TES is an interactive, web-based program theoretically grounded in the evidence-based Community Reinforcement Approach (CRA) to behavior therapy.
TES is composed of interactive, multimedia modules, including those focused on cognitive behavioral skills training (e.g., effective strategies for refusing drugs, managing thoughts about drug use, functional analysis/self-management planning, etc.). TES also includes modules to prevent HIV, hepatitis, and sexually transmitted infections (STIs). Additional modules teach skills to improve psychosocial functioning (e.g., family/social relations, managing negative moods, etc). TES is a self-directed program that includes a module teaching patients how to use the system and a “customization program” to build an individualized treatment plan for patients.
Link for further information: www.sudtech.org
Note: CTBH Director, Dr. Marsch, is affiliated with the small business that developed and licenses TES. This relationship is managed by her academic institution.
Community Reinforcement Approach (CRA)
Contingency management (CM)
Abstinence from opioids and cocaine
HIV risk behaviors
Young Adults (18-30)
Outpatient addiction treatment program
Computerized behavior therapy for opioid dependent outpatients: A randomized, controlled trial.
Bickel WK, Marsch LA, Buchhalter A, Badger GA. Experimental and Clinical Psychopharmacology. 2008. 16(2):132-143. PMCID:PMC274673.
Summary: In this full-scale randomized, controlled trial (3-arm), participants received standard treatment, therapist-delivered CRA with vouchers, or computer-assisted CRA with vouchers during a 23 week study. the therapist-delivered and computer-assisted CRA plus vouchers interventions produced comparable weeks of continuous opioid and cocaine abstinence and significantly greater weeks of abstinence than the standard intervention, yet participants in the computer-assisted CRA condition had over 80% of their intervention delivered by an interactive computer program.
Take Away: The comparable efficacy obtained with computer-assisted and therapist-delivered therapy may enable more widespread dissemination of the evidence-based CRA plus vouchers intervention in a manner that is cost-effective and ensures treatment fidelity.
Computer-assisted HIV prevention for youth with substance use disorders.
Marsch LA, Grabinski MJ, Bickel WK, Desrosiers A, Guarino H, Muehlbach B, Solhkhah R, Talfique S, Acosta M. Substance Use and Misuse. 2011. 46(1):46-56. PMCID:PMC3091163.
Summary: In this randomized, controlled trial (2-arm), participants received a mean of 3.25 sessions (30 minutes each) of a Treatment Prevention Intervention or Enhanced Prevention Intervention (educator delivered as well as access to web-based program) condition. HIV prevention and HIV risk behavior were measured. Results demonstrated that the web-based intervention, when provided as an adjunct to an educator-delivered prevention intervention, increased accurate prevention knowledge, increased intentions to carefully choose partners, and was perceived as significantly more useful relative to the educator-delivered intervention when provided alone.
Take Away: Results suggest the program may be effective and engaging and may increase the adoption of effective HIV and disease prevention science for youth.
Web-based behavioral treatment for substance use disorders as a partial replacement of standard methadone maintenance treatment
Marsch LA, Guarino H, Acosta M, Aponte-Melendez Y, Cleland C, Grabinski M, Brady R, Edwards JA. Journal of Substance Abuse Treatment. 2014. 46: 43-51. PMCID: PMC3839618.
Summary: This article reports on the 12-month outcomes of a randomized trial of opioid-dependent adults in methadone maintenance treatment (MMT). Eligible participants were randomly assigned to either standard treatment-as-usual (TAU: n=80) or reduced standard treatment + Therapeutic Education System (TES: n=80). Standard TAU entailed weekly 1-hour counseling sessions for the first month and bi-monthly sessions thereafter, delivered by Certified Alcohol and Substance Abuse Counselors. Participants in the TES condition reduced their standard treatment counseling sessions to 30 minutes (each session) and spent the remaining 30 minutes using TES. Participants in both conditions provided urine samples once a week, with intermittent random observations.
At follow-up, participants in the TES condition were abstinent a significantly greater percentage of: overall study weeks compared to those in the TAU condition (48% vs. 37%) and tested weeks compared to those in the TAU condition (59% vs. 43%).Additionally, TES participants had significantly more tested weeks of continuous abstinence from opioids compared to those in the TAU condition (27% vs. 20%). Participants in the TES condition were two times more likely to be abstinent from opioids than those in treatment as usual. Retention rates did not differ significantly across conditions.
Take Away: The addition of web-based support to treatment as usual may increase the odds of abstinence among opioid-dependent clients in MMT. This study demonstrates the effectiveness of TES in the absence of contingency management incentives.
A web-based behavior therapy program influences the association between cognitive functioning and retention and abstinence in clients receiving methadone maintenance treatment. Acosta MC, Marsch LA, Xie H, Guarino H, Aponte-Melendez Y. Journal of Dual Diagnosis. 2012. 8(4): 283-293. doi: 10.1080/15504263.2012.723317
Predictors of outcome from computer-based treatment for substance use disorders: Results from a randomized clinical trial. Kim SJ, Marsch LA, Guarino H, Acosta M, Aponte-Melendez Y. Drug and Alcohol Dependence. 2015. 157: 174-178. doi: 10.1016/j.drugalcdep.2015.09.019
Can persons with a history of multiple addiction treatment episodes benefit from technology delivered behavior therapy? A moderating role of treatment history at baseline. Kim SJ, Marsch LA, Acosta MC, Guarino H, Aponte- Melendez Y. Addictive Behaviors. 2016. 54: 18-23. doi: 10.1016/j.addbeh.2015.11.009
Internet-delivered treatment for substance abuse: A multisite randomized controlled trial.
Campbell ANC, Nunes EV, Matthews AG, Stitzer M, Miele GM, Polsky D, Turrigiano E, Walters S, McClure EA, Kyle TL, Wahle A, van Veldhuisen P, Goldman B, Babcock D, Stabile PQ, Winhusen T, Ghitza UE. American Journal of Psychiatry. 2014. 171(6):683-690. PMID: 24700332.
Summary: Patients attending community-based treatment for drug and alcohol dependence were randomly assigned to either standard outpatient treatment (TAU: n=252), or reduced standard treatment plus the Therapeutic Education System (TES: n=255). All participants attended comparable hours of therapy over 12 weeks. In TAU, participants received a minimum of two in-person therapy sessions weekly. Participants assigned to TES attended a reduced schedule of in-person sessions, but also accessed four TES modules each week. Biweekly drug and alcohol screens were completed during treatment, and at 3- and 6-month follow-up assessments.
At 12 weeks, participants receiving TES were more likely to be abstinent than participants receiving TAU only. The TES group also had lower rates of treatment dropout. The effect of TES on substance use was greater for participants who were not abstinent at baseline. Participants testing positive for alcohol or drugs at baseline had better outcomes when assigned to the TES group, including fewer weeks of use and twice the odds of remaining abstinent. Among abstinent participants, no significant differences were found between treatment conditions. Although the TES group had better outcomes at 12 weeks, substance use did not differ between conditions at either the 3- or 6-month follow-ups.
Take Away: During treatment, the addition of TES to standard care is more effective in promoting abstinence and reducing dropout than standard care alone. Patients who are not abstinent at the start of treatment may benefit most from TES.
Web-based, psychosocial treatment for substance use disorders in community treatment settings. Campbell ANC, Miele GM, Nunes EV, McCrimmon S, Ghitza UE. Psychological Services. 2012. 9(2):212-214. doi: 10.1037/a0025968.
Clinician attitudes, social norms and intentions to use a computer-assisted intervention. Buti AL, Eakins D, Fussell H, Kunkel LE, Kudura A, McCarty D. Journal of Substance Abuse Treatment. 2013. 44(4): 433-437. doi: 10.1016/j.jsat.2012.08.220
Recent internet use and associations with clinical outcomes among patients entering addiction treatment involved in a web-delivered psychosocial intervention study. Tofighi B, Campbell ANC, Pavlicova M, Hu MC, Lee JD, Nunes EV. Journal of Urban Health: Bullitin of the New York Academy of Medicine. 2016. 93(5):871-883. doi: 10.1007/s11524-016-0077-2
Coping strategies as a mediator of internet-delivered psychosocial treatment: Secondary analysis from a NIDA CTN multisite effectiveness trial. Lévesque A, Campbell ANC, Pavlicova M, et al. Addictive Behaviors. 2017. 65: 74-80. doi: 10.1016/j.addbeh.2016.09.012
Clinician involvement with internet-delivered treatment and association to outcomes. [Abstract]. Campbell A, Nunes EV, Pavlicova M. Drug and Alcohol Dependence. 2017. 171: e32. doi: j.drugalcdep.2016.08.101
Racial/ethnic subgroup differences in outcomes and acceptability of an internet-delivered intervention for substance use disorders. Campbell ANC, Montgomery L, Sanchez K, et al. Jounral of Ethnicity in Substance Abuse. 2017. doi: 10.1080/15332640.2017.1300550
Predictors of internet-delivered drug treatment outcomes and acceptability among women. Saraiya T, Campbell A, Hu M-C. Drug and Alcohol Dependence. 2017. 171: e183-e184. doi: 10.1016/j.drugalcdep.2016.08.503
Toward national estimates of treatment effectiveness for substance use. Blanco C, Campbell AN, Wall MM, Olfson M, Wang S, Nunes EV. Journal of Clinical Psychiatry. 2017. 78(1): e64-e70. doi: 10.4088/JCP.15m10333
Gender-based outcomes and acceptability of a computer-based psychosocial intervention for substance use disorders.
Campbell ANC, Nunes EV, Pavlicova M, Hatch-Maillette M, Hu MC, Bailey GL, Sugarman DE, Miele GM, Rieckmann T, Shores-Wilson K, Turrigiano E, Greenfield SF. Journal of Substance Abuse Treatment. 2014. 53: 9-15. PMID: PMC4414709.
Summary: This secondary analysis of data from the Campbell et al (2014) randomized controlled trial investigated whether gender moderated substance use outcomes and acceptability of the Therapeutic Education System (TES). Results showed that gender did not moderate the impact of treatment on abstinence, retention, social adjustment, or cravings. Gender did moderate acceptability of the TES. Women gave TES higher acceptability ratings than men one month into treatment. There was an interaction between gender and acceptability with regard to abstinence outcomes. Women with higher acceptability ratings were more likely to be abstinent during their last four weeks of treatment, whereas acceptability ratings did not impact men’s outcomes.
Take Away: TES is equally beneficial for men and women. Treatment acceptability may be associated with better substance use outcomes for women.
Cigarette smoking during substance use disorder treatment: Secondary outcomes from a National Drug Treatment Clinical Trials Network study.
McClure EA, Campbell ANC, Pavlicova M, et al. Journal of Substance Abuse Treatment. 2015. 53: 39-46. doi: 10.1016/j.jsat.2014.12.007
Summary: Researchers examined how smoking status and nicotine dependence impacted treatment effects. Smoking status and (if smoking) nicotine dependence were assessed at 1, 2, 3, 6, and 9 months. Most participants smoked (n=391) at baseline. By the end of treatment, 19 participants who smoked at baseline were not smoking and 11 participants who did not smoke at baseline reported smoking. The only significant determinant of smoking status at the end of treatment was baseline smoking status; participants who did not smoke at baseline were more likely to not smoke at treatment end. At the end of treatment, participants who did not smoke at baseline were more likely to report abstinence from drugs and alcohol in the TES group than in the control group, but there was no such interaction for participants who smoked at baseline.
Take Away: TES may more effective for users who do not smoke than for users who smoke at promoting abstinence from drugs and alcohol.
Web-based treatment for substance use disorders: Differential effects by primary substance.
Cochran G, Stitzer M, Campbell ANC, Hu M-C, Vandrey R, Nunes EV. Addictive Behaviors. 2015. 45: 191-194. doi: 10.1016/j.addbeh.2015.02.002
Summary: Researchers analyzed how primary substance of abuse impacted treatment effects on abstinence and treatment retention. Researchers compared abstinence during the last four weeks of treatment to participant-reported primary substance of abuse. Treatment retention was operationalized as the proportion of participants still in treatment at 12 weeks. Among stimulant users, TES participants had significantly higher rates of abstinence than control participants. Rates of abstinence were higher in the TES group than the control group among alcohol and cannabis users, but these differences were not significant in multivariate analyses. Among opioid users, control participants had higher rates of abstinence than TES participants, but this difference was also not significant in multivariate analyses. Primary drug of abuse did not affect the relationship between treatment condition and treatment retention.
Take Away: TES shows evidence of being effective for stimulant users at promoting abstinence from drugs.
Cost-effectiveness of an internet-delivered treatment for substance abuse: Data from a multisite randomized controlled trial.
Murphy SM, Campbell ANC, Chitza UE, et al. Drug and Alcohol Dependence. 2016. 161: 119-126. doi: 10.1016/j.drugalcdep.2016.01.021
Summary: Researchers used data from the randomized controlled trial to evaluate the cost-effectiveness of TES. Researchers calculated incremental cost-effectiveness ratios (ICERS), or the cost incurred per quality adjusted life year (QALY) or abstinent year per participant, to evaluate the cost-effectiveness of each treatment condition. Calculations of cost were based on resources used per participant. Medical costs for participants that received TES were $278 higher than participants that received TAU for the entire sample, but medical costs for participants who were not abstinent at baseline were $253 higher for those receiving TES than those receiving TAU. Intervention costs were lower for participants who were not abstinent at baseline ($323) than for whole sample ($417). At 12 weeks, participants that had received TES gained 0.13 abstinent years relative to TAU for the whole sample and 0.14 years for participants who were not abstinent at baseline. At 12 weeks, provider costs per abstinent year were $9,073 for the full sample and $7,980 for participants not abstinent at baseline. Payer costs per abstinent year at 12 weeks were $8,832 for the full sample and $11,526 for participants not abstinent at baseline. Researchers calculated that TES would be cost effective when stakeholders were willing to pay $20,000 per abstinent year.
Take Away: Depending on providers’ and patients’ willingness-to-pay, TES could be cost-effective for improving abstinence, especially for those who are not abstinent prior to starting the program
Acceptability and effectiveness of a web-based psychosocial intervention among criminal justice involved adults.
Lee JD, Tofighi B, McDonald R, Campbell A, Hu MC, Nunes E. Health and Justice. 2017. 5(3). doi: 10.1186/s40352-017-0048-z
Summary: Researchers examined whether criminal justice system involvement with substance use treatment was related to TES utilization and acceptability or moderated the relationship between treatment received and end of treatment abstinence or treatment retention. Researchers categorized participants based on whether they reported having been mandated (n=107) or recommended (n=69) for treatment by the criminal justice system or if they were not criminal justice system involved (n=331). Participants in the three involvement categories completed similar numbers of TES sessions and assigned similar acceptability ratings to TES. Criminal justice involvement did not significantly influence relationships between treatment arm and end of treatment abstinence or treatment retention.
Take Away: TES acceptability and effectiveness relative to treatment as usual did not vary by level of criminal justice involvement.
A comparative study of the Therapeutic Education System for incarcerated substance-abusing offenders.
Chaple M, Sacks S, McKendrick K, et al. The Prison Journal. 2016. 96(3): 485-508. doi: 10.1177/0032885516636858
Summary: Researchers recruited 494 incarcerated people with substance use disorders who were scheduled for release within 4-6 months from 10 prisons in 4 states and randomized them to receive standard substance use care or TES. Standard care included 2 hours per week of standard prison counselor led group substance use treatment for 8-12 weeks. TES involved 2 hours per week in a classroom for completing TES modules for 12 weeks. At 3 and 6 months after release from prison, participants completed measures of criminal activity, substance use, and HIV risk behaviors. Researchers extracted data about re-incarceration from Department of Justice records. Rates of re-incarceration and average numbers of days to re-incarceration were similar between groups. Participants in both groups reported significant improvements in criminal activity, substance use, and HIV risk behaviors between baseline and 3 and 6 months, with no significant differences between groups.
Take away: TES as a standalone intervention is comparable to standard prison substance use treatment for reducing substance use, criminal activity, and HIV risk behaviors in soon-to-be-released inmates.
Feasibility of a computerized intervention for offenders with substance use disorders: A research note.
Chaple M, Sacks S, McKendrick K, et al. Journal of Experimental Criminology. 2014. 10:105-127. doi: 10.1007/s11292-013-9187-y
Summary: Researchers examined feasibility of TES compared to standard substance use treatment as a function of skills acquisition, treatment utilization, and treatment satisfaction. At baseline and 3 and 6 months after release, participants completed measures of coping skills and satisfaction with treatment. Researchers also collected treatment attendance and TES module completion data from the one state that made it available. Participants attended similar numbers of sessions of substance use treatment and TES. TES participants completed 35/48 modules on average. Participants in both groups showed statistically significant improvement in coping skills from baseline to 3 months, which was maintained at 6 months. Compared to control participants, TES participants found that treatment was more interesting, taught them more new information, and was more satisfying. Both groups reported that the they had difficulties understanding the information they received in treatment.
Take Away: TES was equally effective as standard substance use treatment at engaging prisoners and teaching inmates coping skills and may be more satisfying for users. Efforts to adapt presentation of information in substance use treatment initiatives may improve comprehension among individuals in criminal justice systems.
Feasibility and effectiveness of computer-based therapy in community treatment.
Brooks AC, Ryder D, Carise D, Kirby KC. Journal of Substance Abuse Treatment. 2010. 39: 227-235. doi: 10.1016/j.jsat.2010.06.003
Summary: In phase 1 of this 2-phase pilot study, researchers recruited 26 cocaine-using patients at a substance use treatment facility and randomized them to receive TES for 8 weeks or to a control group. Both groups received monetary incentives for participation (TES: completion of modules; Control: comparable incentive). At baseline and 10 weeks, participants were assessed for drug use (self-report and weekly urine samples), knowledge about community reinforcement approach (CRA) and HIV, and use of CRA skills in high-risk situations. At 10 weeks, TES participants completed 40 modules on average. TES participants improved knowledge of CRA and reported using coping skills in response to situations with high-risk for cocaine use more than control participants. TES participants with more CRA knowledge had fewer cocaine-positive urine samples. In phase 2, 5 interested counsellors continued offering TES without incentives and recorded use of TES. Researchers conducted a focus group about use of TES with counselors after 12 weeks. Counselors referred fewer than 20% of cases to use TES. Completion of TES modules by 18 consented patients varied widely. Patients completed 11.11 modules on average, only 10 patients completed more than 3 modules, but 3 patients completed 52 modules on average. Counselors reported TES could be improved with greater tailoring to patient populations and by giving counselors the ability to assign TES modules as a supplement to in-person therapy.
Take away: TES has the potential to improve patient skills and knowledge, but incentives are necessary for adherence.
Adding an internet-delivered treatment to an efficacious treatment package for opioid dependence.
Christensen DR, Landes RD, Jackson L, et al. Journal of Consulting and Clinical Psychology. 2014. 82(6): 964-972. doi: 10.1037/a0037496
Summary: Researchers used radio and newspaper advertisements, fliers, and participant and clinician referrals to recruit 170 individuals with opioid dependence who were able to receive buprenorphine. Researchers randomly assigned participants to receive Therapeutic Education System (TES) as an adjunct to treatment as usual (TAU) or to receive TAU. All participants received buprenorphine, contingency management, and minimal counseling (i.e. 30 minute appointments discussing treatment progress) during the 12-week trial. The TES group received access to the TES program, facilitated by a research assistant. Researchers assessed longest continuous abstinence, total days abstinent, and retention in treatment. Participants completed the Addiction Severity Index (severity of impact of addiction on medical employment, substance use, legal, family/social, and psychological domains) at baseline, 6-, and 12-weeks, and provided urine samples 3 times per week. Compared to TAU, participants that received TES were retained in treatment at greater rates (80% vs 64%) and were significantly more likely to complete treatment. Longest continuous abstinence did not differ between groups, but TES participants were abstinent significantly more days on average (67.1) than TAU participants (57.3). TES participants also reported significantly greater improvement in ASI medication subscale scores compared to TAU. Prior treatment was related to improved likelihood of completing treatment, longer continuous abstinence, and more days abstinent for TES participants compared to TAU.
Take Away: TES as an adjunct to CM and counseling may improve treatment retention and total days abstinent in people with opioid dependence receiving buprenorphine compared to CM and counseling alone.
Comparative effectiveness of web-based vs. educator-delivered HIV prevention for adolescent substance users: A randomized controlled trial.
Marsch LA, Guarino H, Grabinski MJ, et al. Journal of Substance Abuse Treatment. 2015. 59: 30-37. doi: 10.1016/j.jsat.2015.07.003
Summary: Researchers recruited 141 new patients aged 12-18 at an outpatient substance abuse treatment facility. Researchers randomized participants to receive in-person group HIV, hepatitis, and STI prevention intervention over 2 1-hour sessions or TES tailored for HIV, hepatitis, and STI prevention over approximately 3 1-hour sessions. Participants completed assessments at baseline and post-intervention of HIV and STI knowledge, behavioral intentions, sexual risk behaviors, condom use skills and self-efficacy, and acceptance of risk-reduction materials. Participants also completed assessments of interest, usefulness, comprehensibility of the intervention, and the extent to which the intervention taught them new information or skills and helped with behavior change. Participants in both groups experienced comparable increases in HIV and Hepatitis knowledge and condom use skills and self-efficacy. Participants in both groups also experienced comparable reductions in the numbers of past-month sexual partners. Participants reported that both interventions were interesting and useful, taught them new information and skills, and helped with behavior change. Participants who used TES reported higher intervention comprehension than those in the in-person intervention.
Take Away: TES is comparable to an in-person group prevention intervention at improving skills and knowledge and reducing some risk behaviors.