Perspectives on a contingency management intervention for alcohol use among consumers with serious mental illness.

OBJECTIVE: This study describes the perspectives of outpatients with serious mental illness (SMI) and alcohol dependence on their participation in a contingency management (CM) intervention for alcohol use. METHODS: Thirty-five adults with SMI and alcohol dependence participated in a randomized trial of CM for alcohol use, where they were rewarded with prizes contingent on abstinence from alcohol. All participants were interviewed regarding their participation in CM with a consistent structure that included nine open-ended questions. Favored and disliked aspects of CM, perception of alcohol biomarker accuracy, and interest in participating in similar CM interventions provided by treatment centers, rather than researchers, were explored. RESULTS: Participants spoke enthusiastically about receiving prizes, as well as how CM increased their awareness of drinking and helped support their abstinence from alcohol. Most participants felt the ethyl glucuronide biomarker urine tests used to measure alcohol use were accurate, and they were interested in enrolling in CM if it was offered as a clinical program. Research staff who implemented the intervention were well regarded by participants, and interactions with research staff were perceived positively. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Adults with SMI and alcohol dependence participating in a trial of CM for alcohol use reported overall positive perceptions of and experiences with CM. Receiving small tangible prizes and having positive interpersonal interactions with study staff were reported as especially impactful. These findings indicate that CM is well received by consumers, in addition to its empirical and practical benefits as an evidence-based, low-cost intervention. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Serious Mental Illness in Heavy Drinkers Is Associated with Poor Treatment Outcomes in Outpatients with Co-occurring Disorders.

The objective of this study was to determine whether the interaction between type of serious mental illness (SMI) and pre-treatment drinking severity, assessed by ethyl glucuronide (EtG), predicts EtG-positive urine samples submitted during treatment in outpatients with co-occurring alcohol dependence and SMI. Seventy-nine participants were randomized to treatment-as-usual or treatment-as-usual and contingency management (CM) targeting alcohol abstinence. Generalized estimating equations were used to assess the interaction of pre-treatment drinking (heavy drinking or light drinking) and SMI diagnosis (major depression, bipolar, or schizophrenia-spectrum disorders) across a 12-week treatment period. In the overall sample, the interaction of drinking severity and SMI diagnosis (p = 0.006) was associated with alcohol abstinence. Exploratory analyses of the interaction term among participants randomized to CM (n = 40; p = 0.008) were associated with alcohol abstinence during CM. Type of SMI diagnosis was associated with treatment outcomes in individuals who engaged in heavy drinking, but not light drinking, prior to treatment.

Homelessness predicts attrition but not alcohol abstinence in outpatients experiencing co-occurring alcohol dependence and serious mental illness.

BACKGROUND: Adults experiencing homelessness and serious mental illnesses (SMI) are at an increased risk of poor mental health and treatment outcomes compared with stably housed adults with SMI. The additional issue of alcohol misuse further complicates the difficulties of those living with homelessness and SMI. In this secondary data analysis, the authors investigated the impact of homelessness on attrition and alcohol use in a contingency management (CM) intervention that rewarded alcohol abstinence in outpatients with SMI. METHODS: The associations between housing status and attrition and alcohol abstinence during treatment, as assessed by ethyl glucuronide (EtG) urine tests, were evaluated in 79 adults diagnosed with alcohol dependence and SMI. RESULTS: Thirty-nine percent (n = 31) of participants reported being homeless at baseline. Individuals who were homeless were more likely to drop out of CM (n = 10, 62.5%) than those who were housed (n = 4, 16.7%), χ2(1) = 8.86, P < .05. Homelessness was not associated with attrition in the noncontingent control group. Accounting for treatment group and prerandomization EtG levels, neither the effect of housing status nor the interaction of housing status and group were associated with EtG-assessed alcohol abstinence during treatment. CONCLUSIONS: Individuals experiencing homelessness and co-occurring alcohol dependence and SMI receiving CM had higher rates of attrition, relative to those who were housed. Homelessness was not associated with differences in biologically assessed alcohol abstinence.

Interaction between pre-treatment drug use and heterogeneity of psychiatric diagnosis predicts outcomes in outpatients with co-occurring disorders.

We examined whether the interaction of baseline stimulant use, assessed by urine drug tests, and type of serious mental illness (SMI) diagnosis predicted stimulant use in a trial of contingency management (CM). The interaction between baseline stimulant use and SMI diagnoses was significant in the overall sample (p=0.002) when controlling for the main effects of treatment condition, baseline stimulant use, and SMI diagnosis. Similar results were also found within the CM sample. Individuals with bipolar disorder were more or less likely, depending on their baseline stimulant-drug test results, to use stimulants during treatment compared to those with other SMI diagnoses.

Prevalence and Correlates of Cannabis Use in Outpatients with Serious Mental Illness Receiving Treatment for Alcohol Use Disorders.

Introduction: People with serious mental illness (SMI) use cannabis more than any other illicit drug. Cannabis use is associated with increased psychotic symptoms and is highly comorbid with alcohol use disorders (AUDs). Despite the national trend toward decriminalization, little is known about the prevalence, correlates, and impact of cannabis use on those with SMI receiving treatment for substance use disorders, a group at high risk for the negative effects of cannabis use. Methods: In this secondary data analysis, cannabis use prevalence, correlates, and impact on treatment outcomes were examined in 121 adults with cooccurring SMI and AUDs receiving outpatient addiction treatment in a randomized trial of contingency management (CM) for alcohol. Prevalence and frequency of cannabis use were calculated across the 7-month study period using self-report and urine tests. Cannabis users were compared with nonusers by SMI diagnosis, psychiatric symptoms, medical problems, legal problems, and HIV-risk behavior. The relationship between cannabis use and longest duration of alcohol abstinence in participants randomized to CM (n=40) was assessed. Results: Fifty-seven (47%) of participants submitted at least one cannabis-positive urine sample during the study. Out of the 2834 total samples submitted, 751 (27%) were positive for cannabis. Cannabis users were 2.2 times more likely to submit an alcohol-positive sample, and 2.5 times more likely to submit a cocaine-positive sample at baseline, relative to noncannabis users (p=0.01). Cannabis users were more likely to engage in risky sexual behavior (p=0.01) and to report being homeless (p=0.03) than nonusers. When controlling for pretreatment alcohol use, the relationship between comorbid cannabis use and alcohol abstinence during CM was not significant (p=0.77). Conclusion: Rates of comorbid cannabis use were high in this sample of adults with SMI and AUDs. Cannabis use was correlated with recent alcohol and cocaine use, risky sexual behavior, and homelessness, but not with alcohol abstinence during CM.

Pretreatment ethyl glucuronide levels predict response to a contingency management intervention for alcohol use disorders among adults with serious mental illness.

BACKGROUND AND OBJECTIVES: This study investigated if pretreatment ethyl glucuronide (EtG) levels corresponding to light (100 ng/mL), heavy (500 ng/mL), and very heavy (1,000 ng/mL) drinking predicted longest duration of alcohol abstinence (LDA) and proportion of EtG-negative urine tests in outpatients receiving a 12-week EtG-based contingency management (CM) intervention for alcohol dependence. METHODS: Participants were 40 adults diagnosed with alcohol use disorders and serious mental illness who submitted up to 12 urine samples for EtG analysis during a 4-week observation period and were then randomized to 12-weeks of CM for alcohol abstinence and addiction treatment attendance. Alcohol use outcomes during CM as assessed by EtG and self-report were compared across those who did and did not attain a pre-treatment average EtG level of 500 ng/mL-a level that equates to frequent heavy drinking. RESULTS: Only the 500 ng/mL cutoff was associated with significant differences in LDA and proportion of EtG-negative samples during CM. Those with a pre-treatment EtG < 500 ng/mL attained a LDA 2.3 (alcohol) to 2.9 (drugs) weeks longer than pre-treatment heavy drinkers. DISCUSSION AND CONCLUSIONS: The EtG biomarker can be used to determine who will respond to a CM intervention for alcohol use disorders and could inform future trials that are designed to be tailored to individual patients. SCIENTIFIC SIGNIFICANCE: Results suggest pre-treatment EtG cutoffs equivalent to heavy and very heavy drinking predict outcomes in CM. (Am J Addict 2017;26:673-675).

A Randomized Controlled Trial of Ethyl Glucuronide-Based Contingency Management for Outpatients With Co-Occurring Alcohol Use Disorders and Serious Mental Illness.

OBJECTIVE: The authors examined whether a contingency management intervention using the ethyl glucuronide (EtG) alcohol biomarker resulted in increased alcohol abstinence in outpatients with co-occurring serious mental illnesses. Secondary objectives were to determine whether contingency management was associated with changes in heavy drinking, treatment attendance, drug use, cigarette smoking, psychiatric symptoms, and HIV-risk behavior. METHOD: Seventy-nine (37% female, 44% nonwhite) outpatients with serious mental illness and alcohol dependence receiving treatment as usual completed a 4-week observation period and were randomly assigned to 12 weeks of contingency management for EtG-negative urine samples and addiction treatment attendance, or reinforcement only for study participation. Contingency management included the variable magnitude of reinforcement "prize draw" procedure contingent on EtG-negative samples (<150 ng/mL) three times a week and weekly gift cards for outpatient treatment attendance. Urine EtG, drug test, and self-report outcomes were assessed during the 12-week intervention and 3-month follow-up periods. RESULTS: Contingency management participants were 3.1 times (95% CI=2.2-4.5) more likely to submit an EtG-negative urine test during the 12-week intervention period, attaining nearly 1.5 weeks of additional alcohol abstinence compared with controls. Contingency management participants had significantly lower mean EtG levels, reported less drinking and fewer heavy drinking episodes, and were more likely to submit stimulant-negative urine and smoking-negative breath samples, compared with controls. Differences in self-reported alcohol use were maintained at the 3-month follow-up. CONCLUSIONS: This is the first randomized trial utilizing an accurate and validated biomarker (EtG) to demonstrate the efficacy of contingency management for alcohol dependence in outpatients with serious mental illness.

Creating a Regional Model to Coordinate and Prioritize Access to Permanent Supportive Housing.

Demand for supportive housing outstrips availability in metropolitan regions around the country. Individuals who are homeless with serious mental illnesses, substance abuse, and other debilitating health conditions are often heavy users of publicly financed services and institutions, such as jails, emergency departments, psychiatric and medical hospitals, and sobering and detoxification services. King County, in collaboration with community partners, has developed a regional system for coordinating and prioritizing access to this limited resource based on utilization of publicly financed services/institutions and/or vulnerability. In this paper, the model, key implementation steps, preliminary results, and lessons learned are described.

Suicide After Evaluation for Involuntary Psychiatric Commitment-Who Gets Them and What Influences Survival Time?

Although involuntary psychiatric hospitalizations are associated with suicide risk, little is known about the relationship between evaluation for involuntary detention and suicide. We analyzed data on 10,082 suicides from 2000 to 2011 to examine demographics related to evaluation for detention and the association between demographics and evaluation dispositions on survival time. Evaluation preceded 11% of suicides; 53.8% of deaths occurred within 365 days, 6.5 times the expected rate. Males and older individuals were least likely to have been evaluated. Minority status and referral disposition influence 30-day survival time. Risk is highly concentrated in the first year following evaluation.

Using ethyl glucuronide in urine to detect light and heavy drinking in alcohol dependent outpatients.

AIMS: This study investigated which ethyl glucuronide immunoassay (EtG-I) cutoff best detects heavy versus light drinking over five days in alcohol dependent outpatients. METHODS: A total of 121 adults with alcohol use disorders and co-occurring psychiatric disorders took part in an alcohol treatment study. Participants provided self-reported drinking data and urine samples three times per week for 16-weeks (total samples=2761). Agreement between low (100 ng/mL, 200 ng/mL), and moderate (500 ng/mL) EtG-I cutoffs and light (women ≤3 standard drinks, men ≤4 standard drinks) and heavy drinking (women >3, men >4 standard drinks) were calculated over one to five days. RESULTS: The 100 ng/mL cutoff detected >76% of light drinking for two days, and 66% at five days. The 100 ng/mL cutoff detected 84% (1 day) to 79% (5 days) of heavy drinking. The 200 ng/mL cutoff detected >55% of light drinking across five days and >66% of heavy drinking across five days. A 500 ng/mL cutoff identified 68% of light drinking and 78% of heavy drinking for one day, with detection of light (2-5 days <58%) and heavy drinking (2-5 days <71%) decreasing thereafter. Relative to 100 ng/mL, the 200 ng/mL and 500 ng/mL cutoffs were less likely to result in false positives. CONCLUSIONS: An EtG-I cutoff of 100 ng/mL is most likely to detect heavy drinking for up to five days and any drinking during the previous two days. Cutoffs of ≥500 ng/mL are likely to only detect heavy drinking during the previous day.

An economic evaluation of a contingency-management intervention for stimulant use among community mental health patients with serious mental illness.

BACKGROUND: This study examines the cost-effectiveness of contingency-management (CM) for stimulant dependence among community mental health patients with serious mental illness (SMI) METHODS: Economic evaluation of a 12-week randomized controlled trial investigating the efficacy of CM added to treatment-as-usual (CM+TAU), relative to TAU without CM, for treating stimulant dependence among patients with a SMI. The trial included 176 participants diagnosed with SMI and stimulant dependency who were receiving community mental health and addiction treatment at one community mental health center in Seattle, Washington. Participants were also assessed during a 12-week follow-up period. Positive and negative syndrome scale (PANSS) scores were used to calculate quality-adjusted life-years (QALYs) for the primary economic outcome. The primary clinical outcome, the stimulant-free year (SFY) is a weighted measure of time free from stimulants. Two perspectives were adopted, those of the provider and the payer. RESULTS: At 12-weeks neither the provider ($2652, p=0.74) nor the payer ($2611, p=0.99) cost differentials were statistically significant. This was also true for the payer at 24-weeks (-$125, p=1.00). QALYs gained were similar across groups, resulting in small, insignificant differences (0.04, p=0.23 at 12-weeks; 0.01, p=0.70 at 24 weeks). CM+TAU experienced significantly more SFYs, 0.24 (p<0.001) at 12 weeks and 0.20 (p=0.002) at 24 weeks, resulting in at least an 85% chance of being considered cost-effective at a threshold of $200,000/SFY. CONCLUSION: Contingency management appears to be a wise investment for both the provider and the payer with regard to the clinical outcome of time free from stimulants.

Determining ethyl glucuronide cutoffs when detecting self-reported alcohol use in addiction treatment patients.

BACKGROUND: Ethyl glucuronide (EtG) is an alcohol biomarker with potential utility as a clinical research and alcohol treatment outcome. Debate exists regarding the appropriate cutoff level for determining alcohol use, particularly with the EtG immunoassay. This study determined the EtG immunoassay cutoff levels that most closely correspond to self-reported drinking in alcohol-dependent outpatients. METHODS: Eighty adults with alcohol dependence and mental illness, taking part in an alcohol treatment study, provided urine samples 3 times per week for up to 16 weeks (1,589 samples). Self-reported drinking during 120 hours prior to each sample collection was assessed. Receiver operating characteristic analyses were conducted to assess the ability of the EtG immunoassay to detect self-reported alcohol use across 24- to 120-hour time periods. Sensitivity and specificity of EtG immunoassay cutoff levels was compared in 100 ng/ml increments (100 to 500 ng/ml) across 24 to 120 hours. RESULTS: Over half (57%) of the 1,589 samples indicated recent alcohol consumption. The EtG immunoassay closely corresponded to self-reported drinking from 24 (area under the curve [AUC] = 0.90, 95% confidence interval [CI]: 0.88, 0.92) to 120 hours (AUC = 0.88, 95% CI: 0.87, 0.90). When cutoff levels were compared across 24 to 120 hours, 100 ng/ml had the highest sensitivity (0.93 to 0.78) and lowest specificity (0.67 to 0.85). Relative to 100 ng/ml, the 200 ng/ml cutoff demonstrated a reduction in sensitivity (0.89 to 0.67), but improved specificity (0.78 to 0.94). The 300, 400, and 500 ng/ml cutoffs demonstrated the lowest sensitivity (0.86 to 0.33) and highest specificity (0.86 to 0.97) over 24 to 120 hours. CONCLUSIONS: For detecting alcohol use for >24 hours, the 200 ng/ml cutoff level is recommended for use as a research and clinical outcome.

A pilot study of the diabetes prevention program on weight loss for adults at community mental health centers.

OBJECTIVE: This study was a pilot evaluation of the Diabetes Prevention Program (DPP) implemented by community mental health center (CMHC) clinicians to reduce weight for individuals with serious mental illnesses. METHODS: Participants (N=60) received the 16-week DPP core curriculum at one of six CMHCs. A comparison group (N=77) received usual care at one of five other CMHCs. RESULTS: Compared with participants in usual care, DPP participants lost significantly more weight and were nearly three times more likely to lose at least 5% of body weight. Participants and staff found the program acceptable and feasible to implement. They also suggested incorporating exercise and cooking components, providing information about diabetes and the impact of medications on weight, simplifying intake and activity monitoring, providing at least twice monthly postcore sessions, monitoring lab values, and reinforcing group involvement between sessions. CONCLUSIONS: The evaluation demonstrated the feasibility, acceptability, and preliminary effectiveness of engaging CMHC clinicians in implementing the DPP for adults with serious mental illnesses.

High levels of agreement between clinic-based ethyl glucuronide (EtG) immunoassays and laboratory-based mass spectrometry.

BACKGROUND: Immunoassay urine drug screening cups that detect use for two or more days are commonly used in addiction treatment settings. Until recently, there has been no comparable immunoassay test for alcohol use in these settings. OBJECTIVES: The aim of this study was to assess the agreement of a commercially available ethyl glucuronide immunoassay (EtG-I) test conducted at an outpatient addiction clinic and lab-based EtG mass spectrometry (EtG-MS) conducted at a drug testing laboratory at three cut-off levels. High agreement between these two measures would support the usefulness of EtG-I as a clinical tool for monitoring alcohol use. METHODS: Forty adults with co-occurring alcohol dependence and serious mental illnesses submitted 1068 urine samples over a 16-week alcohol treatment study. All samples were tested using EtG-I on a benchtop analyzer and 149 were randomly selected for EtG-MS analysis at a local laboratory. Agreement was defined as the number of samples where EtG-I and EtG-MS were both above or below a specific cut-off level. Agreement was calculated at low cut-off levels (100 and 250 ng/ml), as well as at a higher cut-off level (500 ng/ml) recommended by most by commercial drug testing laboratories. RESULTS: Agreement between EtG-I and EtG-MS was high across all cut-off levels (90.6% at 100 ng/ml, and 96.6% at 250 and 500 ng/ml). CONCLUSIONS: EtG immunoassays conducted at low cut-off levels in point-of-care testing settings have high agreement with lab-based EtG-MS. EtG-I can be considered a useful clinical monitoring tool for alcohol use in community-based addiction treatment settings.

Preliminary findings: Contingency management targeting psycho-stimulant use results in secondary decreases in smoking for severely mentally ill adults.

BACKGROUND: Treatments for drug addiction and smoking in severely mentally ill (SMI) adults are needed. OBJECTIVES: To investigate the effect of a contingency management (CM) intervention targeting psycho-stimulant on cigarette smoking. METHODS: 126 stimulant dependent SMI smokers were assigned to CM or a non-contingent control condition. Rates of smoking-negative (<3 ppm) carbon monoxide breath-samples were compared. RESULTS: Individuals who received CM targeting psycho-stimulants were 79% more likely to submit a smoking-negative breath-sample relative to controls. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: This study provides initial evidence that a behavioral treatment for drug use results in reductions in cigarette smoking in SMI adults.

Acceptability of contingency management among clinicians and clients within a co-occurring mental health and substance use treatment program.

BACKGROUND: Emerging evidence supports the effectiveness of contingency management (CM) for addictions treatment among individuals with co-occurring serious mental illness (SMI). Addiction treatment for people with SMI generally occurs within community mental health centers (CMHCs) and it is not known whether CM is acceptable within this context. Client views regarding CM are also unknown. OBJECTIVES: This study is the first to describe CM acceptability among CMHC clinicians, and the first to explore client views. Clinician-level predictors of CM acceptability are also examined. METHODS: This study examined views about CM among 80 clinicians and 29 clients within a CMHC within the context of a concurrent CM study. RESULTS: Three-quarters of clinicians reported they would use CM if funding were available. Clinicians and clients affirmed that incentives enhance abstinence motivation. Clinician CM acceptability was related to greater years of experience, and identifying as an addictions or co-occurring disorders counselor, more than a mental health clinician. CONCLUSIONS: The findings provide preliminary evidence that CMHC clinicians, serving clients with addictions and complicating SMI, and client participants in CM, view CM as motivating and a positive tool to facilitate recovery. SCIENTIFIC SIGNIFICANCE: As an evidence-based intervention, CM warrants further efforts toward funding and dissemination in CMHCs.

Predictors of stimulant abuse treatment outcomes in severely mentally ill outpatients.

BACKGROUND: Severe mental illness is often exclusionary criteria for studies examining factors that influence addiction treatment outcome. Therefore, little is known about predictors of treatment response of individuals receiving psychosocial treatments for addictions who suffer from co-occurring severe mental illness. METHODS: The impact of demographic, substance abuse severity, psychiatric severity, and service utilization variables on in-treatment performance (i.e., longest duration of abstinence) in a 12-week contingency management (CM) intervention for stimulant abuse in 96 severely mentally ill adults was investigated. A 4-step linear regression was used to identify independent predictors of in-treatment abstinence. RESULTS: This model accounted for 37.4% of variance in the longest duration of abstinence outcome. Lower levels of stimulant use (i.e., stimulant-negative urine test) and psychiatric severity (i.e., lower levels of psychiatric distress), as well as higher rates of outpatient treatment utilization at study entry were independently associated with longer duration of drug abstinence. CONCLUSION: These data suggest that individuals with low levels of stimulant use and psychiatric severity, as well as those actively engaged in services are most likely to succeed in a typical CM intervention. For others, modifications to CM interventions, such as increasing the value of reinforcement or adding CM to evidence based psychiatric interventions may improve treatment outcomes.

A pilot study of the impact of housing first-supported housing for intensive users of medical hospitalization and sobering services.

OBJECTIVES: We examined changes in service use in a Housing First (HF) pilot program for adults who were homeless with medical illnesses and high prior acute-care use relative to a similar comparison group. METHODS: We used a 1-year pre-post comparison group design. The 29 participants and 31 comparison group members were adults who were homeless with inpatient claims of at least $10 000 or at least 60 sobering "sleep off" center contacts in the prior year. RESULTS: Participants showed a significantly greater reduction in emergency department and sobering center use relative to the comparison group. At a trend level, participants had greater reductions in hospital admissions and jail bookings. Reductions in estimated costs for participants and comparison group members were $62 504 and $25 925 per person per year-a difference of $36 579, far outweighing program costs of $18 600 per person per year. CONCLUSIONS: HF participants showed striking reductions in acute-care use relative to the comparison group, demonstrating that HF can be a successful model for people with complex medical conditions and high prior acute-care use. Despite notable methodological limitations, these findings could be used to inform a larger multisite study that would establish greater generalizability.