This article describes the development of a support service to meet the needs of opiate users before, during and after detoxification, using mobile phone text messages.
Ron G. Neville, FRCP, FRCGP, DRCOG, MBChB, MD, is GP, Westgate Health Centre, Dundee; Tricia Sullivan, BSc, is freelance qualitative researcher; Brian Boswell, BSc, is programmer; Paul Sergeant, PhD, BSc, is chief executive officer; both at Calico Jack Ltd, Dundee; Shona McIntosh, MA, Dip Clin Psychol, C Psychol, C Sci, AFBPS, is lead consultant clinical psychologist, East Central Scotland MCN Addictions.
Neville, R.G. et al (2008) Evaluating mobile phone support in drug detoxification. This is an extended version of the article published in Nursing Times; 104, 15, 27-28.
This article describes the development of a support service to meet the needs of opiate users before, during and after detoxification, using mobile phone text messages. Despite endorsement from service leaders, drug problems key workers found client recruitment problematic. However, once client trust and engagement had been established, the eight participants rated the service positively. A technical appraisal confirmed that, once established, the service ran smoothly and there were no adverse safety incidents. Those healthcare professionals and clients who used the service were impressed by its style, content and potential.
This pilot study could be of value in planning future strategies to offer 24-hour client-centred support for healthy lifestyle choices across a range of health and social conditions.
Heroin addiction blights individuals, their families and society (Sheldon, 2008). There is no single panacea for preventing young people becoming addicted to heroin or for persuading them to become drug free.
Recently, drug problems services have been offering suitable clients the chance to detoxify and completely withdraw from heroin. This is in contrast to the former policy of harm reduction, which mainly focused on methadone prescribing. This shift in policy, partly due to the introduction of the drug lofexidine (www.britlofex.co.uk), has prompted an appraisal of educational and social support services before, during and after detoxification from opiates. The mobile phone has become a ubiquitous portable communication device for young adults. Text messaging (or SMS) is a very cheap and convenient way for people to keep in touch with social networks, and it allows synchronous or asynchronous communication with peers 24 hours a day.
In addition, text messaging has become the preferred means for drug suppliers and their clients to communicate, and heroin users employ it for social networking. Addiction services are beginning to explore electronic communication to support client interaction (Collins et al, 2007).
There was therefore an opportunity to examine whether users’ and suppliers’ preferred communication tool could be deployed to support withdrawal rather than continued usage.
The project aim was to:
Develop a robust and sustainable mobile phone-based support service for opiate users before, during and after detoxification;
Conduct a qualitative and quantitative evaluation of the service from a technological, service use and human perspective.
Setting up the project
The project team met with three opiate users selected by a senior drug problems key worker to explore client attitudes towards the concept of using text messages. The drug users gave the team useful insights into clients’ priorities and aspirations at various stages of the detoxification process, and provided valuable tips on when and when not to use drug culture jargon. All clients emphasised the central role mobile phones played in obtaining opiate supplies and social networking in the drug-using community. They were all positive about the idea of using text messages to support detoxification.
Opiate users confirmed that mobile phones are the universally accepted means to set up drug deals, keep in touch with other users and allow instant communication with peer groups in and outside the drug environment.
Client A made the forceful point that changing drug habit requires a change in communication device: ‘The first thing you do if trying to go clean is change your SIM card.’
In order to break the cycle of constant offers from dealers, and to disengage from drug-using peers, people keen to come off and stay off opiates need to change how they use their mobile phone. In our initial project planning, we looked at radical changes to how clients might use their phones.
Drug users need positive encouragement and support at each stage of a detoxification programme.
Client B, supported by his fellow clients, explained how opiate users become numb to repeated negative messages from medical and support agencies and find their prime motivation for wanting to come off drugs is positive support from loved ones: ‘I need rewards, not hassle. A “well done” message from my key worker or my girlfriend really helps me stay clean.’
We thus designed our initial service around positive reinforcement messages and the deliberate inclusion of a loved one or key supporter.
Once drug users have successfully completed a detoxification programme, they need long-term support to stay drug free.
Clients liked the idea of this being delivered by SMS with supportive messages sent in a format and at a time of a person’s choosing. A menu-driven message service could run for as long as a former user chose to receive such support. With this in mind, we designed the prototype service as a progression through each phase of detoxification, including long-term support.
People with low levels of literacy might be attracted to mobile phone text jargon, free from the constraints of grammar and spelling.
It is inherently sensible to configure a support service around the communication preferences and abilities of intended recipients. Drug users are unlikely to carry folders and written materials with them, but do carry mobile phones at all times.
Ensuring clients are ready
Clients and key workers told us there is an unmet need for information on how to access and enter a detoxification programme. Users who claim to be ready for such programmes can overwhelm drug problems services. Statutory services have to devote considerable time to trying to establish suitable candidates to enrol. A pre-detox screening questionnaire delivered by text message could help inform drug users of when they might be ready, and help service providers prioritise suitable candidates.
A prototype text message support service was developed, based on comments from the client focus group. We built in flexibility so participants could choose the times in the day they wished to receive messages. For example, we gave them the option of receiving an ‘Are you going to stay off opiates 2nite?’ message in the early evening and a late evening ‘Well done pal’ message.
We made all messages emanate from an imaginary, gender-neutral ‘friend’ residing within their mobile phone. We called the virtual friend Toxi – a pun on text messaging, detoxification and the ‘It’s good to talk’ phone advertising slogan. We built up an extensive bank of messages to fit each stage of detoxification. We included a series of weekly questions to be delivered to clients. These asked them to grade where they were on their journey towards detoxification. The content of the subsequent week’s messages was determined by these responses.
To ensure participants did not incur extra phone costs we obtained £10 mobile phone shop gift vouchers to give to clients.
Craving toolkit and diary function
We built a rapid response text service that clients could use when they felt a craving coming on. This toolkit included a self-rating scale and useful tips to help clients cope.
In addition, we constructed a mechanism to extract and capture text comments sent by clients to Toxi. We knew from previous work that despite the text dialogue supposedly being one way, some mobile phone users like to reply to messages as they receive them, even though they know the sender is not a real person. We built this into a text diary facility to allow clients to tell Toxi how they felt at various stages of the project. We also felt this might provide an additional safety net for vulnerable clients. We were concerned that a client might send Toxi a message indicating possible suicidal intent. We checked this diary function daily so we could alert key workers and the project director about any worrying messages.
The project was approved by the Tayside medical ethics committee. Enrolment was by witnessed, written consent.
Client recruitment was difficult due to staff and policy changes in the local drug problems service. Eight clients were recruited by project staff sitting in on client/key worker meetings - three men and five women, all in their 20s. We do not have verifiable data on length of opiate use but from focus group discussions we believe that all clients who enrolled had experienced opiate and poly-drug use for at least the previous 12 months.
The service was free from any major technical problems. On several occasions it was interrupted for a few hours for upgrades but this was done without interrupting the sending and receiving of messages between clients and Toxi. The craving toolkit was used on several occasions by clients and analysis of user logs demonstrated it functioned well. We have no objective means of knowing if the craving toolkit actually prevented any drug use.
We scheduled messages to be sent mid-morning and then again in the early evening. Participants appeared to accept these times and made no requests to alter them.
Four participants replied to certain messages using the diary function we had installed. Their dialogue with Toxi gave some interesting insights into how they were coping.
In response to a series of supportive messages:
‘thanx – I needed a morale boost’.
‘drug free today – with my family’;
‘havn’t smoked today – I’m feeling good thanks’
Updates on service engagement:
‘got appt at drug problems clinic to begin detox’;
‘appt went well’.
Use of the service as an adjunct to face-to-face appointments:
‘I want my key worker to reduce my meth dose – seems to be dragging it out’.
Qualitative feedback from clients
At the time of recruitment, clients were invited to participate in feedback interviews with a researcher. Clients were contacted via their mobile phones once it was clear that interaction with Toxi had ceased. Although there were limitations in conducting interviews by telephone (for example, clients could not give written consent for interviews to be recorded), this was considered to be the simplest and most effective way of contacting them.
Of the eight clients, four (three men, one woman) provided verbal feedback about their experience of the service. Despite repeated attempts, the remaining clients could not be contacted for interview via their mobile phones. Of the four clients, two indicated they were currently on a detoxification programme, one described himself as ‘stable’ and one said he was not yet on a programme.
Their comments indicated that enrolling in Toxi was straightforward. The provision of the phone voucher motivated two clients to enrol, one of whom stated he had done so even though he did not fully understand initially what the service was about. However, his understanding increased as he began to take part.
Clients expressed mostly positive views about the content of the text messages received via Toxi, which they described as ‘OK’, ‘helpful’ and ‘quite clear’.
The timing and number of messages received each day was highlighted as good, with no sense of them being overpowering. The value of receiving positive messages was mentioned: ‘The praise ones [messages] were good. [They] helped you to feel good about yourself’ (Client 1). One client found that some of the messages he received were irrelevant because he had not begun his detoxification programme when he enrolled with Toxi.
Although clients did not have any strong concerns about the service’s security or safety, two stressed it was important that its confidentiality was made clear. These clients stated they had been unsure if their replies to texts were being forwarded to or seen by their key worker. One client said his uncertainty about whether his key worker was seeing his responses had put him off replying and that it sometimes affected his answers, especially about his current drug use: ‘Say you are having a few smokes and you are worried about slipping, you would need to know if that is going to your key worker. If you think it is, you might be frightened, tell lies, won’t text at all or make excuses like you don’t know how to text’ (Client 2).
One client currently on a detoxification programme felt that Toxi had provided an additional coping resource: ‘They [text messages] helped me to cope a wee bit… just cos, as I said, if you’re on your own and having a hard time, if you’re texting it helps you take your mind off things’ (Client 1).
The other client currently on a programme felt that Toxi had helped in some ways, but he felt the service was not as good as one-to-one support from a key worker.
All clients interviewed said they would recommend it to someone else who was about to participate in a detoxification programme.
Although clients were informed that Toxi was ‘virtual’ at the enrolment stage, interviews indicated that their understanding of this varied and that they had experienced various issues regarding sending messages back to the service. Two clients said they had been uncertain about how to text back to Toxi and they suggested that this should be made clearer at the enrolment stage. Misperception about the financial cost of using the service was raised by another client. There were indications that some perceived they could send text messages to Toxi at any time.
In summary, feedback interviews provided limited but none the less valuable insight into clients’ perceptions of Toxi and its potential role in supporting people going through a detoxification programme.
Client feedback was generally positive and there was a strong sense from interviews that clients understood the service’s aims and principles. Those going through detoxification said in some ways it had helped them to cope better.
Confidentiality was highlighted as important for ensuring clients’ honest and effective interaction with the system.
There were indications that, when clients enrolled, it would have been useful to ascertain the stage which they had all reached in the detoxification process, to ensure the relevance of text messages for each person. It was only possible to gauge this for some but not all clients.
Perhaps a fuller explanation of the virtual nature of Toxi would also have been valuable. The provision of the £10 phone top-up voucher may have acted as a primary motivating factor for enrolling in some cases, perhaps without subsequent full commitment.
Qualitative feedback from the local drug problems service
The project team interviewed the key worker team leader and a team member to find out if recruitment problems were related to their views about the service.
Among the views expressed were that the project motivated clients and that it acted as a ‘really good’ reminder to them about what they were doing. It was also seen as having a particularly useful role when clients were starting on methadone and may experience severe cravings. The key worker felt that free-standing information leaflets were insufficient to attract clients. He felt it was important to be proactive in promoting the service and in carrying out follow-up work with those using it. Overall, the key worker felt the procedure for client enrolment was straightforward.
Both staff members emphasised the importance of the service’s confidentiality in order that clients felt sufficiently confident to interact with it honestly and accurately. The point was made that if a client’s phone was stolen or used by another family member there was potential for a breach of security.
The team leader stressed the importance of ensuring appropriateness of messages for each individual client. He also suggested that, although some clients may have been motivated to enrol in the project by the phone voucher, this was something that such an initiative had to acknowledge might happen.
Regarding perceptions of the project by other key workers, the team leader indicated others had not expressed any doubts about Toxi. He suggested that lack of engagement with the service was perhaps due to their feeling burdened by the implementation of another initiative at a time when there had been many internal changes at the drug problems service and increased administration and monitoring requirements.
Although key workers felt the project’s impact was difficult to measure because it was part of a support package rather than a free-standing intervention, the potential for the service to be tailored to an individual, to be available out of hours and its relative safety were seen as favourable.
There were no adverse safety incidents throughout the project. Neither the project director nor key workers had to attend to any worrying messages posted on the diary function.
Benefits of the service
The first project aim was achieved. Despite the challenge of working with a hard-to-reach client group, it was possible to produce a sophisticated text message support package available to clients 24 hours a day. This package was refined to a high degree, enabling those with low levels of literacy and high levels of social exclusion to take part in an educational dialogue around minimising drug use.
The second aim was to conduct a qualitative and quantitative evaluation of the service from a technological, service use and human perspective. The technical evaluation showed the package to be stable, robust and capable of national roll-out. The major difficulties encountered in client recruitment and retention reflected statutory service configuration and human factors rather than technical shortcomings.
On a more positive note, our experiences will be helpful in planning a randomised controlled trial on using text messaging to support opiate users to reduce or stop consumption. It is important for all healthcare interventions to be subject to as rigorous an analysis as possible, preferably an RCT. We have paved the way in terms of concept, safety monitoring, field-testing and exploration of client recruitment and retention for an RCT.
The eight participants all displayed some enthusiasm and positive reactions. They were interested that the project was a completely different approach to helping them and welcomed the chance to base attempts to minimise drug use around the communication device they had hitherto used to obtain drugs.
Difficulties with client recruitment precludes us from stating which users might benefit and when. One can speculate that the nature of the text message support package makes it more suited to a flexible client-centred approach with less emphasis on institutions and formal research. Perhaps it could be best delivered via the voluntary sector, workplace, internet, NHS Direct or NHS 24.
The service for opiate users was technically feasible to construct, apparently safe and positively rated by clients. Unfortunately, the inherent instability in opiate users’ lives and the changing structure and staff of statutory drug problems services impaired our ability to be able to make valid conclusions regarding clinical outcomes or a firm recommendation for its widespread roll-out.
We believe the project has provided valuable experience on how to set up and run a text support service for a very vulnerable and challenging client group. Although the verdict on its effectiveness must be deemed ‘not proven’, the initiative gives new insight into how and where future supports for opiate users might be deployed. Immediate access to a 24-hour service has obvious attractions to clients struggling to cope with addictive behaviour.
This project has paved the way in terms of service configuration, technical evaluation, safety checking and qualitative feedback from service users and providers. We believe text support has a valid role in supporting opiate users. Its delivery ought to be less formal and more client-centred than we were mandated to do.
People with a range of addictive behaviours, including tobacco and alcohol use, might welcome a text message service as an adjunct to care. There is untapped potential to use a 24-hour text service to help people with diet control, or a wide range of long-term health conditions (Neville et al, 2002). Opiate users are one of the hardest to reach groups in society. Lessons learnt from this project may well be transferred to other less ambitious initiatives.
The experience of setting up and running a pilot text support service in this very difficult area has yielded useful insights and technical solutions for engaging with challenging client groups. It is possible to reach out to opiate users and engage them in a dialogue about healthy living and lifestyle.
Our experiences draw attention to the need to plan any similar projects taking account of other factors in the service user’s ‘system’, such as the timing of staff involvement when faced with changes in the NHS.
We hope our experiences may be of value to others who seek to offer people novel ways of thinking about their communication habits, lifestyle choices and health.
We would like to thank the project staff, drug problems workers and clients. We are grateful to Tayside Health Board, Orange, France Telecom, Calico Jack Ltd and the Scottish Centre for Healthy Working Lives for financial support.
Collins, G.B. et al (2007) Patient provider communication as an adjunctive tool in addiction medicine. Journal of Addictive Diseases; 26: 2, 45-52.
Neville, R.G. et al (2002) Mobile phone text messaging can help young people manage asthma. British Medical Journal; 325: 7364, 600.
Sheldon, T. (2008) More than a quick fix. British Medical Journal; 336: 68-69.