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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
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.

Data Sharing Statement: See Supplement 3.

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.

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