Effectiveness and Outcomes of Combined Contingency Management and CBT for Alcohol Use Disorder

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Alcohol contributes to 88,000 deaths and costs an estimated $223 billion annually in the United States. Alcohol use disorder (AUD) is highly prevalent in veterans; an estimated 32% of veterans meet diagnostic criteria for AUD. The positive public health impact of reducing heavy drinking among veterans with AUD would prevent significant medical morbidity and mortality. Behavioral incentives could increase treatment retention and increase abstinence among Veterans with AUD. Contingency management (CM) is an intensive behavioral therapy that provides incentives to individuals misusing substances. CM has demonstrated effect sizes beyond that of other behavioral treatments across multiple drugs of abuse, including a trial in Veterans with AUD, which demonstrated that CM both increased treatment retention and completion rates and was associated with increased abstinenence from alcohol compared to standard treatment. To date, however, implementation of CM interventions has largely focused on stimulant use disorders (e.g., cocaine; methamphetamine) due to the diffculty of monitoring abstinence from alcohol, which requires daily monitoring. Thus, despite demonstrated efficacy, CM aproaches for treatment of AUD are not currently available to people with AUD. Our group has developed a mobile smart-phone application that allows patients to video themselves using a small FDA-approved alcohol breath monitor and transmits the encrypted data to a secure server. This innovation has made the use of CM for outpatient AUD treatment feasible. Targeting AUD with mobile CM (mCM) paired with evidenced-based cognitive behavioral therapy (CBT) will significantly improve long-term abstinence rates and reduction in heavy drinking days among Veterans with AUD. The aim of the current study is to evaluate the effectiveness and cost effectiveness of contingency management as an adjunct to cognitive behavioral therapy for alcohol use disorders. The trial will also explore the potential utilty of a long-term abstinence incentive on treatment utilization and alcohol outcomes. Proposed is a comparative effectiveness trial with a 2 x 2 factorial design in which 160 Veterans with AUD will be proactively recruited and randomized to receive either CM as an adjunct to state-of-the-art evidenced-based CBT or CBT alone; and to one of two long-term incentive conditions (i.e., receipt of a monetery incentive for abstinence/low-risk drinking at 6- months vs. no incentive). This project aims to advance AUD treatment by 1) testing the effectiveness of a mobile health approach that makes CM for AUD feasible, and 2) providing highly needed cost-effectiveness data on the use of behavioral incentives as an adjunct to CBT for the treatment of AUD. These aims are designed to address two significant barriers to the implementation of efficacious CM for AUD.