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Contingency Management
A single site and multisite test of the efficacy of contingency management approach for alcohol use among American Indian/Alaska Natives (AI/AN).
Two studies investigated contingency management, a method to incentivize abstinence from alcohol use (and other substance use). In each study, participants submitted two to three urine samples to test for the presence of alcohol and/or drugs for 12 weeks. If participants were abstinent from alcohol, they immediately drew chips from a bag of 500 chips. Chips provided messages in English and Native language indicating level of reward. Some said “good job” or other encouraging phrases, but resulted in no prize; other chips resulted in a prize worth $1, $20, or $80. Incentives were culturally congruent and supportive of families, such as beading and jewelry supplies, grocery store gift cards, diapers, fishing poles, and camping gear. All participants in both studies also could receive treatment as usual but attendance was not required. Contingency management was compared to a noncontingent control group that received draws for submitting a urine screen regardless of whether they abstained from alcohol.
Outcomes
In both studies, the contingency management groups were more likely to submit urine samples free of alcohol.
In both studies, the contingency management groups were more likely to submit alcohol-free urine samples during active treatment; no follow-up was reported. In McDonell et al. (2020), study participants in the contingency management group were nearly five times more likely to submit an alcohol-free urine sample than the control group. In McDonell et al. (2021), participants in the contingency management group had a higher likelihood than the control group (65.6% vs. 52.8%, respectively) of submitting alcohol-free urine samples. In both studies, there was similar and substantial attrition from both the contingency management and control conditions as well as loss to follow-up.
Costs
Costs are considered to be medium for both start-up and ongoing activities.
Although the intervention does not require specialized staff, moderate costs are associated with space, staffing, prizes, and urine testing and materials. The average cost per patient for the incentives was $50. The estimated cost per patient, including the costs for staff time and the testing of frequent urine samples, would range from $300 to $500.
Cultural Engagment
Cultural engagement is low, and Tribal engagement is medium.
A community advisory board assembled for 2 hours at the start of the study to inform the intervention and study. It was noted that the board would continue to meet periodically throughout the study. Chips/tokens featured Native language in addition to English; reinforcers included culturally relevant goods, providing prizes that supported families, and an Elder using the prize drawing as a way to present information about American Indian cultural concepts and teachings. These features were applied across both control and intervention groups. This intervention hinged primarily on contingency management, a very western-based approach. The 2020 study was conducted in partnership with a Northern Plains reservation, and an American Indian Elder was the lead interventionist. The 2021 study included Tribal and community organizations in data sharing and ownership agreements.
Participants
Young Adult, Adult, Senior; Native; Female, Male
Setting
Community Center, Clinical/Healthcare, Reservation, Rural, Urban
Delivery
Individual, Face-to-Face
American Indian/Alaska Natives (AI/AN) in urban, rural, and reservation settings participated.
In McDonell et al. (2020), participants were comprised 114 AI/AN adults from a Northern Plains reservation. In McDonell et al. (2021), participants included 158 AI/AN adults from an urban Pacific Northwest clinic or community center; a Tribally operated treatment center on a Northern Plains reservation; and an urban, Tribally owned Alaskan addiction clinic. Across the two studies, participants ranged in age from 35.8 to 42.2 years, roughly half were male, and all were in residential treatment at the time of the intervention.
Staffing Needs
Advanced Degree (post BA) Professional, Community Member
Community members, an Elder, and a cultural educator provided teachings at the prize drawings.
McDonell et al. (2020) utilized trained community members to provide the intervention or to supervise prize draws, and an Elder and a cultural educator provided teachings at the prize drawings. McDonell et al. (2021) specified that the interventionist did not need a clinical license; community members were trained to deliver the contingency management intervention.
Research Design
Randomized controlled experimental design
Developmental stage of research
Two studies demonstrated that contingency management is effective in increasing abstinence among AI/ANs.
Many studies have demonstrated that contingency management is an efficacious treatment for AUD. These two studies represent the first application of contingency management among AI/ANs. Both studies found support for using contingency management to encourage alcohol abstinence. These two studies have a strong research design, but some limitations in recent reports prevent it from being at the mature stage for this population. These studies did not address long-term follow-up, so it is unclear if intervention effects will last. Small samples and no test of baseline equivalence between groups or control variables limit the ability to draw strong conclusions.
Potential
There is potential for contingency management to increase abstinence from alcohol use for AI/ANs.
Contingency management is an evidence-based practice with demonstrated efficacy in the general population. Support was found in two rigorous studies for its application among AI/AN treatment-seeking populations across multiple settings when delivered by organizations that serve AI/ANs. This practice is easy to implement, transportable, and feasible in Native communities. This approach represents a highly westernized approach, which may require further cultural adaptation along with strong Tribal and community involvement in highly traditional AI/AN communities.
References
McDonell MG, Skalisky J, Burduli E, et al. The rewarding recovery study: A randomized controlled trial of incentives for alcohol and drug abstinence with a rural American Indian community. Addiction. 2021;116(6):1569-1579. https://pubmed.ncbi.nlm.nih.gov/33220122. https://doi.org/10.1111/add.15349.
McDonell MG, Hirchak KA, Herron J, et al. Effect of incentives for alcohol abstinence in partnership with 3 American Indian and Alaska Native communities: A randomized clinical trial. JAMA Psychiatry. 2021;78(6):599-606. https://pubmed.ncbi.nlm.nih.gov/33656561. https://doi.org/10.1001/jamapsychiatry.2020.4768.
Hirchak KA, Leickly E, Herron J, et al. Focus groups to increase the cultural acceptability of a contingency management intervention for American Indian and Alaska Native communities. J Subst Abuse Treat. 2018;90:57-63. https://pubmed.ncbi.nlm.nih.gov/29866384. https://doi.org/10.1016/j.jsat.2018.04.014.
McDonell MG, Nepom JR, Leickly E, et al. A culturally-tailored behavioral intervention trial for alcohol use disorders in three American Indian communities: Rationale, design, and methods. Contemp Clin Trials. 2016;47:93-100. https://pubmed.ncbi.nlm.nih.gov/26706667. https://doi.org/10.1016/j.cct.2015.12.010.
O'Malley SS, Crouch MC, Higgins ST. Bringing together behavioral science, community engagement, and cultural adaptations to increase alcohol abstinence among American Indian and Alaska Native people using contingency management therapy. JAMA Psychiatry. 2021;78(6):595-596. https://pubmed.ncbi.nlm.nih.gov/33656541. https://doi.org/10.1001/jamapsychiatry.2020.4757.
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