Novel EtG Based Contingency Management for Alcohol in the Severely Mentally Ill We propose to conduct a randomized clinical trial investigating the effect of a 12-week ethyl glucuronide (EtG) urinalysis based contingency management (CM) intervention on decreasing alcohol use and increasing alcohol treatment attendance among persons with alcohol dependence (AD) and serious mental illness (SMI) receiving long-term community mental health treatment. While CM is an evidence-based treatment for illicit drug use, research regarding its efficacy for AD has been limited due to the absence of a pragmatic alcohol biomarker to base the CM paradigm upon. This study will include the novel application of EtG urine-tests, capable of detecting alcohol use for a two-day period similar to urine-tests of illicit drug use, on which most CM drug research has been based. EtG results will be utilized as both a research outcome and as a basis on which the CM intervention targeting alcohol use is based. In addition, the CM paradigm will include secondary reinforcement of attendance in intensive outpatient (IOP) addiction treatment. It is hypothesized that this secondary contingency will result in higher rates of IOP attendance. 120 AD-SMI adults will participate in a 4-week induction period (reinforcement for providing urinalysis three times a week). All participants will receive treatment as usual (TAU) for SMI and intensive outpatient (IOP) addiction treatment throughout the study. After an induction period participants will be randomized to receive either 1) 12 weeks of CM for alcohol abstinence (assessed 3 times a week by EtG urine-tests) AND weekly reinforcement for IOP addiction treatment attendance;or 2) 12 weeks of reinforcement for providing urine-tests 3 times a week. The primary outcome will be changes in alcohol use assessed by EtG urinalysis, breathalyzer, as well as self-reported and clinician-reported alcohol use. The secondary outcome will be changes in IOP addiction treatment attendance assessed by IOP clinician-report, as well as independent administrative data sources, and self-report. Other outcomes will include: biological measures of illicit drug use, self-reported illicit drug use, psychiatric symptoms, HIV-risk, nicotine use, and utilization f costly emergency department, inpatient psychiatric and residential addiction treatment services. All outcomes will be assessed across the 12-week intervention and a 3-month follow-up period. This proposed study addresses two public health priorities--alcohol use and poor treatment attendance--in a population of adults with SMI for whom these difficulties are especially prevalent and problematic;and is responsive to NIAAA PA-10-100, Alcohol Use Disorders: Treatment, Services Research, and Recovery (R01).

Public Health Relevance

Alcohol dependence disproportionately affects persons with co-occurring severe mental illnesses, such as schizophrenia, bipolar disorders, and chronic major depression, with consequences such as early treatment dropout, increased psychiatric hospitalization, psychiatric illness severity, HIV-risk, and nicotine use. This project proposes to evaluate a behavioral treatment, contingency management, that has strong support as a treatment for reducing drug use, but has been less researched as a treatment for alcohol use because of limitations of alcohol biomarkers, such as alcohol breath-tests. We propose to determine if a contingency management intervention that reinforces 1) alcohol abstinence, as assessed by the alcohol biomarker -ethyl glucuronide- and 2) outpatient alcohol treatment attendance results in reductions in alcohol use and increases in treatment attendance in 120 adults suffering from alcohol dependence and severe mental illness receiving treatment at an urban community mental health center.

National Institute of Health (NIH)
National Institute on Alcohol Abuse and Alcoholism (NIAAA)
Research Project (R01)
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Health Services Research Review Subcommittee (AA)
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Roach, Deidra
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University of Washington
Schools of Medicine
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McDonell, Michael Gerard; Leickly, Emily; McPherson, Sterling et al. (2017) Pretreatment ethyl glucuronide levels predict response to a contingency management intervention for alcohol use disorders among adults with serious mental illness. Am J Addict 26:673-675
McDonell, Michael G; West, Imara I; Ries, Richard K et al. (2017) Response to Urine Drug Testing in a Family Residency Practice. J Addict Med 11:243
Leickly, Emily; Skalisky, Jordan; McPherson, Sterling et al. (2017) High Agreement Between Benchtop and Point-of-Care Dipcard Tests for Ethyl Glucuronide. Ther Drug Monit 39:461-462
McDonell, Michael G; Leickly, Emily; McPherson, Sterling et al. (2017) A Randomized Controlled Trial of Ethyl Glucuronide-Based Contingency Management for Outpatients With Co-Occurring Alcohol Use Disorders and Serious Mental Illness. Am J Psychiatry 174:370-377
Vilardaga, Roger; Rizo, Javier; Kientz, Julie A et al. (2016) User Experience Evaluation of a Smoking Cessation App in People With Serious Mental Illness. Nicotine Tob Res 18:1032-8
McDonell, Michael G; Graves, Meredith C; West, Imara I et al. (2016) Utility of Point-of-care Urine Drug Tests in the Treatment of Primary Care Patients With Drug Use Disorders. J Addict Med 10:196-201
McDonell, Michael G; Nepom, Jenny R; Leickly, Emily et al. (2016) A culturally-tailored behavioral intervention trial for alcohol use disorders in three American Indian communities: Rationale, design, and methods. Contemp Clin Trials 47:93-100
Lowe, Jessica M; McDonell, Michael G; Leickly, Emily et al. (2015) Determining ethyl glucuronide cutoffs when detecting self-reported alcohol use in addiction treatment patients. Alcohol Clin Exp Res 39:905-10
Leickly, Emily; McDonell, Michael G; Vilardaga, Roger et al. (2015) High levels of agreement between clinic-based ethyl glucuronide (EtG) immunoassays and laboratory-based mass spectrometry. Am J Drug Alcohol Abuse 41:246-50
McDonell, Michael G; Skalisky, Jordan; Leickly, Emily et al. (2015) Using ethyl glucuronide in urine to detect light and heavy drinking in alcohol dependent outpatients. Drug Alcohol Depend 157:184-7

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