Using Text Messages to Improve Substance Use Disorders Treatment Outcomes


Nancy Roget, MS, MFT, LADC
Co-Director, Mountain Plains ATTC


Annually, the Substance Abuse Mental Health Services Administration (SAMHSA) conducts a survey called the National Survey on Drug Use and Health (NSDUH). This survey interviews almost 68,000 individuals across the nation regarding their use of alcohol, prescribed medications, and illicit drugs. In 2019, the NSDUH survey found that almost 20 million individuals over the age of 18 had a substance use disorder (SUD), with less than 10% of these 20 million receiving treatment services. To address this vast treatment gap between individuals who report having a SUD and those that enter treatment, both researchers and policy-makers advocated for strategies that increase access to treatment services, promote low-cost resources, and offer engagement activities. An innovative response suggests that behavioral health technologies may offer one solution.

According to Ashford and colleagues (2018), in the last decade the use of technology by
SUD treatment and recovery support providers has helped increase the reach of their services, lower the threshold for patient engagement (e.g., made it easier for patients to enter treatment or recovery support services) and offer services that serve as an adjunct or complement to treatment and recovery services (p.19). At the same time, the use of technology (e.g., mobile phone, smart phone, tablet, computer, and internet) has increased in the general public. Recent data from Pew (2019) found that 81% of adults owned a smartphone, which was up 4% from 2018, and 73% had high speed internet at home. Smartphone use has increased among SUD treatment populations as well, with smartphone ownership ranging from 57% to 80% (Ashford et al., 2018; Dahne & Lejuez, 2015; Milward et al., 2015; Winstanley et al., 2018). These reported smartphone ownership rates for individuals involved with SUD treatment services have increased dramatically from an initial study done in 2013. Mobile phone ownership for this population increased substantially as well, ranging between 83% and 95%. Access to the internet is still low for the SUD treatment population but most individuals reported accessing internet services through their phones rather than home broadband. The bottom line as highlighted in the above-mentioned studies is that most patients have access to a mobile phone that can be used to receive or send text messages and/or to access the internet. Finally, a recent study (Ashford et al., 2018) showed that individuals in SUD treatment expressed a strong interest in using digital resources to manage and monitor their recovery, which included their preference to use an app on their phone or receive text messages. 

In light of these recent findings on technology use and patient feasibility/interest data, the Mountain
Plains ATTC worked with Dr. Scott Walters, a noted professor, National Institute on Drug Abuse (NIDA) researcher, and psychologist to develop a series of products and training/technical assistance activities. These products and activities were created for treatment and recovery support providers on how to create and implement one-way short message service (SMS) text messaging. The goal of implementing this innovation was to increase patient/peer engagement aligning with services like groups/individual sessions. A text messaging curriculum was created by Dr. Walters and piloted by the Mountain Plains ATTC in a two-part webinar series in Spring 2019, after which revisions were made to the manual and webinars, and a text messaging poster created that reminds providers and peers about texting language and tips. In August 2019, the webinar series was facilitated again, recorded, and posted in the products section on the Mountain Plains ATTC website along with the poster and manual. In November 2019, a small four-week intensive technical assistance (ITA) pilot was implemented with six SUD treatment providers located in Region 8 to assist with the implementation of text messaging within one of their treatment/recovery support components. Currently, these six providers are participating in the last part of the ITA project that includes individualized consultation sessions with Dr. Walters to assist with implementation issues. Results from this ITA project will be posted under a ‘lessons learned’ document. Initial feedback from participants reflects the principles of technology transfer that the innovation was easy to use, met a need at the agency, and enhanced their current service delivery. A recent Norwegian study by (Bjerke et al., 2009) on the use of text messaging found that patients felt a greater sense of connectedness to the providers through the use of text messaging. The Mountain Plains ATTC staff hopes the providers involved in this project receive similar patient feedback.

References
Ashford, D. R., Lynch, K., & Curtis, B. (2018). Technology and social media use among patients enrolled in outpatient addiction treatment programs: Cross-sectional survey study. Journal of Medical Internet Research, 20(3), e84. http://dx.doi.org/10.2196/jmir.9172.

Bergman, B. G., Greene, M. C., Hoeppner, B., & Kelly, J. (2018). Expanding the reach of alcohol and other drug services: Prevalence and correlates of US adult engagement with online technology to address substance problems. Addictive Behaviors, 87, 74–81. https://doi.org/10.1016/j.addbeh.2018.06.018.

Bjerke, T. & Kummervold, P., Christiansen, E. & Hjortdahl, P. (2009). “It made me feel connected”—An exploratory study on the use of mobile SMS in follow-up care for substance abusers. Journal of Addictions Nursing, 19, 195-200. 10.1080/10884600802504735.

Bliuc, A. M., Best, D., Iqbal, M., & Upton, K. (2017). Building addiction recovery capital through online participation in a recovery community. Social Science & Medicine, 193, 110–117. https://doi.org/10.1016/j.socscimed.2017.09.050.

Dahne, J. & Lejuez, C. (2015). Smartphone and mobile application utilization prior to and following treatment among individuals enrolled in residential substance use treatment. Journal of Substance Abuse Treatment, 58(Supplement C), 95–99. https://doi.org/10.1016/j.jsat.2015.06.017.

Masson, C. L., Chen, I. Q., Levine, J. A., Shopshire, M. S., & Sorensen, J. L. (2018). Health-related internet use among opioid treatment patients. Addictive Behaviors Reports, 9, 100157. doi:10.1016/j.abrep.2018.100157

Milward, J., Day, E., Strang, J., & Lynskey, M. (2015). Mobile phone ownership, usage and readiness to use by patients in drug treatment. Drug and Alcohol Dependence, 146(Supplement C), 111–115. https://doi.org/10.1016/j.drugalcdep.2014.11.001.

Pew Research Center (2019). Mobile Technology and Home Broadband 2019. Accessed January 2020 from https://www.pewresearch.org/internet/2019/06/13/mobile-technology-and-home-broadband-2019/.

Substance Abuse and Mental Health Services Administration. (2019). Key substance use and mental health indicators in the United States: Results from the 2018 National Survey on Drug Use and Health (HHS Publication No. PEP19-5068, NSDUH Series H-54). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/.

Winstanley, E. L., Stroup-Menge, B., & Snyder, K. (2018). The promise of technology-based services for addiction treatment clients residing in nonurban areas. Journal of Studies on Alcohol and Drugs, 79(3), 503–504.

Changing Practice Through Collaboration, Art, and Science



Respectfully submitted by Holly R. Ireland, LCSW-C


The Central East ATTC serving Health and Human Reserves Region 3 has been managed by the Danya Institute for nearly 20 years. Danya’s tagline is “Changing Communities Through Changing Practice” and collaboration has always been a central core value to our work. Workforce development and capacity building changes in practice could not be successfully sustained without collaboration. The mutual exchange of perspectives, ideas, and investment leads to richer and more lasting changes for systems, organizations, professionals and most importantly the individuals and families receiving behavioral healthcare. From it emerges the necessary innovation to keep pace with rapidly evolving trends, leading to a responsive and adaptive system of care.

In recent years there has been an emerging "science of collaboration."[1] This involves intentional efforts to measure the process of learning what works and what doesn't, then use data-informed decision making to improve how leaders design, manage, and evaluate collaboration projects. The process helps to educate and train future leaders with the necessary organizational and managerial skills in collaboration. Literature about the science of collaboration emerged historically in the science sector but is increasingly found in the health and behavioral health sectors.


Given Danya’s core value and the SAMHSA imperative to accelerate the adoption of evidence-based practices in behavioral health through intensive technical assistance (TA) to organizations, localities, and systems; the Central East ATTC has implemented several intensive TA capacity building collaborative projects in organizations, municipalities, counties, and statewide and regional systems of care. Stakeholder collaborations involving three or more entities or organizations have been central to implement capacity building projects in the adoption of evidence-based practices in Motivational Interviewing (MI) and Screening, Brief Intervention, and Referral to Treatment (SBIRT).



In Year 1, the Mount Rogers Community Services Board (MRCS)[2] in Wytheville, VA, collaborated with the Central East ATTC to increase Motivational Interviewing (MI) capacity. MRCS offers “a wide array of community services for individuals with mental health, intellectual and developmental disabilities, and substance use disorders. All services include the use of person-centered planning and embrace concepts of self-determination, empowerment, and recovery as core principles in supporting individuals to achieve their highest possible level of participation in work, relationships, and all aspects of community life.”[3] Candace Coffin, Director of Specialty Services –
Administration/Training, was the champion and internal facilitator of this project. The Central East ATTC engaged Christine Higgins, MINT Trainer, subject matter expert and external facilitator, to plan and implement this project. As part of the planning process, 20 staff members, mostly clinical supervisors, were identified and engaged as key collaborators and future MI trainers.



In Year 2, the project was launched in November 2018 and concluded in September 2019. It began with an MRCS Senior Leadership dinner meeting, which provided an overview of the 6-9 month project; and included two (2) back-to-back, one-day MI Basic training events on November 1 and 2, training 72 staff members. Christine returned to Wytheville in December 2019 to provide MI intermediate training to 24 staff members and clinical supervision of MI training to 22 supervisors.

From December through March, there were several virtual TA sessions with Chrisitine and the 22 supervisors, both group and individually, that involved video recording, coding and feedback, as well as coaching in the supervision of MI. To enhance relationship building, engagement and collaboration for the in-person and virtual sessions between Christine and the trainees, Candace created name placards with photos.

In March 2019, Christine provided MI Advanced to 14 of the supervisors, and 20 of them participated in an MI Training of Trainers in April 2019.

From April through September 2019, Christine provided an additional 20 hours of virtual TA to support the training plan development and implementation, as well as additional coaching in clinical supervision.

The MRCS MI Spirit Committee was formed to ensure full integration of MI in the onboarding of new staff, training of the existing 700+ staff members, and maintenance of a robust commitment to the spirit of MI throughout the work of the organization.

“We are so deeply grateful to the [Central East ATTC] for all the training – well worth it. Our trainers are ready and Christine has been a huge support.” - Candace Coffin.

MRCS continues to contract with Christine Higgins directly for the development of 15 minute video to show at new employee orientations to introduce Motivational Interviewing. They also have a monthly training calendar for two-day MI training sessions from March through December 2020. The MI Spirit is strong at MRCS and the change in practice will endure.











[1] http://news.mit.edu/2013/the-science-of-collaboration


[2] http://www.mtrogerscsb.com/


[3] https://www.bbb.org/us/va/wytheville/profile/mental-health-services/mount-rogers-csb-0613-90006708#overview

NIATx Tools: What I Learned From My First Walk-through Exercise





Julia Parnell Alexander, Ph.D.
Co-Director, Great Lakes PTTC
State Project Manager, Indiana, for the Great Lakes ATTC, MHTTC, and PTTC



My first NIATx walk-through exercise happened when I was a staff member at a recovery community organization (RCO) in Minnesota. Through this experience, I quickly learned the difference between theory and practice.

I thought I knew our organization well, quite well. A core principle of an RCO is that it is welcoming and serves everyone in the community. We had worked hard to make our space welcoming, and we had organized many events and gatherings over the years that drew large crowds that filled the space with joy and laughter. My confidence in our space, our work, and our welcoming nature was so strong that I thought the walk-through experience would confirm my views. Our welcoming environment, I thought, was solid, with little or no room for improvement.

Cut to the actual walk-through. I did everything I could to leave my routine behind. What would fresh eyes tell me? How could I start from scratch?

I entered our address into Google Maps. I had never Googled the address before because I usually drove to work—because I knew right where to go, right? Google produced two locations. Which one was correct? The address information was confusing, so I decided to call the office to find out what to do. With help from the staff person on the phone, I chose the correct option and made a note to self to get this corrected with Google Maps.

I pulled into the parking lot and was happy to see ample parking. And then it hit me: I’d heard people say that the RCO entrance door was not clearly marked, but it finally resonated for me when I was trying to decide where to park. There were three entrance doors, and I wasn’t sure which one to use. Plus, there was no signage indicating where to go and nothing to differentiate the RCO from the church that hosts the RCO. Was I in the right place?

I first chose the front door, figuring it would lead me to someone who would direct me where I needed to go. This door was locked. Pulling on a locked door felt like rejection. I bypassed the middle door—it looked like something only a staff member would use. Next, I went to a set of double glass doors at the opposite end that looked more inviting and “official.” Nope, these doors were locked as well. Rejected again. I doubled back to that middle door, and it was open. Success! But that feeling was fleeting as I walked into a grand and empty open space. It was bright and spacious, but it was empty. I still didn’t know where to go. Walking toward the sound of lively chatter, I found friendly people who greeted me with a jovial and authentic welcome—finally! It had just taken a lot of work to get there. And it turns out that people don’t really like to provide a critique of their experience when it’s uncomfortable. And we certainly never heard from people we never met because they simply gave up trying to get to us.

My experience was just one type of a walk-through, but it gave insight into a core element of what we were assessing as an RCO. My walk-through led to a few changes: we added signage outside the best entrance to use, and we posted volunteers in an office inside near the entrance so they could immediately welcome visitors. These changes helped make our space much closer to the welcoming nature I had initially thought we had.

If you do your best to do your walk-through with fresh eyes, taking nothing for granted. You’ll be surprised by how much you learn, and you’ll have ample data to use in your change project. It’s key that you conduct the walk-through with an open mind and an eye towards improvement without assigning blame as you go. A walk-through exercise isn’t about monitoring staff or about improving performance—it’s about improving a process.

Visit the newly updated NIATx website to learn more about the walk-through process. You’ll find complete instructions and forms under the “Tools” tab.


We’d love to hear insights from your walk-through experiences. What did you learn? What changes did you make or change projects did you do as a result of your walk-through? Share your experience in the comments section below.

About our guest blogger
Julia Parnell Alexander, Ph.D., is a woman in long-term recovery. Before her work with the Great Lakes ATTC, MHTTC, and PTTC, she was a founding staff member of and then served as Executive Director of Operations for Minnesota Recovery Connection, Minnesota’s first and longest-running Recovery Community Organization.



Tech Transfer in Action Blog Series: Infusing Evidence-Based Substance Use Disorder Treatment and Recovery Information into Existing U.S. College and University Curricula



Beth Rutkowski, MPH
Co-Director, Pacific Southwest Addiction Technology Transfer Center, HHS Region 9


Developing a competent, highly skilled multidisciplinary workforce to provide effective treatment and recovery services to individuals living with a substance use disorder is a cornerstone of the training and technical assistance occurring throughout the SAMHSA-funded Addiction Technology Transfer Center Network. To be most effective, workforce development should begin at the pre-service education level, so that as new professionals graduate and enter into the field, they have the advantage of being equipped with the most up-to-date, science-based clinical tools.

For this reason, a key element of the Pacific Southwest ATTC’s five-year work plan is the development and distribution of a series of Curriculum Infusion Packages (CIPs) on a variety of targeted topics. The first, a 5-part CIP on Opioid Use Disorders (OUD), was developed and released in late summer/early fall 2019. The main developers were Beth Rutkowski, MPH, and Nancy Roget, MS, with additional guidance and editing support provided by Terra Hamblin and Drs. Thomas E. Freese, Michael Shafer, and Joyce Hartje.

The OUD CIP was developed for college and university faculty to infuse brief, science-based OUD-specific content into existing substance use disorder-related course syllabi (e.g., foundations of addiction, screening and assessment, general health-related classes, etc.). Instructors can select the specific content to infuse throughout the duration of the course, depending on specific needs of the learners. Each slide contains notes for the instructor to provide guidance, as necessary. References are included in each slide and handouts when possible.

Part 1 of the OUD CIP provides an overview of addiction as a brain disease, a description of opioids and how they work in the brain and body, the acute and chronic effects of opioid use, the epidemiology of the opioid epidemic, and resources for continued learning. Part 2 discusses the importance of integrated, holistic care for people with OUDs, tools to address the opioid epidemic, the difference between an opioid agonist and antagonist, a review of FDA-approved medications for OUD, and resources for continued learning. Part 3 reviews opioid overdose and prevention strategies. Part 4 provides discusses of the importance of using language that helps decrease stigma associated with SUDs. Lastly, Part 5 provides an overview of recovery supports and treatment recommendations for people with opioid use disorders.

The slide decks are designed to be used by academic faculty in behavioral health programs, trainers, behavioral health providers, and state/county agency staff members for a variety of audiences. Educators are free to use these slides and the pictures, but are asked to provide credit to the Pacific Southwest ATTC when using them by keeping the logo on each slide and referencing the Pacific Southwest ATTC at the beginning of their presentation(s).

For the Opioid CIP, the Pacific Southwest ATTC developed a two-part marketing and dissemination strategy. Wave 1 distribution occurred in August 2019 and targeted more than 160 colleges and universities across HHS Region 9 with a nursing, social work, psychology, and/or SUD counseling program or school. Wave 2 distribution occurred in September 2019 and targeted an additional 90 Region 9-based colleges and universities with a medical, criminal justice, community health service, and/or public health program or school. In addition, leadership in all of the community colleges across the six U.S.-affiliated Pacific Jurisdictions received a link to the electronic copy of the CIP. In a two-month time period from October 1-November 30, 2019, the OUD CIP was viewed and downloaded more than 540 times. Subsequent CIPs will be distributed in a single wave, and the PSATTC evaluation team will follow-up with educators approximately one month following receipt of the new CIP to assess the usefulness of and satisfaction with the information featured in the packages.

Future CIPs released in Years 03-05 of the funding cycle will focus on a variety of topics, including:
  • Compassion Fatigue
  • Stimulant Use Disorders – Methamphetamine and Cocaine
  • Alcohol Use Disorders
  • Chronic Pain Management
  • Smoking Cessation Strategies

To view and download the OUD CIP, please visit: http://uclaisap.org/html2/curriculum-infusion-package-on-oud.html. Additional information is available at http://www.psattc.org or by emailing Beth at brutkowski@mednet.ucla.edu.

Hepatitis C Prescriber Toolkit








Laura W. Cheever, MD, ScM
Associate Administrator for HRSA HIV/AIDS Bureau

Although advances in HIV care and treatment result in longer life expectancy for people with HIV, those who are coinfected with HIV and hepatitis C have a high risk of liver-related illness and death. Viral hepatitis progresses faster and causes more liver-related health problems among people with HIV than among those who do not have HIV. Approximately 25% of people with HIV are coinfected with hepatitis C.

Providers are key partners in national efforts to reduce and, ultimately, eliminate hepatitis C virus (HCV) coinfection among people with HIV. To support providers in diverse settings to effectively engage and remain up to date on state-specific prescribing requirements, the Health Resources and Services Administration’s HIV/AIDS Bureau released the Hepatitis C Prescriber Toolkit on TargetHIV.

The interactive Hepatitis C Prescriber allows providers to select their state and learn about health coverage requirements that may impact the prescription of hepatitis c treatment. The toolkit also includes additional resources such as links to the Ryan White HIV/AIDS Program (RWHAP) Part F AIDS Education and Training Center (AETC) Program’s HIV/HCV Coinfection Curriculum.

Each state-specific page provides a link to the regional AETC partner for training opportunities and additional coinfection resources. , It provides information on Medicare, the state’s Medicaid contact, the state’s AIDS Drug Assistance Program (ADAP) contact with applicable prior authorization form. Providers can also access a list of patient assistance programs if their patient is not eligible for private insurance or ADAP coverage. 

Through the efforts of the RWHAP AETCs, a number of resources have been developed to support RWHAP recipients and providers to encourage increasing hepatitis C screening and treatment to help improve the health outcomes of people with HIV. The Hepatitis C Prescriber Toolkit is one more resource for providers to have at their disposal.

Visit the toolkit today!