Contingency Management Treatment of Alcohol Abuse American Indian People

描述(由申请人提供)：酒精依赖的高度流行，再加上缺乏文化上可接受的治疗选择，是美国印第安人和阿拉斯加土著面临的最严重的健康差距之一。与其他种族和族裔群体相比，人工智能/ANS人不成比例地遭受酒精依赖及其医疗和心理社会后果的影响。与白人相比，AI/ANS接受或完成酒精治疗的可能性也较小。酒精依赖的一些治疗方法在非土著人群中是有效的，但人们对它们的接受性和对AI/ANS的好处知之甚少。减少与酒精相关的健康差距的一种方法是在AI/AN社区、临床医生和研究人员之间建立伙伴关系，以量身定制和测试AI/AN中的治疗方法，这些治疗已经为其他群体确定了好处。这种方法有望开发出文化上可接受的、有效的、可持续的和便携的治疗方法。应急管理(CM)是一种干预措施，每周为戒毒或戒酒提供2-3次奖励，通常超过12周的治疗。在非AI/AN人群中，CM是治疗非法药物滥用最有效和研究最充分的行为疗法之一。与标准护理相比，CM有更高的8周治疗中禁欲率(58%对11%)，12个月治疗后禁酒率(30%对5%)，以及治疗完成率(75%对40%)。然而，很少有研究检查CM的酒精依赖，主要是因为缺乏一种生物标记物可以检测超过2天的酒精使用(CM的要求)。我们已经克服了这一关键的方法障碍，使用了一种新的、更好的最近酒精消费的衡量标准，即乙基葡萄糖醛酸尿液测试，它可以检测到至少在过去两天内的低水平酒精使用。这种方法使我们能够实施和准确地评估CM对AI/AN成年人的酒精依赖。我们建议进行一项文化上可接受的CM干预的随机对照试验，以鼓励和支持居住在2个保留地的3个部落的人工智能和在印度城市医疗机构接受服务的人工智能/ANS。在我们利用定性研究方法修改CM方案以最大限度地提高每个社区的文化可接受性后，400名酒精依赖患者将像往常一样接受治疗，并在随机化之前参加为期4周的诱导期，要么接受12周的CM干预，要么接受正常治疗和非偶然奖励的对照条件。我们的具体目标是1)最大限度地提高CM干预的文化可接受性；2)确定随机进入CM组的参与者是否比对照组使用更少的酒精；2)量化两组在与继发性成瘾相关的结果和与酒精相关的健康损害行为方面的差异；以及3)确定CM组中治疗结果的人口统计学、文化和其他预测因素。我们的结果将为CM作为治疗城市和农村AI/AN人群酒精依赖的有效性提供确凿证据，并为我们的社区合作伙伴建立研究和临床基础设施。

DESCRIPTION (provided by applicant): A high prevalence of alcohol dependence, compounded by a lack of culturally acceptable treatment options, is one of the most severe health disparities faced by American Indians and Alaska Natives (AI/AN). AI/ANs suffer disproportionately from alcohol dependence and its medical and psychosocial consequences relative to other racial and ethnic groups. AI/ANs are also less likely to receive or complete alcohol treatment relative to Whites. Some treatments for alcohol dependence are effective in non-Native populations, yet little is known about their acceptability and benefit for AI/ANs. One approach to reducing alcohol-associated health disparities is to form partnerships between AI/AN communities, clinicians, and researchers to tailor and test treatments in AI/ANs that have established benefits for other groups. This approach holds promise for developing treatments that are culturally acceptable, effective, sustainable, and portable. Contingency management (CM) is an intervention that offers rewards 2-3 times weekly for drug or alcohol abstinence, typically over 12 weeks of treatment. In non-AI/AN populations, CM is one of the most effective and well-studied behavioral treatments for illicit drug abuse. Compared to standard care, CM has higher rates of 8-week in-treatment abstinence (58 percent vs. 11 percent), 12-month post-treatment abstinence (30 percent vs. 5 percent), and treatment completion (75 percent vs. 40 percent). However, few studies have examined CM for alcohol dependence, primarily because of the lack of a biomarker that can detect alcohol use over more than 2 days (a requirement for CM). We have overcome this critical methodological barrier by using a new and superior measure of recent alcohol consumption, namely, ethyl glucuronide urine tests, which can detect low levels of alcohol use for at least the past 2 days. This approach permits us to implement and accurately evaluate CM for alcohol dependence in AI/AN adults. We propose to conduct a randomized, controlled trial of a culturally-acceptable CM intervention to encourage and support abstinence among AIs from 3 tribes living on 2 reservations and AI/ANs receiving services at an urban Indian healthcare facility. After we utilize qualitative research methods to modify the CM protocol to maximize cultural acceptability in each community, 400 individuals with alcohol dependence will receive treatment-as-usual and take part in a 4-week induction period before randomization either to an intervention consisting of 12 weeks of CM, or to a control condition of treatment as usual and non- contingent rewards. Our specific aims are to 1) maximize the cultural acceptability of the CM intervention; 2) determine if participants randomized to the CM group use less alcohol than those in the control group; 2) quantify group differences in secondary addiction-related outcomes and alcohol-associated health-impairing behaviors; and 3) identify demographic, cultural, and other predictors of treatment outcome in the CM group. Our results will offer definitive evidence on the efficacy of CM as a treatment for alcohol dependence in urban and rural AI/AN populations and build the research and clinical infrastructure of our community partners.