Technology, Addiction Treatment, and Recovery: An Ever-Changing Landscape

Technology is a growing part of our daily lives. Addiction treatment and recovery also continue to grow rapidly with more and more in need of finding services every day. Many facets of recovery can be enhanced or threatened in the digital world by today’s advancements in technology. We are more connected, more accessible, and more visible than ever. However, not everyone who needs substance use or mental health treatment gets the help they need. In fact, a vast majority of those needing support for addiction do not receive any form of treatment whatsoever.

Why Are People Not Getting Help?

According to the 2020 National Survey on Drug Use and Health (NSDUH) conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA), “Among people aged twelve or older in 2020, 14.9 percent (or 41.1 million people) needed substance use treatment in the past year.” However, only “1.4 percent (or 4.0 million people) received any substance use treatment in the past year” (SAMHSA, 2021).

The gap between who needs help and who gets help is over tenfold. Addiction treatment centers could be serving many more individuals with substance use disorders. However, barriers to treatment can prevent many people from receiving support.

An article in the Journal of Substance Abuse Treatment stated that treatment barriers are in two broad categories (Priester et al., 2016):

1. Personal characteristic barriers (e.g., co-occurring mental health disorders, coping skills, intelligence, cultural beliefs, and negative stigma)
2. Structural barriers (e.g., availability of treatment, proper diagnosis, provider training, wait times for access, lack of childcare while in treatment, racial and ethnic disparities, and insurance coverage and finances)

The ever-changing landscape of technology and addiction treatment can help to address several barriers that many people might face when seeking help. According to the Pew Research Center, as of 2020, “93 percent of American adults use the Internet” and “85 percent own a smartphone” (2021a, 2021b). The widespread use of the Internet via broadband or smartphones provides a new avenue of treatment that overcomes barriers to treatment.

How Is Technology Helping People Get and Stay Sober?

Technology can help by:

• Making treatment more accessible and more affordable with online platforms for people who cannot get to a facility due to childcare, transportation, or distance
• Broadening the reach of facilities to potential clients especially to marginalized groups such as the BIPOC and LGBTQIA+ communities
• Providing the real-time ability to track symptoms and increase the accuracy of self-reporting for evaluation and diagnosis
• Connecting supportive peers within the recovery community and among other groups
• Sharing valuable resources and information (e.g., coping skills, crisis services, current scientific literature) to clients and professionals
• Facilitating provider training via online platforms or recordings to keep professionals up to date on best practices
• Combating the negative stigma of addiction and treatment by sharing stories via podcasts, personal blogs, and social media

In some ways, we are more empowered than ever by technology. We can reach further, connect deeper, and simply help more.

The Who, What, Where, When, and Why of Blogs

West Jones, the CEO of Addiction Recovery, states, “Content is far more than words on a page, marketing, or even generating leads. Content is one of humanity’s most primary forms of communication, and the majority of your patients will connect to your digital voice long before a phone call or speaking with your team in person. Every word should be an offer of altruism, a virtual extension of your hand to theirs, and the best education you can possibly give. Even within technology, never forget this is about saving lives, not a sales pitch” (Z. Spowart, personal communication, January 1, 2022).

Well-written blogs and web content can be a valuable resource for treatment providers and those in recovery. Blogs can be written to appeal to potential clients the provider is best suited to treat. By reaching out to a targeted client base people seeking recovery can easily find the best treatment solution for their unique needs and preferences.

For example, an adolescent treatment facility can write blogs focused on parenting tips to reach out to parents of teens who struggle with addiction and other behavioral health issues. Or a women-only facility can create content about the unique issues women encounter while dealing with addiction. These kinds of blog posts would be all unique, all organic, and all topic-specific to help those in need who are researching for help.

A blog can help individuals seeking comfort during tough times or those looking for guidance for loved ones. This comfort and familiarity with treatment centers through blogs can open the door for many people to feel secure about getting treatment. Loved ones might search online for guidance, support, or inspiration to help them through challenging times. Blogs can be a valuable resource for family members and loved ones, even just to send the message that they are not alone.

For those who struggle with addiction, blogs can shed light on the underlying issues driving addiction while inspiring hope and encouraging recovery. Blogs can provide a personalized touch to understand what will occur during addiction treatment and ongoing recovery. Treatment facilities can target content to alumni to help them maintain a relationship with the facility, which could help prevent relapse or ease individuals back into treatment if they need additional support.

People are frequently researching online to test the waters for many different services. Most people check online before investing their time and money into anything. For example, it is rare for people to try out a new restaurant without first looking online for a menu or reviews. When looking for addiction and mental health treatment, blogs and web content can be potential clients’ first impression of a treatment facility, providing a sampling of the facility’s overall approach, philosophy, and services.

Blogs and web pages can help treatment providers and clients in several ways, like building a research library for them to access information on recovery; optimizing search engine results to connect clients or referrals to appropriate treatment providers based on location, diagnosis, and needs; sharing personal stories of recovery to help normalize getting help and combat the negative stigma of addiction; learning new coping skills for relapse prevention, co-occurring mental health disorders, lifestyle changes, and healthy living; keeping alumni and family members up to date and connected to treatment centers by updating blog pages; and tailoring content to reach marginalized groups, like those in the BIPOC and LGBTQIA+ communities.

Well-written blogs and web content help connect clients to the appropriate treatment services when created with some of the following aspects:

• Search engine optimization (SEO), which considers the use of keywords and phrases to target potential clients’ questions and concerns
• Content supported with reliable sources and up-to-date information
• Easy-to-read content that is relatable and understood by most people, regardless of educational background
• A “call to action” that encourages potential clients to take the next steps in treatment for themselves or loved ones by reaching out to a specific facility
• Web content that can send a message of hope, inspiration, encouragement, and connection within the recovery community

Technology and New Therapies

According to Steve McCall, the CEO and cofounder of Alleva, “Technology has changed how things work in the treatment world now. How can we build a connection long term? How do we keep people connected posttreatment? It’s not just sobriety, it’s connection—keeping clients/patients connected” (Z. Spowart, personal communication, December 30, 2021).

The influence of technology on addiction treatment goes beyond accessibility and combating treatment barriers. Some new forms of therapy would not exist without the technological advances that make them possible. In addition, some forms of treatment can be enhanced with technology, resulting in positive outcomes, real-time monitoring, and increased accountability.

Examples of these therapeutic modalities and enhancements include the following areas.

Biofeedback

Biofeedback involves practitioners attaching sensors to clients’ bodies to measure heart rate, muscle tone, skin temperature, brain waves, and/or other bodily functions. The sensors provide information to a computer to measure these automatic bodily functions, which might be influenced by clients’ difficulty managing stress, trauma, and negative emotions. Clients can start to gain control over these automatic responses by first understanding the patterns and measuring improvement throughout the sessions.

Transcranial Magnetic Stimulation

Transcranial magnetic stimulation (TMS) helps treat depression by using magnetic fields to stimulate nerve cells in the brain. This type of therapy is noninvasive and can be used when other treatments are ineffective.

Eye Movement Desensitization and Reprocessing

During eye movement desensitization and reprocessing (EMDR) sessions, clients process trauma and negative emotions while therapists provide bilateral stimulation to relax the central nervous system. While EMDR does not require much technology, technology can significantly enhance this modality to provide optimal bilateral stimulation with visual, physical, and/or auditory sensations.

Sound Therapy Beds

Sound therapy beds measure biofeedback while clients relax and listen to soothing sounds or music. Sound therapy can help “tune” clients’ brainwaves to a specific frequency or teach them to relax while processing painful memories or negative emotions.

Computer-Based Training for CBT

Cognitive behavioral therapy (CBT) is one of the most commonly used evidence-based therapeutic modalities for addiction and mental health issues. Computer-based training for CBT (i.e., CBT4CBT) is a computer program that clinicians can use to help clients work through interactive exercises and videos. Other modalities, like dialectical behavioral therapy (DBT) and rational emotive behavioral therapy (REBT) also have tech-based analogs for clients to complete therapeutic homework.

When accessibility is a challenge, the digital reach is much further than traditional literature and workbooks. Many clients in trauma recovery enjoy the benefits of digitally enhanced modalities due to the somatic effects. Reintegrating clients’ minds, bodies, and spirits can significantly increase their chances of sustained recovery.

There Is an App for That

Individuals can order food to their front doors, speak with therapists electronically by the end of the day, and even find a date and/or potential spouse with a few simple swipes. The ease of access and ultimately increased distractibility can be a major hindrance to recovery, especially in early recovery (i.e., within one year) when most people are encouraged not to date or engage in instant-gratification behaviors.

Sure, it is cultural lore to warn someone against dating in the first year of recovery, but how easy is it for people to detach from those behaviors in a meaningful way? Dating and hookup apps allow individuals to present depersonalized, highly-edited versions of themselves, counter to the raw vulnerability required for success in recovery. Swiping can become compulsive, and the sense of “What’s next?” settles in, along with a flood of dopamine when people “like” back and the rush of the first communication with strangers showing interest. All of this has the potential to take away from the humility and vulnerability necessary to keep us sober.

On the heels of initiatives in California and other states, sports betting could soon be more accessible than ever, while throngs of young sober people fill casinos late at night. Replacement addictions, also known as “cross addictions,” become a cycle of engaging in a new, potentially detrimental behavior while moving away from a primary addiction. Cross addictions often lead to feelings of emptiness, remorse, and “incomprehensible demoralization,” as quoted from the Alcoholics Anonymous (AA) Big Book (AA World Services, 2013). This is often cyclical, as typically attempts are then made to amend the behavior and recover until emotions once again become unmanageable or the temptation becomes too great.

However, not all apps are unhelpful or damaging for users. Technology can assist those in recovery in a profound way. Accessibility has been a significant barrier to treatment, and the Internet has allowed many individuals access to resources previously unattainable. Some apps can provide access to peer support or therapists. Many apps can help people improve, monitor, and maintain their recovery with space for journaling, tips, coping skills, daily meditations, and even check-ins with recovery specialists. A growing number of treatment programs even pioneer their own apps to allow for sustained alumni connectivity, while some choose to create Facebook groups that house a safe haven for alumni to remain connected.

Here are a few more popular apps amongst individuals in recovery:

I Am Sober

I Am Sober is a simple app that tracks recovery using a sobriety counter to log milestones, tracks how much money users have saved on drugs or alcohol in their sobriety, and offers motivational quotes for support.
Price: Free
Platform: iOS and Android

AA Speakers To Go

AA Speakers To Go is a database of more than four hundred audio recordings of AA speakers. It also offers in-app purchases for access to specialty workshops and presentations.
Price: Free
Platform: iOS and Android

NA Speakers

NA Speakers is a database of more than three hundred audio recordings of Narcotics Anonymous (NA) speakers from various conventions.
Price: Free
Platform: iOS and Android

Recovery Box

Recovery Box is a comprehensive toolkit following the Twelve Step method. The app includes tools from the Big Book and features like a recovery calculator, recovery stories, readings, in-app sponsorship, notes, inventories, and chat messaging.
Price: Free
Platform: iOS

Sober Grid

Sober Grid is a social networking app that allows people to connect with other sober individuals in their local community and worldwide.
Price: Free
Platform: iOS and Android

Headspace

Headspace has a digital library of sleep casts (i.e., soothing stories with themed environmental ambiance), relaxation and focus music, guided meditations, and even children’s content.
Price: $12.99/monthly or $69.99/yearly after a free week-long trial
Platform: iOS and Android

Meeting Finder

Meeting Finder is the official app provided by AA to find meetings, purchase AA literature, stay current on AA news, and read daily reflections.
Price: Free
Platform: iOS and Android

For parents, some apps even have tracking and drug-test monitoring to increase accountability for adolescents’ treatment plans. These apps can help parents keep track of their children’s activities when they have limited adult supervision. Even randomized or scheduled drug tests, like oral swabbing, can be completed with a health care professional monitoring over video chat.

Technology-Related Addictions

Of course, every good thing has a downside to consider. Technology can bring remarkable improvements to many people’s overall quality of life with the ease of access to fulfill crucial needs like connection, stimulation, and knowledge. However, too much of a good thing can be detrimental to recovery, especially if individuals use technology to replace drugs or alcohol.

Smartphones and the Internet have become critical to many aspects of modern life. During the COVID-19 pandemic, many computer programs like Zoom and Slack helped keep businesses running during lockdowns and social distancing protocols. Many people used their phones to stay connected to family, friends, and other loved ones when in-person visits were unsafe. Many Twelve Step meetings quickly moved to virtual platforms to assist with the dangers of isolation associated with those in recovery from addiction.

Yet, some people might have excessively used technology as a negative coping skill to manage stress or distract themselves from mental health issues. Social media apps can provide similar highs to drugs or alcohol without much effort. Any activity with a low cost/high reward ratio has the possibility of becoming an addiction, as a need is being met without much effort—picture the brainpower associated with “liking” a Facebook post or scrolling through an Instagram feed, for example.

Some of the following technology-related addictions can occur with excessive use of the Internet or smartphones.

Gambling

Many gambling apps have cropped up over the years, bringing an addictive habit right to peoples’ smartphones.

Social Media

Various social media apps can have users chasing “likes” and feedback from others. Teens and young people can be especially vulnerable to social media addiction, as they want to feel popular, attractive, and respected by their peers.

Pornography

Some people can become addicted to pornographic videos or pictures found online, as pornography can be a shortcut to the brain’s feel-good reward system that is activated during sexual intimacy.

Video Games

Video game addiction is generally associated with teenage boys and young men. However, anyone can become addicted to playing games on their smartphones, occupying large portions of their daily lives and distracting them from dealing with emotional issues.

Anything that has significant benefits can have potentially negative effects. Technology is such an integral part of people’s personal and professional lives that it is difficult to just avoid or “quit” like other addictions. Instead, maintaining a healthy relationship with technology can help individuals get the benefits without the problems. In this case, technology has some solutions for technology-related addictions.

Some apps can help monitor smartphone use in order to maintain a healthy relationship with technology. Apps can help people understand their online behavior by timing how often they open their phone, how much time they spend looking at the screen, and showing them which apps appear to be problematic. Time limits can be set for specific apps, and time-wasting websites can be blocked to keep individuals from overusing technology.

The New Paradigm of Care

The CEO of Lightning Step Technologies, Kirk Monroe, notes, “Technology in behavioral health has been outdated for many years and has been a disservice to the industry. Counselors need to be able to rely on technology providers to provide the data to make the best data-driven decisions for their clients. Factual data through a modern EMR [electronic medical record] system will be the future in how to treat clients. Knowledge is powerful and EMRs need to provide data at counselors’ fingertips to make more data-driven decisions on how to produce the best outcomes based on each specific individual case” (Z. Spowart, personal communication, December 31, 2021).

Telehealth broke onto the scene as a convenient aid aimed toward increasing accessibility, but the COVID-19 pandemic catapulted digital care to the forefront. When considering telehealth as an option, there are many factors to be mindful of: HIPAA compliance, the potential for screen burnout, poor Internet connections, technical issues, and overall cost of operations.

Billing for clinical services can be a burden for many addiction treatment providers. Clinicians are spending more time than ever documenting, and if the rule of thumb is documenting a conversation longer than five minutes, the challenge then becomes the balancing act of engaging with those in need versus the time it takes to document that interaction. Thoughts of “Do I really need to document that?” begin to creep in. The answer—and the gold standard for documentation—is almost always yes, you most likely do.

In addition, public and private insurances can have different definitions of billable services, which can lead to challenges associated with client care and length-of-stay concerns. Insurance companies require more information faster, thus burdening clinicians to perform. In this scenario, it seems that the speed and efficiency technology has brought to the industry and documentation arena actually can remove clinicians from the very thing they are seeking to engage in: face-to-face interactions with clients.

However, as technology continues to advance, documentation for services performed by clinicians and associated billing is also advancing. Electronic medical record (EMR) software companies are streamlining record-keeping and charting processes. They also provide increased security with coding and privacy protections, improve legibility and access of documentation, and shorten the turnaround time for insurance approval, thus increasing clients’ ability to receive the treatment services they need to achieve long-term recovery. For clinicians, many EMRs offer voice-to-text transcriptions, and there is also additional third-party software, such as Dragon Naturally Speaking, for those who struggle with speedy typing.

While documentation may be easier, telehealth might feel invasive to clinicians. They might struggle to establish boundaries between work and home life, leading to burnout and compassion fatigue. An example of this is in the work-life separation, or lack thereof, of clinicians working from their homes. Where does the dissociation of work duties come in when people are working from the same place they relax? How easy is it to “unplug” when e-mails, texts, Slacks, video chats, Facetime or Skype calls, and WhatsApp connections are all present, blinging, ringing, and dinging incessantly and relentlessly until a response is given? Do people dare put their phones down? What if there is an emergency? What if something else “has” to be done?

There is a solution and there is a way to accept technology without allowing it to overrun one’s life or practice. With all the positive aspects of telehealth, it is crucial for clinicians to integrate these services as one component of a thriving practice and to do so with balance and healthy boundaries.

How to Thrive While Utilizing Telehealth Services

Compassion fatigue is more likely now that the overall workload has increased due to efficiency; pings, chimes, and alerts all demanding equal priority creates a cacophony of circumstances leading to burnout. Clinicians might feel like there is no separation between work and home life, especially if they set up a home office to continue providing virtual services when in-person appointments were unsafe due to the pandemic.

Telehealth services have created a solution to many barriers to treatment for clients with disabilities, lack of transportation, or limited access to in-person treatment in their communities. Clinicians may find themselves relearning how to provide adequate care while balancing their own needs so they can be at their best for clients.

Many facilities and practices have found their flow in hybrid in-person and virtual care, but managing the workload may require different organizational tactics such as the following:

• The pomodoro technique: Working in twenty-five-minute increments with five-minute breaks can help streamline administrative tasks and break up monotonous data entry.
• Prioritize and execute: Making lists may seem like a waste of time to some, but giving tasks numerical priority allows the brain to compartmentalize more effectively.
• Make long-term plans: Making unattainable short-term goals leads to feelings of being overwhelmed and allows for goals to be moved back.

Clinicians cannot pour from an empty cup, and they cannot transmit what they do not have. Maintaining healthy boundaries and practicing good sleep hygiene and effective self-care are vital in preventing burnout and avoiding becoming overwhelmed.

Virtual Care from the Clients’ Perspectives

While clients might now have access to treatment that was limited or not an option due to barriers, they might also need to adjust to telehealth and virtual care services. The pros appear to outweigh the cons, yet clinicians need to consider their clients’ perspectives when utilizing a novel treatment approach.

Client satisfaction with virtual care can hinge on many factors, such as whether or not the individuals have adequate privacy at home; participation requirement in programming; knowledge of virtual platforms; access to a reliable Internet connection; verbal communication skills; and sometimes language barriers. When using virtual services, clinicians might need solutions to some of these issues to provide the best care. Many of these issues can be worked out in the moment, though it is best to be prepared and bring these things up even before beginning telehealth for seamless treatment.

The following tips can help clinicians connect with their clients to deliver the best possible treatment and positive outcomes:

Privacy during Sessions

Do clients have the skills to establish boundaries at home in order to have uninterrupted privacy during sessions? Family members may or may not be supportive of the clients’ treatment, and the clients also might not have the skills to ask for help to maximize their privacy. Discuss these things with clients when providing virtual care. If they have limited privacy at home, they can try things like going out to their car during sessions; scheduling therapy when family members are not home; asking other family members to help out by watching the kids or fulfilling other duties during the session; the entire house can focus on self-care during this time to foster a healthy home environment; and/or using written communication, like texts or e-mails, to supplement for struggles to communicate over the phone or video chat.

Encouraging Participation

One-on-one sessions might be easier to elicit client participation. However, group sessions can be a challenge to clients during virtual sessions. Before a telehealth session, remind clients about privacy expectations and reassure them that this is a safe space for them to open up. Clinicians might need to discuss the security and privacy of virtual platforms in order for clients to feel secure.

During group sessions, clinicians might want to have everyone do a short introduction or call on people who might be hesitant to participate, just like with an in-person group.

Teaching Clients about the Platform Being Used

While many people are familiar with a number of virtual services and apps, clinicians still want to familiarize clients with the platforms they will utilize for telehealth services. Clinicians can create tutorials with videos, pictures, and/or text to ensure that clients understand the basics, such as how to turn their cameras and microphones on, how to connect to the session, and how to communicate between sessions.

Reliable Internet Connection

While many people have access to the Internet, some clients may struggle with connectivity issues during sessions. Connectivity issues can be frustrating! Clients might open up to share vulnerable knowledge only to discover that the connection dropped, and their clinician heard nothing that was said. Troubleshooting in the moment may be indicated, or coming up with back-up plans before the session (e.g., rescheduling, switching to a phone call, and/or recapping over an e-mail or text message) may be a good practice.

Verbal Communication Skills

Without in-person meetings, clinicians and/or clients might struggle to communicate effectively without nonverbal cues. Remember that much of communication is nonverbal! Body postures, facial expressions, and gestures are just as critical as the words people speak. Be aware of clients’ ability to understand what is being said to them and limit reliance on nonverbal cues to get the message across. While web cameras can help minimize this issue, clinicians should be aware of the potential disconnect in communication without as many nonverbal cues.

Preparing for potential pitfalls in virtual care can help clinicians and clients get the most out of their sessions together. Partner with clients to navigate these new platforms and establish a shared responsibility in delivering the best treatment. Ask for feedback and be open to discussing ways to make sessions more effective for clients.

How Data Collection Helps the Recovery Community

Daniel J. Callahan, the chief visionary officer of ZenCharts, notes, “ZenCharts was founded to assist counselors with the most progressive clinical tools in their pursuit to impact lives. Simplify documentation, notify and remind for a compliant treatment episode, and assist the clinician and support staff with advanced technology for clinical decision support ensuring best practice therapeutic services (Z. Spowart, personal communication, January 2, 2022).

Data collection is critical to providing effective treatment. However, data collection can be flawed, leading to several misrepresentations about addiction treatment outcomes and who needs treatment. Technology can be used to reach underserved populations and can improve assessments prior to addiction treatment.

Due to their ease of use and anonymity, online surveys have been useful in understanding public health issues. Additionally, online surveys can be sent to a wide array of individuals from different backgrounds in terms of age, gender, sexual orientation, race, and income. For the recovery community, this information can help to identify strengths and weaknesses of various treatment modalities, relapse rates, treatment gaps within specific areas, and underserved populations.

Because most Americans carry a smartphone with them throughout the majority of their day, they can also check in with therapists throughout the day before sessions, and even get feedback on their urine tests and/or blood alcohol levels from remote monitoring options. Real-time monitoring and feedback regarding clients’ symptoms can improve outcomes in therapy and help to gain a deeper understanding of any underlying issues.

When clients and clinicians team up to monitor symptoms and emotions throughout the day, a more thorough evaluation of clients’ issues can come to light. While one-on-one sessions are valuable for clients to learn new coping skills, the real work takes place outside clinicians’ offices. With daily feedback via smartphone therapy apps or text messaging between sessions, both clinicians and clients gain a clearer construct of the issues at hand.

Overall, data collection can lead to more accurate diagnoses and can help to meet treatment needs that might otherwise be overlooked between sessions.

According to Jones, “The future of treatment is bright. There are now so many companies working with data in mind. The more we collaborate, refine, and learn from this data, the more the quality of treatment will continue to increase. There’s a long road ahead, but I’m very optimistic” (Z. Spowart, personal communication, January 1, 2022).

Conclusion

While the advancement of technology in addiction and mental health recovery presents many positives and challenges, none of them are impossible to navigate with our human ingenuity. The continuum of care is broader, the reach we have is greater, and our connections are more profound now than ever.

Technology is here to stay and will forever advance. It is up to us to adapt along with it and ensure that—as humans and as people in recovery—we are practicing healthy boundaries, remaining vulnerable to those who seek to help us, and monitoring those desires for instant gratification, which have become so easily accessible to us. What we choose to do with the technology we are presented with defines us. Let us choose to use it well!

References

• Alcoholics Anonymous World Services (AA World Services). (2013). Alcoholics anonymous. New York, NY: Author.
• Pew Research Center. (2021a). Internet/broadband fact sheet. Retrieved from https://www.pewresearch.org/internet/fact-sheet/internet-broadband/
• Pew Research Center. (2021b). Mobile fact sheet. Retrieved from https://www.pewresearch.org/internet/fact-sheet/mobile/
• Priester, M. A., Browne, T., Iachini, A., Clone, S., DeHart, D., & Seay, K. D. (2016). Treatment access barriers and disparities among individuals with co-occurring mental health and substance use disorders: An integrative literature review. Journal of Substance Abuse Treatment, 61, 47–59.
• Substance Abuse and Mental Health Services Administration (SAMHSA). (2021). Key substance use and mental health indicators in the United States: Results from the 2020 National Survey on Drug Use and Health. Retrieved from https://www.samhsa.gov/data/sites/default/files/reports/rpt35325/NSDUHFFRPDFWHTMLFiles2020/2020NSDUHFFR1PDFW102121.pdf