New technologies in the prevention and treatment of substance use problems

There is rapidly growing interest among the public, governments and researchers in the delivery of interventions for substance use problems via novel technologies, such as the Internet and mobile telephony. This interest arises in part from the understanding that such technology can help broaden the base of treatment for substance use problems, increase the provision of stepped care and facilitate strategies that ‘overcome the tyranny of distance’ and other barriers to maximising the reach of intervention. Another motivation is the recognition of the need to develop approaches which engage young people more effectively [1]. The dynamics of interactions via the Internet have been shown to differ in important ways from those operating in the traditional face-to-face paradigm [2], some of which have the potential to improve the quality of service delivery and research. Less is known about the newer wireless technologies, but one would expect there to be important differences in these too. Generally, the purpose of applying new technology is not to replace an existing approach but to supplement, enhance or extend the reach of interventions to improve patient and population health outcomes. The purpose of this special issue is to highlight work from around the world that uses non-traditional tools for research and intervention including the Internet, mobile phones and computer technology. The special issue includes studies from Australia, USA, UK, Canada and Spain on alcohol, smoking, prescription drugs and illicit drugs. The papers cover a broad range of interventions delivered via various new technologies. In addition, there are papers examining the use of ‘old’ communications technology (stand-alone computers, telephone and mail) in novel ways. Studies cover measurement issues, intervention development, outcome evaluation and the application of new approaches to clinical practice. From the perspective of enhancing and facilitating research implementation, Vahabzadeh et al. describe the development of sophisticated e-technologies designed to enhance efficient operations, adherence to protocol and better communications among research staff. Within the environment of a treatment research clinic, the use of this new technology can enhance research outcomes and expand methods for research. This technology might one day be used in treatment services to enhance both treatment implementation and monitoring. In addition to the methodological issues arising in all intervention research, Web-based studies present some unique challenges. Cunningham provides an overview of some of the methodological challenges that have to be addressed in the evaluation of Web-based interventions. Limitations of the existing literature include problems of external validity in trials conducted in laboratory conditions, and conversely, challenges to internal validity in trials based on web browser recruitment, primarily as a result of attrition bias. He concludes with some important questions concerning the population health significance of Web-based interventions. Measurement and assessment are fundamental to research and practice and traditional approaches may or may not be validly transferable across settings and communication modalities. McCambridge and Thomas examine the reliability of the widely used Alcohol Use Disorders Identification Test (AUDIT) screening questionnaire administered online to young adults. They analyse the variance in total scores according to existing short forms of the AUDIT and various new combinations of items. Their findings contrast sharply with those of studies examining short forms of the AUDIT with older populations in traditional settings, ‘. . . call[ing] into question the appropriateness of existing brief screening tools for detecting hazardous drinking among young people’ (p. 18). The widespread use of mobile telephones, especially among young people, creates some fascinating opportunities for the collection of data during or shortly after substance use events of interest to researchers and practitioners. Kauer et al. report on the use of mobile phones in the mobiletype program to improve data collection among younger school attending adolescents. This new technology captures data about alcohol and drug use that may not be measured by conventional means and may prove to be an effective tool when adapted to treatment programs in the future. Often absent from the scientific literature, because of space constraints, are descriptions and analyses of how interventions are developed. Hallett et al. describe and reflect on the development of a Web-based alcohol intervention for university students. They focus particularly on the process of development and the design features that improve access, uptake and potentially effectiveness. Young people's substance use is known to be strongly influenced by their perceptions of peer behaviour. LaBrie et al. present a trial of wireless keypads to provide real-time normative drinking feedback to groups of student athletes. The immediacy of this approach could reasonably be expected to make an impression on young heavy drinkers. The authors demonstrate ingenuity with this exciting technology which poses opportunities and challenges not previously encountered. Using a chat room-style technology, Counselling Online offers a new way for information and counselling to be provided to the community. Swan and Tyssen present an evaluation of this approach, making comparisons with traditional face-to-face and telephone counselling services and highlighting differences in the population that accesses this new service indicating a way to reach a potentially new audience. It should be remembered that many Internet users want to access Web-based services in languages other than English. Rodríguez-Martos and Castellano studied the use of a Spanish language Web-based brief intervention instrument—El Alcohol y Tú (Alcohol and You)—for hazardous drinkers. The program is based on sound principles of motivational enhancement, with a standard screening measure and visually appealing, easy to navigate assessment and feedback. Smoking remains by far the leading cause of drug-related mortality internationally, and accordingly, finding methods of encouraging smokers to quit remains a global health priority. Wolfenden et al. describe a series of studies they conducted in a preoperative hospital clinic, examining organisational support, medical staff knowledge and skills, patient attitudes and the efficacy of a computerised intervention. The paper documents an impressively systematic approach to the development of practice relevant knowledge and its continuing application. QuitCoach provides a new option for the moderately dependent smoker to receive support while quitting smoking. Like Counselling Online, Balmford et al. have found that this style of intervention is more likely to attract young women, reaching an important population group that has a comparatively high prevalence of smoking in many developed countries. Mail correspondence as an intervention for substance use disorders remains surprisingly underutilised, given the known preferences of many heavy drinkers to avoid face-to-face contact with services and the difficulties of servicing remote communities in Australia and elsewhere. Kavanagh and Connolly present a randomised controlled trial of mail therapy to augment primary care intervention. It has the potential to provide a low-cost, follow-up intervention in place of referral to a specialist service for some patients. Like Counselling Online, it may reach a non-mainstream population, for example, older people with prescription drug use problems who are less familiar with online technologies, but still able to benefit from remote treatment. The special issue concludes with a cautionary note. The Internet has created numerous opportunities for improving services for people with substance use problems, but Nielsen and Barratt remind us that it creates new risks which have to be managed carefully. They discuss the thought-provoking question of whether online access to prescription drugs (e.g. through online pharmacies) facilitates drug acquisition for non-prescribed use, and discuss the potential for the technology to be used to remedy this new problem. As a community of drug, alcohol and tobacco policy makers, practitioners and researchers, we are presented with unprecedented opportunity for innovation in the development and provision of flexible and effective interventions to the public, and in the acquisition of policy-relevant knowledge. At the dawn of this new era, the papers in this special issue highlight promising avenues for research, potential pitfalls and methodological challenges.