As a researcher and director of Dartmouth's Center for Technology and Behavioral Health (CBTH) in New Hampshire, Dr Lisa A Marsch explores how to use technology to connect evidence-based behavioural treatments with people whose lives may depend on their getting effective help, reports the American Psychological Association.
Marsch, a professor of psychiatry at the Geisel School of Medicine at Dartmouth, works on the front lines of the opioid epidemic raging in this country. She has researched how to stop the deaths, fight the addiction and find alternative ways of treating pain, writes Delia O’Hara.
Now, as director of the Northeast Node of the National Drug Abuse Clinical Trials Network, based at Dartmouth, and a member of the National Advisory Council to the National Institute on Drug Abuse, she is helping shape the national conversation on opioid use.
"If there's any silver lining in what's happening with the opioid crisis, it's that we've launched a national dialogue around addiction," says Marsch. "We're able to talk about it as a health condition that's treatable."
The opioid epidemic landed in Marsch's backyard shortly after she came to Dartmouth in 2011. Overdoses in New Hampshire from fentanyl, a relatively new, potent synthetic opioid, increased by nearly 1,600% in five years, until by 2016, the state had the highest number of fentanyl deaths in the country.
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Digital technology and behavioural therapy
Marsch believes digital technology can be a boon in behavioral therapy overall, including treatment for opioid addiction. She began working with digital interventions more than 20 years ago, well before four-fifths of Americans had smartphones in their pockets, initially to suit teenagers addicted to opioids, including heroin.
Interventions were emerging and testing well, but there were "so many barriers to scaling them up”. One problem even now, she says, is that behavioural interventions that look promising in the lab don't necessarily translate well to real life.
Marsch's team at CBTH created and validated the Therapeutic Education System (TES), which was later rebranded as reSET by Pear Therapeutics, she says. In 2017, reSET became the first FDA-cleared prescription digital therapeutic (PDT) for the treatment of substance abuse, followed in 2018 by reSET-O, designed specifically for opioid addiction. The two apps provide cognitive-behavioural therapy interventions in conjunction with outpatient treatment.
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Self-directed behavioural treatment
TES was designed to see if digital technology could deliver "an entirely interactive, self-directed version of evidence-based behavioural treatments."
Research has shown that, embedded in standard treatment, the technology can "extend clinicians' reach and impact," she says. "Outcomes are much better than with medication alone."
While working with a provider is best, Marsch says, she believes good stand-alone mHealth interventions have value — though not for opioid addiction.
"One in 10 people with a substance abuse problem touches our health care system," Marsch says. “Up to 90% don’t. There are a lot of reasons for that – there is a stigma attached to seeking help; some people have limited access. Digital tools they could use in the privacy of their own homes could have great value."
Opioid treatment is a stark exception to that; with opioids, medication is essential to recovery. Marsch says that people addicted to opioids are by no means trading one crutch for another when they use prescribed drugs as part of their recovery. "Most people relapse who don't take (therapeutic) drugs as part of their treatment, and many of those people die," she says.
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Hot Spot Study
In 2016 and 2017, the Northeast Node oversaw a "rapid epidemiological Hot Spot Study” of the opioid crisis in New Hampshire.
The first phase of the survey, which took a few months in all, was a series of meetings with health experts, law enforcement leaders, community groups and state and local officials attempting to address the crisis.
The second phase got down on the ground to talk with 75 addicts, families, and 36 emergency medical personnel and other first responders in six New Hampshire counties, especially the two counties that border Massachusetts, where the fentanyl was being manufactured.
The Hot Spot Study gave investigators a "snapshot" of the crisis in their own backyard. In New Hampshire's rural culture, many good jobs had disappeared in the preceding decades, depressing the economy, eliminating more wholesome pastimes and turning tight communities into effective drug-distribution networks.
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Treatment in short supply
While Marsch says the situation has improved, at the time, only one other state in the country was spending less on drug treatment than New Hampshire. Drugs to treat addiction were in short supply, and so was Narcan, a drug that reverses overdoses on the spot.
Opioid users were being rushed to emergency rooms with overdoses, sometimes the same person several times a day. In some families, multiple generations were addicted. All the opioid users interviewed for the study reported witnessing overdoses among friends and family members.
Physicians talked about the significant "medical harms" that drug abuse causes, including damage to the heart and other organs, and infection. First responders expressed frustration that they had no way to link the people they were seeing in homes and emergency rooms to programmes that could help them stop abusing drugs.
Marsch says: "We have effective behavioural treatments, we have medications, we have other tools in the toolbox that can be really helpful, but we need to have low-threshold access to these lifesaving resources."
One fairly new model of such a programme is Safe Station, launched in 2016 in Manchester, New Hampshire, which has designated the city's firehouses as places where people can go around the clock to get help and begin the process of stopping opioid use without fear of legal consequences.
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A role for psychologists
Psychologists can play a role, too, Marsch says. They can raise awareness around addiction, and with their own patients who are addicted, therapists can employ evidence-based therapeutic models and tools, help set goals and work toward them, and coach how to disrupt unhealthy patterns. Addicts' family members, especially children, are damaged by disruption and loss, too.
She says: "The risk to our next generation is extraordinary."
Marsch, who grew up in Maryland, got her start in her life's work as an undergraduate at Towson University. She interned at the Johns Hopkins Bayview Medical Center in East Baltimore, working on two clinical trials with opioid use disorder, behavioural treatment, and the use of a technology platform to teach job skills. Not only did she see, and fall in love with, rigorous scientific protocols in that "life-changing experience", but she also came face-to-face with the power and devastation of addiction.
Marsch recalls: "I heard people say, 'I lost my job, my kids, my house,' but they were still unable to stop their substance abuse. It was fascinating, and heartbreaking. I thought, 'What can I do to change this?'"
She's been answering that question ever since.
[link url="https://www.apa.org/members/content/digital-interventions-opioid-addiction"]Lisa A Marsch Develops Digital Interventions for the Treatment of Opioid Addiction[/link]