The objective of this competing continuation (renewal) application is to determine whether modifications to a contingency management (CM) intervention improve outcomes and reduce costs in heavy drinkers with serious mental illness (SMI). Up to 46% of adults with SMI experience an alcohol use disorder in their lifetimes. Alcohol use contributes to high rates of homelessness, psychiatric hospitalization, HIV infection, cigarette smoking, and drug use in this population, for which CM is an especially promising treatment. In CM, patients receive tangible rewards for demonstrating drug abstinence. CM for alcohol use requires a biomarker that can detect alcohol use for more than 48 hours after consumption. As no such biomarker was available until recently, little research has investigated CM as a treatment for alcohol use disorders. In our initial funding period we found that the alcohol biomarker ethyl glucuronide (EtG) can detect drinking for up to 5 days when administered as part of a randomized 12-week trial of CM. Those randomized to EtG-based CM were 3 times more likely to submit alcohol-negative EtG tests than controls. CM participants also had lower levels of heavy drinking, stimulant drug use, and cigarette smoking than controls. However, CM was ineffective for participants with an average pre-treatment EtG level that indicated frequent, recent heavy drinking (EtG > 499 ng/mL). We propose to investigate whether 2 strategies ? a) increasing reinforcer magnitude or b) reinforcing light drinking before reinforcing abstinence ? can improve outcomes in heavy drinkers with SMI. While initial research indicates that these strategies are associated with improved outcomes in treatment-resistant drug users and cigarette smokers, no randomized trial has compared them, investigated them in alcohol users or adults with SMI, investigated their relative cost-effectiveness, or investigated modifiers of CM efficacy using a theoretical model. Therefore, we will compare the efficacy of these 2 approaches to the CM intervention implemented in the initial funding period in heavy drinkers with SMI. A total of 400 participants receiving treatment as usual at 2 treatment agencies will take part in a 4-week induction period. Participants (n=240) who attain a mean EtG > 499 ng/mL during the induction period will be randomized to either a) 4 months of standard-magnitude reinforcement CM for submitting alcohol-abstinent EtG samples (EtG < 100 ng/mL) (Usual CM), b) 4 months of high-magnitude CM for submitting alcohol-abstinent EtG samples (High-Magnitude CM), or c) 1 month of CM for submitting alcohol samples that indicate light drinking (EtG < 500 ng/mL), followed by 3 months of CM for submitting alcohol-abstinent EtG samples (Shaping CM). The primary outcome will be EtG-verified alcohol abstinence during the last 3 months of treatment (when all reinforcement is contingent on abstinence) and during 6 months of follow-up. We will also investigate group differences in secondary outcomes, conduct a comprehensive economic analysis of CM conditions, and determine whether variables that make up the NIAAA Addictions Neuroclinical Assessment framework moderate alcohol abstinence in the 3 CM conditions.

Public Health Relevance

PROJECT RELEVANCE Alcohol use disorders disproportionately affect persons with co-occurring serious mental illness, such as schizophrenia, bipolar disorders, and recurrent major depression, with consequences such as increased treatment dropout, drug use, psychiatric hospitalization, HIV-risk, and cigarette smoking. In our initial funding period we observed that relative to light drinkers, heavy drinkers did not respond to contingency management, a behavioral treatment where individuals receive tangible rewards for alcohol abstinence. Therefore, we propose to determine if increasing the amounts of rewards or rewarding people for light drinking before rewarding abstinence are more effective than a typical contingency management intervention for 240 heavy drinkers who also suffer from serious mental illness.

National Institute of Health (NIH)
National Institute on Alcohol Abuse and Alcoholism (NIAAA)
Research Project (R01)
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Study Section
National Institute on Alcohol Abuse and Alcoholism Initial Review Group (AA)
Program Officer
Roach, Deidra
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Washington State University
Schools of Medicine
United States
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Oluwoye, Oladunni; Monroe-DeVita, Maria; Burduli, Ekaterina et al. (2018) Impact of tobacco, alcohol and cannabis use on treatment outcomes among patients experiencing first episode psychosis: Data from the national RAISE-ETP study. Early Interv Psychiatry :
Oluwoye, Oladunni; Stiles, Bryan; Monroe-DeVita, Maria et al. (2018) Racial-Ethnic Disparities in First-Episode Psychosis Treatment Outcomes From the RAISE-ETP Study. Psychiatr Serv :appips201800067
Oluwoye, Oladunni; Leickly, Emily; Skalisky, Jordan et al. (2018) Serious Mental Illness in Heavy Drinkers Is Associated with Poor Treatment Outcomes in Outpatients with Co-occurring Disorders. Int J Ment Health Addict 16:672-679
Oluwoye, Oladunni; Hirchak, Katherine; Leickly, Emily et al. (2018) Interaction between pre-treatment drug use and heterogeneity of psychiatric diagnosis predicts outcomes in outpatients with co-occurring disorders. Psychiatry Res 260:233-235
Oluwoye, Oladunni; Skalisky, Jordan; Burduli, Ekaterina et al. (2018) Using a randomized controlled trial to test whether modifications to contingency management improve outcomes for heavy drinkers with serious mental illness. Contemp Clin Trials 69:92-98
McPherson, Sterling M; Burduli, Ekaterina; Smith, Crystal Lederhos et al. (2018) A review of contingency management for the treatment of substance-use disorders: adaptation for underserved populations, use of experimental technologies, and personalized optimization strategies. Subst Abuse Rehabil 9:43-57
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
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; West, Imara I; Ries, Richard K et al. (2017) Response to Urine Drug Testing in a Family Residency Practice. J Addict Med 11:243
Skalisky, Jordan; Leickly, Emily; Oluwoye, Oladunni et al. (2017) Prevalence and Correlates of Cannabis Use in Outpatients with Serious Mental Illness Receiving Treatment for Alcohol Use Disorders. Cannabis Cannabinoid Res 2:133-138

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