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Effect of Incentives for Alcohol Abstinence in Partnership With 3 American Indian and Alaska Native CommunitiesA Randomized Clinical Trial

Educational Objective:
To determine whether a culturally tailored contingency management intervention, in which incentives were offered for biologically verified alcohol abstinence, resulted in increased abstinence among American Indian and Alaska Native adults. This study hypothesized that adults assigned to receive a contingency management intervention would have higher levels of alcohol abstinence than those assigned to the control condition.

1 Credit CME

JAMA Psychiatry

Published Online: March 3, 2021

Original Investigation

Article Information and Disclosures

Michael G. McDonell, PhD^1,2,3;

Katherine A. Hirchak, PhD^1,2;

Jalene Herron, MS^4,5;

et al

Abram J. Lyons, MSW^1,2;

Karl C. Alcover, PhD^1,2;

Jennifer Shaw, PhD⁶;

Gordon Kordas, MS^1,2;

Lisa G. Dirks, MSIS, MLIS⁶;

Kelley Jansen, MS⁶;

Jaedon Avey, PhD⁶;

Kate Lillie, PhD⁶;

Dennis Donovan, PhD^7,8;

Sterling M. McPherson, PhD^1,2,3;

Denise Dillard, PhD⁶;

Richard Ries, MD⁸;

John Roll, PhD^1,2;

Dedra Buchwald, MD^1,9;

for the HONOR Study Team

Author Affiliations

¹Department of Medical Education and Clinical Sciences, Elson S. Floyd College of Medicine, Washington State University, Spokane
²Program of Excellence in Addictions Research, Washington State University, Spokane
³Institute for Research and Education to Advance Community Health, Washington State University, Spokane
⁴Center on Alcoholism, Substance Abuse and Addictions, University of New Mexico, Albuquerque
⁵Department of Psychology, University of New Mexico, Albuquerque
⁶Southcentral Foundation, Anchorage, Alaska
⁷Alcohol and Drug Abuse Institute, University of Washington, Seattle
⁸Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle
⁹Institute for Research and Education to Advance Community Health, Washington State University, Spokane

HONOR Study Teamfor the

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Key Points

Question Are incentives for alcohol abstinence an effective intervention for reducing alcohol use among American Indian and Alaska Native adults diagnosed with alcohol dependence?

Findings In this randomized clinical trial of 158 American Indian and Alaska Native adults with alcohol dependence, participants who received incentives for biologically confirmed alcohol abstinence were significantly more likely to submit alcohol-abstinent urine samples during the intervention period compared with participants who did not receive incentives for abstinence.

Meaning The study’s results indicated that the provision of tangible incentives for alcohol abstinence, also known as contingency management, may be an effective strategy to help American Indian and Alaska Native adults diagnosed with alcohol dependence attain abstinence.

Abstract

Importance Many American Indian and Alaska Native communities are disproportionately affected by problems with alcohol use and seek culturally appropriate and effective interventions for individuals with alcohol use disorders.

Objective To determine whether a culturally tailored contingency management intervention, in which incentives were offered for biologically verified alcohol abstinence, resulted in increased abstinence among American Indian and Alaska Native adults. This study hypothesized that adults assigned to receive a contingency management intervention would have higher levels of alcohol abstinence than those assigned to the control condition.

Design, Setting, and Participants This multisite randomized clinical trial, the Helping Our Native Ongoing Recovery (HONOR) study, included a 1-month observation period before randomization and a 3-month intervention period. The study was conducted at 3 American Indian and Alaska Native health care organizations located in Alaska, the Pacific Northwest, and the Northern Plains from October 10, 2014, to September 2, 2019. Recruitment occurred between October 10, 2014, and February 20, 2019. Eligible participants were American Indian or Alaska Native adults who had 1 or more days of high alcohol-use episodes within the last 30 days and a current diagnosis of alcohol dependence. Data were analyzed from February 1 to April 29, 2020.

Interventions Participants received treatment as usual and were randomized to either the contingency management group, in which individuals received 12 weeks of incentives for submitting a urine sample indicating alcohol abstinence, or the control group, in which individuals received 12 weeks of incentives for submitting a urine sample without the requirement of alcohol abstinence. Regression models fit with generalized estimating equations were used to assess differences in abstinence during the intervention period.

Main Outcomes and Measures Alcohol-negative ethyl glucuronide (EtG) urine test result (defined as EtG<150 ng/mL).

Results Among 1003 adults screened for eligibility, 400 individuals met the initial criteria. Of those, 158 individuals (39.5%; mean [SD] age, 42.1 [11.4] years; 83 men [52.5%]) met the criteria for randomization, which required submission of 4 or more urine samples and 1 alcohol-positive urine test result during the observation period before randomization. A total of 75 participants (47.5%) were randomized to the contingency management group, and 83 participants (52.5%) were randomized to the control group. At 16 weeks, the number who submitted an alcohol-negative urine sample was 19 (59.4%) in the intervention group vs 18 (38.3%) in the control group. Participants randomized to the contingency management group had a higher likelihood of submitting an alcohol-negative urine sample (averaged over time) compared with those randomized to the control group (odds ratio, 1.70; 95% CI, 1.05-2.76; P = .03).

Conclusions and Relevance The study’s findings indicate that contingency management may be an effective strategy for increasing alcohol abstinence and a tool that can be used by American Indian and Alaska Native communities for the treatment of individuals with alcohol use disorders.

Trial Registration ClinicalTrials.gov Identifier: NCT02174315

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Article Information

Accepted for Publication: December 18, 2020.

Published Online: March 3, 2021. doi:10.1001/jamapsychiatry.2020.4768

Corresponding Author: Michael G. McDonell, PhD, Department of Medical Education and Clinical Sciences, Elson S. Floyd College of Medicine, Washington State University, PO Box 1495, Spokane, WA 99210-1495 (mmcdonell@wsu.edu).

Author Contributions: Dr McDonell had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: McDonell, Avey, Dillard, Ries, Roll, Buchwald.

Acquisition, analysis, or interpretation of data: McDonell, Hirchak, Herron, Lyons, Alcover, Shaw, Kordas, Dirks, Jansen, Avey, Lillie, Donovan, McPherson, Buchwald.

Drafting of the manuscript: McDonell, Hirchak, Herron, Lyons, Alcover, Kordas, Dirks, Jansen, Donovan, McPherson, Buchwald.

Critical revision of the manuscript for important intellectual content: McDonell, Herron, Lyons, Shaw, Jansen, Avey, Lillie, Donovan, McPherson, Dillard, Ries, Roll, Buchwald.

Statistical analysis: McDonell, Lyons, Alcover, Kordas, Donovan, McPherson, Buchwald.

Obtained funding: McDonell, Roll.

Administrative, technical, or material support: McDonell, Hirchak, Herron, Lyons, Shaw, Dirks, Jansen, Avey, Lillie, McPherson, Roll.

Supervision: McDonell, Shaw, McPherson, Dillard, Buchwald.

Other - site PI: Shaw.

Conflict of Interest Disclosures: Dr McDonell reported receiving grants from the National Institutes of Health during the conduct of the study and receiving funding from a tribally owned for-profit medical clinic to evaluate clinical outcomes outside the submitted work. Dr Hirchak reported receiving grants from the National Institute on Alcohol Abuse and Alcoholism during the conduct of the study. Ms Herron reported receiving grants from the National Institute on Alcohol Abuse and Alcoholism during the conduct of the study. Dr Avey reported receiving grants from the National Institute on Alcohol Abuse and Alcoholism during the conduct of the study. Dr McPherson reported receiving grants from the National Institutes of Health during the conduct of the study and serving as a consultant for Consistent Care and receiving funding from the Bristol Myers Squibb Foundation, Managed Health Connections, the Orthopedic Specialty Institute (Coeur d’Alene, Idaho), Ringful Health, and the US Department of Justice outside the submitted work. Dr Ries reported receiving grants from the National Institutes of Health during the conduct of the study and serving as a consultant for 2 tribally operated addiction treatment programs outside the submitted work. No other disclosures were reported.

Funding/Support: Funding for this study was provided by grant R01 AA022070 from the National Institute on Alcohol Abuse and Alcoholism and the Office of Behavioral and Social Science Research at the National Institutes of Health (Drs McDonell and Buchwald). The dissemination of study results was supported by grant P60 AA024334 from the National Institute on Alcohol Abuse and Alcoholism (Dr Buchwald), grant T32 AA018108 from the National Institute on Alcohol Abuse and Alcoholism (Dr McCrady), grant K01 AA028831-01 from the National Institute on Alcohol Abuse and Alcoholism (Dr Hirchak), grant S06 GM127911 from the National Institute on Alcohol Abuse and Alcoholism (Dr Ferucci), grant S06 GM123545 from the National Institute of General Medical Sciences Native American Research Centers for Health (Dr Hiratsuka), and grant S06 GM127911 from the National Institute of General Medical Sciences Native American Research Centers for Health (Dr Ferucci).

Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Group Information: The HONOR Study Team members are listed in Supplement 2.

Disclaimer: The views expressed in this article do not necessarily represent the views of any participating tribe or partnering organization.

Additional Contributions: We thank the communities who chose to partner with us on this study as well as all the participants who made this study possible. We also thank the members of our data safety and monitoring board. We acknowledge in a special way our relatives who died during the study, including our data safety monitoring board chair, Nancy Petry, PhD, without whom this study would not have been possible.

References

Getches DH , Wilkinson CF , Williams RA , Jr. Cases and Materials on Federal Indian Law. 4th ed. West Group; 1998.

National Conference of State Legislatures. Federal and state recognized tribes. Updated March 2020. Accessed May 26, 2020. https://www.ncsl.org/research/state-tribal-institute/list-of-federal-and-state-recognized-tribes.aspx

Cunningham JK , Solomon TA , Muramoto ML . Alcohol use among Native Americans compared to Whites: examining the veracity of the ‘Native American elevated alcohol consumption’ belief. Drug Alcohol Depend. 2016;160:65-75. doi:10.1016/j.drugalcdep.2015.12.015 PubMed Google Scholar Crossref

National Institute on Alcohol Abuse and Alcoholism. Alcohol Use and Alcohol Use Disorders in the United States: Main Findings From the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). National Institutes of Health; 2006. US Alcohol Epidemiologic Data Reference Manual. Vol 8. NIH publication 05-5737. Accessed May 8, 2020. https://pubs.niaaa.nih.gov/publications/NESARC_DRM/NESARCDRM.pdf

Center for Behavioral Health Statistics and Quality. Results from the 2017 National Survey on Drug Use and Health: detailed tables. Substance Abuse and Mental Health Services Administration; 2018. Accessed April 27, 2020. https://www.samhsa.gov/data/report/2017-nsduh-detailed-tables

Grant BF , Goldstein RB , Saha TD , et al. Epidemiology of DSM-5 alcohol use disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions III. JAMA Psychiatry. 2015;72(8):757-766. doi:10.1001/jamapsychiatry.2015.0584 PubMed Google Scholar Crossref

Landen M , Roeber J , Naimi T , Nielsen L , Sewell M . Alcohol-attributable mortality among American Indians and Alaska Natives in the United States, 1999-2009. Am J Public Health. 2014;104(suppl 3):S343-S349. doi:10.2105/AJPH.2013.301648 PubMed Google Scholar Crossref

Center for Behavioral Health Statistics and Quality. The NSDUH report: need for and receipt of substance use treatment among American Indians or Alaska Natives. Substance Abuse and Mental Health Services Administration; 2012. Accessed February 18, 2019. https://www.samhsa.gov/data/sites/default/files/NSDUH120/NSDUH120/SR120-treatment-need-AIAN.htm

Emerson MA , Moore RS , Caetano R . Correlates of alcohol-related treatment among American Indians and Alaska Natives with lifetime alcohol use disorder. Alcohol Clin Exp Res. 2019;43(1):115-122. doi:10.1111/acer.13907 PubMed Google Scholar Crossref

10.

Beals J , Novins DK , Spicer P , Whitesell NR , Mitchell CM , Manson SM ; American Indian Service Utilization, Psychiatric Epidemiology, Risk, and Protective Factors Project Team. Help seeking for substance use problems in two American Indian reservation populations. Psychiatr Serv. 2006;57(4):512-520. doi:10.1176/ps.2006.57.4.512 PubMed Google Scholar Crossref

11.

Dickerson DL , Spear S , Marinelli-Casey P , Rawson R , Li L , Hser Y-I . American Indians/Alaska Natives and substance abuse treatment outcomes: positive signs and continuing challenges. J Addict Dis. 2011;30(1):63-74. doi:10.1080/10550887.2010.531665 PubMed Google Scholar Crossref

12.

Johnson JL , Cameron MC . Barriers to providing effective mental health services to American Indians. Ment Health Serv Res. 2001;3(4):215-223. doi:10.1023/A:1013129131627 PubMed Google Scholar Crossref

13.

Evans E , Spear SE , Huang Y-C , Hser Y-I . Outcomes of drug and alcohol treatment programs among American Indians in California. Am J Public Health. 2006;96(5):889-896. doi:10.2105/AJPH.2004.055871 PubMed Google Scholar Crossref

14.

Legha RK , Novins D . The role of culture in substance abuse treatment programs for American Indian and Alaska Native communities. Psychiatr Serv. 2012;63(7):686-692. doi:10.1176/appi.ps.201100399 PubMed Google Scholar Crossref

15.

Koithan M , Farrell C . Indigenous Native American healing traditions. J Nurse Pract. 2010;6(6):477-478. doi:10.1016/j.nurpra.2010.03.016 PubMed Google Scholar Crossref

16.

Villanueva M , Tonigan JS , Miller WR . Response of Native American clients to three treatment methods for alcohol dependence. J Ethn Subst Abuse. 2007;6(2):41-48. doi:10.1300/J233v06n02_04 PubMed Google Scholar Crossref

17.

Foley K , Pallas D , Forcehimes AA , et al. Effect of job skills training on employment and job seeking behaviors in an American Indian substance abuse treatment sample. J Vocat Rehabil. 2010;33(3):181-192. doi:10.3233/JVR-2010-0526 PubMed Google Scholar Crossref

18.

O’Malley SS , Robin RW , Levenson AL , et al. Naltrexone alone and with sertraline for the treatment of alcohol dependence in Alaska natives and non-natives residing in rural settings: a randomized controlled trial. Alcohol Clin Exp Res. 2008;32(7):1271-1283. doi:10.1111/j.1530-0277.2008.00682.x PubMed Google Scholar Crossref

19.

Benishek LA , Dugosh KL , Kirby KC , et al. Prize-based contingency management for the treatment of substance abusers: a meta-analysis. Addiction. 2014;109(9):1426-1436. doi:10.1111/add.12589 PubMed Google Scholar Crossref

20.

Dutra L , Stathopoulou G , Basden SL , Leyro TM , Powers MB , Otto MW . A meta-analytic review of psychosocial interventions for substance use disorders. Am J Psychiatry. 2008;165(2):179-187. doi:10.1176/appi.ajp.2007.06111851 PubMed Google Scholar Crossref

21.

McDonell MG , Srebnik D , Angelo F , et al. Randomized controlled trial of contingency management for stimulant use in community mental health patients with serious mental illness. Am J Psychiatry. 2013;170(1):94-101. doi:10.1176/appi.ajp.2012.11121831 PubMed Google Scholar Crossref

22.

McDonell MG , Leickly E , McPherson S , et al. A randomized controlled trial of ethyl glucuronide–based contingency management for outpatients with co-occurring alcohol use disorders and serious mental illness. Am J Psychiatry. 2017;174(4):370-377. doi:10.1176/appi.ajp.2016.16050627 PubMed Google Scholar Crossref

23.

Petry NM , Martin B , Cooney JL , Kranzler HR . Give them prizes, and they will come: contingency management for treatment of alcohol dependence. J Consult Clin Psychol. 2000;68(2):250-257. doi:10.1037/0022-006X.68.2.250 PubMed Google Scholar Crossref

24.

Koffarnus MN , Wong CJ , Diemer K , et al. A randomized clinical trial of a therapeutic workplace for chronically unemployed, homeless, alcohol-dependent adults. Alcohol. 2011;46(5):561-569. doi:10.1093/alcalc/agr057 PubMed Google Scholar Crossref

25.

Hirchak KA , Leickly E , Herron J , et al; HONOR Study Team. Focus groups to increase the cultural acceptability of a contingency management intervention for American Indian and Alaska Native communities. J Subst Abuse Treat. 2018;90:57-63. doi:10.1016/j.jsat.2018.04.014 PubMed Google Scholar Crossref

26.

McDonell MG , Skalisky J , Burduli E , et al. The rewarding recovery study: a randomized controlled trial of incentives for alcohol and drug abstinence with a rural American Indian community. Addiction. Published online November 21, 2020. PubMed Google Scholar

27.

Burduli E , Skalisky J , Hirchak K , et al. Contingency management intervention targeting co-addiction of alcohol and drugs among American Indian adults: design, methodology, and baseline data. Clin Trials. 2018;15(6):587-599. doi:10.1177/1740774518796151 PubMed Google Scholar Crossref

28.

World Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA. 2013;310(20):2191-2194. doi:10.1001/jama.2013.281053 PubMed Google Scholar Crossref

29.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. American Psychiatric Association; 1994.

30.

Lecrubier Y , Sheehan DV , Weiller E , et al The Mini International Neuropsychiatric Interview (MINI). a short diagnostic structured interview: reliability and validity according to the CIDI. Eur Psychiatry. 1997;12(5):224-231. doi:10.1016/S0924-9338(97)83296-8 Google Scholar Crossref

31.

McDonell MG , Nepom JR , Leickly E , et al. A culturally-tailored behavioral intervention trial for alcohol use disorders in three American Indian communities: rationale, design, and methods. Contemp Clin Trials. 2016;47:93-100. doi:10.1016/j.cct.2015.12.010 PubMed Google Scholar Crossref

32.

Silverman K , Wong CJ , Needham M , et al. A randomized trial of employment-based reinforcement of cocaine abstinence in injection drug users. J Appl Behav Anal. 2007;40(3):387-410. doi:10.1901/jaba.2007.40-387 PubMed Google Scholar Crossref

33.

Lowe JM , McDonell MG , Leickly E , et al. Determining ethyl glucuronide cutoffs when detecting self-reported alcohol use in addiction treatment patients. Alcohol Clin Exp Res. 2015;39(5):905-910. doi:10.1111/acer.12699 PubMed Google Scholar Crossref

34.

McDonell MG , Skalisky J , Leickly E , et al. Using ethyl glucuronide in urine to detect light and heavy drinking in alcohol dependent outpatients. Drug Alcohol Depend. 2015;157:184-187. doi:10.1016/j.drugalcdep.2015.10.004 PubMed Google Scholar Crossref

35.

Carise D , McLellan AT . Increasing cultural sensitivity of the Addiction Severity Index (ASI): an example with Native Americans in North Dakota. Special Report. Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration; 1999. Accessed March 19, 2020. https://files.eric.ed.gov/fulltext/ED449953.pdf

36.

van Buuren S . Flexible Imputation of Missing Data. 2nd ed. Chapman & Hall; 2018. doi:10.1201/9780429492259

37.

van Buuren S , Groothuis-Oudshoorn K . MICE: multivariate imputation by chained equations in R. J Stat Softw. 2011;45(3):1-67. doi:10.18637/jss.v045.i03 Google Scholar

38.

Halekoh U , Hojsgaard S , Yan J . The R package geepack for generalized estimating equations. J Stat Softw. 2006;15(2):1-11. doi:10.18637/jss.v015.i02 Google Scholar Crossref

39.

McDaniel LS , Henderson NC , Rathouz PJ . Fast pure R implementation of GEE: application of the matrix package. R J. 2013;5(1):181-187. doi:10.32614/RJ-2013-017 PubMed Google Scholar Crossref

40.

Vinikoor MJ , Zyambo Z , Muyoyeta M , Chander G , Saag MS , Cropsey K . Point-of-care urine ethyl glucuronide testing to detect alcohol use among HIV-hepatitis B virus coinfected adults in Zambia. AIDS Behav. 2018;22(7):2334-2339. doi:10.1007/s10461-018-2030-8 PubMed Google Scholar Crossref

41.

EtG test. Confirm Biosciences. Published 2020. Accessed May 26, 2020. https://www.confirmbiosciences.com/knowledge/terminology/etg/

42.

McPherson S , Barbosa-Leiker C , McDonell M , Howell D , Roll J . Longitudinal missing data strategies for substance use clinical trials using generalized estimating equations: an example with a buprenorphine trial. Hum Psychopharmacol. 2013;28(5):506-515. doi:10.1002/hup.2339 PubMed Google Scholar Crossref

43.

McPherson S , Barbosa-Leiker C , Burns GL , Howell D , Roll J . Missing data in substance abuse treatment research: current methods and modern approaches. Exp Clin Psychopharmacol. 2012;20(3):243-250. doi:10.1037/a0027146 PubMed Google Scholar Crossref

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Effect of Incentives for Alcohol Abstinence in Partnership With 3 American Indian and Alaska Native CommunitiesA Randomized Clinical Trial

Increasing Alcohol Abstinence in American Indian and Alaska Native People Using Contingency Management Therapy

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