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Abstract

The wide prevalence of substance use among adolescents has become a rising public health concern, demanding innovative approaches for effective intervention and support. Traditional therapeutic methods, such as individual counseling and group therapy, have demonstrated efficacy in addressing substance use issues. However, their reach and impact often fall short due to various barriers, including limited availability of specialized treatment providers, logistical challenges, and stigma associated with seeking help. The objective of this review was to explore the utility of digital-based therapies in the treatment of substance use disorders in adolescent populations. A review of the literature comparing digital-based psychological interventions for youth with substance use disor- ders compared to traditional therapy modalities was conducted using a set of search terms across established medical databases (EMBASE, PSYCINFO, PUBMED).

Therapies for specific use disorders that were successful and even superior to in-person intervention were identified. It was seen that digital therapies do not replace traditional therapies and treatments. However, with their wide scope, digital therapies can complement existing treatments to promote accountability and the development of recovery focused life skills. It can be concluded that the emergence of digital therapies demonstrates potential in the treatment of substance use. Multiple challenges and barriers exist, including funding, privacy, ownership of the data. However, due to the nature of addictive disorders, digital therapies might be most effective when required and monitored by the treating entities.

Keywords

Substance use adolescents therapies digital-based digital

Introduction

The wide prevalence of substance use problems among adolescents has always been a public health concern, demanding innovative approaches for effective intervention and support. Traditional therapeutic methods, such as individual counseling and group therapy, have demonstrated efficacy in addressing substance use issues.¹ However, their reach and impact often fall short due to various barriers, including limited availability of specialized treatment providers, logistical challenges, and stigma associated with seeking help.²

In recent years, the rapid advancement of digital technologies has opened new possibilities for improving the accessibility and effectiveness of interventions for adolescents with substance use problems. Digital therapy, encompassing a wide range of digital tools and platforms, has emerged as a promising alternative to traditional face-to-face therapy.³ These digital interventions utilize technologies and programs such as social media, smartphone applications, web-based programs, virtual reality, and wearable devices to deliver therapeutic content and support remotely.

With the advancement of medical knowledge, we more clearly understand that addiction is a chronic brain disease with a neurobiological basis. Addictive behaviors are not merely limited to the partaking of psychoactive substances, rather, any pleasurable behavior left unleashed has the potential to become an addiction. Until the completion of brain maturation, the developing brain is vulnerable to potentially lifelong effects when exposed to addictive behaviors, with potential for developmental stunting.³⁷ Adolescence is a vulnerable period of neurodevelopment when brains are susceptible to promoting addictive behaviors, including risky and experimental behaviors, including exposure to psychoactive substances, while increasing risk for trapping the individual within the addictive cycle, leading to acquisition of a substance use disorder and stunting of normal neurodevelopment.³⁸

According to the National Survey on Drug Use and Health, 95% of individuals with a substance use disorder did not feel they needed treatment. Understanding one’s need for treatment is limited by the individual’s defense mechanisms, compounding psychosocial factors, and sequelae, in context of societal stigma and limited access to evidence-based treatments. However, if left untreated, addictive behaviors can precipitate and complicate medical and psychiatric conditions, with widespread effects, starting with the individual, and extending to the family and the community at large.

When treating adolescents, multiple types of interventions are necessary, including family, school, and community-based preventive interventions. Many of the traditionally administered evidence-based therapies like Cognitive behavioral therapy (CBT), Motivational interviewing (MI), and contingency management have been utilized in the development of digital therapies. To date, there has been no review of the literature comparing digital-based psychological interventions for youth with substance use disorders to traditional therapy modalities.

Methods

We review overall studies around therapeutic interventions for youths with substance use disorders, focusing mostly on digital interventions, including mobile applications and social media and text-based interventions, with their challenges and potential for future directions. We conducted a literature search across relevant medical databases such as PubMed, Embase, and PsycINFO. The search was standardized by combining select key terms for therapeutic interventions such as “digital interventions,” “mobile applications,” “social media,” with “substance use disorders.” Filters were used to screen for ages of the subjects included in research articles. While the adolescent age group (12–18) was preferred, we did include transitional age (18–24) for this paper.

Mobile Applications

Adolescents in general have a much more robust experience with mobile applications than the generations before them. Mobile applications have become a more intuitive and accessible method of communication and obtaining information. Because of this, mobile applications provide an ideal platform for interventions in this population due to being convenient, user-friendly, and cost-effective.^4,5

While in person interventions are the gold-standard, access to these treatments is limited by affordability, scarcity of trained staff, availability of services, and physical access to treatment.⁶ One of the most beneficial aspects of smartphone technology is the ability to provide immediate, “just-in-time alerts” to prevent patients from using substances.⁷ These alerts can be employed in a variety of situations, such as parties, when adolescents are at the highest risk of substance use.⁸ By being ever present, these apps could potentially use environmental cues to trigger interactions or notifications from the app. A lot of substance use in adolescents comes from peer pressure and instantaneous decisions, things that the traditional method of substance use treatment cannot easily address. One study showed that 40% of people with hazardous drinking use and 34% of people with nonhazardous drinking would be interested in a mobile application to manage their drinking.⁹ It can be assumed that the notifications when they are feeling especially pressured to drink are a large reason for this interest.

While using smartphone applications to address substance use has many benefits, one of the potential pitfalls of using a mobile application is the concern of security. For the app to be effective, it must be able to collect data from its user to act on it. There is increasing mistrust with releasing private data to some unknown service, and this can be a drawback compared to having a one-on-one or closed group approach to substance abuse treatment. However, one study showed that 92% of participants felt comfortable providing sensitive information to the app⁷. It seems like users are more trusting of the apps if the apps are transparent about where and how their data will be sent to and used, respectively. A lot of mobile apps are diligent about encrypting their data and abiding by Health Insurance Portability and Accountability Act (HIPAA) guidelines to protect patients’ privacy. As a result, mobile apps can provide an ideal platform for patients who want to remain anonymous or cannot attend treatments in person.¹⁰ The ability to receive treatment from anywhere in the world is one of the biggest values that mobile apps bring. Patients may not be able to physically attend treatment for any number of reasons, such as distance, lack of access to transportation, physical limitations, etc. Through the app, they are still able to benefit from the treatment remotely. As mentioned previously, even if users could attend physical treatment, they may benefit by having access to treatment at any time of day—something that is impossible with traditional treatment.

Another area of improvement for mobile apps is maintaining engagement. One study showed that at 3 months follow-up, only 37% of participants continued to use the substance abuse treatment app. They stated that forgetting to use the app, rather than disliking the app, was the primary reason for nonuse. The long-term app engagement could be increased through reminders or alerts that encourage daily habit formation.¹¹ In this way, users would start to make the app part of their daily routine instead of something that they have to remember to do. This way, it would be easier to employ when needed because it remains at the front of their mind instead of something that they must search for. One study reports that as far as smoking cessation is concerned, decision-based apps are more beneficial than static information dissemination apps.¹² This means that apps that require users to interact with it and change based on the input by the user are more likely to have increased rates of follow-up compared to apps that provided passive information about quitting strategies. One study showed increased anti-tobacco industry behavior at 3 months, with a dose response based on the level achieved in an anti-tobacco themed mobile game.¹³

A new frontier of mobile engagement in smoking cessation is the use of augmented reality. Augmented reality is the ability to virtually add or experience things into the natural environment through apps. Augmented reality can facilitate cue exposure therapy, so that patients can experience the benefits from their own home, receiving the cues from mobile screens or virtual reality headsets, improving accessibility if they cannot attend in person due to physical or temporal restraints.¹⁴ Studies showed that the augmented reality demonstrated elicited substantial cue reactivity and extinction in a laboratory setting, with 56.5% of patients reporting reduction in smoking.¹⁵ More research is contributing to augmented reality every day, and in the future, there may be completely virtual sessions that mimic reality.

Any mobile app should focus on combating relapse and attrition.¹⁵ As with any sort of addiction treatment, relapse is a major factor that can impact the recovery of anyone. Mobile apps are useful because they can seamlessly “follow up” with users even years down the road unless deleted by the user. One way to combat this is by making sure that the reward system used by the mobile app is familiar and is something the users can engage with on a day-to-day basis. This is particularly vital for increasing engagement and retention in adolescents, who have information overload and can forget about treatment extremely quickly.¹⁶ One example of this is in a research study where WhatsApp, the communication platform, was used in conjunction with hospital cessation therapy, leading to increased follow-up and continuity of medication at the 1st and 3rd months compared to hospital cessation therapy alone. WhatsApp is used by a significant proportion of the world as their primary communication app, and by integrating this with hospital cessation therapy, the users were able to receive input in a way that did not cause them to change their behavior.^12,17

Social Media and Text-based Interventions

Social media has proven to be a major form of communication and serves as a source of connection among many adolescents. As such, interventions utilizing the ubiquitous nature of social media, especially in this age group, can allow for easy-access, large-scale, wide-network campaigns designed for key psychoeducation regarding a variety of topics.^18,19 Online interventions also provide opportunities to extend to subpopulations and include marginalized and geographically isolated individuals.²⁰ Hence, both web-based applications, social media, text messaging, and other web-based interventions are appealing. In addition to the accessibility component, web-based and mobile interventions are generally perceived as “more private and less-stigmatized than traditional clinical evaluations.” Individuals also have value in utilizing digital tools, citing them to be “user-friendly and appropriate.” This allows for enhanced motivation from participants and can help facilitate self-efficacy, relapse prevention, and social support.^21-23 In one study, with individuals placed in private, unsearchable Facebook messenger groups led by a trained professional with the use of motivational interviewing and relevant psychoeducational content, adolescents, and young adults were found to have a reduction in several-drug related outcomes.^18,24

Social media can also provide an alternative to the mainstay of large-scale, mass media educative campaigns. Mass media for example utilizes the distribution of material through radio and television ads, traditionally unidirectional manner. A study of a nationwide marketing campaign utilizing radio and TV ads demonstrated mixed findings with limited influence on rates of growth in drug use behaviors,²⁵ whereas social media sites allow for a 2-way interchange to allow users to actively engage and share personalized content.^20,26 Adolescents may also consider information passed through social media to be reliable, if from credible, reputable sources. One of the downfalls and perhaps most significant challenges to this benefit is that many teens have difficulty spreading messages of drug prevention campaigns because of peer reprisal.²⁷

Family interventions have been shown to be valuable in adolescent drug use prevention and intervention. Social media provides a method to capitalize on the accessibility of social media sites and enhance the recruitment of parents for education and potential interventions for their children. One study utilized Facebook to engage parents in a self-directed family program for the prevention of adolescent drug use through evidence-based educational programs. While the utilization of Facebook for this intervention proved to be more effective and efficient in the recruitment of parents compared to standard models of recruitment, the final sample in the study proved to be demographically homogeneous parents and further studies need to be done to reach diverse samples.²⁸

SMS text messages, while separate from social media, have also been found to be a useful tool when considering adolescent substance use. They have shown positive results for both physical and mental health issues—serving as tools to remind individuals to improve medication adherence and maintain health care appointments and provide information on various mental health issues from bipolar and psychotic disorders to depression and anxiety. SMS messages have proven to be useful in reducing the likelihood of binge drinking in young adults.^19,21 However, in adolescents, applications appeared to be more effective from an intervention in reducing tobacco use in adolescents.²⁹ SMS can serve as useful forms of relaying psychoeducation in a private method.

Certain online interventions that recruited patients through social media have proven to be effective in both relaying information and providing effective interventions in adolescents. One online intervention, aimed at adolescent girls, proved to be effective in reducing binge drinking, and cigarette smoking and improved their skills in drug refusal, coping skills, and media literacy.²⁷ Online interventions allow widespread use and can be applied in the school setting to target and reduce drug use and even cooccurring mood and anxiety disorders in this population.^21,30–32

As mentioned, one of the biggest challenges in the prevalence of drug and alcohol use displayed on social media and adolescent’s concern for peer reprisal and social isolation going against the grain. One study is utilizing social media as a form of communication for certain interventions, such as in the form of Facebook groups utilizing motivational interviewing along with weekly themes for psychoeducation have shown improvement in reduction in drug-related outcomes—including reduction in cannabis consumption, reduction in vaping days, and reduction in cannabis-impair driving.^18,24

Overall, there is some evidence that social media, SMS text messaging, and other online applications can be utilized as either primary interventions or adjunctive methods to traditional methods.

Challenges

In adolescent populations, unique challenges exist considering their cognitive, emotional, and social development, marked by risk taking and reward seeking, lack of future orientation, peer orientation, and limited trust in authority figures. The incomplete development of prosocial behaviors during childhood, coupled with substance use during adolescence places the teen at risk for delinquent behaviors.⁴⁰ Digital therapies do not replace previous medication and therapeutic recommendations, rather, they work together to complement existing treatments. The use of digital treatments can provide accountability and healthy decision making in real time, with individualized rewards, increasing frequency of contact with the patient. Utilizing contingency management within the digital therapy could increase the likelihood for treatment adherence and thus move the individual toward a recovery lifestyle. In addition to these developmental challenges, potential areas of concern may arise for individuals who are considering the use of digital therapies, including privacy concerns, security, and ownership of the data.⁴¹ Great caution and protective measures should be in place to guard everyone’s private data and to prevent the individual from being targeted later. Adaptability and fluidity of the software to identify and target the specific needs of anyone utilizing the software. Individuals who demonstrate technological addictions may benefit from taking breaks from use of the app. Similar to in-person treatment modalities, the individual’s sincere participation, or lack thereof, could further complicate the treatment and monitoring processes.

Conclusion

The wide scope and availability of digital tools and therapies that integrate evidence-based modalities demonstrate potential in the treatment of substance use.³⁹ Most individuals demonstrating addictive behaviors do not see a need for treatment and those who recognize they have a problem either do not seek treatment or believe they can figure it out on their own. Only a small minority have access to the indicated level of care for their condition.

Individuals with internal motivation toward recovery can benefit from regular use of the app due to the multiple layers of protection it can afford in real time. Therapy modalities can be individualized to the individual’s imminent needs and increase awareness of the process of addiction and can aid in the development of skills that promote delaying gratification. Regular monitoring and psychoeducation can be provided, along with tangible rewards for continued use of the app/tool. Contingency management and implementation of regular tangible rewards can be received in real time for participating in verified recovery-focused activities. Camera-monitored testing, along with an ignition interlock device can limit driving under the influence. When adding friends to the app, there’s a potential to develop a recovery-focused online community who engage in the app.

For externally motivated individuals, registration and active participation in digital therapies could provide psychoeducation, implementing motivational interviewing techniques to gain insight, incentivize recovery-focused decisions, and build confidence and trust. Some benefits could include rewards for daily sign-on, with increasing rewards with active cooperation and participation. Honest input from participants could aid in the identification of experimental substance use and provide relevant psychoeducation. Through the app, entities can have immediate access to individuals who have missed appointments or are demonstrating risky behaviors or relapse, along with the use of notifications, SMS messages, and/or phone calls.

Though multiple individual challenges and system-wide barriers exist, digital tools can aid in the treatment of addictive behaviors. As with any treatment modality, great care and appropriate measures must be in place to protect each participant’s privacy and to prevent the individual from being targeted. The tool could be designed with these barriers in mind to cater to the unique needs of the individual and the monitoring entity (families, schools, physicians, court-ordered treatment facilities, juvenile justice system, and/or community centers). Digital therapies show great promise and future directions for their widespread accessibility and use, yet further studies are required to measure the long-term effectiveness of digital modalities.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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Exploring Digital-based Therapies for Adolescents with Substance Use Disorders: A Brief Literature Review