Stand Down-Think Before You Drink: An RCT of a Mobile App for Hazardous Drinking with Peer Phone Support

Background: One in four Veterans presenting to VA primary care screen positive for hazardous drinking.
However, due to barriers such as Veterans’ stigma about seeking alcohol use treatment and challenges with
traveling to VA, most of these Veterans do not receive any alcohol-related care. Mobile applications (apps) are
an innovative means of expanding access to alcohol use treatment. The evidence for mobile apps, such as
“Step Away”, to improve drinking outcomes is emerging. Nevertheless, poor patient engagement remains the
Achilles’ heel of these apps. Peer Specialists (“Peers”) can facilitate Veterans’ engagement with mobile apps
intended for self-management of hazardous drinking by helping to orient patients to these apps and by
providing technical support and accountability. In a VA HSR&D pilot study (PPO 16-305), we created a Veteran
version of the Step Away app (“Stand Down: Think Before You Drink”) and conducted an open trial in which
Veterans with hazardous drinking used the app while receiving Peer phone support. The intervention (“Peer-
Supported [PS]-Stand Down”) was highly acceptable to patients, and patients reported significant
improvements in drinking outcomes. These data provide a strong foundation for a larger pragmatic trial to test
the effectiveness of the Stand Down app and PS-Stand Down to reduce hazardous drinking among Veterans
seen in primary care, relative to the current standard of care that these patients receive.
Significance: By capitalizing on a high-value workforce shown to improve Veterans engagement in care (i.e.,
Peers), this research can expand access to alcohol care for Veterans with low staff burden and, in turn, reduce
the long-term health consequences associated with untreated hazardous drinking. Our proposed research
responds to HSR&D priorities of Access to Care, Mental Health, and Virtual Care, and the VA MISSION Act.
Innovation and Impact: Poor patient engagement severely limits the potential effectiveness of mobile apps for
self-management of alcohol use problems. Use of Peers to enhance patients’ engagement with such apps is a
novel approach to overcoming this problem. Peers are ideally suited to this role by virtue of their lived
experience with addiction. This approach represents a novel application of the supportive accountability model
of adherence to e-health interventions. Combined with VA’s expansion of Peers on Patient Aligned Care
Teams (PACT), PS-Stand Down, if shown to be effective, can transform the delivery of care for Veterans in
primary care who screen positive for hazardous drinking.
Specific Aims: We propose to evaluate whether the Stand Down app reduces drinking among Veteran
primary care patients who engage in hazardous drinking, and for whom PS-Stand Down is more effective than
the app alone. Aim 1: Test whether Stand Down (vs. Usual Care; UC) and PS-Stand Down (vs. UC and vs.
app only) predicts better drinking outcomes, and test mediators of these effects. Aim 2: Test for differences in
satisfaction with care across conditions, and conduct qualitative interviews with patients and PACT staff to
understand potential barriers/facilitators to implementing PS-Stand Down in primary care. Aim 3: Explore
baseline moderators to elucidate for whom PS-Stand Down (vs. app only) is most beneficial.
Methodology: In a 3-group RCT at the Palo Alto and Syracuse VAs, 274 Veteran primary patients who screen
positive for hazardous drinking, received a brief intervention following a positive screen, and are not currently
in alcohol use treatment will complete a baseline interview, be randomized to either (i) UC, (ii) UC plus Stand
Down, or (iii) UC plus PS-Stand Down (four phone sessions with a Peer over 8 weeks to enhance app
engagement), and be re-interviewed at 8, 20, and 32 weeks. For Aim 2, the CFIR framework will guide key
informant interviews with 12 patients and 12 PACT providers from each site.
Next Steps/Implementation: Depending on the results, we will work with our VACO partners in the Offices of
Mental Health & Suicide Prevention and Connected Care to conduct a large multisite implementation trial.

Grant Number: 5I01HX003274-04
NIH Institute/Center: VA
Principal Investigator: Daniel Blonigen