Incentives Might Boost Abstinence Among American Indians, Alaska Natives

By Marilynn Larkin

March 09, 2021

NEW YORK (Reuters Health) - A culturally tailored version of contingency management (CM), a behavioral intervention involving positive reinforcement, increased abstinence among American Indians (AIs) and Alaska Natives (ANs) with alcohol use disorder in a randomized trial.

CM recipients received treatment as usual in addition to incentives for submitting alcohol-negative urine samples. In this study, CM was adapted by decreasing the frequency of intervention visits from three to two times weekly, providing materials in the native languages of participating communities, and offering practical and cultural incentives.

"An adapted form of CM is an effective tool that can be used to help AI/AN adults reduce their alcohol use and it is a low-cost intervention that can be implemented in a variety of AI/AN healthcare settings," Dr. Michael McDonell of the Elson S. Floyd College of Medicine, Washington State University in Spokane told Reuters Health by email.

"While we didn't report drinking results (beyond) the end of the intervention, other studies in non-AI/AN populations have observed long-term effects of the intervention for up to one year," he said. "The best predictor of long-term abstinence after any treatment is the duration of abstinence during treatment, so I would anticipate that those who responded well to CM would go on to maintain abstinence after the study."

As reported in JAMA Psychiatry, 400 participants were enrolled in a one-month observation period before randomization to determine whether they needed the intervention (i.e., those who continued to use alcohol, as verified by ethyl glucuronide levels) and could make the required twice-weekly visits.

Ultimately, 158 individuals (39.5%) who submitted four or more urine samples and one alcohol-positive urine test result were randomized to CM or the control group. The mean age was 42 and 53% were men. The three-month intervention was conducted at three healthcare organizations in Alaska, the Pacific Northwest and the Northern Plains from 2014-2019.

During the intervention phase, participants submitted urine samples twice weekly for 12 weeks. CM participants only received incentives - prizes - when the test result from their submitted urine sample showed alcohol abstinence.

Control group participants received prizes for each urine sample submitted, regardless of the urine test results. The control group was used to reduce missing data and equalize the value of incentives across the groups.

At 16 weeks -- four weeks after the end of the intervention -- 19 participants (59.4%) in the intervention group submitted an alcohol-negative urine sample versus 18 (38.3%) in the control group.

CM group participants had a higher likelihood of submitting an alcohol-negative urine sample (averaged over time) compared with controls (odds ratio, 1.70).

Based on generalized estimating equation estimates, participants in the control and CM groups had a 52.8% and 65.6% probability, respectively, of submitting an alcohol-abstinent urine sample during the intervention period. The estimated risk difference between treatment groups was 12.8%.

Further, the CM group had fewer adverse events (85 vs. 65) and fewer serious adverse events (four vs. one). No events were study-associated. The most common adverse event was a non-alcohol-associated emergency department visit (66 events).

Dr. McDonell noted, "Federal prohibitions to using incentives with Medicare and Medicaid clients really prohibit the ability of providers to use CM. We need policy changes to make sure that clinicians and providers serving AI/AN people are able to use this important intervention."

Dr. Christopher Johnston, Chief Medical Officer of Pinnacle Treatment Centers, headquartered in Mount Laurel Township, New Jersey, commented by email to Reuters Health, "This is a simple approach that is easy to teach to people who work with patients with alcohol use disorder. It has no side effects and is beneficial to a population that is hard to help."

"The data collected confirmed previous studies' positive outcomes," he said. "The design of the study carefully eliminated other variables that might have led to beneficial effects. Similar findings have been reported in other populations with this approach."

That said, he added, "This is a short-term study. Longer term studies would be helpful to see how long the effects of the intervention last."

Like Dr. McDonell, he noted, "Coverage by commercial insurance and Medicaid would be an important piece in using this widely."

SOURCE: https://bit.ly/2OA9ODI and https://bit.ly/30p5wSu JAMA Psychiatry, online March 3, 2021.

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