Adapting a Financial Incentives Intervention for Smoking Cessation with Alaska Native Families: Phase 1 Qualitative Research to Inform the Aniqsaaq (To Breathe) Study

INTRODUCTION

Alaska Native and American Indian (ANAI) peoples in Alaska currently experience a disproportionate burden of morbidity and mortality from tobacco cigarette use. Financial incentives for smoking cessation are evidence-based, but a family-level incentive structure has not been evaluated. We used a community-based participatory research and qualitative approach to culturally adapt a smoking cessation intervention with ANAI families.

METHODS

We conducted individual, semi-structured telephone interviews with 12 ANAI adults who smoke, 12 adult family members, and 13 Alaska Tribal Health System stakeholders statewide between November 2022-March 2023. Through content analysis, we explored intervention receptivity, incentive preferences, culturally aligned recruitment and intervention messaging, and future implementation needs.

RESULTS

Participants were receptive to the intervention. Involving a family member was viewed as novel and aligned with ANAI cultural values of commitment to community and familial interdependence. Major themes included choosing a family member who is supportive and understanding, keeping materials positive and encouraging, and offering cash and non-cash incentives for family members to choose (e.g., fuel, groceries, activities). Participants indicated that messaging should emphasize family collaboration and that cessation resources and support tips should be provided. Stakeholders also reinforced that program materials should encourage the use of other existing evidence-based cessation therapies (e.g., nicotine replacement, counseling).

CONCLUSIONS

Adaptations, grounded in ANAI cultural strengths were made to the intervention and recruitment materials based on participant feedback. Next steps include a beta-test for feasibility and a randomized controlled trial for efficacy.

IMPLICATIONS

This is the first study to design and adapt a financial incentives intervention promoting smoking cessation among Alaska Native or American Indian (ANAI) peoples and the first to involve the family system. Feedback from this formative work was used to develop a meaningful family-level incentive structure with ANAI people who smoke and family members and ensure intervention messaging is supportive and culturally aligned. The results provide qualitative knowledge that can inform future family-based interventions with ANAI communities, including our planned randomized controlled trial of the intervention.

Budget Impact Tool for Implementing Contingency Management for Co-occurring Alcohol Use Disorders and Serious Mental Illness

OBJECTIVE

Contingency management (CM) is a behavioral intervention in which tangible incentives are provided to patients when they achieve a desired behavior (e.g., reducing or abstaining from alcohol use). The authors sought to describe the resource requirements and associated costs of various CM versions (usual, high magnitude, and shaping) tailored to a high-risk population with co-occurring serious mental illness and severe alcohol use disorder.

METHODS

A microcosting analysis was conducted to identify the resource requirements of the different CM versions. This approach included semistructured interviews with site investigators, who also staffed the intervention. The resource costing method-multiplying the number of units of each resource utilized by its respective unit cost-was used to value the resources from a provider's perspective. All cost estimates were calculated in 2021 U.S. dollars.

RESULTS

The cost of setting up a CM program was $6,038 per site. Assuming full capacity and 56% of urine samples meeting the requirement for receipt of the CM incentive, the average cost of 16 weeks of usual and shaping CM treatments was $1,119-$1,136 and of high-magnitude CM was $1,848-$1,865 per participant.

CONCLUSIONS

A customizable tool was created to estimate the costs associated with various levels of treatment success and CM design features. After the trial, the tool will be updated and used to finalize per-participant cost for incorporation into a comprehensive economic evaluation. This costing tool will help a growing number of treatment providers who are interested in implementing CM with budgeting for and sustaining CM in their practices.

Feasibility of a telehealth-based contingency management intervention for alcohol use disorders using the phosphatidylethanol (PEth) 16:0/18:1 alcohol biomarker: a pilot randomized trial

Background: Phosphatidylethanol (PEth) is a blood-based biomarker for alcohol consumption that can be self-collected and has high sensitivity, specificity, and a longer detection window compared to other alcohol biomarkers.Objectives: We evaluated the feasibility and acceptability of a telehealth-based contingency management (CM) intervention for alcohol use disorder (AUD) using the blood-based biomarker PEth to assess alcohol consumption.Methods: Sixteen adults (7 female, 9 male) with AUD were randomized to Control or CM conditions. Control participants received reinforcers regardless of their PEth levels. CM participants received reinforcers for week-to-week decreases in PEth (Phase 1) or maintenance of PEth consistent with abstinence (<20 ng/mL, Phase 2). Blood samples were self-collected using the TASSO-M20 device. Acceptability was assessed by retention in weeks. Satisfaction was assessed with the Client Satisfaction Questionnaire (CSQ-8) and qualitative interviews. The primary efficacy outcome was PEth-defined abstinence. Secondary outcomes included the proportion of visits with PEth-defined heavy alcohol consumption, negative urine ethyl glucuronide results, and self-reported alcohol use.Results: Retention averaged 18.6 ± 8.8 weeks for CM participants. CM participants reported high levels of satisfaction (CSQ-8, Mean = 30.3 ± 1.5). Interview themes included intervention positives, such as staff support, quality of life improvement, and accountability. 72% of PEth samples from CM participants were consistent with abstinence versus 34% for Control participants (OR = 5.0, p = 0.007). PEth-defined heavy alcohol consumption was detected in 28% of CM samples and 52% of Control samples (OR = 0.36, p = 0.159). CM participants averaged 1.9 ± 1.7 drinks/day versus 4.2 ± 6.3 for Control participants (p = 0.304).Conclusion: Results support the acceptability and satisfaction of a telehealth PEth-based CM intervention, though a larger study is needed to assess its efficacy [NCT04038021].

Mobile Medication Adherence Platform for Buprenorphine (MAP4BUP): A Phase I feasibility, usability and efficacy pilot randomized clinical trial

BACKGROUND/AIM

Poor medication adherence is one of the main barriers to the long-term efficacy of buprenorphine/naloxone (BUP/NAL). The aims of this pilot investigation were to examine if a Bluetooth-enabled pill cap and mobile application is a feasible, usable tool for increasing BUP/NAL adherence among people with an opioid use disorder.

METHODS

This pilot randomized clinical trial (RCT; total n = 41) lasted 12 weeks and was conducted in two office-based BUP/NAL provider locations in Spokane, WA and Coeur d'Alene, ID from January 2020 to September of 2021 with an 11-month gap due to COVID-19. Patients receiving BUP/NAL who consented to participate were randomized to receive the pill cap device (PLY group; n = 19) or a service as usual (SAU group; n = 22) group that included an identical but inactive cap for their bottle. The PLY group received reminders via text and voice, and the support of a "helper" (e.g., friend) to monitor pill cap openings.

RESULTS

Most participants in PLY group found the device both feasible (92.86 %) and usable (78.57 %). Most participants liked using the device (92.86 %) and were satisfied with the device (85.71 %). While not statistically different from one another, medication adherence per the Medication Possession Ratio was 75 % in the SAU group and 84 % in the PLY group. Pill cap openings were significantly higher in the PLY group with an average of 91.8 openings versus the SAU group's average of 56.7 (p < 0.05).

CONCLUSION

The devices was feasible, usable, and patients had high levels of satisfaction. The device was associated with increased pill openings.

Financial incentives for reduced alcohol use and increased isoniazid adherence during tuberculosis preventive therapy among people with HIV in Uganda: an open-label, factorial randomised controlled trial

BACKGROUND

Alcohol use is common among people with HIV and is a risk factor for tuberculosis disease and non-adherence to isoniazid preventive therapy (IPT). Few interventions exist to reduce alcohol use and increase IPT adherence in sub-Saharan Africa. The aim of this study was to test the hypothesis that financial incentives conditional on point-of-care negative urine alcohol biomarker testing and positive urine isoniazid testing would reduce alcohol use and increase isoniazid adherence, respectively, in people with HIV who have latent tuberculosis infection and hazardous alcohol use.

METHODS

We conducted an open-label, 2×2 factorial randomised controlled trial in Uganda. Eligible for the study were non-pregnant HIV-positive adults (aged ≥18 years) prescribed antiretroviral therapy for at least 6 months, with current heavy alcohol use confirmed by urine ethyl glucuronide (biomarker of recent alcohol use) and a positive Alcohol Use Disorders Identification Test-Consumption (AUDIT-C; ≥3 for women, ≥4 for men) for the past 3 months' drinking, no history of active tuberculosis, tuberculosis treatment, or tuberculosis preventive therapy, and a positive tuberculin skin test. We randomly assigned participants (1:1:1:1) initiating 6 months of IPT to: no incentives (group 1); or incentives for recent alcohol abstinence (group 2), isoniazid adherence (group 3), or both (group 4). Escalating incentives were contingent on monthly point-of-care urine tests negative for ethyl glucuronide (groups 2 and 4), or positive on IsoScreen (biomarker of recent isoniazid use; groups 3 and 4). The primary alcohol outcome was non-hazardous use by self-report (AUDIT-C <3 for women, <4 for men) and phosphatidylethanol (PEth; past-month alcohol biomarker) <35 ng/mL at 3 months and 6 months. The primary isoniazid adherence outcome was more than 90% bottle opening of days prescribed. We performed intention-to-treat analyses. This trial is registered with ClinicalTrials.gov (NCT03492216), and is complete.

FINDINGS

From April 16, 2018, to Aug 2, 2021, 5508 people were screened, of whom 680 were randomly assigned: 169 to group 1, 169 to group 2, 170 to group 3, and 172 to group 4. The median age of participants was 39 years (IQR 32-47), 470 (69%) were male, 598 (90%) of 663 had HIV RNA viral loads of less than 40 copies per mL, median AUDIT-C score was 6 (IQR 4-8), and median PEth was 252 ng/mL (IQR 87-579). Among 636 participants who completed the trial with alcohol use endpoint measures (group 1: 152, group 2: 159, group 3: 161, group 4: 164), non-hazardous alcohol use was more likely in the groups with incentives for alcohol abstinence (groups 2 and 4) versus no alcohol incentives (groups 1 and 3): 57 (17·6%) of 323 versus 31 (9·9%) of 313, respectively; adjusted risk difference (aRD) 7·6% (95% CI 2·7 to 12·5, p=0·0025). Among 656 participants who completed the trial with isoniazid adherence endpoint measures (group 1: 158, group 2: 163, group 3: 168, group 4: 167), incentives for isoniazid adherence did not increase adherence: 244 (72·8%) of 335 in the isoniazid incentive groups (groups 3 and 4) versus 234 (72·9%) of 321 in the no isoniazid incentive groups (groups 1 and 2); aRD -0·2% (95% CI -7·0 to 6·5, p=0·94). Overall, 53 (8%) of 680 participants discontinued isoniazid due to grade 3 or higher adverse events. There was no significant association between randomisation group and hepatotoxicity resulting in isoniazid discontinuation, after adjusting for sex and site.

INTERPRETATION

Escalating financial incentives contingent on recent alcohol abstinence led to significantly lower biomarker-confirmed alcohol use versus control, but incentives for recent isoniazid adherence did not lead to changes in adherence. The alcohol intervention was efficacious despite less intensive frequency of incentives and clinic visits than traditional programmes for substance use, suggesting that pragmatic modifications of contingency management for resource-limited settings can have efficacy and that further evaluation of implementation is merited.

FUNDING

National Institute on Alcohol Abuse and Alcoholism.

TRANSLATION

For the Runyankole translation of the abstract see Supplementary Materials section.

Lessons learned from statewide contingency management rollouts addressing stimulant use in the Northwestern United States

Increases in stimulant drug use (such as methamphetamine) and related deaths creates an imperative for community settings to adopt evidence-based practices to help people who use stimulants. Contingency management (CM) is a behavioral intervention with decades of research demonstrating efficacy for the treatment of stimulant use disorder, but real-world adoption has been slow, due to well-known implementation barriers, including difficulty funding reinforcers, and stigma. This paper describes the training and technical assistance (TTA) efforts and lessons learned for two state-wide stimulant-focused CM implementation projects in the Northwestern United States (Montana and Washington). A total of 154 providers from 35 community-based service sites received didactic training in CM beginning in 2021. Seventeen of these sites, ten of eleven in Montana (90.9%) and seven of 24 in Washington (29.2%), went on to implement contingency management programs adherent to their state's established CM protocol and received ongoing TTA in the form of implementation coaching calls. These findings illustrate that site-specific barriers such as logistical fit precluded implementation in more than 50% of the trained sites; however, strategies for site-specific tailoring within the required protocol aided implementation, resulting in successful CM program launch in a diverse cross-section of service sites across the states. The lessons learned add to the body of literature describing CM implementation barriers and solutions.

The urgent need for contingency management among Tribal communities in the United States: Considerations for implementation, policy, and sovereignty

In two randomized controlled trials, culturally adapted contingency management (i.e., incentives provided for substance-negative urine samples) was associated with reduced alcohol and drug use among geographically diverse American Indian and Alaska Native (AI/AN) adults. In response to interest in contingency management from other Tribal and AI/AN communities, our research team in collaboration with AI/AN behavioral health experts, translated the research into practice with new AI/AN community partners. Tenets of community-based participatory research were applied to develop, pilot, and refine contingency management training and implementation tools, and identify implementation challenges. In partnership with the AI/AN communities, four members of the university team developed tools and identified implementation and policy strategies to increase the successful uptake of contingency management in each location. Through our collaborative work, we identified policy barriers including inadequate federal funding of contingency management incentives and a need for further clarity regarding federal anti-kickback regulations. Adoption of contingency management is feasible and can strengthen Tribal communities' capacity to deliver evidence-based substance use disorder treatments to AI/AN people. Unfortunately, non-evidence-based limits to the use of federal funding for contingency management incentives discriminate against AI/AN communities. We recommend specific federal policy reforms, as well as other practical solutions for Tribal communities interested in contingency management.

Factors Associated with Child Removal Among American Indian and Alaska Native People in an Alcohol Intervention Study

This study was a secondary data analysis of factors associated with alcohol-related child removal among American Indian/Alaska Native (AI/AN) adults enrolled in a clinical trial of an alcohol intervention. Among 326 parent participants, 40% reported ever having a child removed from their care in part because of the parent's alcohol use, defined here as alcohol-related child removal. Seventy-five percent of parents reported at least one separation during their own childhood (M = 1.3, SD = 1.0). In a multivariable analysis, alcohol-related child removal was associated with parental boarding school attendance. No relationship was found between alcohol-related child removal and alcohol intervention outcomes. Results may provide evidence of multigenerational child removal impacts of boarding schools on AI/AN adults receiving an alcohol use disorder intervention. Assessment of parental history of child removal by practitioners, strategies to prevent alcohol-related separation and to support reunification should be integrated into addiction treatment in AI/AN communities.

Cannabis for Healing in a Native Community Clinic: Development and Results from an Informatics Research Tool

This paper describes how the Puyallup Tribe created a clinic specializing in cannabis-based treatments and partnered with a university research team to assess the impacts of cannabis on patient outcomes. Clinic leaders and research team co-developed an informatics research tool that included survey questions about patient demographics, cannabis use, and measures of pain, depression, anxiety, other substance use, and trauma. Over the first 2.5 years of operations, 69 patients completed a survey. Participants were an average age of 50 years old (SD = 16.7), female (77.6%) and American Indian/Alaska Native (61.5%) with more than 12 years of education (66.7%). Over 77% of the participants used either cannabidiol-dominant (CBD) alone or both CBD and Tetrahydrocannabinol-dominant (THC) products, nearly 23% used neither CBD nor THC products. Most came to the clinic for a pain relief appointment (70.3%). Compared to the general population, participants experienced more pain-related comorbidities, such as anxiety, fatigue, sleep, and pain, and fewer physical functioning capabilities. Over half reported symptoms consistent with depressive or post-traumatic stress disorder. The informatics research tool was successfully integrated into a unique Tribally owned medical clinic.

Coming together for something good: recommendations from a scoping review for dissemination and implementation science to improve indigenous substance use disorder treatment

Introduction

Dissemination and Implementation (D&I) science is growing among Indigenous communities. Indigenous communities are adapting and implementing evidence-based treatments for substance use disorders (SUD) to fit the needs of their communities. D&I science offers frameworks, models, and theories to increase implementation success, but research is needed to center Indigenous knowledge, enhancing D&I so that it is more applicable within Indigenous contexts. In this scoping review, we examined the current state of D&I science for SUD interventions among Indigenous communities and identified best-practice SUD implementation approaches.

Methods

PubMed and PsycINFO databases were queried for articles written in English, published in the United States, Canada, Australia, and New Zealand. We included key search terms for Indigenous populations and 35 content keywords. We categorized the data using the adapted and extended Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework that emphasizes equity and sustainability. RE-AIM has also been used as a primary model to consistently identify implementation outcomes.

Results

Twenty articles were identified from the original unduplicated count of over 24,000. Over half the articles discussed processes related to Reach, Adoption, and Implementation. Effectiveness was discussed by 50% of the studies (n = 10), with 25% of the articles discussing Maintenance/sustainability (n = 4). Findings also highlighted the importance of the application of each RE-AIM domain for meaningful, well-defined community-engaged approaches.

Conclusion

Finding indicated a need to prioritize Indigenous methods to culturally center, re-align and adapt Western treatments and frameworks to increase health equity and improve SUD treatment outcomes. Utility in the use of the modified RE-AIM and the continued modification for Indigenous communities was also noted.

Effects of a COVID-19 Public Health Lockdown on Drinking and Health Behavior Among Persons with HIV and with Unhealthy Alcohol use in Uganda

To better understand the impact of Uganda's initial COVID-19 lockdown on alcohol use, we conducted a cross-sectional survey (August 2020-September 2021) among persons with HIV (PWH) with unhealthy alcohol use (but not receiving an alcohol intervention), enrolled in a trial of incentives to reduce alcohol use and improve isoniazid preventive therapy. We examined associations between bar-based drinking and decreased alcohol use, and decreased alcohol use and health outcomes (antiretroviral therapy [ART] access, ART adherence, missed clinic visits, psychological stress and intimate partner violence), during lockdown. Of 178 adults surveyed whose data was analyzed, (67% male, median age: 40), 82% reported bar-based drinking at trial enrollment; 76% reported decreased alcohol use during lockdown. In a multivariate analysis, bar-based drinking was not associated with greater decreases in alcohol use during lockdown compared to non-bar-based drinking (OR = 0.81, 95% CI: 0.31-2.11), adjusting for age and sex. There was a significant association between decreased alcohol use and increased stress during lockdown (adjusted β = 2.09, 95% CI: 1.07-3.11, P < 0.010), but not other health outcomes.

An unexplored equity factor: differential beliefs and attitudes toward contingency management by providers' ethnicity

BACKGROUND

Although considered one of the most effective interventions for substance use disorders (SUD), the widespread implementation of contingency management (CM) has remained limited. In more recent years there has been surge in the implementation of CM to address increasing rates of substance use. Prior studies at the provider-level have explored beliefs about CM among SUD treatment providers and have tailored implementation strategies based on identified barriers and training needs, to promote implementation of CM. However, there have been no implementation strategies that have actively sought to identify or address potential differences in the beliefs about CM that could be influenced by the cultural background (e.g., ethnicity) of treatment providers. To address this knowledge gap, we examined beliefs about CM among a sample of inpatient and outpatient SUD treatment providers.

METHODS

A cross-sectional survey of SUD treatment providers was completed by 143 respondents. The survey asked respondents about their attitudes toward CM using the Contingency Management Beliefs Questionnaire (CMBQ). Linear mixed models examined the effect of ethnicity (non-Hispanic White and Hispanic) on CMBQ subscale (general barriers, training-related barriers, CM positive-statements) scores.

RESULTS

Fifty-nine percent of respondents to the CMBQ self-identified as non-Hispanic White and 41% as Hispanic. Findings revealed that treatment providers who identified as Hispanic had significantly higher scores on the general barriers (p < .001) and training-related barriers (p = .020) subscales compared to the non-Hispanic White treatment providers. Post-hoc analyses identified differences in the endorsement of specific individual scale items on the general barriers (e.g., CM interventions create extra work for me) and training-related (e.g., I want more training before implementing CM) subscales.

CONCLUSIONS

Dissemination and implementation strategies for CM need to consider equity-related factors at the provider-level that may be associated with the adoption and uptake of CM.

Study protocol for a multi-level cross-sectional study on the equitable reach and implementation of coordinated specialty care for early psychosis

BACKGROUND

Approximately 115,000 young adults will experience their first episode of psychosis (FEP) each year in the USA. Coordinated specialty care (CSC) for early psychosis is an evidence-based early intervention model that has demonstrated effectiveness by improving quality of life and reducing psychiatric symptoms for many individuals. Over the last decade, there has significant increase in the implementation of CSC programs throughout the USA. However, prior research has revealed difficulties among individuals and their family members accessing CSC. Research has also shown that CSC programs often report the limited reach of their program to underserved populations and communities (e.g., ethnoracial minorities, rural and low socioeconomic neighborhoods). Dissemination and implementation research focused on the equitable reach and implementation of CSC is needed to address disparities at the individual level.

METHODS

The proposed study will create a novel integrative multi-level geospatial database of CSC programs implemented throughout the USA that will include program-level data (e.g., geocoded location, capacity, setting, role availability), provider-level data (race, ethnicity, professional credentials), and neighborhood-level census data (e.g., residential segregation, ethnic density, area deprivation, rural-urban continua, public transit time). This database will be used to characterize variations in CSC programs by geographical location and examine the overall reach CSC programs to specific communities. The quantitative data will be combined with qualitative data from state administrators, providers, and service users that will inform the development of dissemination tools, such as an interactive dashboard, that can aid decision making.

DISCUSSION

Findings from this study will highlight the impact of outer contextual determinants on implementation and reach of mental health services, and will serve to inform the future implementation of CSC programs with a primary focus on equity.

Investigating Secondary Alcohol Outcomes in a Contingency Management Intervention among American Indian and Alaska Native Adults

OBJECTIVE

The aim of the study is to investigate clinically meaningful, secondary outcomes in a randomized trial of a culturally adapted contingency management (CM) intervention for alcohol use in 3 diverse American Indian and Alaska Native communities.

METHODS

Three American Indian and Alaska Native communities located in the Northern Plains, Alaska, and the Inland Northwest were partnering sites. A total of 158 individuals were randomized to either a 12-week CM intervention or a noncontingent (NC) control group. The CM group received reinforcers for providing alcohol-negative ethyl glucuronide (EtG < 150 ng/mL) urine samples, while the NC group received reinforcers unconditionally. Outcomes included EtG as a continuous measure (range, 0-2,000 ng/mL), EtG > 499 ng/mL (a measure of higher levels of recent alcohol use), longest duration of abstinence, and time-to-first alcohol-positive EtG during the trial. Generalized estimating equations along with Cox proportional hazard and negative binomial regressions were used.

RESULTS

Participants randomized to the CM group had lower mean EtG levels (-241.9 ng/mL; 95% confidence interval [CI], -379.0 to -104.8 ng/mL) and 45.7% lower odds (95% CI, 0.31 to 0.95) of providing an EtG sample indicating higher levels of alcohol use during the intervention. Longest duration of abstinence was 43% longer for the CM group than the NC group (95% CI, 1.0 to 1.9). Risk of time-to-first drink during treatment did not differ significantly.

CONCLUSIONS

These secondary outcome analyses provide evidence that CM is associated with reductions in alcohol use and longer durations of abstinence (as assessed by EtG), both clinically meaningful endpoints and analyses that differ from the primary study outcome.

Assessing Clinically Significant Cognitive Impairment Using the NIH Toolbox in Individuals with Co-occurring Serious Mental Illness and Alcohol Use Disorder

OBJECTIVE

Serious mental illnesses (SMI) and alcohol use disorder (AUD) co-occurrence (SMI-AUD) is common, yet little is known about the prevalence and risk factors of cognitive impairment for this population. We used the National Institutes of Health (NIH) Toolbox to identify clinically significant cognitive impairment (CSCI), describe the cognitive profile, and investigate whether psychiatric and AUD severity measures are associated with CSCI in individuals with SMI-AUD.

METHODS

CSCI was defined as 2 or more fully corrected fluid subtest T scores below a set threshold based on an individual's crystalized composite score. Psychiatric severity measures included the Structured Clinical Interview for DSM-V (SCID-5) for SMI diagnosis and the Positive and Negative Syndrome Scale. AUD severity measures included the SCID-5 for AUD symptom severity score, years of alcohol use, and urine ethyl glucuronide levels. A multivariable logistic regression was used to investigate the adjusted effects of each variable on the probability of CSCI.

RESULTS

Forty-one percent (N = 55/135) of our sample had CSCI compared with the base rate of 15% from the NIH Toolbox normative sample. Subtests measuring executive function most frequently contributed to meeting criteria for CSCI (Flanker and Dimensional Change Card Sort). A history of head injury ( P = 0.033), increased AUD symptom severity score ( P = 0.007) and increased negative symptom severity score ( P = 0.027) were associated with CSCI.

CONCLUSIONS

Cognition should be considered in the treatment of people with SMI-AUD, particularly in those with history of brain injury, higher AUD symptom severity, and/or negative symptom severity.

An Unexplored Equity Factor During Pre-Implementation of Contingency Management: Differential Beliefs and Attitudes by Providers' Ethnicity

Background Although considered one of the most effective interventions for substance use disorders (SUD), the widespread uptake of contingency management (CM) has remained limited. Prior studies at the provider-level have explored beliefs about CM among SUD treatment providers and have tailored implementation strategies based on identified barriers and training needs. However, there have been no implementation strategies that have actively sought to identify or address potential differences in the beliefs about CM that could be influenced by the cultural background (e.g., ethnicity) of treatment providers. To address this knowledge gap, we examined beliefs about CM among a sample of inpatient and outpatient SUD treatment providers. Methods A cross-sectional survey of SUD treatment providers was completed by 143 respondents. The survey asked respondents about their attitudes toward CM using the Contingency Management Beliefs Questionnaire (CMBQ). Linear mixed models were used to examine the effect of ethnicity on CMBQ subscale (general barriers, training-related barriers, CM positive-statements) scores. Results Fifty-nine percent of respondents self-identified as non-Hispanic White and 41% as Hispanic. Findings revealed that SUD providers who identified as Hispanic had significantly higher scores on the general barriers (p < .001) and training-related barriers (p = .020) subscales compared to the non-Hispanic White SUD providers. Post-hoc analyses identified differences in the endorsement of specific individual scale items on the general barriers and training-related subscales. Conclusions Dissemination and implementation strategies for CM among treatment providers need to consider equity-related factors at the provider-level that may be associated with the adoption and uptake CM.

Contingency Management for Stimulant Use Disorder: Progress, Challenges, and Recommendations

The United States is currently in the fourth wave of the overdose crisis wherein stimulants together with fentanyl are the major drivers of overdose deaths. To date, there has been limited effort outside the US Veterans Administration Health System health system to disseminate evidence-based treatment for people with stimulant use disorder. Contingency management, a behavioral intervention in which positive reinforcement is provided for a target behavior indicating treatment progress, has decades of empirical support but limited implementation in real-world, non-US Veterans Administration Health System settings. The purpose of the report is to provide an overview of contingency management, the barriers to adoption, and recommendations for overcoming these barriers.

Aniqsaaq (To Breathe): Study protocol to develop and evaluate an Alaska Native family-based financial incentive intervention for smoking cessation

Background

Alaska Native and American Indian (ANAI) communities in Alaska are disproportionately affected by commercial tobacco use. Financial incentive interventions promote cigarette smoking cessation, but family-level incentives have not been evaluated. We describe the study protocol to adapt and evaluate the effectiveness and implementation of a remotely delivered, family-based financial incentive intervention for cigarette smoking among Alaskan ANAI people.

Methods

The study has 3 phases: 1) qualitative interviews with ANAI adults who smoke, family members, and stakeholders to inform the intervention, 2) beta-test of the intervention, and 3) randomized controlled trial (RCT) evaluating intervention reach and effectiveness on verified, prolonged smoking abstinence at 6- and 12-months post-treatment. In the RCT, adult dyads (ANAI person who smokes [index participant] and family member) recruited throughout Alaska will be randomized to a no-incentives control condition (n = 328 dyads) or a 6-month incentive intervention (n = 328 dyads). All dyads will receive cessation support and family wellness materials. Smoking status will be assessed weekly for four weeks and at three and six months. Intervention index participants will receive escalating incentives for verified smoking abstinence at each time point (maximum $750 total); the family member will receive rewards of equal value.

Results

A community advisory committee contributed input on the study design and methods for relevance to ANAI people, particularly emphasizing the involvement of families.

Conclusion

Our study aligns with the strength and value AIAN people place on family. Findings, processes, and resources will inform how Indigenous family members can support smoking cessation within incentive interventions.

Clinical Trials Registry

NCT05209451.

Validation of the quantification of phosphatidylethanol 16:0/18:1 concentrations in TASSO-M20 devices

BACKGROUND

Phosphatidylethanol 16:0/18:1 (PEth), found in whole blood, is a biomarker for alcohol consumption with high sensitivity, specificity, and a long detection window. The TASSO-M20 device is used to self-collect capillary blood from the upper arm and has advantages over finger stick methods. The purpose of this study was to (1) validate PEth measurement using the TASSO-M20 device, (2) describe the TASSO-M20 for blood self-collection during a virtual intervention, and (3) characterize PEth, urinary ethyl glucuronide (uEtG) and self-reported alcohol in a single participant over time.

METHODS

PEth levels in blood samples dried on TASSO-M20 plugs were compared to those in (1) liquid whole blood (N = 14) and (2) dried blood spot cards (DBS; N = 23). Additionally, the self-reported drinking, positive or negative uEtG results (dip card cutoff ≥300 ng/mL), and observed self-collection of blood with TASSO-M20 devices for PEth levels were obtained over time during virtual interviews of a single contingency management participant. High-performance liquid chromatography with tandem mass spectrometry detection was used to measure PEth levels for both preparations.

RESULTS

PEth concentrations from dried blood on TASSO-M20 plugs and liquid whole blood were correlated (0 to 1700 ng/mL; N = 14; r2  = 0.988; slope = 0.951) and in a subgroup of samples with lower concentrations (N = 7; 0 to 200 ng/mL; r2  = 0.944, slope = 0.816). PEth concentrations from dried blood on TASSO-M20 plugs and DBS were correlated (0 to 2200 ng/mL; N = 23; r2  = 0.927; slope = 0.667) and in a subgroup of samples with lower concentrations (N = 16; 0 to 180 ng/mL; r2  = 0.978, slope = 0.749). Results of the contingency management participant indicate that changes in PEth levels (TASSO-M20) and uEtG concentrations were consistent with each other and with changes in self-reported alcohol use.

CONCLUSIONS

Our data support the utility, accuracy, and feasibility of using the TASSO-M20 device for blood self-collection during a virtual study. The TASSO-M20 device had multiple advantages over the typical finger stick method, including consistent blood collection, participant acceptability, and less discomfort as indicated by acceptability interviews.

Cultural Factors and Alcohol Use in American Indian Adults: Results From a Culturally Tailored Contingency Management Intervention

OBJECTIVE

American Indian and Alaska Native (AI/AN) populations experience greater health disparities in alcohol use outcomes compared with the general population. This secondary data analysis examines cultural factors related to alcohol use in reservation-based American Indian (AI) adults (N = 65; 41 males; mean age = 36.7 years) in a randomized controlled trial of a culturally tailored contingency management (CM) program. It was hypothesized that individuals with higher rates of cultural protective factors would have lower rates of alcohol use, whereas individuals with higher rates of risk factors would have higher rates of alcohol use. It was also hypothesized that enculturation would moderate the relationship between treatment group and alcohol use.

METHOD

Generalized linear mixed modeling was used to calculate odds ratios (ORs) for the repeated measure, biweekly urine tests of the biomarker, ethyl glucuronide (EtG), across 12 weeks. The relationships between alcohol use (abstinence [EtG < 150 ng/ml]) or heavy drinking [EtG > 500 ng/ml]) and culturally relevant protective (enculturation, years lived on the reservation) and risk factors (discrimination, historical loss, historical loss symptoms) were examined.

RESULTS

There was a negative association between enculturation and probability of submitting a heavy drinking urine sample (OR = 0.973; 95% CI [0.950, 0.996], p = .023), indicating that enculturation may serve as a protective factor against heavy drinking.

CONCLUSIONS

Cultural factors (e.g., enculturation) may be important constructs to assess and incorporate into treatment planning with AI adults engaged in alcohol treatment.

Automated Reinforcement Management System: Feasibility study findings of an app-based contingency management treatment for alcohol use disorder

Alcohol Use Disorder (AUD) is the most prevalent substance use disorder in the United States and is directly related to 5% of all annually reported deaths worldwide. Contingency Management (CM) is among the most effective interventions for AUD, with recent technological advancements allowing CM to be provided remotely. Objective: To evaluate the feasibility and acceptability of a mobile Automated Reinforcement Management System (ARMS) designed to provide CM for AUD remotely. Methods: Twelve participants with mild or moderate AUD were exposed to ARMS in a A-B-A within-subject experimental design where they were required to submit three breathalyzer samples per day. During the B phase participants could earned rewards with monetary value for submitting negative samples. Feasibility was determined by the proportion of samples submitted and retention in the study and acceptability was based on participants self-reported experience. Results: The mean number of samples submitted per day was 2.02 out of 3. The proportion of samples submitted in each phase was 81.5%, 69.4% and 49.4%, respectively. Participants were retained for a mean of 7.5 (SD=1.1) out of 8 weeks with 10 participants (83.3%) completing the study. All participants found the app easy to use and stated it helped them reduce their alcohol use. Eleven (91.7%) would recommend the app as an adjunct to AUD treatment. Preliminary indicators of efficacy are also presented. Conclusions: ARMS has shown to be feasible and well accepted. If shown effective, ARMS can serve as an adjunctive treatment for AUD.

Recent substance use among clients with early psychosis and the potential to graduate from New Journeys

AIM

This study examined the relationship between recent substance use prior to intake and program graduation among young adults with early psychosis enrolled in coordinated specialty care.

METHODS

Participants (N = 248) were from New Journeys, a network of coordinated specialty care programs in Washington State. Recent (i.e., past 30 days) alcohol, cannabis, and other substance use was collected at intake and process data (e.g., contact) was collected by clinicians across a 2-year period.

RESULTS

At intake, 32% of participants reported alcohol use only, 26% cannabis use only, and 15% both alcohol and cannabis use. Participants who reported alcohol use only (p = .02), cannabis use only (p = .03), and any substance use (p = .02) had significantly lower chances of graduating from coordinated specialty care than individuals who do not use substances.

CONCLUSIONS

Unlike prior work, recent substance use influences clients' potential to graduate from New Journeys. Additional focus on the implementation of substance use treatment, with an emphasis on alcohol use, in coordinated specialty care programs is needed improve program completion rates.

Patient Feedback on a Mobile Medication Adherence Application for Buprenorphine/Naloxone: Feasibility and Acceptability Study (Preprint)

BACKGROUND

Opioid use disorders impact the health and well-being of millions of Americans. Buprenorphine and naloxone (BUP and NAL) can reduce opioid overdose deaths, decrease misuse, and improve quality of life. Unfortunately, poor medication adherence is a primary barrier to the long-term efficacy of BUP and NAL.

OBJECTIVE

We aimed to examine patient feedback on current and potential features of a Bluetooth-enabled pill bottle cap and associated mobile app for patients prescribed BUP and NAL for an opioid use disorder, and to solicit recommendations for improvement to effectively and appropriately tailor the technology for people in treatment for opioid use disorder.

METHODS

A convenience sample of patients at an opioid use disorder outpatient clinic were asked about medication adherence, opioid cravings, experience with technology, motivation for treatment, and their existent support system through a brief e-survey. Patients also provided detailed feedback on current features and features being considered for inclusion in a technology designed to increase medication adherence (eg, inclusion of a personal motivational factor, craving and stress tracking, incentives, and web-based coaching). Participants were asked to provide suggestions for improvement and considerations specifically applicable to people in treatment for opioid use disorder with BUP and NAL.

RESULTS

Twenty people with an opioid use disorder who were prescribed BUP and NAL participated (mean age 34, SD 8.67 years; 65% female; 80% White). Participants selected the most useful, second-most useful, and least useful features presented; 42.1% of them indicated that motivational reminders would be most useful, followed by craving and stress tracking (26.3%) and web-based support forums (21.1%). Every participant indicated that they had at least 1 strong motivating factor for staying in treatment, and half (n=10) indicated children as that factor. All participants indicated that they had, at some point in their lives, the most extreme craving a person could have; however, 42.1% indicated that they had no cravings in the last month. Most respondents (73.7%) stated that tracking cravings would be helpful. Most respondents (84.2%) also indicated that they believed reinforcers or prizes would help them achieve their treatment goals. Additionally, 94.7% of respondents approved of adherence tracking to accommodate this feature using smart packaging, and 78.9% of them approved of selfie videos of them taking their medication.

CONCLUSIONS

Engaging patients taking treatment for opioid use disorder with BUP and NAL allowed us to identify preferences and considerations that are unique to this treatment area. As the technology developer of the pill cap and associated mobile app is able to take into consideration or integrate these preferences and suggestions, the smart cap and associated mobile app will become tailored to this population and more useful for them, which may encourage patient use of the smart cap and associated mobile app.

Contingency management for alcohol use disorder reduces cannabis use among American Indian and Alaska Native adults

OBJECTIVE

Determine whether a culturally tailored contingency management (CM) intervention targeting alcohol abstinence resulted in secondary effects on cannabis use among American Indian and Alaska Native (AI/AN) adults.

METHODS

The research team conducted this secondary data analysis to examine cannabis abstinence using data from a randomized control trial of CM for alcohol use among three AI/AN-serving organizations. One hundred and fifty-eight adults met the randomization criteria (i.e., submission of 50% or more urine samples and one alcohol-positive urine test during a 4-week, pre-randomization, observation period). For 12 weeks after randomization, participants received incentives for submitting a urine test negative for ethyl glucuronide (EtG < 150 ng/mL, CM group) or incentives for submitting a urine sample regardless of abstinence (Non-contingent [NC] Control group). Generalized linear mixed effects models assessed group differences in cannabis abstinence during the intervention, verified by urine tetrahydrocannabinol negative tests (11-nor-delta-9-tetrahydrocannabinol-9-carboxylic acid <50 ng/mL).

RESULTS

At baseline, 42.2% (n = 35) of participants in the NC group and 40.0% (n = 30) of those in the CM group had a cannabis positive urine test. An overall intervention by time interaction was detected for a cannabis negative urine test (χ2 = 13.40, p = 0.001). Compared to the NC group, the CM group had 3.92 (95% CI:1.23-12.46) times higher odds of having a cannabis negative urine test during the intervention period and 5.13 (95% CI:1.57-16.76) times higher odds of having a negative cannabis test at the end of intervention period.

CONCLUSION

CM addressing alcohol misuse may be an effective strategy for decreasing cannabis use among AI/AN adults.

TRIAL REGISTRATION

ClinicalTrials.gov number, Identifier: NCT02174315.

Variations in national availability of waivered buprenorphine prescribers by racial and ethnic composition of zip codes

BACKGROUND

Opioid overdose remains a public health crisis in diverse communities. Between 2019 and 2020, there was an almost 40% increase in drug fatalities primarily due to opioid analogues of both stimulants and opioids. Medications for opioid use disorder (MOUD; e.g., buprenorphine) are effective, evidence-based treatments that can be delivered in office-based primary care settings. We investigated disparities in the proportion of national prescribers who have obtained a waiver issued to prescribe MOUD by demographic characteristics.

METHODS

Data for the secondary data analyses were obtained from the Drug Enforcement Administration that maintains data on waivered MOUD prescribers across the US. Proportion of waivered prescribers were examined by ZIP code, race and ethnicity composition, socioeconomic status, insurance, and urban-rural designation using generalized linear mixed effects models.

RESULTS

Compared with predominantly Non-Hispanic White ZIP codes, other racially and ethnically diverse areas had a higher proportion of waivered buprenorphine prescribers. Differences in prescriber availability between predominant racial group was dependent on rurality based on the interaction found in our fitted model. In metropolitan areas, we found that predominantly Non-Hispanic White ZIP codes had a lower rate of waivered prescribers compared to predominantly Black/African American ZIP codes.

CONCLUSIONS

Our findings suggest that among AI/AN and Black/African American neighborhoods, availability of waivered prescribers may not be a primary barrier. However, availability of waivered prescribers and prescribing might potentially be an obstacle for Hispanic/Latinx and rural communities. Additional research to determine factors related to improving MOUD availability among diverse communities therefore remains vital to advancing health equity.

Automated Reinforcement Management System (ARMS): focused phase I provider feedback

Background

Alcohol use increases risk for morbidity and mortality and is associated with over 3 million annual deaths worldwide. Contingency Management (CM) is one of the most effective interventions for substance use disorders, and has recently been coupled with technologies to promote novel treatments for alcohol use disorders (AUD). Leveraging these technological advances, we are developing the Automated Reinforcement Management System (ARMS), an integrated CM system designed to enable CM treatment as a component of a digital therapeutic or adjunct therapy remotely to anyone with a smartphone.

Objective

To collect detailed provider feedback on ARMS and determine the need for modifications to make the system most feasible, acceptable, and useful to providers.

Methods

Seven providers completed one-hour structured interviews/focus groups wherein we described the ARMS system and its application to clinical care. Providers viewed screen shots of the ARMS provider facing and patient facing systems. Providers gave feedback on their current AUD treatment practices, preferences for the functionality and appearance of the system, preferences for receipt of information on their patients, why they and their patients would or would not use the system, suggestions for improvement, and the proposed intervention overall. To analyze the qualitative data gathered, we used a qualitative descriptive approach with content analysis methods.

Results

The overarching theme of Individualized Treatment emerged throughout the interviews. This sentiment supports use of ARMS, as it is intended to supplement provider communication and intervention as an adjunctive and customizable tool with the ability to reach rural patients, not a stand-alone option. Themes of Accountability and Objective Assessment arose during discussions of why people would use the system. Themes within provider obstacles included, Information Overload and Clinical Relevance, and in patient obstacles, Sustained Engagement and Security Concerns. Two themes emerged regarding suggestions for improvement: Increasing Accessibility and Bi-directional Communication.

Discussion

Themes from provider input are being used to modify ARMS to make it more user friendly, time saving, and relevant to treatment of AUD. If successful, ARMS will provide effective, individualized-digital therapeutic for those needing adjunctive treatment or those living in rural remote areas needing better connected care.

Onset of alcohol use disorder among alcohol initiates by race/ethnicity

Prevalence of alcohol use disorders (AUD) varies across racial/ethnic groups. It remains unclear whether rapid transition from first-time alcohol use to developing AUD varies by race and ethnicity. In this study, we investigate racial/ethnic differences in AUD onset among first-time alcohol drinkers and identify specific predictors of AUD onset by racial/ethnic group. The study population was non-institutionalized US residents aged 12 and older. Within four nationally representative probability samples (n ∼70,000/year) drawn from the 2015-2018 National Surveys on Drug Use and Health, we identified 9,381 individuals who initiated alcohol use within 1-12 months prior to the survey. The probability of AUD after initiation was estimated for the entire sample, followed by racial/ethnic group stratification. Bivariate and multivariable logistic regression models were used to identify predictors of AUD onset among alcohol initiates. The overall incidence estimate of AUD among alcohol initiates was 3.7% (95% CI = 3.0%, 4.6%). There was no significant variation in the incidence of AUD between racial/ethnic groups. Drug use, drug use disorders, and major depressive episode were significant predictors of AUD onset among all alcohol initiates. However, these predictors were not significant among non-Hispanic/Latinx Black individuals. Drug use and drug use disorders were strong predictors of AUD onset among alcohol initiates, except among non-Hispanic/Latinx Black individuals. These findings strengthen the importance of focusing on the co-use of alcohol and other drugs and the need to further investigate the risk profile differences between racial/ethnic groups.

Post-traumatic stress disorder among persons with HIV who engage in heavy alcohol consumption in southwestern Uganda

BACKGROUND

We aimed to describe the prevalence of PTSD symptoms and its associated factors in persons living with HIV (PLWH) in Uganda who engage in heavy alcohol use.

METHODS

We analyzed baseline data from the Drinkers Intervention to Prevent Tuberculosis study which enrolls PLWH with latent tuberculosis who engage in heavy alcohol consumption. Using the primary care Post Traumatic Stress Disorder (PTSD) screening scale from the DSM-5 (PC-PTSD-5), probable PTSD was defined as reporting ≥3 of 5 assessed symptoms. We conducted the Alcohol Use Disorders Identification Test-Consumption and assessed demographics, smoking, symptoms of depression, and spirituality/religiosity.

RESULTS

Of 421 participants enrolled from 2018 through 2020, the majority (68.2%) were male, median age was 40 years (interquartile range [IQR]: 32-47), and median AUDIT-C score was 6 [IQR: 4-8]. Half (50.1%) of the participants reported ever experiencing a traumatic event, and 20.7% reported ≥3 symptoms of PTSD. The most commonly reported PTSD symptoms in the past 1 month in the entire sample were avoidance (28.3%), nightmares (27.3%), and being constantly on guard (21.6%). In multivariable logistic regression analyses, level of alcohol use was not associated with probable PTSD (adjusted odds ratio [AOR] for each AUDIT-C point: (1.02; 95% CI: 0.92-1.14; p = 0.69); however, lifetime smoking (AOR 1.89; 95% CI: 1.10-3.24) and reporting symptoms of depression (AOR 1.89; 95% CI: 1.04-3.44) were independently associated with probable PTSD.

CONCLUSIONS AND RECOMMENDATIONS

A history of traumatic events and probable PTSD were frequently reported among persons who engage in heavy drinking, living with HIV in Uganda. Level of alcohol use was not associated with probable PTSD in this sample of PLWH with heavy alcohol use, however other behavioral and mental health factors were associated with probable PTSD. These data highlight the high prevalence of PTSD in this group, and the need for screening and interventions for PTSD and mental health problems.

Cannabis use and metabolic syndrome among clients with first episode psychosis

AIM

To explore the relationship between cannabis use and metabolic syndrome (MetS) among those who have experienced first episode psychosis (FEP).

METHODS

A retrospective analysis of 404 participants enrolled in the Recovery After Initial Schizophrenia Episode-Early Treatment Program (RAISE-ETP) was conducted. Using multiple logistic regression, we investigated the correlation between cannabis use and rate of MetS at baseline and across time as well as the specific metabolic derangements among cannabis users and abstainers.

RESULTS

Although cannabis users had similar rates of MetS at baseline when compared with abstainers, those who used cannabis at any time during the study period tended to have lower triglycerides and elevated high-density lipoprotein (HDL). Cannabis users were less likely to develop MetS, relative to nonusers.

CONCLUSIONS

Cannabis use may be associated with lower incidence of MetS in patients who have experienced FEP. Further research is indicated to develop these observations.

Access to medication-assisted treatment in the United States: Comparison of travel time to opioid treatment programs and office-based buprenorphine treatment

OBJECTIVES

Disparities in access to medication-assisted treatment are a major problem. This study estimated and compared drive time to the nearest opioid treatment program (OTP) and office-based buprenorphine treatment (OBBT) across the urban-rural continuum in the U.S.

METHODS

Drive time was calculated between the longitude and latitude of population weighted block group centroids and the longitude and latitude of the nearest OTP and OBBT. Rural-Urban Commuting Area (RUCA) codes were used for defining rurality. The Integrated Nested Laplace Approximation approach was used for statistical analysis.

RESULTS

The mean travel time to the nearest OBBT compared to OTP decreased by 7.18 min (95 % CI = 7.23-7.14) in metropolitan cores, 36.63 min (95 % CI = 37.12-36.15) in micropolitan cores, 38.84 min (95 % CI = 39.57-38.10) in small town cores, and 40.16 min (95 % CI = 40.81-39.50) in rural areas. Additionally, travel burden to the nearest OTP would be more than 60 min for 13,526,605 people and more than 90 min for 5,371,852 people. The travel burden to the nearest OBBT would be more than 60 min for 845,991 people and more than 90 min for 149,297 people.

CONCLUSIONS

The mean drive time to the closest OBBT was significantly smaller than the mean drive time to the closest OTP. Analysis of barriers to access is necessary to devising creative initiatives to improve access to critical opioid use disorder treatment services.

Assessing the Predictive Validity of the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES) in Alaska Native and American Indian People

OBJECTIVES

The objective of this study was to examine the predictive validity of the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES) among Alaska Native and American Indian (ANAI) people with an alcohol use disorder.

METHODS

The sample was 170 ANAI adults with an alcohol use disorder living in Anchorage, Alaska who were part of a larger alcohol intervention study. The primary outcome of this study was alcohol use as measured by mean urinary ethyl glucuronide (EtG). EtG urine tests were collected at baseline and then up to twice a week for four weeks. We conducted bivariate linear regression analyses to evaluate associations between mean EtG value and each of the three SOCRATES subscales (Recognition, Ambivalence, and Taking Steps) and other covariates such as demographic characteristics, alcohol use history, and chemical dependency service utilization. We then performed multivariable linear regression modeling to examine these associations after adjusting for covariates.

RESULTS

After adjusting for covariates, mean EtG values were negatively associated with the Taking Steps (P = 0.017) and Recognition (P = 0.005) subscales of the SOCRATES among ANAI people living in Alaska. We did not find an association between mean EtG values and the Ambivalence subscale (P = 0.129) of the SOCRATES after adjusting for covariates.

CONCLUSIONS

Higher scores on the Taking Steps and Recognition subscales of the SOCRATES at baseline among ANAI people predicted lower mean EtG values. This study has important implications for communities and clinicians who need tools to assist ANAI clients in initiating behavior changes related to alcohol use.

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

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.

The Drinkers' Intervention to Prevent Tuberculosis (DIPT) trial among heavy drinkers living with HIV in Uganda: study protocol of a 2×2 factorial trial

Background

The risk of tuberculosis (TB) is high among people with HIV (PWH). Heavy alcohol drinking independently increases TB risk and approximately 25% of PWH globally engage in heavy drinking. While isoniazid (INH) preventive therapy decreases TB incidence and mortality among PWH, heavy drinking during INH is associated with liver toxicity and poor adherence. Interventions are, therefore, urgently needed to decrease alcohol use and improve adherence to INH in this population in settings with high prevalence of HIV and TB like Uganda.

Methods

The Drinkers’ Intervention to Prevent TB (DIPT) study is a 2×2 factorial randomized controlled trial among HIV/TB co-infected adults (≥18 years) who engage in heavy alcohol drinking and live in Uganda. The trial will allocate 680 participants with a 1:1:1:1 individual randomization to receive 6 months of INH and one of the following interventions: (1) no incentives (control), (2) financial incentives contingent on low alcohol use, (3) financial incentives contingent on high adherence to INH, and (4) escalating financial incentives for both decreasing alcohol use and increasing adherence to INH. Incentives will be in the form of escalating lottery-based monetary rewards. Participants will attend monthly visits to refill isoniazid medications, undergo liver toxicity monitoring, and, except for controls, determine eligibility for prizes. We will estimate (a) the effect of incentives contingent on low alcohol use on reduction in heavy drinking, measured via a long-term objective and self-reported metric of alcohol use, at 3- and 6-month study visits, and (b) the effect of incentives contingent on high adherence to INH, measured as >90% pill-taking days by medication event monitoring system cap opening. We will use qualitative methods to explore the mechanisms of any influence of financial incentives on HIV virologic suppression.

Discussion

This study will provide new information on low-cost strategies to both reduce alcohol use and increase INH adherence among people with HIV and TB infection who engage in heavy drinking in low-income countries with high HIV and TB prevalence.

Trial registration

ClinicalTrials.gov NCT03492216. Registered on April 10, 2018

Geographic Disparities in Access to Specialty Care Programs for Early Psychosis in Washington State

Supported by the 10% set-aside funds in the Community Mental Health Block grant, distributed at the state level, coordinated specialty care (CSC) have been widely disseminated throughout the U.S. This study explores variations in the geographical accessibility of CSC programs by neighborhood level characteristics in Washington State. CSC locations were geocoded. Socioeconomic neighborhood deprivation (i.e., Area deprivation index) and rurality (i.e., Rural-Urban Commuting Area codes) were neighborhood level characteristics extracted from the 2018 American Community Survey. Geographic accessibility of CSC was assessed using a two-step floating catchment area technique and multilevel linear models were used to examine the association between specific neighborhood characteristics and geographic accessibility. The association between access and socioeconomically deprived neighborhoods varied differentially by neighborhood rurality (an interaction effect). Model estimates indicated that the least deprived, metropolitan neighborhoods had the best access (M = 0.38; CI: 0.34, 0.42) and rural neighborhoods in the second most deprived quartile had the worst access (M = 0.16; CI: 0.11, 0.21) to CSC. There was a clear decrease in accessibility for more rural neighborhoods, regardless of other neighborhood characteristics. In conclusions, findings provide important insight into how resource distribution contributes to geographic disparities in access to CSC. The use of spatial analytic techniques has the potential to identify specific neighborhoods and populations where there is a need to expand and increase availability of CSC to ensure access to rural and socioeconomically deprived neighborhoods.

Mixed-methods trial of a phosphatidylethanol-based contingency management intervention to initiate and maintain alcohol abstinence in formerly homeless adults with alcohol use disorders

Background

Contingency management (CM) is an intervention where incentives are provided in exchange for biochemically confirmed alcohol abstinence. CM is effective at initiating alcohol abstinence, but it is less effective at maintaining long-term abstinence. Phosphatidylethanol (PEth), collected via a finger-stick, can detect alcohol use for 14–28 days. PEth allows for the development of a CM model that includes increasingly less frequent monitoring of abstinence to assist high risk groups, such as formerly homeless individuals, maintain long-term abstinence.

Aims

Investigate whether PEth-based CM intervention targeting alcohol abstinence in formerly homeless, currently housed individuals with alcohol use disorders is: (1) acceptable and feasible for housing program tenants and personnel; and is associated with increased (2) alcohol abstinence and (3) housing tenure.

Methods

Acceptability and feasibility will be assessed using a QUAL+quant mixed-methods design using qualitative interviews and quantitative measures of satisfaction and attrition. Effectiveness will be evaluated through a randomized pilot trial of 50 study participants who will receive 6 months of either treatment as usual (TAU) including incentives (e.g., gift cards) for providing blood samples (Control Condition) or TAU and incentives for negative PEth results (PEth-CM Condition). Outcomes will be assessed during the intervention and at a three-month follow-up visit. The trial will be conducted via telehealth as a result of COVID-19.

Discussion

This protocol seeks to utilize a novel alcohol biomarker to evaluate the acceptability, feasibility, and initial effectiveness of a CM model that encourages long-term abstinence in a high-risk group.

HIV and syphilis infections and associated factors among patients in treatment at a Specialist Alcohol, Tobacco, and Drugs Center in São Paulo's "Cracolândia"

INTRODUCTION

This study describes the epidemiological scenario of human immunodeficiency virus (HIV) and syphilis at the biggest specialist drug addiction center in Brazil. The great challenge is to find strategies to reduce the impact of inequality and discrimination and develop policies to protect individuals living with - or at risk of - infections.

METHODS

During the period from January 1 to May 31, 2016, a cross-sectional study was conducted on which all patients (N = 806) seeking inpatient treatment were enrolled. A structured diagnostic interview and rapid tests were conducted initially, and diagnoses were confirmed by tests conducted at a venereal disease research laboratory (VDRL).

RESULTS

HIV and syphilis rates were 5.86% and 21.9%, respectively. Women were nearly 2.5 times more likely to have syphilis. HIV infection was associated with unprotected sex (odds ratio [OR]: 3.27, p = 0.003, 95% confidence interval [95%CI]: 1.51-7.11), and suicidal ideation (OR: 6.63, p = 0.001, 95%CI: 3.37-14.0). Although only 1.86% reported injecting drugs at any point during their lifetimes, this variable was associated with both HIV and syphilis. Elevated rates of HIV and syphilis were observed in the context of this severe social vulnerability scenario.

CONCLUSION

The risk factors identified as associated with HIV and syphilis should be taken into consideration for implementation of specific prevention strategies including early diagnosis and treatment of sexually transmitted infections (STI) to tackle the rapid spread of STIs in this population.

Disparities in Access to Opioid Treatment Programs and Office-Based Buprenorphine Treatment Across the Rural-Urban and Area Deprivation Continua: A US Nationwide Small Area Analysis

OBJECTIVES

To measure access to opioid treatment programs (OTPs) and office-based buprenorphine treatment (OBBTs) at the smallest geographic unit for which the Census Bureau publishes demographic and socioeconomic data (ie, block group) and to explore disparities in access to treatment across the rural-urban and area deprivation continua across the United States.

METHODS

Access to OTPs and OBBTs at the block group in 2019 was quantified using an innovative 2-step floating catchment area technique that accounts for the supply of treatment facilities relative to the population size, proximity of facilities relative to the location of population in block groups, and time as a barrier within catchments. Block groups were stratified into tertiles based on the rural-urban continuum codes (metropolitan, micropolitan, small town, or rural) and area deprivation index (least-deprived, middle-deprived, most-deprived). The Integrated Nested Laplace Approximation approach was used for statistical analysis.

RESULTS

Across the United States, 3329 block groups corresponding to 2 915 949 adults lacked access to OTPs within a 2-hour drive of their community and 130 block groups corresponding to 86 605 adults did not have access to OBBTs. Disparities in access to treatment were observed across the urban-rural and area deprivation continua including (1) lowest mean access score to OBBTs were found among most-deprived small towns, and (2) lower mean access score to OTPs were found among micropolitan and small towns.

CONCLUSIONS

The results of this study revealed disparities in access to medication-assisted treatment. The findings call for creative initiatives and local and regional policies to develop to mitigate access problems.

The rewarding recovery study: a randomized controlled trial of incentives for alcohol and drug abstinence with a rural American Indian community

AIMS

To test if contingency management (CM) interventions for alcohol and drug abstinence were associated with increased alcohol and drug abstinence among American Indian adults with alcohol dependence who also use drugs.

DESIGN

In this 2 × 2 factorial randomized controlled trial, American Indian adults with alcohol dependence who also used drugs were randomized to four conditions: (1) incentives for submission of urine samples only (control condition), (2) CM incentives for alcohol abstinence, (3) CM incentives for drug abstinence or (4) CM incentives for abstinence from both alcohol and drugs.

SETTING

A Northern Plains Reservation in the United States.

PARTICIPANTS

A total of 114 American Indian adults aged 35.8 years (standard deviation = 10.4); 49.1% were male.

INTERVENTION AND COMPARATOR

Participants received incentives if they demonstrated abstinence from alcohol (CM for alcohol, n = 30), abstinence from their most frequently used drug (CM for drugs, n = 27) or abstinence from both alcohol and their most frequently used drug (CM for alcohol and drugs, n = 32) as assessed by urine tests. Controls (n = 25) received incentives for submitting urine samples only.

MEASUREMENTS

Primary outcomes were urine ethyl glucuronide (alcohol) and drug tests conducted three times per week during the 12-week intervention period. Data analyses included listwise deletion and multiple imputation to account for missing data.

FINDINGS

The three CM groups were significantly (P < 0.05) more likely to submit alcohol-abstinent urine samples compared with the control condition, with odds ratios ranging from 2.4 to 4.8. The CM for drugs (OR = 3.2) and CM for alcohol and drugs (OR = 2.5) were significantly more likely to submit urine samples that indicated drug abstinence, relative to the control condition (P < 0.05). However, these differences were not significant in multiple imputation analyses (P > 0.05).

CONCLUSIONS

Contingency management (CM) incentives for abstinence were associated with increased alcohol abstinence in American Indian adults diagnosed with alcohol dependence who also used drugs, living on a rural reservation. The effect of CM incentives on drug abstinence was inconclusive.

Understanding differences in family engagement and provider outreach in New Journeys: A coordinated specialty care program for first episode psychosis

The present study examined clinician outreach efforts to families and family engagement; and predictors of engagement in a coordinated specialty care (CSC) for first episode psychosis. From 2015 to 2019, 211 clients experiencing their first episode of psychosis and their family members received services from New Journeys, a network of CSC programs in the United States. Analyses examined the association between race/ethnicity, insurance type, referral source, housing stability, and outreach efforts and family attendance. Overall, 70% of client family members attended at least one psychoeducation appointment and in the first month of treatment 40% of family members attended family psychoeducation. Outreach efforts including phone attempts (β=1.09; p = 0.02) and phone contact (β=1.10; p = 0.02) were significantly higher for Black families relative to White families; whereas Black families were scheduled less often for a family psychoeducation (β=-0.28; p = 0.02) compared to Whites families. Significant differences in family attendance based on insurance type were also found (p<0.01). Referral source and housing stability were not significant predictors of outreach or attendance. These findings suggest that alternative engagement efforts that extend beyond in-person contact may be needed to continuously engage families, specifically Black families and those with public and no insurance.

Family Experiences Prior to the Initiation of Care for First-Episode Psychosis: A Meta-Synthesis of Qualitative Studies

OBJECTIVES

This study systematically reviewed existing qualitative evidence of family members' experiences prior to the initiation of mental health services for a loved one experiencing their first episode of psychosis (FEP).

METHODS

A meta-synthesis review of published peer-reviewed qualitative studies conducted between 2010 and 2019 were included. Keyword searches were performed in four electronic databases and the reference lists of primary manuscripts. Two independent reviewers used the Critical Appraisal Skills Programme (CASP) qualitative checklist to assess methodological quality of each study.

RESULTS

A total of 365 articles were initially identified and 9 were articles identified in a secondary review and literature search. A total of 21 met inclusion criteria. Of those included in this review 169, mothers were the primary family to recall experiences. The meta-synthesis identified four major themes related to family member experiences prior to the initiation of mental health services for FEP: the misinterpretation of signs, the emotional impact of FEP on family members, the effect of stigma on family members, and engaging with resources prior to mental health services for FEP.

CONCLUSIONS

Additional research is needed to develop healthy communication strategies that effectively deliver educational information about psychosis. This meta-synthesis also identified the need to understand help-seeking behaviors among families of those with FEP in effort to reduce the duration of untreated psychosis and improve pathways to care often initiated by a family member.

Developing and implementing a culturally informed mily otivational ngagement trategy (FAMES) to increase family engagement in first episode psychosis programs: mixed methods pilot study protocol

INTRODUCTION

Despite the proven effectiveness of coordinated specialty care (CSC) programmes for first episode psychosis in the USA, CSC programmes often have low levels of engagement in family psychoeducation, and engagement of racial and ethnic minority family members is even lower than that for non-Latino white family members. The goal of this study is to develop and evaluate a culturally informed FAmily Motivational Engagement Strategy (FAMES) and implementation toolkit for CSC providers.

METHODS AND ANALYSIS

This protocol describes a mixed methods, multi-phase study that blends intervention mapping and the Promoting Action on Research in Health Services framework to develop, modify and pilot-test FAMES and an accompanying implementation toolkit. Phase 1 will convene a Stakeholder Advisory Committee to inform modifications based on findings from phases 1 and 2. During phase 1, we will also recruit approximately 200 family members to complete an online survey to assess barriers and motivation to engage in treatment. Phase 2 we will recruit five family members into a 3-month trial of the modified FAMES and implementation toolkit. Results will guide the advisory committee in refining the intervention and implementation toolkit. Phase 3 will involve a 16-month non-randomised, stepped-wedge trial with 50 family members from five CSC programmes in community-based mental health clinics to examine the acceptability, feasibility and initial impact of FAMES and the implementation toolkit.

ETHICS AND DISSEMINATION

This study received Institutional Review Board approval from Washington State University, protocol #17 812-001. Results will be disseminated via peer review publications, presentations at national and international conferences, and to local community mental health agencies and committees.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT04188366).

Preliminary Evaluation of Washington State's Early Intervention Program for First-Episode Psychosis

OBJECTIVE

Early intervention programs are designed to address the needs of youths experiencing first-episode psychosis (FEP). Washington State developed New Journeys, a network of coordinated specialty care programs for FEP. In this study, the authors have outlined components of the New Journeys model and preliminary findings since its initial implementation.

METHODS

Youths and young adults diagnosed as having psychosis (N=112) completed measures at and after intake on a range of mental health assessments and functional outcomes for the first 12 months of treatment. Administrative data including state-funded emergency department and psychiatric hospitalizations were assessed 24 months before and after intake. Generalized estimating equations were used to assess change over time on multiple measures of mental health status.

RESULTS

Compared with their condition at intake, clients had significant decreases in symptoms of anxiety (β=-2.48, p<0.001), psychotic experiences (β=-3.37, p<0.05), and clinician-rated psychotic symptoms (β=-1.47, p<0.05) during treatment. Additionally, quality of life (β=-5.95, p<0.001) and school attendance (odds ratio=1.42, p<0.05) significantly improved during treatment. Administrative data indicated that postintake, clients were less likely to visit the emergency department for psychiatric reasons (β=0.22, p<0.05), utilize community psychiatric inpatient services (β=0.31, p<0.001), and utilize public assistance (β=0.71, p<0.05) compared with 24 months before intake.

CONCLUSIONS

New Journeys clients experienced improved clinical and functional outcomes during their first year of treatment, and rates of state-funded service utilization decreased during their treatment.

Assessing the Interest and Cultural Congruence of Contingency Management as an Intervention for Alcohol Misuse Among Younger American Indian Adults

A qualitative study was conducted to assess interest in contingency management (CM) for younger American Indian (AI) adults (18-29 years old), how to culturally and developmentally adapt CM for younger AI adults, and interest in CM relative to culturally grounded treatment approaches. We conducted a total of four focus groups with younger adults and families in two AI communities: a rural reservation and an urban Indian health clinic (n = 32). Four overarching themes emerged suggesting that offering prizes, cultural activities, and activities that capture the attention of younger adults integrated into the CM intervention is ideal for enhancing engagement.

The dissemination and implementation of contingency management for substance use disorders: A systematic review

Contingency management is one of the most effective behavioral interventions for substance use. However, the implementation of contingency management has not been as widespread as might be expected given its efficacy. This review summarizes literature that examines the dissemination and implementation of contingency management for substance use in community (e.g., specialized substance use treatment) and clinical (e.g., primary care) settings. A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Databases including Google Scholar, World of Knowledge, PsycINFO, and PubMed were searched. Search results yielded 100 articles and after the screening of titles and abstracts 44 were identified. Full-text articles were examined for eligibility and yielded 24 articles that were included in this review. Of the 24 articles included in the review, the majority (n = 11) focused on implementing contingency management in methadone clinics and opioid treatment programs. Training methods, implementation strategies, fidelity assessments, and attitudes toward the implementation of contingency management are discussed in greater detail. These findings highlight the importance of organizational input and ongoing supervision and consultation, and the need for additional research that is guided by theoretical frameworks and use rigorous study designs. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Spatial access to opioid treatment program and alcohol and cannabis outlets: analysis of missed doses of methadone during the first, second, and third 90 days of treatment

Background: The burden of access to opioid treatment programs (OTPs) may change as clients become eligible for take-home privileges. Our previous study showed clients who lived more than 10-miles away from an OTP were more likely to miss methadone doses during the first 30 days of treatment. Proximity to alcohol and cannabis outlets may also negatively influence treatment adherence.Objective: To examine the association between access to this OTP, alcohol and cannabis outlets, and the number of missed methadone doses during the first, second, and third 90 days of treatment.Methods: The number of missed methadone doses was calculated for 752, 689, and 584 clients who remained in treatment, respectively, for at least 3, 6, and 9 months (50% female). Distance between client's home and the OTP, alcohol, and cannabis outlets was measured. Generalized linear models were employed.Results: Shorter distance from a client's residence to the OTP was associated with a decreased number of missed methadone doses during the first 90 days of treatment. Shorter distance to the closest cannabis retail outlet was associated with an increased number of missed methadone doses during the first and second 90 days of treatment. Shorter distance to the closest off-premise alcohol outlet was associated with an increased number of missed methadone doses during the third 90 days of treatment.Conclusions: Improving spatial accessibility of OTPs are essential to ensure treatment opportunities are available for individuals so affected. Exploring to what extent residing in areas that facilitate alcohol and cannabis availability can influence treatment adherence is warranted.