Grant No. 3 R44 AA08140
"Secondary prevention of alcoholism via computer software"
PI Reid K. Hester, Ph.D.
Project dates 9/01/93--8/31/97
The goal of this research project was to develop and evaluate an interactive computer software program as a form of secondary prevention of alcohol abuse. Secondary prevention was defined as training in behavioral skills for people who are at risk because of heavy drinking and/or early alcohol-related problems. The goal of such training is to reduce (or eliminate) alcohol use to levels low enough that the person's drinking is not causing problems.
We have achieved all of the specific aims initially defined in our application and more. In the first year of Phase II, we developed an interactive program and named it "Behavioral Self-Control Program for Windows." In years 2 and 3 we conducted a controlled clinical trial of its effectiveness. A description of that clinical trial and its outcomes are detailed in the attached manuscript that is in press in the Journal of Consulting and Clinical Psychology. Allow us to briefly summarize those results here.
Forty nonalcoholic heavy drinkers were randomly assigned to receive a computer-based version of behavioral self-control training either immediately after pretreatment assessment or after a 10 week waiting period. Results at each of three follow-ups (10 weeks, 20 weeks, and 12 months) strongly support the study hypotheses. Participants in the Immediate treatment group significantly reduced their drinking relative to their pretreatment levels and relative to those in the Delayed treatment condition at the initial follow-up, 10 weeks after the pretreatment assessment. The Delayed group did not change their drinking behaviors during this period of time. However, they significantly reduced their drinking by the second follow-up conducted after they received training. At the 12 month follow-up participants maintained the gains they had achieved during treatment. There were no interactions involving participant ethnicity or gender. While use of other drugs was not specifically addressed, such use did not increase and there was some evidence of a decline.
Of particular interest were some comparison of effect sizes between our study and a number of other studies where the Behavioral Self-Control Training (BSCT) was given via other modalities (e.g., individual, group, and bibliotherapy formats). Our effect size was comparable to these other modalities. This comparability reinforces the conclusion that computer programs that provide treatment can be as effective as face-to-face therapies. This is good news because early stage problem drinkers are an under served population (IOM, 1990). Also the age group with the heaviest concentration of this group of drinkers happens to be the most computer literate. Given this, we are working on high-tech strategies for disseminating this software via the Internet.
We made a number of presentations at both national and international conferences on these results as they became available. Here is a list of the conferences and dates:
Addictions ‘96 Conference, Hilton Head Island, SC, September 28, 1996.
Research Society of Alcoholism, June 25, 1996.
State Dept. of Health symposium on DWI treatment, Albuquerque, NM. December 6, 1995.
29th Annual Convention of the Association for the Advancement of Behavior Therapy, November 17, 1995, Washington, D.C.
Seventh International Conference on the Treatment of Addictive Behaviors, Leeuwenhorst, Holland, May 29, 1995.
Our software has also been reviewed by others. Dr. Martin Briscoe, co-moderator of the Computers in Mental Health discussion group on the Internet has favorably reviewed the software (http://www.ex.ac.uk/ cimh /bscpw.htm). Dr. Larry Rosen has also reviewed the software and included it in his new (1997) book, The Mental Health Technology Bible (1997) which is being published by John Wiley and Sons (ISBN 0471-17618-4).
When we originally proposed this project we indicated that we would develop BSCPWIN for therapists. This we have done. We also made a single-user version of the program for individuals to use either under the supervision of a therapist or on their own. With the explosion of traffic on the World Wide Web (Web), it is now relatively easy to disseminate software from a Web site. We are negotiating with an organization to sponsor free (to the end user) dissemination of the single user version of our software, Behavioral Self-Control Take Home Deluxe (BSCPTHDL). We, the Alcohol Self-Control Program, would receive a royalty for each copy of the BSCPTHDL downloaded from the organization’s Web site. The organization we are currently discussing this proposal with is the Century Council, an organization funded by the liquor industry. We find it a bit ironical that the liquor industry might sponsor the dissemination of a software program designed to teach moderate drinking when the funds from such sponsorship would come from liquor industry profits. If successful with these negotiations, it would be a win-win-win situation both for the Council, the end user, and our company. The Century Council could tout its sponsorship of an effective training program under their "Drinking Responsibly" program, the end user could receive the software free of charge, and we could make a tidy profit on an annual basis for a number of years. Naturally we are very excited about successfully negotiating this proposal. We are also making a similar proposal to the Swedish government agency responsible for collecting and using liquor taxes, Systembloget. We have developed an agreement with an individual in Stockholm, Henn Koch. Mr. Koch has translated the files into Swedish. In addition, our new version 4.16 allows for metric measurements and international date standards. These aspects of 4.16 allow it to be disseminated abroad.
We have finalized a distribution agreement with Psychological Assessment Resources (PAR). They began advertising BSCPWIN in their August 1997 catalog and have pre-purchased six copies. They will distribute and provide software support. We hope that this distribution channel will be highly successful.
We also developed a demo version of our Therapist’s version of the software. This demo version is fully functioning except that the program will only recognize the first client listed in the client database and only the first 25 drink lines on their self-monitoring cards. The copy of the demo version is available through our Internet ftp site (ftp.lobonet.com/home/ftp/users/rhester).
Half way through year 3, we learned about the rapid growth of company intranets and saw the potential for adapting our BSCPWIN program for large company intranets. We proposed an extension to our Phase II project and a supplemental budget to develop a version of our software that would run on company intranets.
We began this effort to develop a Web version of the software, Behavioral Self-Control Program for the Web (BSCPWeb) by programming in the language of the Internet, hypertext markup language (html). This required an extensive reprogramming effort because of the technical differences between html and BSCPWIN that was originally written in Visual Basic 3.0 for the Microsoft Windows operating system. We were feverishly engaged in this reprogramming effort when we discovered a new technology that allows companies to run full 32-bit Windows programs across both company intranets and the Internet. The software, WINFRAME, by Cytrix runs on top of a Windows NT Server and allows a company that uses Windows NT and WINFRAME to share any Windows NT program with any user they choose. To access a Windows program on an NT Server and WINFRAME, a user must download a small (200K) plug-in file to his or her Web browser (e.g., Netscape, Internet Explorer, and others). To view more information about WINFRAME and see a demo, point your browser to http://www.citrix.com/hotspot.htm. You’ll notice that you can run their Windows programs as though they were residing on your computer (even though they are residing on their NT Server). Also of interest is the ability to run these programs either embedded in a Web page or to run them full screen.
We contacted Cytrix just before Christmas, 1996 and were given the name of a local WINFRAME reseller to contact. He met with us and provided us with the technical details necessary to configure our program to work with WINFRAME. He also reported that Cytrix had sold 50,000 copies of their Server software in 1996. This told us that there is a vast and growing market for programs such as ours that could run through their software. After this meeting my programmer and I decided to immediately shift our efforts to taking our current 16-bit version of BSCPWIN program to a full 32-bit version. This has involved a sequence of taking BSCPWIN programmed in Visual Basic 3.0 to Visual Basic 4.0, first in 16-bit, then in 32-bit. The final step was to take the program to 32-bit in Visual Basic 5.0. We also needed to switch to Microsoft Access as the underlying database for the self-monitoring cards. This switch from Btrieve was necessary to allow multiple users to access the database simultaneously. These tasks have taken a substantial amount of programming effort.
At the same time we modified the program both in response to software reviewers (see http://www.ex.ac.uk/cimh/bscpw.htm) and to therapists who had purchased the software. Briefly we revised our standard drink size to be more consistent with common drinking practices and other treatment programs that teach moderate drinking. We changed from a standard drink being the equivalent of 10 ounces of 5% beer to 12 ounces of 5% beer. This also necessitated changes in our self-monitoring instructions and in our estimated peak Blood Alcohol Concentration (BAC) tables. We also added options for metric measures and international date formats as mentioned above.
We have accomplished the goals of revising our program to have a Web version for company intranets. We have also initiated discussions with the Medical Department of Sandia National Labs here in Albuquerque that involve using it as a test site for our new BSCPWeb software. Sandia has a Windows NT Server running WINFRAME and Dr. Clevinger, Sandia’s Medical Director, is keen to acquire BSCPWeb for his patients. We will negotiate a reduced price for Sandia as it will be a test site for BSCPWeb.
We have achieved the goals we have set from the standpoints of innovation, science, and bringing the software to the commercial market place. As best we can tell, our BSCPWIN is still the only treatment software in the field of alcohol problems. We have demonstrated its efficacy in a controlled clinical trial. The results from that clinical trial were presented at two international conferences, two national conferences, and one state-wide conference. The final report, has just been published (August 1997) in the Journal of Consulting and Clinical Psychology. We have released the various versions of the software to the commercial market place after we had evidence of the efficacy of BSCPWIN and we completed the additional programming. The marketing, which has not been done on grant time, has entailed a commitment of effort but not additional financial resources. With the rapid prevalence of the Internet and the Web, advertising and sales have not required capital outlay. It is available through our web site, http://www.lobo.net/~rhester and we are receiving orders based on its availability on the web.
Finally, allow me to make a few statements about the profitability of this project. One of the goals of SBIR funding is to develop and bring to the commercial market innovative technology that meets the needs and mission of the funding agency. We think that, to date, we have been highly successful in accomplishing these goals. We have developed a number of different versions of the software and brought them to the commercial market. We released the original version of BSCPWIN last year and software sales to date have been over $7,500. We are currently (April, 1997) selling, on average 4-6 Therapist versions per month (at a retail price of $200 each). We are negotiating for sponsorship of free dissemination of our single-user version (as discussed above) which could net us annual royalties in the range of $55,000. We also have an agreement to distribute copies of the single user version to appropriate DWI offenders as a part of a DWI prevention program in Torrance County, New Mexico, just east of Albuquerque. Estimated revenue from that project in this next fiscal year is $2,500.
We anticipate pricing the BSCPWeb version for large company intranets in the $10,000 range. A distributor of accounting software for large multi-national firms has expressed interest in reselling our BSCPWeb version to his large multinational clients. We consider this project to be a financial success already with great promise for significant future cash flow.
In the spring of 1996 we requested a supplement and then subsequently a time extension to 8/31/97 to develop a Windows CE version of our self-monitoring module. Windows CE is the operating system on many of the latest generation Personal Digital Assistants (PDAs), also known as palmtops. We reasoned that users having the option to self-monitor in real-time electronically would be preferable for some to self-monitoring with paper and pencil then entering data later on their laptops. With the PDA, the user could enter data as he or she was drinking, receive immediate feedback on his or her estimated peak BACs, and be able to automatically upload their data to BSCPWIN when it was convenient for him or her. As users tend to keep appointments and contacts in their PDAs, they upload and download data files from their desktop computer frequently, often on a daily basis. So this could serve as an additional reminder to moderate their consumption. We have just completed this programming and it will be an option in both Version 4 programs (Therapist and Single User).
In summary, we are pleased that this project has been a success with respect to its innovation, its effectiveness in helping study participants moderate their drinking, the advance of scientific knowledge, and its commercial viability. The success of this project has inspired a program of development and research. We have already proposed to develop a precursor program to BSCPWIN: a computer-based brief motivational intervention. Once we have finished that project, we plan to develop an abstinence oriented software program, then finish up with a software program that addresses drug abuse. We anticipate that this program of research will take about 15 years.