Here’s a question you may be surprised to discover on a digital health blog: Have you ever played a Smartphone drinking game? With names like iPuke, Drink-a-thon, and Drunk Potato, they are quite easily found (no endorsements here!). But, try this trick question: Within the universe of Smartphone applications, what is the ratio of drinking games versus evidence-based tools that can actually help those with potential alcohol problems or with addiction recovery?
Alcohol use is a leading risk factor for disease burden worldwide. The results from a 2018 global study on alcohol risk (assessing 195 locations from 1990 to 2016) found alcohol use accounts for nearly 10% of global deaths among the primary working age (15–49 years). The most recent USDDHS data show that of those suffering from or at high-risk of alcohol disorder and need treatment, less than 7% actually receive any treatment.
Given the serious public health need, especially for working adults, apps and technologies may provide affordable, accessible support for those wishing to manage their alcohol consumption or other substance use risks. Recent systematic reviews and meta-analyses suggests that mobile technology with electronic brief self-assessments or self-control of unhealthy alcohol use can reduce these risks. Unfortunately, we see low availability of effective resources. Online app stores advertise many harm-reduction tools. However, and to answer the trick question above, a recent analysis of over 70 apps showed that none of these were evidence-based or associated with long-term use.
This year my team finished a research grant funded by the National Institute of Alcohol Abuse and Alcoholism that applied both an evidence-based and theoretical approach to substance use prevention. We specifically targeted working adults because the majority of current mHealth alcohol interventions focus on young adults. Moreover, substance abuse problems (including Rx misuse) in the working population is a growing concern, especially with increased problems related to the opioid epidemic.
We built an online system (called ‘iLinkWell™’) based on five major criteria that we broadly recommend others adapt for workplace substance abuse prevention:
- Follow guidelines from a previously established evidence-based model; in our case this was Screening, Brief Intervention, and Referral to Treatment (or “SBIRT”)
- Adopt a well-tested or promising theory for health behavior change; we used the Health Action Process Approach
- Incorporate user design elements shown in the mHealth literature to support behavior change; we used self-assessment with feedback, tailored messaging or delivery of content, and email reminders
- Link users to helping professionals (in the workplace, this is often an Employee Assistance Professional or EAP)
- Couch the intervention within a general wellness framework to support de-stigmatization of abuse and help-seeking. We provided access to a previously tested and online and highly interactive resilience program. We also developed a free online wellness/health game (“Daily Habits Game”) that cast alcohol within a broader wellness framework.
We conducted a clinical trial with 156 participants who reported previously drinking alcohol and randomly assigned them to receive iLinkWell™ or to a no-intervention control group. Assessing outcomes at 4-months, we found that, compared to controls, participants who used iLinkWell™ reported feeling less stressed, less misuse of prescription drugs, and greater intentions to reduce alcohol consumption.
Importantly, we also found differences between users who were recruited via their workplace (and known to have an EAP) and those recruited via online social media (via Facebook and Craigslist). Workplace-recruited users were more likely to have visited a mental health professional during the study. These findings are promising; they support the extension of SBIRT into an electronic format for adult workers.
These results (which are pending publication) were reassuring. We learned things that may help future developers of workplace-relevant apps. Of the five recommended criteria above, we highly advocate couching substance abuse within a broader wellness effort. Participants reported gaining insights or otherwise benefitting from using wellness resources, planning health behaviors, and/or playing the health game.
Developers should also consult with workplace employers and relevant stakeholders (those working in wellness, EAP, human resources, benefits) to find diverse ways to internally market resources. Workers should know that tools are available from different access points. Some employees might benefit from accessing general health promotion or resilience tools away from the workplace context. Other employees may benefit from non-stigmatized access to a mental health counselor through an online health tool that the company endorses directly.
We recommend incorporating self-help and resilience resources directly into the application in ways that are anonymized so employees feel comfortable using them without concerns about employer oversight. At the same time, when it comes to seeking professional help, users should know they have options from the employer’s EAP.