Reducing Relapse in Patients Through Smartphone Technology Dr. Anthony DeFulio, associate professor of psychology, was two months into a study in partnership with DynamiCare Health in early 2020 when the pandemic hit. The study, funded by a $222,383 grant from the NIH’s Helping to End Addiction Long-term (HEAL) Initiative, was intended to facilitate DeFulio’s collaboration with local hospitals to recruit recent overdose patients to enroll in treatment and to participate in his research. Recruitment for the study started in February of 2020, and went well for the first month. “Recruiting in emergency departments became a functional impossibility for the duration of 2020,” DeFulio said. “We even tried bringing on additional hospitals,” expanding beyond Kalamazoo to St. Joseph and Grand Rapids. That didn’t work. “After a lot of effort of trying to complete the study as originally planned, we realized that if we wanted to produce something meaningful out of this project, we were going to have to shift our focus.”
Also available to those participating in the contingency management therapy is a team of recovery coaches who are readily accessible to patients via text messaging and video calls. What is perhaps most important to the success of contingency management is the incentive system. For DeFulio’s study, the incentive was money delivered via reloadable gift cards. The monetary incentive does come with restrictions that ensure that patients use the money for daily needs, and not to further fuel drug dependence. Spending can be tracked by clinicians to determine if extra help is needed in recovery.
LONG-TERM OUTCOMES The study conducted by DeFulio’s team was shortterm, and as such, does not have data on the longterm outcomes of patients who participated. Relapse is an ongoing challenge for many patients, regardless of their specific substance dependence. If a patient stops taking prescribed medication or stops going to counseling, relapse is common.
And so, the research team targeted a population that was more accessible – patients in treatment centers and clinics rather than hospitals. By partnering with a clinic in Kalamazoo and one in Ohio, the team finally had everything in place to test DynamiCare’s technology, designed to disrupt opioid dependence and subsequent relapse in patients.
“There’s growing evidence that the effects of contingency management for a significant proportion of the people who receive it produce really long-term positive outcomes,” said DeFulio. “We’ll really learn the most about long-term outcomes as this becomes more widely available because we’ll have much bigger datasets. Once we have that then we’ll understand the kinds of things that will help us promote those good long-term outcomes.” This will be the focus of research for at least the next ten years.
The project began without precise procedures to promote medication adherence. By the end of the project, DeFulio says that they were able to develop these procedures and complete feasibility testing, which proved that their approach was working.
THE PROCEDURES What are these procedures and how do they work? Patients download a smart phone app which offers a reliable, verifiable measure of their behavior by tracking GPS location data, proving patients are where they’re supposed to be, when they’re supposed to be there. It also allows patients to upload what DeFulio calls “video selfies” as proof that they are taking prescribed medications or completing saliva toxicology testing.
WHAT’S NEXT? “There’s growing evidence that the effects of contingency management for a significant proportion of the people who receive it produce really long-term positive outcomes”
The app implements an intervention called contingency management, which has been studied since the early 90s with ample evidence of its effectiveness in modifying a wide variety of behaviors. Despite its demonstrated efficacy, it hasn’t been widely implemented. The biggest barriers to implementation and dissemination of contingency management therapy to date have been resources, time and space – and outpatient treatment clinics lack all of these. Smartphone technology allows clinicians to implement the intervention right in your pocket at relatively low cost. “There is a bigger need for treatment than there is a capacity for treatment,” said DeFulio. “It’s important for the community to understand and support” the work of Doctoral candidate Hayley Brown and Dr. DeFulio discuss the results of a recent contingency management study. clinics.
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DeFulio is working on a new grant funded study that addresses one of the primary barriers to implementation – the human element. “Even after we sort out the whole problem about logistics with this smartphone intervention, people still have to do stuff … clinicians in particular have to introduce their patients to this intervention, explain it to them, and then assist in monitoring outcomes as the intervention unfolds, and provide additional support.” DeFulio’s team is coupling two independent intervention methods — interdisciplinary teams who develop individualized care plans to meet each patients’ unique needs and incentives shown to be highly effective at achieving specific clinical outcomes — to create a better delivery method for substance abuse treatment, which they’re calling “incentivized collaborative care.”
COMMUNITY IMPACT Given that treatment of drug addiction costs upwards of a trillion dollars annually in the United States, DeFulio’s research has the potential to save millions of dollars each year. More importantly, DeFulio’s work could save countless lives. ◆
