SMART PHONES AND RECOVERY 1
Utilizing Smartphone Technologies in Recovery Services
Nicole Wisser and Starla Salazar
Substance & Alcohol Abuse
George Warren Brown School of Social Work
Washington University in St. Louis
Introduction to Smart Phones
In today’s globalized world, people are finding innovative and creative ways to benefit from the growing amount of available technology. In the alcohol and substance abuse field, using smart phone technology as an aid in recovery is becoming increasingly popular. A smart phone is a modern and advanced mobile telephone (AT&T, 2014). As of 2013, 61% of the United States population reported owning a smartphone (Stern, 2013). Smartphones have many of the same capabilities as personal computers. For instance, smart phones have access to high speed internet, the ability to download music and the capability to store files (AT&T, 2014). In addition to music and high speed internet, smartphones also have the ability to download useful applications. These applications include things such as GPS navigation systems, games, budgeting tools, calorie counting apps, and photo editing applications (Google Play, 2014).
Although smartphones are seemingly everywhere, not all smart phones are alike. Different types of smartphones run on different operating systems. There are many different types of operating systems (OS) for smartphones. Some of the most popular operating systems include; Apple, Microsoft, Android, and Symbian (Hall & Anderson, 2009). Each operating system has its own unique application store for the buyers to purchase “apps”. For example, Android’s application store is called Google Play Store (Google Play, 2014), iOS refers to their application store as App Store (Apple, 2014). Depending on the smart phone that is purchased it will have a different operating system and its own unique application store (Google Play, 2014). It is important to mention that only smartphones have the ability to download applications. Regular mobile devices do not have the ability to access the previously discussed application stores.
Utilization of Smart Phones in Recovery Services
Currently, there is a lack of people seeking treatment for alcohol and substance related issues. In Canada and the United States, only 1 in 3 and 1 in 14 people with alcohol problems seek treatment (Cunningham, Kypri, & McCambridge, 2011). The most common reasons for this phenomena is due to stigma, embarrassment, desire to handle own problems, and the difficulty in accessing treatment especially in rural areas. For these reasons, emerging technologies have made it more helpful for this population when seeking treatment online rather than face-to-face interactions. In addition, these technologies have the potential to contribute to evidence-based research (Cunningham, Kypri, & McCambridge, 2011).
There is current research on the utilization of smartphone applications in recovery services for drug and alcohol abuse. Due to the boom in technology within the past decades, the internet has made it easier to find resources for those struggling with addiction. Developers have created apps that make it easier for recovery. These applications include a variety of tools to help those recovering from using alcohol and other drugs. One such application is called Alcoholics Anonymous' (AA) Speakers to Go, which has over 500 recordings of AA speakers from the Speakers Collection. Other applications that agencies can utilize in recovery services include; AA Steps Away , which is a directory of meetings in the U.S.A., Canada, and abroad, AA Companion that has a sobriety calculator, daily meditations, and the AA Big Book digital reader. Another application is called iHeal, for this application users wear a wrist sensor to keep track of cravings and triggers through the sympathetic nervous system. Additionally, iPromises is another application that provides users access to sponsors, visual journals, and calendars to keep track of progress and meetings. Finally, Afternoon Affirmation is an app that offers inspirational quotes, photos, and videos every day at 1pm (Peters, 2013).
Agencies and services should be aware that there are recovery applications for many ages. Teenagers who own smartphones can also benefit from recovery and preventative applications. One application, Drinking Mirror, is mainly used for entertainment and educational purposes for teenagers. Drinking Mirror provides a visual outcome of alcohol consumption. This involves the users taking a picture of themselves with their smartphone and then providing the number of alcoholic drinks consumed per day. As a result they will see a display of what they will look like after a decade of drinking (Cornerstone Recovery Center, 2013).
There are other apps that agencies should be aware of for clients to utilize. One application is known as A Day at a Time, which provides access to the digital AA Big Book along with daily meditations, an abstinence tracking system, and other resources. Another application on the market is called My Ongoing Recovery Experience (MORE) "Field Guide to Life", this application is part of a web-based recovery program that guides users in early recovery for a year. Finally, Mindfulness Meditation is an application that helps users set a daily time to meditate and relax (Ianculescu, 2014).
For agencies to utilize these applications they should be aware of what types of operating systems their client’s smartphone uses. Once they are aware of the type of operating system that their clients use they can direct their client to the correct application store. As previously mentioned, different smartphones have different application stores. If a client reports having an android smartphone then their application store will be called Google Play Store and will already be installed on their phone. Once they open the Google Play Store they can search for the application in the search bar. (Google Play, 2014).
In 2012, researchers investigated how many smartphone applications were available for addiction recovery and available on Android’s application store, Google Play Store. Eighty Seven recovery applications were available on Google Play. These applications were reviewed by the researchers for their content and treatment models. It was discovered that many of the applications had common factors. The majority of the applications had an educational piece to them, to inform the user and help increase their knowledge about addiction and addictive substances. In addition to the information piece, the applications typically also involved motivational strategies to increase the user’s motivation to remain free of the addictive substance. The applications also involved inspirational messages and access to social support groups (Savic, Best, Rodda & Lubman, 2013).
In addition to analyzing the content of the applications on Google Play Store, the researchers also reviewed user comments. Savic, Best, Rodda & Lubman (2013) reported that many of the users who commented on the recovery applications had positive remarks. Many of the users stated that their experiences with recovery based applications was informative, inspirational and helpful (Savic, Best, Rodda & Lubman, 2013).
The costs of applications vary. In 2012, when the recovery applications were analyzed on Google Play Store, about one-third of the recovery applications were available for free. The mean cost of a recovery application was $2.31. The most expensive application that was available on Google Play Store for recovery treatment was $10.40 (Savic, Best, Rodda & Lubman, 2013).
Currently, there is a limited amount of research focused on the impacts of smartphones in recovery services. Although there is a lack of research, there is a growing amount of applications becoming available on smartphone application stores. Agencies in the substance abuse field should familiarize themselves with such applications. Many of the applications are free or available at a low cost. It is important to read user comments, ratings, and experiences prior to informing clients of such applications. As a clinician, it would be beneficial to download the application and familiarize oneself with it. As a result, the client can be presented with a general overview of what the different applications have to offer. As more research becomes available, it is likely that an increased amount of applications will be clinically tested in order to better understand their impacts.
Current Research on Recovery Outcomes
Current studies present a limited amount of evidence based research on the outcomes of recovery based smartphone applications. Geospatial technology has made it relevant for scientists to keep track of sobriety and relapse of users on smartphone apps (Stahler, Mennis, & Baron, 2013). Ecological momentary assessment (EMA) along with geospatial data is used in smartphones to keep track of the location of the user and monitor movements, evaluating how the environment can impact the user (Stahler, Mennis, & Baron, 2013). Applications such as the Body Awareness Research Network (BARN) have shown positive impacts on HIV-infected people, disadvantaged persons, asthma control, smoking cessations, and alcoholism (Gustafson et al., 2011).
Through cognitive-behavioral therapy, mindfulness has been helpful to sobriety in becoming aware of one’s distressing thoughts, emotions, and actions that could lead to relapse (Appel & Kim-Appel, 2009). Smartphone technology can improve the outcome of mindfulness in helping the user monitor their sobriety. Other measures such as the Addiction Severity Index (ASI), WHO Quality of Life instrument, Electronic Health Records (EHR), and Treatment Effectiveness Assessment (TEA) have been traditional ways in assessing clients on their recovery (Ling et al., 2014). Smartphones applications can contribute to these assessments by making it easier on the client and the medical professionals to monitor and track recovery. Tested Models of Technology in Addiction Services
Just as there are numerous smart phone operating systems, there are also numerous models of technology in addiction treatment. Not all of the models of technology in addiction treatment yield the same results. The concept of using smart phone technology as a tool in addiction recovery is a relatively new idea; as a result almost all of the applications have not been clinically tested. The University of Wisconsin-Madison has begun to shift the expectations of technology used in recovery. For the past 6 years an application to aid a person in recovery has been designed and developed. The application is referred to as Addiction-Comprehensive Health Enhancement Support System (A-CHESS). This is a cutting edge technology because it is the first of its kind to be clinically tested. This smart phone application uses an array of techniques to reduce a person’s likelihood to drink (Center for Health Enhancement Systems Studies, University of Wisconsin-Madison, 2014).
The application reduces a person’s risk of drinking by implementing relaxation techniques, daily messages of inspiration and support, and helpful reminders and tips. In addition to these techniques, A-CHESS also has a weekly assessment tool to track the progress of the person in recovery. The assessment survey is taken by the participant and as a result their counselor is able to assess their risk of relapse. Finally, A-CHESS also has a GPS tracking system to monitor the location of the recovering person. This is helpful because the person in recovery pre-programs trigger spots for drinking. This could include their favorite bar or club. If the person gets within a certain distance of their trigger spot they will have individualized tools to help them avoid the trigger location. This could include personalized messages or reminders. There is even an option to add a self-made video journal that begins playing if the person is too close to the trigger spot. The video journal is typically the person in recovery reminding themselves why recovery is so important to their wellbeing (Center for Health Enhancement Systems Studies, University of Wisconsin-Madison, 2014).
As previously stated, the reason that A-CHESS is raising the expectations of smartphone technology is because it was the first of its kind to undergo a randomized clinical trial. It is important to mention that A-CHESS has not been released to the general public yet. Agencies have used A-CHESS and persons in recovery have voluntarily agreed to try the application. The clinical trial set out to test drinking levels as well as risky drinking. Risky drinking is considered when women drink more than 3 drinks in a two hour time period and when men drink more than 4 drinks in a 2 hour time period (Gustafson, McTavish, Chih, Atwood, Johnson, Boyle, & Shah 2014).
The clinical study was made up of 349 participants who were all recovering from an alcohol addiction. All participants received rehabilitation treatment. There were two distinct groups in the study; one group received a smart phone after treatment with the application and the other group received no smart phone or application. Throughout the study the researchers gathered data about how many times the participants engaged in drinking and risky drinking. After the study concluded there was a one year follow up. It was reported that those who had access to the A-CHESS app participated in one day of risky drinking that month. The control group who did not have access to the application reported an average of three days of risky drinking that month. Interestingly, over half (52%) of the participants with access to A-CHESS reported that they had completely abstained from alcohol for the past year. In comparison, 40 percent of those without the application reported that they had maintained complete sobriety for the entire year (Gustafson, et al., 2014).
Benefits and Barriers to Recovery
The value of face-to-face interaction is conflicted with technology where there is little personal connection. Nancy Barnett, an associate professor at Brown University Center for Alcohol and Addiction Studies, stated that an app cannot duplicate a face-to-face meeting (Peters, 2014). On the other hand, smartphone apps are seen as helpful in addiction recovery. Supporters of smartphone apps in recovery state that smartphone apps can be used adjunct to treatment or by itself in therapy (Vimont, 2011). Other benefits include cost-effectiveness, reaching new target audiences, creating access to places with limited resources such as prisons and schools, and increasing availability of resources when clinicians are not around (Vimont, 2011).
Although many recovery programs are utilizing smartphone technology as a tool in the aid of addiction there are specific barriers that need to be addressed. The first and most overt barrier is that not everyone who needs treatment owns a smartphone. As previously stated, about 61% of the adult population owns a smartphone (Stern, 2013). The remaining 40% of the population would be unable to benefit from smartphone applications. The reason that a person does not own a smartphone varies. Some individuals may not own a smartphone because of a lack of funds to pay for the phone and maintain the monthly payments.
Another barrier is that smartphone technology can be hard to learn and hard to use for many individuals. Many people who do not own new technology report apprehension because of the difficulty of learning how to use technology (Smith, 2014). In addition, some people may have difficulty reading or barriers, such as blindness, that make reading a screen impossible (SHYPERLINK "http://www.pewinternet.org/2014/04/03/attitudes-impacts-and-barriers-to-adoption/"mith, 2014). Another consideration about the use of smartphones in recovery is confidentiality concerns. When using technology in any health care setting, there is risk of private and confidential information being less secure (Gill, Kamath, & Gill, 2012).
Another limitation to smartphone applications in recovery services is that the majority of applications are specifically tailored to the continuing treatment of alcoholism. Very few applications currently on the market focus on other drug use or other types of addictions such as a gambling addiction (Savic, Best, Rodda & Lubman, 2013).
Overcoming Barriers and Conclusion
Future research should include more clinically tested trials of smartphone applications. Since only one major smartphone application, A-CHESS, has implemented a clinical trial, much is still unknown about the impacts of applications in recovery. When more research is completed in applications for recovery, it may be possible to overcome some of the previously discussed barriers. The barriers include a lack of funds for recovering persons to afford smartphones, a lack of funds for monthly payments, and a lack of knowledge on how to use smartphones. With additional research supporting the positive impacts of smartphone technologies in addiction, it is possible that the area can apply for more funding. With increased funding available for recovery technologies, agencies may be able to provide clients in need with smartphones and smartphone education.
For more information on technology available for addiction recovery and current research, below are list of further readings and online resources:
Center for Health Enhancement Systems Studies Awarded Five-Year NIAAA Grant UW-Madison Press Release. November 2008. Engineering recovery: An expert in organizational change turns his eye to addiction. (PDF) On Wisconsin. Summer 2006.
UW Professor to present at national mental health conference. UW-Madison Press Release. November 2005.Shaw, B. & Isham, A. (2007). Wearing recovery on one's sleeve: Research examines the potential of biomonitoring technology to prevent relapse Addiction Professional. May-June 2007, Posted on 5/1/2007.
Shaw, B. (2006). Exploring the potential of body monitoring technology to prevent addiction relapse. Behavioral Healthcare. Retrieved February 13, 2007, from http://behavioral.net/issues/2006/06/030
Gustafson, D.H., Palesh, T.E., Picard, R.W., Plsek, P.E., Maher, L., Capoccia, V.A. (2005). Automating addiction treatment: enhancing the human experience and creating a fix for the future. Studies in Health Technology and Informatics, 118, 186-206. Retrieved Febuary 13, 2007, from http://www.ncbi.nlm.nih.gov
The following technology-based interventions are free of charge and accessible through the internet (Cunningham, Kypri, & McCambridge, 2011):
Appel, J., & Kim-Appel, D. (2009, October). Mindfulness: Implications for Substance Abuse
and Addiction. International Journal of Mental Health & Addiction, 7(4), 506-512.
Apple (2014). App Store by Apple. Retrieved from
AT&T (2014). What is a smartphone? Retrieved from http://www.att.com/esupport/article.jsp?sid=KB101001&cv=821#fbid=gIDL- qbRy_1
Center for Health Enhancement Systems Studies, University of Wisconsin-Madison (2014). Addiction CHESS project: developing and testing a computer-based alcohol use disorder recovery system. Retrieved from http://chess.wisc.edu/chess/projects/AddictionChess.aspx
Chambers, B. (2011, February 28). Drug court tests recovery app for smartphones. In The
Partnership at Drugfree.org. Retrieved April 21, 2014, from http://www.drugfree.org/join-together/drugs/mass-drug-court-tests
Cornerstone Recovery Center. (2013, September 9). Addiction recovery has gone mobile. In
Cornerstone Recovery Center. Retrieved April 21, 2014, from http://cornerstonerecoverycenter.com/cornerstone-recovery-center/addiction-recovery-has-gone-mobile/.
Cunningham, J. A., Kypri, K., & McCambridge, J. (2011). The use of emerging technologies
in alcohol treatment. Alcohol Research & Health, 33(4), 320-326.
Gill, P. S., Kamath, A., & Gill, T. S. (2012). Distraction: an assessment of smartphone
usage in health care work settings. Risk management and healthcare policy, 5, 105.
Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3437811/
Google Play (2014). Apps. Retrieved from https://play.google.com/store/apps/collection/promotion_2013_playyourheartout? utm_source=HA_Desktop_&utm_medium=SEM&utm_campaign=pyho&pcampa ignid=MKTAD1225PY7.
Gustafson, D. H., Boyle, M. G., Shaw, B. R., Isham, A., & McTavish, F. (2011). An e-health
solution for people with alcohol problems. Alcohol Research & Health, 33(4), 327-337.
Gustafson, D. H., McTavish, F. M., Chih, M. Y., Atwood, A. K., Johnson, R. A., Boyle,
M. G., & Shah, D. (2014). A smartphone application to support recovery from
alcoholism: a randomized clinical trial. JAMA psychiatry. Retrieved from http://archpsyc.jamanetwork.com/article.aspx?articleid=1847578
Gustafson, D. H., Shaw, B. R., Isham, A., Baker, T., Boyle, M. G., & Levy, M. (2011).
Explicating an Evidence-Based, Theoretically Informed, Mobile Technology-Based
System to Improve Outcomes for People in Recovery for Alcohol Dependence. Substance Use & Misuse, 46(1), 96-111.
Hall, S. P. & Anderson, E. (2009). "Operating systems for mobile computing.
Journal of Computing Sciences in Colleges 25.2: 64-71.
Ianculescu, O. (2014). 9 Addiction recovery apps. In Castle Craig Hospital. Retrieved April 21,
2014, from http://www.castlecraig.co.uk/blog/10/2013/9-addiction-recovery-apps
Ling, W., Farabee, D., Liepa, D., & Wu, L. (2012). The Treatment Effectiveness Assessment
(TEA): an efficient, patient-centered instrument for evaluating progress in recovery from addiction. Substance Abuse & Rehabilitation, 3(2), 129-136.
Peters, S. (2013). Addiction recovery: Is there an app for that?. In Technorati. Retrieved
April 21, 2014, from
Peters, S. (2014). Can Recovery Apps Ever Replace Face-To-Face Addiction
Treatment?. In Huffpost Healthy Living. Retrieved April 21, 2014, from http://www.huffingtonpost.com/2014/02/21/recovery-apps-addiction-treatment_n_4831756.html.
Savic, M., Best, D., Rodda, S., & Lubman, D. I. (2013). Exploring the focus and experiences of
Smartphone applications for addiction recovery. Journal of addictive diseases,
Smith, A. (2014). Attitudes, impacts, and barriers to adoption;
Retrieved from http://www.pewinternet.org/2014/04/03/attitudes-impacts-and-
Stahler, G. J., Mennis, J., & Baron, D. A. (2013). Geospatial Technology and the "Exposome":
New Perspectives on Addiction. American Journal Of Public Health, 103(8), 1354-1356. doi:10.2105/AJPH.2013.301306.
Stern, J. (2013). More than half of Americans own smartphones. Retrieved from http://abcnews.go.com/blogs/technology/2013/06/more-than-half-of-americans-own- smartphones/
Vimont, C. (2011). Technology Shows Promise in Substance Use Prevention and
Treatment. In The Partnership at Drugfree.org. Retrieved April 21, 2014, from https://www.drugfree.org/join-together/addiction/technology-shows-promise-in-substance-use-prevention-and-treatment.