 No. 4 P. 26

Apps offer digital support for individuals struggling with substance use.

In March of this year, the North Carolina Department of Health and Human Services (NCDHHS) announced a partnership with CHESS Health and Trillium Health Resources. Together, they’ll make available CHESS Health’s eRecovery program, specifically its Connections app, to individuals in the state of North Carolina struggling with a substance use disorder.

The app is free to those who enroll through their providers and offers, along with other features, 24/7 peer support—something that Kelly Crosbie, MSW, LCSW, director of the Division of Mental Health, Developmental Disabilities, and Substance Use Services at NCDHHS, is particularly excited about.

“People go to treatment. They might even go for a while every day. But people also spend a lot of time by themselves,” she explains, noting that it can be difficult to maintain recovery and deal with triggers when alone. “[The peer support feature] bridges those moments. There are people who are online all the time, responding to chats. They are literally people in recovery. They are people who know what it’s like at 3 am. They are there. They can empathize.”

The hope is that the app will serve as a complement to clinical treatment, acting as an additional support and tool for individuals with substance use disorders.

North Carolina is not alone in this goal. Providers, researchers, and others working in the field of substance use are increasingly looking to apps as an additional recovery tool, aiming to find ways not only to support but also to better engage individuals.

The Appeal
One of the primary reasons apps are of interest to those working in substance use is accessibility. “Most people nowadays have access to at least a basic smartphone. There is even a [federal] program for people of limited financial means,” says Karen Ingersoll, PhD, a professor of psychiatry and neurobehavioral sciences at the University of Virginia (UVA) School of Medicine, referencing the Lifeline Program—a federal strategy that offers discounted wireless services to low-income individuals and families. Some are also eligible for a free cell phone.

As of 2023, it was estimated that 90% of adults in the United States have a smartphone, and 95% of adults use the internet.

The same cannot be said for access to substance use treatment. The 2022 Access to Care Survey by the National Council for Mental Wellbeing found that 43% of adults in the United States who reported needing substance use or mental health care in the 12 months prior to the survey did not receive it. Barriers to care included cost as well as the ability to both find and reach a provider. The survey notes that “Inability to find a conveniently located provider prevented 28% from getting mental health care and 22% from getting substance use care. In some rural areas, providers may be hours away.”1

That’s not to say that a smartphone and an app should or could replace clinical treatment. They can, however, be utilized in a way that keeps individuals engaged in treatment and, as Crosbie highlighted, supports them when they are in between appointments and far from in-person support.

Ingersoll agrees. “We live in central Virginia. A lot of the parts of Virginia that surround us are very rural. Even Charlottesville is a small town. We have patients that come to the UVA clinics and then disperse. One of our concerns is how do we stay in touch with patients? We wanted to extend our ability to keep in touch with patients, especially folks with conditions that maybe they want to keep hidden.”

The stigma of substance use Ingersoll alludes to is another reason apps can be a powerful tool in recovery. Rather than having to go to the one 12-step meeting in the county that’s either prohibitively far away or composed of all-too-familiar faces, individuals can seek support with more anonymity and less real or perceived judgment. “Those stigmas can kind of keep people from getting the care that they need because they’re afraid of being viewed in a negative way. Mobile apps have a friendly feel no matter who you are and still connect you to care and help you maintain your goals,” Ingersoll says.

The Research
Given the potential these apps have to support and build upon clinical treatment for individuals struggling with substance use, researchers, as well as providers, are keen to study their efficacy.

In North Carolina, data is just starting to come in about the state’s rollout of the Connections app. “CHESS is very motivated to track its utilization but also the outcomes. We’re already getting some data now on the number of providers who are going through training. We will get data on if it’s helping people to stay and maintain their treatment; if it’s helping people have a reduction in things that we know are triggers,” Crosbie says. Overtime, CHESS and NCDHHS will assess how app users engage with the app itself, as well as with treatment, and whether the users report a reduction in trigger symptoms.

They are hoping for positive outcomes, which are not unlikely, as other apps have shown promise in studies throughout the country. For example, at UVA, the HOPE (Heal Overcome Persist Endure) app was created to support individuals struggling with opioid use. The app allows users to contact their providers, access peer support through message boards, and self-report their progress in recovery. In 2022, after an initial test of the app, researchers reported that more than 50% of users were still active in substance use treatment and that even many of those who had stopped attending treatment continued to use the app.

“We had a couple of colleagues who really were struggling with retaining patients with opioid use disorder,” Ingersoll says. “They were just having a hard time staying in touch with patients, and they didn’t always know why. In part, they wanted to understand through self-report features on the app how patients perceive how they were doing, and if they’re in medication-assisted therapy, if they would report any relapses or usage of opioids when they weren’t supposed to be using it.

“Surprisingly, patients did report they had a lapse. What they also said is they liked features in the HOPE app. They could request support from anonymous users of the app. They could request a message of support. They felt like it was a place where they could get some positivity,” she explains.

However, these positive results don’t mean that all apps targeted at substance use are inherently helpful.

HOPE and the Connections app are tools being used in concert with clinical treatment. To access either, the individual has to sign up through their provider.

In contrast, there are apps commercially available to individuals, and the data on those is less promising. For instance, a 2019 analysis of 74 apps that are available for free or low cost through Apple and Google found that few apps promoted evidence-based interventions and rather “centered on basic informational content summarizing how many calories or money would be saved with alcohol abstinence, tracking time of abstinence with timers, using graphs to chart quantities of consumed alcoholic beverages, and basic information about addiction.”2 The researchers further note that many of the apps seemed to actually promote continued use.

Thus, the efficacy of an app likely will depend on why, where, and how it was developed, as well as how it is made available and utilized.

Challenges
Other challenges also exist in creating and rolling out effective, evidence-based apps that support recovery. While the majority of US adults might have a smartphone, they don’t always have reliable service. “We have some concerns with broadband,” Crosbie says. “Getting broadband everywhere is hard.”

Additionally, when providers are a part of the process, they need to be supportive of the tool and willing to interface with it as well. Crosbie says that it was actually providers in North Carolina who approached NCDHHS about partnering with CHESS Health having learned about the eRecovery program. However, not all clinicians will be as eager.

Ingersoll, who’s been a part of developing numerous apps, including HOPE and PositiveLinks, an app designed for people living with HIV, says that even within the UVA clinic there are mixed feelings about apps. “There are clinicians and trainees who say, ‘I don’t want to do it,’ and other people who totally embrace it. The super-users we’ve typically had have been nurses, case managers, substance use counselors. They tend to love it. Some of the physicians and trainees feel like we already have to do EPIC [an EHR system],” so they don’t want to do more.

As more is learned about the best ways to incorporate apps and other resources into substance use treatment, these challenges ideally will lessen. After all, technology is not going away. It’s becoming more prevalent in everyday life every day. As Crosbie notes, “In 2024, it’s silly not to be using something like an app.”

— Sue Coyle, MSW, is a freelance writer and social worker in the Philadelphia suburbs.

References
1. More than 4 in 10 U.S. adults who needed substance use and mental health care did not get treatment. National Council for Mental Wellbeing website. https://www.thenationalcouncil.org/news/more-than-4-in-10-us-adults-who-needed-substance-use-and-mental-health-care-did-not-get-treatment/

2. Tofighi B, Chemi C, Ruiz-Valcarcel J, Hein P, Hu L. Smartphone apps targeting alcohol and illicit substance use: systematic search in in commercial app stores and critical content analysis. JMIR Mhealth Uhealth. 2019;7(4):e11831.