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The road to recovery is a day-by-day climb for most people living with an alcohol use disorder, but for those experiencing homelessness, the challenges are even greater.

More than 14.5 million people in the U.S. had an alcohol use disorder in 2019. Only 10% of those individuals, according to the National Institutes of Health, received treatment. An estimated 95,000 people die from alcohol-related causes annually, making this substance the third-leading preventable cause of death in the nation.

Alcohol use disorders impact approximately 33% of U.S. adults experiencing homelessness. For this population, the risk of alcohol misuse is eight times greater than for housed individuals, resulting in shorter life expectancy, higher health care utilization and costs, increased rates of illness and greater risk of interpersonal violence.

Through a $650,000 National Institutes of Health grant, Dr. Scott Walters with The University of North Texas Health Science Center at Fort Worth, and collaborator Dr. Michael Businelle from the University of Oklahoma Health Sciences Center, have developed and tested a novel smartphone-based alcohol treatment program for adults experiencing homelessness.

The result of their work was recently published in Alcoholism Clinical & Experimental Research Control. This journal provides the most significant and current research findings on the nature and management of alcoholism and alcohol-related disorders.

HSC co-authors on the paper included School of Public Health faculty Dr. Eun-Young Mun and Dr. Justin Luningham, and HSC School of Public Health epidemiology Ph.D. candidate Zhengqi Tan.

The project, called Smart-T Alcohol, offers a “just in time” smartphone-based app that can provide tailored coping suggestions when cravings to drink are highest.

“Alcohol treatment is common in homeless shelters, but compliance is typically very poor,” Walters said. “The goal of our project has been to create more effective treatment services for these people in ways more suited to their drinking behaviors and the events in real time that trigger drinking episodes.”

In developing Smart-T Alcohol, the team connected with a common thread among the people experiencing homelessness — cellphone use. About 80% of homeless individuals have access to cellphones through government programs, Walters noted.

“Cellphones are already an important resource,” he said. “They use them for safety concerns, to keep up with friends and appointments — and the phones are always with them.

“This method of communication makes it easier to stay in touch with an otherwise highly mobile population,” he continued. “This tool enabled our team to learn about their drinking behaviors and motivations in real-time, as urges to drink occurred, and to develop tailored notifications that could be pushed to the phone to help them curb those urges.

“Being able to keep up with in-person intervention programs is difficult when your life is in transition — finding shelter, searching for jobs or seeking a more permanent place to live — while the cellphone connection gives us a more consistent, daily way of staying in touch,” he added.

This study designed and tested an automated cellphone app that anticipated when people would drink, even before drinking occurred, and delivered a tailored intervention message. The program was designed and tested with participants in three phases: first, with phone surveys to collect data on where people were when urges to drink occurred, the time of day and mood they were in, people they may have been with at the time and whether they were drinking.

Stage two analyzed the cellphone data, developing a formula that predicted with an 80% accuracy whether the person was likely to drink in the next four hours.

“This prediction uses the same kind of tailored analytics as Netflix or Amazon in getting to know a person’s habits, preferences and actions,” Walters said. “While Netflix, Amazon and others use these predictive analytics to promote movies or sell products, our smartphone app uses the technology to help users avoid drinking when the urges are highest, based on what is personally important to them in their plan for recovery.

These intervention formulas were tested with North Texas-area participants in the project’s third phase.

When people received these tailored messages in real-time, the findings demonstrated a downward curve in drinking days, heavy drinking episodes and drinks per day over a 28-day period. People drank less over time as they received the messages.

Participants also reported the app was useful in avoiding drinking, and they would recommend it to a friend. An overwhelming majority accessed the app’s on-demand tips features.

“This shows very promising evidence that the messages are indeed helping people to drink less over time,” Walters noted. “The innovation of this system is that it’s portable, easily accessible anytime and it reaches the individual at key moments to head off drinking even before it’s occurred.

This project represents the first smartphone app specifically designed for adults with alcohol misuse who are experiencing homelessness, giving new hope and support to this disadvantaged and understudied population.

The final goal, Walters said, is to build on these results to introduce the app on an even wider scale to reach more individuals across Texas and the U.S.

The article can be read in its entirety here.

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