Remote alcohol monitoring to facilitate abstinence reinforcement

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1 Remote alcohol monitoring to facilitate abstinence reinforcement Mikhail N. Koffarnus; Anita S. Kablinger; Amy E. Swallow; Warren K. Bickel Virginia Tech Carilion Research Institute, Roanoke, VA We have no conflicts of interest to report

2 Incidence of untreated alcohol dependence One in eight adults in the US meets criteria for alcohol dependence sometime in their life (Hasin et al., 2007) Only 24% of those individuals ever receive treatment, leaving 10s of millions of untreated adults Of the top 10 most common reasons for not seeking treatment, 7 relate to an inability or unwillingness to attend existing treatment services: (Cohen et al., 2007) Should be strong enough to handle it alone Was too embarrassed Could not afford it Did not want to go to treatment Hated answering questions Did not think anyone could help Did not know any place to go The pervasiveness of alcohol dependence indicates a need for continued development of high-impact treatments that are both effective and easily disseminated widely 2

3 Contingency management for alcohol dependence Contingency management is a highly efficacious treatment for alcohol and other drug abuse (Higgins et al., 2008) In contingency management treatments, a tangible reward (e.g., money, privilege, or prize) is delivered contingent on verified abstinence In practice, this method is not often used for alcohol dependence due to difficulties with frequently verifying alcohol abstinence Only 60% of samples collected in our recent intervention (Koffarnus et al., 2011) Koffarnus et al.,

4 Contingency management for alcohol dependence Treatment Contingency Management Treatment Ingredient Abstinencecontingent Reinforcers Frequency Immediacy of consequences Dependent Variable Abstinence (negative breathalyzer screens) In the present experiment, we are using technology to extend this treatment and make it feasible to remotely delivered contingency management for alcohol dependence 4

5 Use of technology to facilitate remote treatment SOBERLINK breathalyzer Accurate fuel cell breathalyzer Cellular module for submitting results remotely Camera photographs user mid-submission Debit card for payment Incentives and other compensation is delivered via reloadable debit card Payments are available for use by participant immediately after RA submits it Card can be used anywhere that accepts MasterCard Cell phones Participants send daily text message reports of alcohol use and withdrawal Participants are sent reminders and notifications of payments 5

6 Participants All participants are alcohol-dependent at intake and interested in quitting 23% female 8% African American, 92% white Mean age: 46.3 (SD = 11.1) Mean education: 14.6 years (SD = 2.5 years) Mean monthly income: $2511 (SD = $1562, median = $2400) Mean drinks per day at intake: 7.4 (SD = 3.4) Mean years of heavy drinking: 21.4 (SD = 9.0) Participants are excluded for meeting dependence criteria on other drugs of abuse (except caffeine and nicotine), for scoring highly on the Alcohol Withdrawal Symptoms Checklist 6

7 Procedures Monitoring only phase: 1 week of daily self-reports of alcohol use and withdrawal symptoms Mild or greater withdrawal symptoms are followed up with the Alcohol Withdrawal Symptom Checklist Participants with at least 2 heavy drinking days move on to the treatment phase Treatment phase: For 21 days, participants submit 3 breathalyzer screens per day at times they pick (with restrictions) Daily self-reports of alcohol use and withdrawal symptoms continue The consequences of the breathalyzer screens differ by group Assessment sessions occur before the study, after the study, and at a one-month follow-up Week number 1 group Day of week M Tu W Th F Sa Su assignment M Tu W Th F Sa Su M Tu W Th F Sa Su M Tu W Th F Sa Su M any All subjects Cont. Noncont. Assessment 3 contingent BAs 3 noncontingent BAs Daily self-report of alcohol use and withdrawal 7

8 Groups CONTINGENT GROUP Participants earn an abstinence incentive for submitting three ontime negative breathalyzer screens Abstinence incentives begin at $5/day and raise by $1 for each negative day up to $25 If positive, incentives reset to $5 Incentive amount reverts back to previous amount after 3 negative days NONCONTINGENT GROUP Participants earn an incentive for submitting three on-time negative or positive breathalyzer screens Payments are yoked to a finished contingent group participant Both groups receive $1 for each submitted sample and $1 for reporting their alcohol use and withdrawal symptoms 8

9 Preliminary alcohol use results 13 participants completed so far out of a projected 58 Percent Days Abstinent Percent days abstinent in contingent group is 85% compared to 56% in the noncontingent group Effect size: d = 0.82 (large effect) >97% sample collection rate 9

10 Acceptability and satisfaction data All features of the study were rated at least somewhat positive with most rated very positively Most features were rated more highly in the contingent group 100% of contingent participants were very satisfied with the treatment overall Taking all things into account, how satisfied are you with this treatment? How likely would you be to recommend this treatment to a friend or relative? How clear is the payment system used in this study? How helpful is the breathalyzer feedback to motivate you to quit drinking? How helpful are the payments in motivating you to quit drinking? How convenient is it to use the debit card system to receive payments? How convenient is it to use a cell phone to communicate with us? How convenient is it to use the SOBERLINK device? How easy is it to adhere to the scheduled requirements? How satisfied are you with this treatment reducing your alcohol use? Contingent Noncontingent Not at all Not very Somewhat Very 10

11 Contingency management for alcohol dependence Treatment Contingency Management Treatment Ingredient Abstinencecontingent Reinforcers Frequency Immediacy of consequences Dependent Variable Abstinence (negative breathalyzer screens) Our preliminary results so far support the idea that using technology to extend contingency management to a remote treatment model retains the established efficacy of this treatment while making it more practical to deliver This intervention appears to be: Feasible Effective Acceptable to participants 11

12 Implications for practice Practitioners interested in reinforcing abstinence from alcohol, but who were unable to do so effectively due to difficulty in verifying abstinence and/or delivering incentives could use the technologies employed in this study to facilitate treatment delivery If this type of treatment become available, alcohol-dependent individuals who might not otherwise have access to or be willing to attend treatment will be able to receive evidence-based treatment The procedures for verifying and reinforcing abstinence piloted in this study may be applicable to similar remote abstinence verification technologies (e.g., SCRAM) Next steps: Finish the current experiment Test as a longer-term treatment with longer-term follow-ups Test in combination with other treatments (e.g., online CBT) Pilot treatment funding mechanisms (e.g., deposit contracts) 12

13 Acknowledgements Kenneth Silverman The Addiction Recovery Research Center Funding: NIAAA grant R21 AA

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