Video-enabled cue based intervention for relapse prevention.

A major goal of long-term management of substance use disorders is to empower recovering individuals in resisting drug use when confronted with real-world high-risk situations (cues). Since opportunities to reproduce and learn from real-life situations are limited in treatment settings, the key is to bring those real-world drug use cues to the treatment setting through vicarious learning. Cue-exposure approaches achieve this by presenting these cues while the usual drug-use response is prevented. This provides opportunity to practice how to deal with the cues before being discharged from the treatment setting. Videos are one way to present the cues as well as demonstrate how to deal with them successfully. In this article, we discuss our experiences with the use of videos to model relapse prevention strategies for specific cues, and provide some future directions for the use of video-based interventions for relapse prevention in substance use disorders.

INTRODUCTION

A major concern in the long-term management of substance use disorders is that recovering individuals return to real life, with many high-risk situations that can cause them to relapse.(1) In cue-exposure approaches, the individual is presented with various high-risk situations (cues) while his/her usual drug-using response is prevented. Using technology is one way of delivering cue-based interventions to help individuals practice skills needed to deal successfully with the identified cues. Recent literature documents the use of technology-based interventions for the management of psychoactive drug use use disorders,(234) including cue exposure interventions.(56) These authors have reported use of technology such as mobile, computerised therapies, online resources, virtual reality and 3D animation, and so on. Constraints associated with the use of technology can be the cost, computer skills to navigate through various programmes/modules, etc., Using videos is one method of delivering interventions for substance use disorders using technology, which can help to overcome these constraints to some extent.

THEORETICAL BACKGROUND

Previous authors have highlighted that video-based interventions are less resource-intensive, provide standardised education, are suitable for individuals with low health literacy,(7) can be administered in several forms (e.g. DVD, downloadable media files), can more accurately represent real-world exposures, and therefore are more advantageous over other media.(89) Since opportunities to learn from real-life situations are limited in current treatment settings, the key is to bring those high-risk real-world cues to the treatment setting through vicarious learning, rather than through conventional methods alone (e.g. lectures/discussions). The individual is then instructed how to effectively manage these cues, so that they do not trigger relapse.

CLINICAL APPLICATIONS

Our experience with using videos for teaching management of substance use cues: At the Centre for Addiction Medicine (CAM), NIMHANS, Bengaluru, an intervention based on cue-exposure treatment was developed called the Video-Enabled Cue-Exposure-Based Intervention (VE-CEI).

Brief description of the VE-CEI

§ The VE-CEI comprises of a series of live action videos (in regional language), shot in simulated settings designed to conform to real-life situations as much as possible. The scenes were based on the stories narrated by patients (and family members) about their own life contexts that had caused them to restart drinking despite treatment.

§ The videos involve local theatre artists modelling how the following potential alcohol cues can be effectively managed so that they do not trigger drinking: (1) craving cues (e.g. a bar on the way to work) (2) peer pressure (3) distrust of family and friends (4) stress (5) fatigue (6) boredom (7) anger (8) alcohol lapse. The eighth video portrays how to manage if drinking does occur so that the person does not return to the previous drinking state. Each theme has two video clips: the first clip portrays how a specific cue can trigger drinking. The second clip models strategies to handle that cue, so that drinking does not occur.

Empirical testing of the VE-CEI: The VE-CEI was administered to an inpatient alcohol-dependent sample (n = 43) and compared with Treatment-As-Usual (TAU) (n = 42), at NIMHANS. Over a 6-month follow-up, the VE-CEI group (vs. TAU) reported significantly lesser alcohol consumption quantity and fewer drinking days, and took significantly longer time to lapse/relapse.(10)

Our impressions about using the VE-CEI to augment regular therapy sessions

§ Using the VE-CEI as an educational tool seemed to act as a catalyst in facilitating an effective dialogue with the patients during the sessions, by enabling them to visualise life after discharge in a very real manner. Patients engaged in role plays and active discussions more effectively, making frequent references to the video content and citing examples from their own individual life experiences. It was thus easier for us to understand, and respond more pragmatically to the patients' needs and life circumstances.

§ Overall, using the video mode of teaching seemed to generate more interest among patients, besides making the therapy sessions livelier and realistic. For instance, faulty communication patterns often act as relapse triggers. Peer and other social pressures frequently lie at the heart of many relapse instances. But positive communication techniques, including the ability to assert oneself in social situations, are difficult to demonstrate, and rely heavily on the therapists' (as well as the patients’) skill and mental imagination. The success of role plays would then be a function of this skill and imagination, which may be difficult to achieve each time, particularly within the confines of the treatment setting. We thus believe that using audiovisual aids such as the VE-CEI helps to provide a dynamic learning experience by supporting face-to-face interventions.

Snapshot from the ‘Anger_relapse trigger’ video clip of the VE-CEI

Being counseled by the doctor – scene from the VE-CEI

Conducting a video-supported group session:

The following table with Box 1 provides an example of how a video-supported group session may be conducted. The example is adapted from our own session at CAM using the VE-CEI, addressing the theme “Managing stress to prevent relapse”:

Box 1

Snapshot of an intervention

At this point, the first part of the video can be played, which portrays a stressful event that caused the protagonist (referred to here as Mr. Suresh), to relapse after four months of staying abstinent post-discharge. The group is then asked specific questions about what they have viewed, e.g.:

- Please summarise the situation portrayed in the video which led to Mr. Suresh's relapse?

- What were Mr. Suresh's thoughts and feelings afterwards? What was the final outcome?

(While discussing the above, the group's attention is drawn to significant points in the video such as the protagonist's negative thinking which preceded the drug use, etc.)

The session can then be continued as follows:

Following viewing of the videos, the group can be engaged in behavioural rehearsals (role plays and/or oral/written practice exercises). Such rehearsals can be based on pre-prepared structured formats to help them apply the videos in the context of their own lives and contemplate how to confront real-life triggers after discharge (at CAM, following viewing of the VE-CEI, we used Practice Exercises from a Manual developed earlier by the present team, to facilitate the rehearsals).(11)

SUMMARY AND FUTURE DIRECTIONS

Our findings about the effectiveness of the VE-CEI suggest that cue-exposure-based intervention delivered using video technology improved post discharge outcomes for alcohol-dependent individuals. Some future considerations for use of such video-based interventions can be:

§ Developing videos which address cues relevant for specific psychoactive drugs: Although the principles of relapse prevention broadly remain the same for substance use disorders, certain issues may be more relevant for specific substances. For instance, videos to enable cannabis users to quit would need to mention that cannabis can cause psychotic experiences, as well as address issues such as people's low perception of the harms from cannabis use, the general belief that cannabis dependence may not occur, or that cannabis is a harmless source of relaxation. The videos would have to clarify such misperceptions, emphasise the adverse health impact, and then model relapse prevention strategies.

Videos to manage opioid use disorders would need to address craving triggers such as seeing injecting paraphernalia, going to a place where he/she had used opiates before, being in the company of injection drug users. Dangers of contracting blood-borne infections through unsafe injecting practices would have to be addressed as well, as part of motivating users to quit.

§ Developing videos that are inclusive of other drug use cues (e.g. using at parties, use of cocktails, using in the company of female friends).

§ Developing videos addressing vulnerable populations such as women and children (e.g. hazards of using during pregnancy, second-hand smoke effects).

§ Making the videos available in different languages.

§ Making the videos more self-directive so that they can serve as a stand-alone intervention (as opposed to therapist-delivered).

§ Online video-based modules – at least in settings where the clientele is familiar with the use of technology.

In conclusion, despite the challenges involved, careful planning and use of video-based interventions can be an important consideration for future interventions for the long-term management of psychoactive use disorders in the country.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.