Criminal Justice-Referred Patients with SUD Prefer Human Connection to App-Delivered CBT

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While digital therapeutics offer convenient, easy-to-access treatment for people with substance use disorder (SUD), a new report suggests patients who are referred to treatment by the justice system have a preference for personal connection.

The study, published in the International Journal of Drug Policy, found that patients who referred themselves for treatment were more likely to embrace digital therapy. The findings could help inform corrections agencies, some of whom have turned to digital therapeutics as a way to expand access to SUD therapy.

The COVID-19 pandemic led to more widespread adoption of telehealth and digital health technology, but the pandemic also led to increases in social isolation, which is a risk factor for risky behavior, noted corresponding author Judith A. Wilde, Ph.D., of George Mason University. That social isolation included the suspension of in-person support groups and group therapy sessions, they added.

The situation raises the question whether telehealth services could be adequate for those with a history of SUD. The question is particularly pressing for people who were referred to treatment by the criminal justice system because they are already more likely to face a lack of social support, financial difficulties and inadequate housing. They are also more likely to have more severe SUD symptoms and to resist treatment when referred to outpatient treatment, the authors said.

In the new study, the authors used the Connections App, a digital therapy that has been shown to reduce heavy substance-use days and promote prosocial behavior. The investigators wanted to see whether people with SUD would use and benefit from the app, which offered cognitive behavioral therapy (CBT), weekly Brief Addiction Monitor (BAM) assessments, daily check-ins, and sobriety tracking. The participants were also given access to a social worker and peer support specialists.

The investigators created two cohorts of patients: one group that responded to an invitation from the Addiction Policy Forum (referred to as the “self-referred” cohort), and one group of patients referred by an agency associated with the criminal justice system.

Nearly 2,000 people were offered the app, 40% downloaded it, but just 350 people ended up using the it. Two-thirds of the app-users were from the criminal justice-referred cohort.

The investigators found that users of the app generally fit into one of three usage patterns. Some patients only used the CBT aspects of the app, some only used the recovery support services offered in the app, and some used both.

When investigators compared the criminal justice-referred group to the self-referred group, the authors found people referred by the criminal justice system preferred to use the app to access telehealth recovery support services with a social worker, while people in the self-referred groups used both the CBT and support services in roughly equal amounts.

Both groups saw improved BAM scores over time, although the criminal justice-referred patients had greater improvement.

Wilde and colleagues said their study, which took place over nine months, shows that telehealth can sustain participants’ interest and engagement over a long period of time. It also showed, however, that people referred by the legal system had a “keen interest in personal contact” from support services personnel.

The fact that self-referred patients were more ready to engage with the CBT aspects of the app suggests that they have a high level of internal motivation, the authors said, but they added that it could also be that criminal justice-referred patients were more wary of digital products due to privacy concerns.

“While there is no evidence that the app is problematic with regard to privacy, research has indicated that this still can be a fear among justice-involved individuals,” they wrote.

In the study, participants were told that the information collected by the app would not be shared with justice-related agencies.

The authors also said usability may have been a factor in usage patterns. They said newer digital therapeutics might have better results if they were designed with simpler interfaces. They said it might also be possible to improve engagement if incentives were tied to use of the app.