Abstract
This pilot proof-of-concept study examined the feasibility and acceptability of a Continuing Care mobile application (app) designed to meet the recovery and personal support needs of individuals under justice supervision who were receiving outpatient substance use disorder (SUD) treatment. The study included adults on probation or parole who were enrolled in an outpatient SUD treatment program (N = 15; 86.7% males). Participants were instructed to utilize the Continuing Care app daily for 4 weeks. At the end of the study, they completed a satisfaction questionnaire. Of the 15 participants enrolled in the study, 12 (80%) completed the Continuing Care app modules and the satisfaction questionnaire, and all of these participants indicated high levels of satisfaction with the app (on a scale of 1–10, Mean = 1.8, SD = 1.2). The Continuing Care app was well-utilized and perceived as valuable by this group of low-income, underserved, and hard-to-reach individuals. Further research is needed to refine app content and evaluate its ability to meaningfully enhance and extend the benefits of SUD treatment.
Keywords
Introduction
Substance use disorders (SUDs) continue to be one of the most serious public health problems in the US (Center for Behavioral Health Statistics and Quality, 2016). Studies have found that SUDs are more prevalent among adults under justice supervision in the community (i.e., probation or parole) than in the general population (Belenko et al., 2013; Bose et al., 2018; Fearn et al., 2016; Moore et al., 2020; Vaughn et al., 2012). Substance use among probationers and parolees is associated with a range of adverse outcomes including increased risk of mental and physical health problems (Clark et al., 2001; Ḳaminer & Bukstein, 2008; The National Center on Addiction and Substance Abuse (CASA) at Columbia University, 2011a, 2011b, & 2011c), increased involvement in criminal activities resulting in rearrest and incarceration (Belenko et al., 2013; Dembo & Sullivan, 2009; Mulvey et al., 2010; CASA at Columbia University, 2011a, 2011b, & 2011c), and increased risk of death (CASA at Columbia University, 2011a, 2011b, & 2011c; Proctor & Herschman, 2014). Often, as a condition of fulfilling their criminal justice supervision (i.e., probation and/or parole) requirements, probationers and parolees must obtain treatment in the community for drug or alcohol dependence (Belenko et al., 2013; Bose et al., 2018; Center for Substance Abuse Treatment, 2005).
Outpatient treatment delivered in community-based settings is the dominant modality for substance use treatment, typically involving weekly psychosocial counseling sessions in an individual and/or group format (Substance Abuse and Mental Health Services Administration, 2012; White, 2008). Unfortunately, premature dropout and low treatment completion rates among probationers and parolees are quite common (Marlowe, 2003; Proctor & Herschman, 2014). Longer retention in treatment is associated with better outcomes, including reductions in substance use, mental health problems, and societal costs (i.e., lost productivity, theft and violence, premature death) (Acevedo et al., 2012; Hatzenbuehler et al., 2008; Substance Abuse and Mental Health Services Administration, 2014; White, 2008).
Probationers and Parolees and SUDs
There were 4.4 million individuals under community supervision in the US in 2017 − 2018 (Kaeble et al., 2020). Studies have consistently documented a substantially higher prevalence of SUDs among adults on probation or parole as compared to the general population (Belenko et al., 2013; Fearn et al., 2016; Vaughn et al., 2012). A study that examined data collected between 2002 and 2014 from the National Survey on Drug Use and Health found that SUD rates among probationers and parolees were between four and nine times higher than for non-supervised individuals, with this disparity persistent over time (Fearn et al., 2016).
the Needs of Individuals Under Community Supervision
Individuals under community supervision often deal with multiple stressors, including the stigma associated with being incarcerated, the need for housing and employment, family reunification issues, probation/parole requirements, and numerous opportunities to engage in drug use and illicit activities, which increase the likelihood of relapse, rearrest, and incarceration (Center for Substance Abuse Treatment, 2005; Chandler et al., 2009). SUD treatment services for individuals under community supervision should include substance use education, assistance in changing attitudes and beliefs that support a lifestyle involving illicit behavior, guidance in adopting new skills for avoiding drug use and criminal activities, learning and improving relapse prevention skills, peer support, journal writing, and community resource information (Belenko et al., 2013; Center for Substance Abuse Treatment, 2005; Chandler et al., 2009; National Institute on Drug Abuse, 2014). Few treatment providers are able to offer this array of programming and resources (Taxman et al., 2007), which leaves individuals under community supervision with significant gaps in care.
Traditional Continuing Care Initiatives
Continuing care initiatives for individuals with SUDs have gained increased attention with the recognition that substance use treatment requires long-term care (Brown et al., 2004; Dennis & Scott, 2007; McKay, 2005, 2009, 2020; Scott et al., 2005; White, 2008). In the field of addiction, continuing care typically refers to the provision of any form of treatment services following an initial stage of treatment (McKay, 2009). In general, SUD treatment can be viewed as a “stepped-care” approach in which treatment starts out very intensive, but then gradually steps down in the intensity of care (e.g., medically managed residential treatment; intensive outpatient treatment, which may include partial hospitalization; standard outpatient treatment; community-based self-help groups) (Proctor & Herschman, 2014). Continuing care is predicated on the need to supplement primary (i.e., residential, outpatient) treatment with ongoing efforts to maintain treatment gains, and may be provided through a broad range of formats and modalities (Garner et al., 2008; McKay & Hiller-Sturmhöfel, 2011; Proctor & Herschman, 2014). Research-based continuing care interventions have been found to extend treatment gains regarding reductions in substance use, relapse, and illicit activity (Brown et al., 2004; Carroll et al., 2008; Godley et al., 2007; McAuliffe, 1990; McKay & Hiller-Sturmhöfel, 2011; McKay et al., 2005; McKay et al., 2004; White, 2008). Continuing care strategies that are effective and efficient hold great potential for interrupting the relapse cycle and facilitating longer-term recovery.
Technology-Based Interventions
Continuing care interventions that leverage the capabilities of technology have been shown to be effective in studies of healthcare regarding patient monitoring (Cho et al., 2009; Holtz & Whitten, 2009; McKellar et al., 2012), treatment initiation (Lerch et al., 2017), treatment adherence (Harris et al., 2012; Kornman et al., 2010; Proctor & Herschman, 2014; Woolford et al., 2010), reducing alcohol use (Gustafson et al., 2014), and the provision of information and education (Gold et al., 2011; Tofighi et al., 2018; Wangberg et al., 2008; Wright et al., 2011). Even though advances have been made in recent decades regarding the use of technology-based interventions (TBIs) to address substance use, the availability of TBIs for SUDs is limited (Sugarman et al., 2017). As such, TBIs that address SUDs, particularly in community-based settings with disadvantaged and disenfranchised populations, are still needed (Sugarman et al., 2017; Tofighi et al., 2018).
the Present Study
The current study is a pilot proof-of-concept examining the feasibility and acceptability of a Continuing Care mobile app designed to meet the recovery and personal support needs of individuals under community supervision with SUDs who were receiving treatment in a community-based outpatient clinic. The study was approved by the Institutional Review Board (IRB) of Friends Research Institute (FRI).
Method
Setting
The study was conducted at a community-based clinic that provides outpatient and intensive outpatient behavioral treatment for adults with SUDs. The clinic operates in ten locations, has been in operation for over 50 years, and is located in a large metropolitan city in which there are high rates of SUDs and illicit activity. The clinic also provides comprehensive healthcare services to adults and children, including pediatric and adult primary care, pediatric and adult preventive services, obstetrics and gynecology, dental services, and mental health treatment. In 2019, the clinic served the needs of 34,199 patients, with approximately 65% being adults between 18 − 64 years of age and 29% were children who were less than 18 years of age. Over 98% of patients were at or below 200% of the poverty line, over 67% received Medicaid, and 90% were African American (Health Resources & Services Administration, 2019).
the Continuing Care App
The Continuing Care app is a mobile-friendly software program designed to meet the recovery and personal support needs of probationers and parolees with SUDs who are at elevated risk of relapse, rearrest, and incarceration. The app content is based on the Your Own Reintegration System (YOURS) program (Rudes et al., 2016), developed under funding from the Bureau of Justice Assistance, an empirically-supported intervention (Taxman & Caudy, 2015) that focuses on substance use recovery, reducing criminal thinking and behavior, and managing and building support systems.
Based on the YOURS program materials and research findings regarding probationer and parolee needs, the Continuing Care app is organized into 4 didactic and interactive modules with topic areas focused on: 1) recovery management, 2) cravings, 3) stress reduction, and 4) positive support. Each module offers specialized content designed to assist probationers and parolees in exercising vigilance against relapse and the avoidance of risky behaviors through a) assistance in improving problem-solving skills, including problem-solving regarding drug use and illicit activity and meeting community supervision requirements [e.g., regularly attending probation/parole meetings, providing urine drug screens, and attending substance abuse treatment], b) assistance in the adoption of risk-avoidance strategies, c) assistance in developing techniques to avoid and cope with cravings, d) assistance in learning and enacting refusal skills [i.e., refusing substance use and refusing involvement in criminal activities, avoiding negative peers and environments], and e) providing publicly available counselor and peer support videos from SAMHSA that provide encouragement and support for positive behavioral change.
The app also includes the following personalized tools and additional supportive content: 1) tools for assessing and monitoring drug use and involvement in risky behaviors, 2) daily guidance and motivational/inspirational messages to support recovery, 3) community resources and crisis support information, and 4) SMART (Specific, Measurable, Achievable, Relevant, and Time-bound) goals. In addition, the app homepage has a tracker that, at a glance, indicates how long a client has not relapsed based on user information and provides optional positive support messages.
The app is username and password protected to keep a user's privacy secure. User data are not stored locally on a smartphone, but are encrypted and directly transferred via the web to a secure, password-protected server that was only accessible to research staff. During initial study orientation, participants were given a brief tutorial by research staff regarding the app's features and capabilities. Participants were also provided contact information for technical support.
Theoretical Framework
The Continuing Care app is guided by the principles of the Transtheoretical Model of Behavior Change (Prochaska & DiClemente, 1983, 1986; Prochaska et al., 1993; Prochaska et al., 2013; Prochaska & Velicer, 1997; Velicer et al., 1998), also known as the Stages of Change (SOC) Model, which outlines a series of stages that occur over time regarding modifying health risk behaviors. The stages of change are: 1) Pre-Contemplation, 2) Contemplation, 3) Preparation, 4) Action, 5) Maintenance, and 6) Termination. Pre-contemplation is the stage in which individuals do not plan to take action in the near future (i.e., the next 6 months). Contemplation is the stage in which individuals do plan to take action within the next 6 months. Preparation is the stage in which individuals plan to take action within the next month. Action is the stage in which individuals have made changes to their behaviors within the past 6 months. Maintenance is the stage in which individuals have sustained behavior change for more than 6 months and are working to prevent relapse. Termination is the stage in which individuals no longer desire to engage in past unhealthy behaviors. According to the SOC Model, most individuals stay in the maintenance stage or cycle back through the other stages (Boston University, 2019). For the current pilot study, we developed appropriate content primarily for the maintenance stage. However, we also recognized that substance use may involve a chronic cycle of relapse and recovery (Dennis & Scott 2007), may not be confined to a specific stage, and that people may not always make coherent and stable plans, or engage in conscious decision-making (West, 2005). As such individuals may experience shifts in their behavior based on a number of factors including rewards and punishments and other social factors (West, 2005). Thus, the app was also designed to respond to the transitory and ephemeral nature of human motivation by providing appropriate content and motivational messaging regardless of the stage of change that an individual was in at the time.
Study Eligibility Criteria
The study recruited individuals from the participating SUD treatment clinic, with the following eligibility criteria: 1) age 18 or older, 2) currently on community supervision, 3) currently scheduled to complete the outpatient substance use treatment program (scheduled for program “graduation”), and 4) willing to receive continuing care services through a mobile app. The exclusion criteria were: 1) severe psychiatric problems (e.g., untreated psychosis, untreated bipolar disorder) or suicidality within the past 6-months, as determined by clinical staff, which could make participation in a novel treatment hazardous.
Participants
Clients who met study eligibility criteria and provided written informed consent to participate were included in the study. Between September and November of 2017, 23 clients showed initial interest in the study and were pre-screened at the substance use treatment program's primary location. During the pre-screening process, it was determined that 8 clients were deemed not eligible for study participation because they failed to meet one or more of the eligibility criteria outlined above and were not consented. The remaining 15 participants were included in the pilot study sample and they were provided a smartphone (although many participants already had smartphones, providing a smartphone allowed us to “hold constant” the hardware and operating system, which was critical for the early development, field testing, and troubleshooting of the app during this proof-of-concept phase). Participants were instructed to utilize the Continuing Care app daily for 4 weeks and provide feedback regarding app satisfaction at the end of the study.
Study participants completed a brief self-report questionnaire at study initiation (focusing on background characteristics, treatment history, and app expectations) administered by a research assistant and after the 4-week feasibility trial (focusing on their experiences with the app and suggestions for improvement). They were paid $30 for completing each assessment for a total of $60 for their time.
Results
Participant Characteristics
Client participants were primarily male 13/15 (86.7%), 100% were African American, with a mean age of 49.3 years (SD = 8.3), and 80% had at least a high school education. Participants self-reported lifetime using cocaine (20%), heroin (60%), and marijuana (13.3%). All participants were under criminal justice supervision (i.e., 46.7% were on probation, 46.7% were on parole, and 6.6% were on both probation and parole). See Table 1 below for additional information.
Participant Characteristics.
Ten participants reported no substance use during the past 30 days.
Client Adherence and Satisfaction
Of the 15 participants enrolled in the study, 12 (80%) completed the Continuing Care app modules and the post-satisfaction questionnaire, and all of them indicated high levels of satisfaction and engagement. Overall, participants were highly satisfied with the app and endorsed the following: 1) 11/12 (91.7%) logged into the app daily; 2) 11/12 (91.7%) used the modules, the personalized tools, and the supportive content, and 1 participant only used the personalized tools; 3) 12/12 (100%) would recommend that the participating healthcare organization use the app during treatment periods or after treatment has ended, and 4) 12/12 (100%) would continue to use the app during treatment periods or after treatment has ended.
Feasibility and Usability
Figure 1 shows the mean responses to the feasibility questionnaire. The highest mean agreement was found regarding the statements “Using the app increased my participation in recovery support activities,” “Using the app increased my confidence in staying abstinent,” and “Overall, I liked receiving continued care support through the app.” In addition, participants indicated the app was relatively easy to use and navigate. Participants also had high mean agreement regarding the following statements, “It was easy to navigate the different features in the app,” “It was easy to go through the different modules,” “The daily reminders were helpful in encouraging me to use the app” and “Overall, I liked the user interface (i.e., look and feel) of the app.”
Client responses to the feasibility questionnaire (n = 12)*.
Participants endorsed app utility with respect to decreasing cravings, decreasing alcohol and drug use, decreasing involvement in high-risk situations, and increasing participation in recovery support activities. Finally, there was high mean agreement among participants regarding their overall satisfaction with using the app (see Figure 1).
Suggestions for Future Enhancements
Based on the information obtained from the post-satisfaction questionnaire, participants also offered suggestions for improving the app, including a) additional content regarding triggers, cravings, and improving coping skills, b) additional support videos focused on recovery management, c) additional information about other illicit substances (e.g., cocaine/crack and methamphetamines), d) personalized weekly feedback reports and a journaling tool, and e) gamification features.
Discussion
Overall, our findings demonstrated proof-of-concept for the Continuing Care app, with participants reporting a high level of engagement and satisfaction using the app.
Similar to literature findings (Alemi et al., 1996; Alemi et al., 2007; Bischof et al., 2008; Hester & Miller, 2006; Ondersma et al., 2005; Ruggiero et al., 2006; Sugarman et al., 2017; VanDeMark et al., 2010; Watkins & Sprang, 2018), our pilot study results suggest that the app may be a promising approach for providing ongoing recovery support tools to individuals under community supervision who are completing SUD treatment. Typically, these individuals are low-income, underserved, hard-to-reach, and at high risk of relapse. Future research is needed to further refine app content and test its efficacy in extending gains for SUD treatment and improving outcomes. Currently, in order to address this issue, we have enhanced the interactivity and capabilities of the Continuing Care app based on participant suggestions from the post-satisfaction questionnaire and are currently conducting a randomized controlled trial to assess efficacy among clients on probation or parole who are enrolled in outpatient substance use treatment.
Limitations
A cautious interpretation of study findings is recommended in light of study limitations. First, the study consisted of a small convenience sample derived from a SUD treatment program that agreed to use the app in a proof-of-concept feasibility study. Second, we did not include a control group in this feasibility study, and the lack of a comparison group that did not receive the app should be an additional cause for caution in the interpretation of the findings. Finally, our data are limited to individuals who were actively enrolled in treatment and nearing the completion of an outpatient treatment episode; therefore, our findings are limited to a narrow window of time, and we were not able to examine longitudinal outcomes after treatment completion or discharge. Future research should measure long-term outcomes.
Conclusions
Notwithstanding these limitations, this proof-of-concept study indicates that the Continuing Care app can be feasibly delivered to individuals under community supervision in SUD treatment, and was well-received by participants. Mobile apps offer the potential to deliver interventions in ways that are private, secure, easily accessible, continuously available, and comprehensive. This will make it easier to augment or extend treatment for users, increasing the likelihood of treatment utilization, and allowing users to access treatment in the evenings or late at night when treatment facilities are typically closed but when the risk of relapse may be high.
Recent years have seen the development and marketing of several mobile health apps designed to address SUDs (e.g., A-Chess, reSET [https://www.resetforrecovery.com]) (Tofighi et al., 2018). However, the overall availability of technology-based interventions for individuals with SUDs is limited (Sugarman et al., 2017). The Continuing Care app provides a novel mobile application drawing from theory and an established behavioral treatment to address the specific recovery and personal needs of probationers and parolees who are completing SUD treatment. The app's didactic and interactive lessons and tools encourage and support healthy behavioral change. Thus, it holds great promise as a potential novel strategy to interrupt the relapse cycle and facilitate longer-term recovery.
Footnotes
Acknowledgments
The content is solely the responsibility of the authors and does not necessarily represent the official views of NIMHD. The authors wish to thank Dr. Derrick Tabor, our NIMHD Program Official. We would also like to thank the staff at the participating healthcare organization for their assistance with this project. Finally, we wish to thank our project staff for their efforts related to this study and Ms. Jane Gannod for manuscript preparation and assistance regarding journal submission.
Declaration of Conflicting Interests
The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: I am one of the co-owners of the small business to whom the grant was awarded. Two of the authors, Drs. Carswell and Gryczynski, are co-owners of the small business to whom the grant award was made. The other authors, Drs. Gordon and Taxman, and Ms. Ferguson, Maher, and Schadegg do not have any declarations of interest to report. The authors alone are responsible for the content and writing of this paper.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Institute on Minority Health and Health Disparities (grant number 1R41 MD 008848-01A1).
