A high prevalence of alcohol dependence, compounded by a lack of culturally acceptable treatment options, is one of the most severe health disparities faced by American Indians and Alaska Natives (AI/AN). AI/ANs suffer disproportionately from alcohol dependence and its medical and psychosocial consequences relative to other racial and ethnic groups. AI/ANs are also less likely to receive or complete alcohol treatment relative to Whites. Some treatments for alcohol dependence are effective in non-Native populations, yet little is known about their acceptability and benefit for AI/ANs. One approach to reducing alcohol-associated health disparities is to form partnerships between AI/AN communities, clinicians, and researchers to tailor and test treatments in AI/ANs that have established benefits for other groups. This approach holds promise for developing treatments that are culturally acceptable, effective, sustainable, and portable. Contingency management (CM) is an intervention that offers rewards 2-3 times weekly for drug or alcohol abstinence, typically over 12 weeks of treatment. In non-AI/AN populations, CM is one of the most effective and well-studied behavioral treatments for illicit drug abuse. Compared to standard care, CM has higher rates of 8-week in-treatment abstinence (58 percent vs. 11 percent), 12-month post-treatment abstinence (30 percent vs. 5 percent), and treatment completion (75 percent vs. 40 percent). However, few studies have examined CM for alcohol dependence, primarily because of the lack of a biomarker that can detect alcohol use over more than 2 days (a requirement for CM). We have overcome this critical methodological barrier by using a new and superior measure of recent alcohol consumption, namely, ethyl glucuronide urine tests, which can detect low levels of alcohol use for at least the past 2 days. This approach permits us to implement and accurately evaluate CM for alcohol dependence in AI/AN adults. We propose to conduct a randomized, controlled trial of a culturally-acceptable CM intervention to encourage and support abstinence among AIs from 3 tribes living on 2 reservations and AI/ANs receiving services at an urban Indian healthcare facility. After we utilize qualitative research methods to modify the CM protocol to maximize cultural acceptability in each community, 400 individuals with alcohol dependence will receive treatment-as-usual and take part in a 4-week induction period before randomization either to an intervention consisting of 12 weeks of CM, or to a control condition of treatment as usual and non- contingent rewards.
Our specific aims are to 1) maximize the cultural acceptability of the CM intervention;2) determine if participants randomized to the CM group use less alcohol than those in the control group;2) quantify group differences in secondary addiction-related outcomes and alcohol-associated health-impairing behaviors;and 3) identify demographic, cultural, and other predictors of treatment outcome in the CM group. Our results will offer definitive evidence on the efficacy of CM as a treatment for alcohol dependence in urban and rural AI/AN populations and build the research and clinical infrastructure of our community partners.

Public Health Relevance

Alcohol dependence and consequences disproportionately affect American Indians and Alaska Natives, yet few evidence based treatments are available in Native communities. We propose to evaluate a culturally acceptable contingency management intervention, a behavioral treatment that is highly effective for substance abuse, in 400 American Indians and Alaska Natives suffering from alcohol dependence. If beneficial, this sustainable and portable intervention may have considerable public health impact for the many American Indians and Alaska Natives who experience alcohol-related health disparities.

National Institute of Health (NIH)
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Health Disparities and Equity Promotion Study Section (HDEP)
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Litten, Raye Z
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University of Washington
Schools of Medicine
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