Peth-Based Contingency Management to Reduce Alcohol Use and Improve Housing Outcomes

摘要 近40%的无家可归的成年人目前患有酒精使用障碍（AUD）。虽然“住房第一” 由于越来越多的计划，大多数无家可归的人必须避免使用酒精来获得和维持 住房应急管理（CM）是最有效的行为干预措施之一， 戒酒和戒毒。在一项在同时发生严重 精神疾病，其中60%是无家可归者，我们发现那些接受CM的人有3倍的可能性 提交酒精阴性尿乙基葡萄糖醛酸苷试验（uEtG），相对于对照。无家可归的人 8倍更有可能退出CM，相对于居住的个人。因此，CM似乎最有效 对于那些有房子的人来说。通过使用CM来减少以前无家可归的人的酒精使用， 如果有足够的住房，CM可能会防止随后与酒精相关的无家可归。uEtG检测的短暂时间 (2-5天）和其他酒精生物标志物需要每天多次监测戒酒（呼吸测试），或 周（uEtG）。这种频繁的监测在大多数住房方案中是不可行的， 一旦个人获得长期的禁欲，这是必要的。磷脂酰乙醇（PEth）是一种基于脂质的 生物标志物可以检测酒精使用长达28天。PEth的漫长检测周期将允许 更可行的监测和强化时间表（例如，每1至4周进行一次评估）， 开发可以加强长期禁欲维持的CM干预措施（例如，监测和 每4周强化一次）。我们建议评估基于PEth的CM的可行性和初步疗效 通过随机选择50名目前居住的、以前无家可归的成年人进行干预， 斯波坎天主教慈善机构提供的住房受试者将被随机分配至6个月的a）作为 常规（TAU）和提交血样的验证者，无论PEth结果如何（非偶然对照）， 或B）TAU和PEth结果与禁欲一致的验证者（CM）。他们将完成为期3个月的 干预后的后续行动。我们的CM干预将包括两个阶段。在初始阶段，PEth样品将 收集并每周递送一次，直到个体达到与长期 禁欲（即，PEth 16：0/18：1 <20 ng/mL）。然后，CM参与者将进入维护阶段， 将提交频率较低的PEth样本，每2至4周1份样本。在这项治疗开发研究中，我们 将使用定量和定性方法同时评估干预的可接受性和可行性 通过记录戒酒、住房保有权和酒精相关性方面的差异， 伤害我们将使用理论领域框架来指导我们对可能影响 实施干预。结果将用于支持R 01申请，以进行多中心 混合有效性/实施试验，以确定干预措施对酒精使用、住房 结果和酒精相关的危害，以及评估实施科学的结果。

ABSTRACT Nearly 40% of homeless adults currently struggle with an alcohol use disorder (AUD). While “housing first” programs are increasingly available, most homeless people must refrain from alcohol use to obtain and maintain housing. Contingency management (CM) is one of the most effective behavioral interventions for initiating abstinence from alcohol and drugs. In a randomized trial of CM for AUDs in adults with co-occurring serious mental illness, 60% of whom were homeless, we found that those who received CM were 3 times more likely to submit alcohol-negative urine ethyl glucuronide tests (uEtG), relative to controls. However, homeless individuals were 8 times more likely to drop out of CM, relative to housed individuals. Therefore, CM appears to work best for those who are housed. By using CM to reduce alcohol use in formerly homeless individuals who are now housed, CM might prevent subsequent alcohol-associated homelessness. The brief periods of detection of uEtG (2-5 days) and other alcohol biomarkers require monitoring of abstinence multiple times a day (breath tests) or week (uEtG) in a CM intervention. Such frequent monitoring is not feasible in most housing programs or necessary once individuals obtain prolonged periods of abstinence. Phosphatidylethanol (PEth) is a lipid-based biomarker that can detect alcohol use for up to 28 days. The lengthy detection period of PEth would allow for a more feasible monitoring and reinforcement schedule (e.g. 1 assessment every 1 to 4 weeks) and allows for the development of a CM intervention that can reinforce maintenance of long-term abstinence (e.g., monitoring and reinforcement once every 4 weeks). We propose to assess the feasibility and initial efficacy of a PEth-based CM intervention by randomizing 50 currently housed, formerly homeless adults with AUDs receiving supported housing from Catholic Charities Spokane. Participants will be randomized to either 6 months of a) treatment-as- usual (TAU) and reinforcers for submitting blood samples, regardless of PEth results (Non-contingent Control), or b) TAU and reinforcers for PEth results consistent with abstinence (CM). They will then complete a 3-month post-intervention follow-up. Our CM intervention will include 2 phases. In the initiation phase, PEth samples will be collected and reinforcers delivered weekly until individuals attain a PEth level consistent with prolonged abstinence (i.e., PEth 16:0/18:1 <20 ng/mL). CM participants will then enter the maintenance phase where they will submit less frequent PEth samples, 1 sample every 2 to 4 weeks. In this treatment development study, we will simultaneously evaluate intervention acceptability and feasibility using quantitative and qualitative methods and initial efficacy by documenting differences in alcohol abstinence, housing tenure and alcohol associated harms. We will use the Theoretical Domains Framework to guide our assessment of factors that might influence implementation of the intervention. Results will be used to support an R01 application to conduct a multi-site hybrid effectiveness/implementation trial to determine the impact of the intervention on alcohol use, housing outcomes, and alcohol related harms, as well as assess implementation science outcomes.