A culturally-tailored behavioral intervention trial for alcohol use disorders in three American Indian communities: Rationale, design, and methods
Introduction
For complex reasons the need for alcohol treatment is great in many American Indian and Alaska Native (AI/AN) communities. Previous studies have observed higher rates of alcohol use disorders (AUD) in AI/AN communities than in the mainstream U.S. population (10.7% vs. 7.6%) [1]. In another study, nearly twice as many AI/AN adults reported needing alcohol treatment, when compared to others in the U.S. [3] Alarmingly, only 13% of AI/ANs who needed AUD treatment received it in the last year [3]. When AI/AN adults do receive treatment, their completion rate is lower than that of the general population [2], [3], [4]. As a result of these disparities, the alcohol mortality rate AI/ANs experience is approximately twice that of other Americans [5]. AI/AN communities are seeking culturally acceptable, feasible, and cost-effective strategies to combat AUDs.
Despite this need, little information exists about the effectiveness of AUD interventions for AI/AN populations. Observational studies support use of “Western” and AI/AN cultural-based AUD interventions in Native communities [6], [7], [8], [9]. Surprisingly, there are only three published randomized, controlled trials of AUD interventions in AI/AN adults [10], [11], [12]. Two observed reductions in alcohol use associated with pharmacological (naltrexone) [10] and behavioral (motivational interviewing) [11] interventions; while another found no impact on drinking when AI/AN women participated in an online intervention focused on preventing prenatal alcohol exposure [12]. While two of these studies observed reductions in drinking; one was not focused exclusively on AI/ANs and therefore, lacked the statistical power to determine intervention effectiveness for AI/ANs, and the other only included individuals involved in the criminal justice system [11]. Further research is needed to identify effective AUD interventions for AI/AN communities.
Contingency Management (CM) is an addiction intervention where participants receive reinforcers such as vouchers or prizes for providing objective evidence of drug abstinence [13], [14]. CM is an effective intervention for illicit drugs, and relative to other psychosocial interventions, CM is the most successful at initiating abstinence [14], [15], [16], [18], [19], [20], [21], [22], [23], [24], [25]. In previous studies CM has demonstrated cost-effectiveness, feasibility, and a long term reductions in substance use that are comparable to cognitive behavioral therapies [15], [16], [17]. Though untested in AI/ANs, CM is an effective intervention for illicit drug use in other minority racial and ethnic groups [18], [19], [20], [21].
Feasible CM interventions require a biomarker that can detect substance use in the preceding three days. Previous research on CM for AUDs has been limited by lack of such a biomarker. Ethyl glucuronide (EtG) is an alcohol metabolite [22], [23], [24], [25], [26], [27], [28], [29], [30], [31] that can be detected in urine for up to five days after drinking and can be evaluated in a clinical setting using a benchtop analyzer [29], [32], [33], [34], [35]. Our work supports the efficacy and feasibility of an EtG-based CM intervention [36].
In collaboration with three communities, we are conducting the Honoring Our Native Ongoing Recovery (HONOR) study, funded by the National Institutes of Health (R01AA022070), to: 1) determine whether participants randomized to a culturally-tailored CM intervention are more likely to achieve alcohol abstinence, as assessed by EtG urine tests, compared with those assigned to a control group; 2) quantify group differences for other addiction and health outcomes; and 3) identify demographic, clinical and cultural factors that modify the effect of CM on alcohol abstinence.
Section snippets
Design
The HONOR Study involves two phases: 1) a qualitative phase focused on identifying cultural adaptations to the CM intervention and 2) an RCT of the adapted CM intervention (Fig. 1). One or more focus groups will be conducted at each of the three study sites to improve the cultural acceptability of the study recruitment and intervention procedures. Up to 20 alcohol treatment providers, individuals with alcohol dependence, and their family members will be recruited from each community to
Preliminary data analyses
We will describe each treatment arm and study site in terms of demographic and clinical variables using percentages (categorical variables) and means and standard deviations (continuous variables). We will assess randomization by comparing the baseline distributions of variables in the two treatment arms, using t-tests for continuous factors and chi square tests for categorical factors. For primary and secondary biochemical outcomes, we will create indicator variables for abstinence at each
Implementation
Considerable planning and partnership development have been required to successfully implement this study. Community collaboration has been key to success at every step of this process from initial community engagement, to grant writing to implementation. Using the principles of Community Based Participatory Research as a framework, this project was initiated from community requests, followed by engagement with key stakeholders and public discussions with members of each community. Following
Summary
To our knowledge, the HONOR Study will be the largest RCT ever conducted of an intervention designed to treat alcohol problems in AI/AN adults, as well as the largest CM RCT targeting alcohol use disorders in any population. The financial costs and negative impact of alcohol misuse in American Indian/Alaska Native communities underscore the need for alcohol interventions that are effective, culturally acceptable to these communities, and can be implemented practically. Contingency management
Acknowledgments
The funding for this research is provided by the National Institute on Alcohol Abuse and Alcoholism and the Office of the Director's Office of Behavioral and Social Science Sciences research grant R01AA022070, Principal Investigators McDonell and Buchwald, as well as a small grant from the University of Washington's Institute for Translational Health Sciences, Principal Investigator Buchwald. We would like to thank our community partners for their ongoing collaboration and support throughout
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Current treatments of alcohol use disorder
2024, International Review of NeurobiologyContingency management for alcohol use disorder reduces cannabis use among American Indian and Alaska Native adults
2022, Journal of Substance Abuse TreatmentCitation Excerpt :CM group participants began the intervention period with five prize draws per EtG negative urine sample. For a continuously abstinent participant the maximum value was projected to be approximately $500, calculated by the number of prize draws possible at each visit multiplied by the probability of earning a $1 (small), $20 (large), or $80 (jumbo) prize (McDonell et al., 2016). Similar to the pre-randomization observation period, individuals assigned to the NC group continued to receive prizes for providing urine samples twice a week, regardless of abstinence, and we based prize draws on the average number of weekly draws in the CM group during the same week.
Quantifying opioid use disorder Cascade of Care outcomes in an American Indian tribal nation in Minnesota
2021, Drug and Alcohol DependenceCitation Excerpt :These insights have also been voiced in previous research: for example, Donovan et al. (2015) found that a culturally-tailored prevention program was associated with increased hope, optimism, self-efficacy, and cultural identity, as well as reduced substance use among tribal youth, and Venner et al. (2018) have reviewed importance of culturally tailored treatments in OUD treatment for American Indians, including adopting a holistic “medicine wheel” approach. There is little research on specific culturally tailored OUD treatments (Venner et al., 2018), although research on culturally tailored treatments for other substance use disorders may provide some guidance (McDonell et al., 2015). Future studies should evaluate culturally tailored treatment approaches, as well as culturally tailored versions of the Cascade of Care that account for cultural practices and tribal views of recovery, which in turn may require additional measurement methods and data sources.
Trending the evidence on opioid use disorder (OUD) continuum of care among rural American Indian/Alaskan Native (AI/AN) tribes: A systematic scoping review
2021, Addictive BehaviorsCitation Excerpt :While the Burdili et al., study had the limitation of its short duration and small sample size (n = 14), it suggests the potential for contingent rewards for treating OUD among rural AI/AN. OUD treatment and recovery CM would work with AIN/AN with cultural adaptation (i.e., use of culturally congruent prize awards methods and items Non-monetary CM methods have also been supported with other substance use disorders (e.g., Gruber, Chutuape, & Stitzer, 2000; Hirchak et al., 2018; McDonell et al., 2012, 2016; Tuten, DeFulio, Jones, & Stitzer, 2012; Tuten, Shadur, Stitzer, & Jones, 2017). These CM interventions provide non-monetary reinforcements such as free lunch, program-sponsored recreational activities within the community, vocational training, group therapy, goods such as formula and diapers, and other culturally-relevant items, which has great adaptation and sustainability potential for AI/AN communities (see also Hirchak et al., 2018).
Focus groups to increase the cultural acceptability of a contingency management intervention for American Indian and Alaska Native Communities
2018, Journal of Substance Abuse TreatmentCitation Excerpt :The HONOR Study includes two phases. Focus groups to inform the adaptation of the CM intervention followed by an RCT of the modified CM intervention in three AI/AN communities, as described in McDonell et al. (2016). Focus group recruitment included three research sites: an urban Indian health organization in the Pacific Northwest, a large tribal healthcare system in Alaska serving both rural and urban communities, and a rural reservation community in the Great Plains region.