Home-Based Contingency Management Delivered by Community Health Workers to Improve Alcohol Abstinence

A Randomized Control Trial

Tawanchai Jirapramukpitak; Keerati Pattanaseri; Kia-Chong Chua; Patcharapim Takizawa

Disclosures

Alcohol Alcohol. 2020;55(2):171-178. 

In This Article

Abstract and Introduction

Abstract

Aim: To evaluate the effectiveness of home-based contingency management (CM) in improving abstinence in an incentive-dependent manner among alcoholic individuals.

Methods: A 12-week, home-visit (HV) only controlled, randomized incentive-ranging trial of 161 adults with current alcohol dependence was recruited using social network theory techniques. Participants randomly received HV, low- (CM-L) or higher-magnitude CM (CM-H). Community health workers made regular home visits, monitored drinking behavior and delivered CM as appropriate. Two follow-up visits at weeks 13 and 16 were conducted to assess whether abstinence would still be maintained after the interventions discontinued. Rates of continuous reported abstinence (primary), numbers of positive breath samples (secondary) over the intervention period and rates of prolonged reported abstinence (secondary) were evaluated.

Results: CM did not significantly improve the rates of continuous reported abstinence across the 12-week intervention period (odds ratio (OR) for trend 1.2, 95% confidence interval (CI) 0.7–2.1, P = 0.601). There was a significant reduction, however, in the average number of positive breath samples submitted by the CM-H group (generalized linear model, β −0.5, 95% CI −0.9 to −0.2, P = 0.005). The CM-H arm also had a significantly higher abstinence rate during the follow-up period (OR 3.4, 95% CI 1.3–8.8, P = 0.013). Event history model suggested that the CM-H condition had significantly higher chances of achieving renewed abstinence across the study period (OR 2.0, 95% CI 1.3–3.2, P = 0.003).

Conclusions: Home-based CM with sufficient incentive is promising in reducing alcohol use and in improving rates of abstinence over time. Allowing for a certain grace period may better capture the delayed treatment effect of home-based CM.

Introduction

Alcohol imposes a huge social and economic burden worldwide (Thavorncharoensap et al., 2009; GBD 2016 Alcohol and Drug Use Collaborators, 2018). In Thailand, alcohol drinking problem is a leading cause of disease burden and ranks number one cause among men, contributing to 8.1% of the total burden of disease from all causes (in disability-adjusted life years) (Thai Working Group on Burden of Disease, 2018). A national mental health survey estimated that 5.3% of the Thai population aged 18 or over had alcohol-use problems in the past 12 months (Silpakit et al., 2017).

Existing evidence-based treatment programs for alcoholic patients are largely facility based (Raistrick et al., 2006) and delivered by highly skilled health professionals; thus, their use is limited by complexity, low availability, high costs and high dropout rates. As in many low- and middle-income countries, facility-based treatment programs for alcohol and drug use in Thailand are scarce, making it difficult for the majority of patients to access these services. Thus, there is a great need for alternatives, which are less costly and easier to deliver in order to increase their availability and accessibility.

The treatment approach 'contingency management' (CM) has been found to be effective. Meta-analysis of the efficacy of psychosocial therapies for various substance-using populations found that CM has the largest effect size (Dutra et al., 2008). However, CM is typically delivered by facility-based providers and offered in a relatively limited number of places. CM delivered instead at home by community health workers may be a more practical alternative. Moreover, home-based CM could potentially be cheaper, decrease treatment drop-out rates, and promote a deeper engagement of patients and their families in care, due to the benefits commonly found in the home-care approach (Kanter, 1996). Such benefits might also help in improving abstinence.

In Thailand, simple home-based interventions are often delivered by community health workers, also widely known as village health volunteers (VHVs). They are a major part of the country's primary healthcare system, playing a crucial role in basic and continuing care and making health services more available, accessible and acceptable. Currently, there are approximately a million VHVs across the country, each working with 7–12 families in most communities (Kowitt et al., 2015).

In the present study, we sought to develop and test a model of home-based care to be delivered by VHVs for alcoholic patients based on the CM principles. The aims were: (a) to assess the effectiveness of CM in improving continuous abstinence rates among alcohol-dependent individuals during the intervention period (primary outcome), and (b) to examine their effectiveness in reducing alcohol use during the intervention period and in improving renewed abstinence over time (secondary).

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