Homelessness and alcohol-use disorders (AUDs) are commonly co-occurring and serious public health issues. Unfortunately, abstinence-based treatment approaches are generally ineffective in engaging and successfully treating homeless individuals with AUDs. There have therefore been calls for more flexible and client-centered approaches tailored to this population. In response to this need, we are proposing the development and pilot evaluation of a harm-reduction treatment for homeless individuals with AUDs (HaRT-A) as an innovative, empirically informed and client-driven alternative to abstinence-based AUD treatment. As initially planned, the HaRT-A will comprise a 3-session, individual, behavioral intervention. Preliminary components include providing personalized alcohol feedback, eliciting clients'harm-reduction goals, building motivation to change, and encouraging safer drinking using a nonjudgmental, empathetic stance, and acceptance of clients wherever they are along the spectrum of behavior change. To maximize its efficacy, the HaRT-A is being collaboratively designed with a community advisory board (CAB) made up of homeless advocates as well as staff, management and clients (i.e., homeless individuals with AUDs) at two, nonprofit agencies on the forefront of harm reduction oriented supportive service provision for homeless individuals. Consistent with NIH Stage I treatment development guidelines, we will develop and pilot test the HaRT-A in four phases. In Phase I, we will collect qualitative data via interviews and focus groups with agency clients and staff. Grounded theory analyses will yield a conceptual/thematic description of key alcohol themes and will thereby identify potential points for intervention to be addressed in the HaRT-A. In Phase II, we will develop the HaRT-A treatment manual using qualitative data gleaned from Specific Aim 1;evidence-based, best-practice approaches;and guidance of the CAB. Phase III will feature a small, pilot RCT (N=160) of the HaRT-A at the two agencies. Participants will be randomized to receive either the HaRT-A or agency services as usual (TAU), and will be assessed at baseline, posttest (immediately following treatment end), 1-month and 3-month follow-ups. Quantitative analyses will test the efficacy of the HaRT-A compared to TAU. It is hypothesized that HaRT-A participants will show significantly greater improvements on alcohol outcomes, motivation to change, and health-related quality of life (HRQoL) compared to TAU participants. Secondary, exploratory analyses will preliminarily test HaRT-A effects on health-care and criminal justice utilization outcomes up to 6 months posttreatment. Consistent with NIH treatment fidelity recommendations, treatment integrity will be tested in Phase IV of this project. In achieving these specific aims, this project will lay the groundwork for longer-term research objectives, including a larger RCT of the HaRT-A and dissemination of this intervention to researchers, clinicians and community-based organizations to improve outcomes for affected individuals and their communities.

Public Health Relevance

In this project, the research team will work with community-based agencies and homeless clients to collaboratively develop and pilot a harm-reduction treatment for homeless individuals with alcohol-use disorders (AUDs). In the short-term, this project is positioned to make a strong, immediate public health impact by reducing alcohol-related harm and improving quality of life in a vulnerable and marginalized population. In the long-term, this project may have a broader impact on public health by introducing an effective AUD treatment that engages people wherever they are along the spectrum of readiness to change.

National Institute of Health (NIH)
National Institute on Alcohol Abuse and Alcoholism (NIAAA)
Planning Grant (R34)
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Health Services Research Review Subcommittee (AA)
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Falk, Daniel
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University of Washington
Schools of Medicine
United States
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