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Background: Previous research has highlighted the role of stress in substance misuse and addiction, particularly for relapse risk. Mobile health interventions that incorporate real-time monitoring of physiological markers of stress offer promise for delivering tailored interventions to individuals during high-risk states of heightened stress to prevent alcohol relapse. Before such interventions can be developed, measurements of these processes in ambulatory, real-world settings are needed., Objective: This research is a proof-of-concept study to establish the feasibility of using a wearable sensor device to continuously monitor stress in an ambulatory setting. Toward that end, we first aimed to examine the quality of 2 continuously monitored physiological signals-electrodermal activity (EDA) and heart rate variability (HRV)-and show that the data follow standard quality measures according to the literature. Next, we examined the associations between the statistical features extracted from the EDA and HRV signals and self-reported outcomes., Methods: Participants (N=11; female: n=10) were asked to wear an Empatica E4 wearable sensor for continuous unobtrusive physiological signal collection for up to 14 days. During the same time frame, participants responded to a daily diary study using ecological momentary assessment of self-reported stress, emotions, alcohol-related cravings, pain, and discomfort via a web-based survey, which was conducted 4 times daily. Participants also participated in structured interviews throughout the study to assess daily alcohol use and to validate self-reported and physiological stress markers. In the analysis, we first used existing artifact detection methods and physiological signal processing approaches to assess the quality of the physiological data. Next, we examined the descriptive statistics for self-reported outcomes. Finally, we investigated the associations between the features of physiological signals and self-reported outcomes., Results: We determined that 87.86% (1,032,265/1,174,898) of the EDA signals were clean. A comparison of the frequency of skin conductance responses per minute with previous research confirmed that the physiological signals collected in the ambulatory setting were successful. The results also indicated that the statistical features of the EDA and HRV measures were significantly correlated with the self-reported outcomes, including the number of stressful events marked on the sensor device, positive and negative emotions, and experienced pain and discomfort., Conclusions: The results demonstrated that the physiological data collected via an Empatica E4 wearable sensor device were consistent with previous literature in terms of the quality of the data and that features of these physiological signals were significantly associated with several self-reported outcomes among a sample of adults diagnosed with alcohol use disorder. These results suggest that ambulatory assessment of stress is feasible and can be used to develop tailored mobile health interventions to enhance sustained recovery from alcohol use disorder., (©Parastoo Alinia, Ramesh Kumar Sah, Michael McDonell, Patricia Pendry, Sara Parent, Hassan Ghasemzadeh, Michael John Cleveland. Originally published in JMIR Formative Research (https://formative.jmir.org), 21.07.2021.)

Background: Alcohol use is directly related to over 3 million deaths worldwide every year. Contingency management is a cost-effective treatment for substance use disorders; however, few studies have examined its efficacy for alcohol use disorder. Recent technological advances have enabled the combined use of mobile apps and low-cost electronic breathalyzer devices to remotely monitor alcohol use. Leveraging this type of technology, our study group has recently developed an integrated contingency management system that would enable community treatment programs to remotely deliver contingency management to anyone who owns a smartphone., Objective: In this paper, we present a full description of our integrated contingency management system, Automated Reinforcement Management System (ARMS), and describe a protocol that will evaluate its feasibility and usability., Methods: Initially, 6 clinicians will participate in a 1-hour focus group where the study staff will navigate through ARMS as it would be used by clinicians and patients. Clinicians will provide feedback on the intervention in general, which will be used to modify ARMS to make it more user friendly, time saving, and relevant to treatment. A second focus group will summarize the changes made following the initial clinician feedback and will provide additional input regarding the potential utilization of ARMS. Thereafter, the clinicians' acceptability of ARMS will be evaluated using the System Usability Scale. Following the clinicians' assessments of ARMS and final modifications, the system will be evaluated in terms of feasibility and patient usability by using an A-B-A within-subject experimental design wherein 20 treatment-seeking individuals with alcohol use disorder will be recruited. The two A phases (control conditions) will each last 2 weeks, and the B phase (contingency management condition) will last 4 weeks. During all phases, participants will be asked to use the ARMS app to submit three breathalyzer samples per day (at 10 AM, 2 PM, and 8 PM). Participants will be prompted by the ARMS app at these predetermined times to record and submit their breathalyzer samples. During the A phases, participants will earn vouchers for every breathalyzer sample submitted, independent of their sample results. During the B phase, vouchers will be provided contingent upon the submission of alcohol-negative breathalyzer samples (breath alcohol content = 0.00). At the end of the A-B-A experiment trial, patients' usability of the ARMS app will be evaluated using the System Usability Scale. Feasibility will be measured based on whether the ARMS app helped significantly increase alcohol abstinence., Results: Recruitment for this study began in January 2021 and is expected to be completed by December 2021., Conclusions: This study will provide the baseline capability for the implementation of a remotely monitored contingency management platform. If successful, ARMS has the potential to provide effective treatment for alcohol use disorders to individuals living in remote rural areas., (©Andre Miguel, Crystal Smith, Nicole Perea, Kim Johnson, Michael McDonell, Sterling McPherson. Originally published in JMIR Formative Research (https://formative.jmir.org), 19.07.2021.)

Background: Contingency management (CM) is an intervention where incentives are provided in exchange for biochemically confirmed alcohol abstinence. CM is effective at initiating alcohol abstinence, but it is less effective at maintaining long-term abstinence. Phosphatidylethanol (PEth), collected via a finger-stick, can detect alcohol use for 14-28 days. PEth allows for the development of a CM model that includes increasingly less frequent monitoring of abstinence to assist high risk groups, such as formerly homeless individuals, maintain long-term abstinence., Aims: Investigate whether PEth-based CM intervention targeting alcohol abstinence in formerly homeless, currently housed individuals with alcohol use disorders is: (1) acceptable and feasible for housing program tenants and personnel; and is associated with increased (2) alcohol abstinence and (3) housing tenure., Methods: Acceptability and feasibility will be assessed using a QUAL+quant mixed-methods design using qualitative interviews and quantitative measures of satisfaction and attrition. Effectiveness will be evaluated through a randomized pilot trial of 50 study participants who will receive 6 months of either treatment as usual (TAU) including incentives (e.g., gift cards) for providing blood samples (Control Condition) or TAU and incentives for negative PEth results (PEth-CM Condition). Outcomes will be assessed during the intervention and at a three-month follow-up visit. The trial will be conducted via telehealth as a result of COVID-19., Discussion: This protocol seeks to utilize a novel alcohol biomarker to evaluate the acceptability, feasibility, and initial effectiveness of a CM model that encourages long-term abstinence in a high-risk group., (© 2021 The Authors.)

Objectives: To measure access to opioid treatment programs (OTPs) and office-based buprenorphine treatment (OBBTs) at the smallest geographic unit for which the Census Bureau publishes demographic and socioeconomic data (ie, block group) and to explore disparities in access to treatment across the rural-urban and area deprivation continua across the United States., Methods: Access to OTPs and OBBTs at the block group in 2019 was quantified using an innovative 2-step floating catchment area technique that accounts for the supply of treatment facilities relative to the population size, proximity of facilities relative to the location of population in block groups, and time as a barrier within catchments. Block groups were stratified into tertiles based on the rural-urban continuum codes (metropolitan, micropolitan, small town, or rural) and area deprivation index (least-deprived, middle-deprived, most-deprived). The Integrated Nested Laplace Approximation approach was used for statistical analysis., Results: Across the United States, 3329 block groups corresponding to 2 915 949 adults lacked access to OTPs within a 2-hour drive of their community and 130 block groups corresponding to 86 605 adults did not have access to OBBTs. Disparities in access to treatment were observed across the urban-rural and area deprivation continua including (1) lowest mean access score to OBBTs were found among most-deprived small towns, and (2) lower mean access score to OTPs were found among micropolitan and small towns., Conclusions: The results of this study revealed disparities in access to medication-assisted treatment. The findings call for creative initiatives and local and regional policies to develop to mitigate access problems., (Copyright © 2020 ISPOR–The Professional Society for Health Economics and Outcomes Research. Published by Elsevier Inc. All rights reserved.)

Objectives: The objective of this study was to examine the predictive validity of the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES) among Alaska Native and American Indian (ANAI) people with an alcohol use disorder., Methods: The sample was 170 ANAI adults with an alcohol use disorder living in Anchorage, Alaska who were part of a larger alcohol intervention study. The primary outcome of this study was alcohol use as measured by mean urinary ethyl glucuronide (EtG). EtG urine tests were collected at baseline and then up to twice a week for four weeks. We conducted bivariate linear regression analyses to evaluate associations between mean EtG value and each of the three SOCRATES subscales (Recognition, Ambivalence, and Taking Steps) and other covariates such as demographic characteristics, alcohol use history, and chemical dependency service utilization. We then performed multivariable linear regression modeling to examine these associations after adjusting for covariates., Results: After adjusting for covariates, mean EtG values were negatively associated with the Taking Steps (P = 0.017) and Recognition (P = 0.005) subscales of the SOCRATES among ANAI people living in Alaska. We did not find an association between mean EtG values and the Ambivalence subscale (P = 0.129) of the SOCRATES after adjusting for covariates., Conclusions: Higher scores on the Taking Steps and Recognition subscales of the SOCRATES at baseline among ANAI people predicted lower mean EtG values. This study has important implications for communities and clinicians who need tools to assist ANAI clients in initiating behavior changes related to alcohol use.

Introduction: Despite the proven effectiveness of coordinated specialty care (CSC) programmes for first episode psychosis in the USA, CSC programmes often have low levels of engagement in family psychoeducation, and engagement of racial and ethnic minority family members is even lower than that for non-Latino white family members. The goal of this study is to develop and evaluate a culturally informed FAmily Motivational Engagement Strategy (FAMES) and implementation toolkit for CSC providers., Methods and Analysis: This protocol describes a mixed methods, multi-phase study that blends intervention mapping and the Promoting Action on Research in Health Services framework to develop, modify and pilot-test FAMES and an accompanying implementation toolkit. Phase 1 will convene a Stakeholder Advisory Committee to inform modifications based on findings from phases 1 and 2. During phase 1, we will also recruit approximately 200 family members to complete an online survey to assess barriers and motivation to engage in treatment. Phase 2 we will recruit five family members into a 3-month trial of the modified FAMES and implementation toolkit. Results will guide the advisory committee in refining the intervention and implementation toolkit. Phase 3 will involve a 16-month non-randomised, stepped-wedge trial with 50 family members from five CSC programmes in community-based mental health clinics to examine the acceptability, feasibility and initial impact of FAMES and the implementation toolkit., Ethics and Dissemination: This study received Institutional Review Board approval from Washington State University, protocol #17 812-001. Results will be disseminated via peer review publications, presentations at national and international conferences, and to local community mental health agencies and committees., Trial Registration Number: ClinicalTrials.gov Registry (NCT04188366)., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Monitoring devices provide a platform for assessing alcohol use and implementing alcohol interventions. This pilot study focused on assessing the early-stage feasibility and usability of a smartphone-based application and breathalyzer used in a contingency management intervention for alcohol use., Methods: Six nontreatment-seeking participants completed a 9-week ABA within-subjects designed intervention targeting alcohol use. Participants submitted 2 to 8 alcohol breathalyzer samples per day and completed self-report drinking measures and usability assessments. During the A phases (weeks 1-3 and 8-9), participants received reinforces for submitting breathalyzer samples, regardless of their results. During the contingency management, B phase (weeks 4-7), and received reinforcers only when negative breathalyzer samples were submitted. Usability assessment of the application was also conducted during weeks 2 and 9., Results: Participants in the contingent B phase (49%) were more likely to submit alcohol-negative breathalyzer samples compared with the noncontingent A phases (27%; P < 0.001). Usability assessment of the application varied, and participants noted several technical concerns., Conclusion: The use of smartphones and breathalyzers may be a practical solution to extend the reach of contingency management during and after treatment.

Contingency management (CM) is associated with decreases in off-target drug and alcohol use during primary target treatment. The primary hypothesis for this trial was that targeting alcohol use or tobacco smoking would yield increased abstinence in the opposite, nontargeted drug. We used a 2 [CM vs. noncontingent control (NC) for alcohol]×2 (CM vs. NC for smoking tobacco) factorial design, with alcohol intake (through urinary ethyl glucuronide) and tobacco smoking (through urinary cotinine) as the primary outcomes. Thirty-four heavy-drinking smokers were randomized into one of four groups, wherein they received CM, or equivalent NC reinforcement, for alcohol abstinence, smoking abstinence, both drugs, or neither drug. The CM for alcohol and tobacco group had only two participants and therefore was not included in analysis. Compared with the NC for alcohol and tobacco smoking group, both the CM for the tobacco smoking group [odds ratio (OR)=12.03; 95% confidence interval (CI): 1.50-96.31] and the CM for the alcohol group (OR=37.55; 95% CI: 4.86-290.17) submitted significantly more tobacco-abstinent urinalyses. Similarly, compared with the NC for the alcohol and tobacco group, both the CM for smoking (OR=2.57; 95% CI: 1.00-6.60) and the CM for alcohol groups (OR=3.96; 95% CI: 1.47-10.62) submitted significantly more alcohol-abstinent urinalyses. These data indicate cross-over effects of CM on indirect treatment targets. Although this is a pilot investigation, it could help to inform the design of novel treatments for alcohol and tobacco co-addiction.

Although contingency management (CM) is effective in promoting abstinence and treatment retention among crack cocaine users who meet the criteria for cocaine dependence, less is known about its off-target effects. In this secondary analysis, we evaluated the impact of CM on depressive and anxiety symptoms in a sample of cocaine-dependent individuals under treatment. Sixty-five crack cocaine users who met the criteria for cocaine dependence were randomly assigned to receive 12 weeks of standard treatment alone (STA; n = 32) or 12 weeks of standard treatment plus CM (STCM; n = 33). The outcome measures of the secondary analysis were depressive and anxiety symptoms assessed with the Beck Depression Inventory-II (BDI-II) and the Beck Anxiety Inventory (BAI). At baseline, 59 (90.8%) of the participants reported at least mild depressive symptoms and 47 (72.5%) reported at least mild anxiety symptoms. The mean BDI-II (24.5 ± 12.1) and BAI (20.7 ± 13.5) scores in the sample as a whole was moderate. After treatment, the reported levels of depressive symptoms (β = -9.6, p < .05) and anxiety symptoms (β = -9.9, p < .05) were lower among the individuals receiving STCM than among those receiving STA. This study provides evidence that an STCM intervention targeting crack cocaine abstinence also produces significant reductions in depressive and anxiety symptoms. This low cost intervention also demonstrated significant promise and optimization potential for crack cocaine users in a setting of scarce resources and high mental health comorbidity. Relevance Statement: We found that the prevalence of depressive and anxiety symptoms were extremely high among crack cocaine users, and that, among such individuals, contingency management (CM) reduced depressive and anxiety symptomatology to a greater degree than did standard treatment. Our results suggest that CM targeting crack cocaine abuse can have off-target effects on psychiatric symptomatology. (PsycINFO Database Record, ((c) 2017 APA, all rights reserved).)

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)., (© 2017 American Academy of Addiction Psychiatry.)

Objectives: To determine if urine drug tests (UDTs) can detect under-reporting of drug use (ie, negative self-report, but positive UDT) and identify patient characteristics associated with underreporting when treating substance use disorders in primary care., Methods: Self-reported use (last 30 d) and UDTs were gathered at baseline, 3, 6, 9, and 12 months from 829 primary care patients participating in a drug use intervention study. Rates of under-reporting were calculated for all drugs, cannabis, stimulants, opioids, and sedatives. Logistic regressions were used to identify characteristics associated with under-reporting., Results: Among the participants, 40% (n = 331) denied drug use in the prior 30 days despite a corresponding positive UDT during at least 1 assessment. Levels of under-reporting during 1 or more assessments were 3% (n = 22) for cannabis, 20% (n = 167) for stimulants, 27% (n = 226) for opioids, and 13% (n = 106) for sedatives. Older (odds ratio [OR] 1.04), female (OR 1.66), or disabled (OR 1.42) individuals were more likely to under-report any drug use. Under-reporting of stimulant use was also more likely in individuals with lower levels of educational attainment, previous arrests, and family and social problems. Under-reporting of opioid use was more likely in those with other drug problems, but less likely in those with better physical health, more severe alcohol and psychiatric comorbidities, and African-Americans., Conclusions: With the exception of cannabis, UDTs are important assessment tools when treating drug use disorders in primary care. UDTs might be particularly helpful when treating patients who are older, female, disabled, have legal and social problems, and have more severe drug problems.

Background: Disproportionately high rates of alcohol use disorders are present in many American Indian/Alaska Native (AI/AN) communities, yet little information exists regarding the effectiveness of alcohol treatments in AI/AN populations. Contingency management is an intervention for illicit drug use in which tangible reinforcers (rewards) are provided when patients demonstrate abstinence as assessed by urine drug tests. Contingency management has not been widely studied as an intervention for alcohol problems because until recently, no alcohol biomarker has been available to adequately verify abstinence., Aims: The HONOR Study is designed to determine whether a culturally-tailored contingency management intervention is an effective intervention for AI/AN adults who suffer from alcohol use disorders., Methods: Participants include 400 AI/AN alcohol-dependent adults residing in one rural reservation, one urban community, as well as a third site to be decided, in the Western U.S. Participants complete a 4-week lead-in phase prior to randomization, then 12 weeks of either a contingency management intervention for alcohol abstinence, or a control condition where participants receive reinforcers for attending study visits regardless of alcohol use. Participants are then followed for 3-more months post-intervention. The primary study outcome is urinary ethyl glucuronide-confirmed alcohol abstinence; secondary outcomes include self-reported alcohol and drug use, HIV risk behaviors, and self-reported cigarette smoking., Discussion: This will be the largest randomized, controlled trial of any alcohol for AI/ANs and the largest contingency management study targeting alcohol use disorders, thus providing important information to AI/AN communities and the alcohol treatment field in general., (Copyright © 2015. Published by Elsevier Inc.)

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., (Copyright © 2015 by the Research Society on Alcoholism.)

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., (© American Academy of Addiction Psychiatry.)

Mobile technologies are growing rapidly around the world to broad demographics of society. These technologies hold great promise for their integration with Single Case Designs (SCDs) and the study of individuals in their natural environment. This paper discusses the theoretical, methodological and analytic implications of these tools for the advancement of the contextual behavioral etiology of behavioral disorders, and their remediation. We hope this paper will highlight the scientific advantages of combining mobile technologies and SCDs and encourage their adoption among CBS scientists.

Background: Medical-surgical rehospitalizations within a month after discharge among patients with diabetes result in tremendous costs to the US health care system., Objective: The study's aim was to examine whether co-morbid serious mental illness diagnoses (bipolar disorder, schizophrenia, or other psychotic disorders) among patients with diabetes are independently associated with medical-surgical rehospitalization within a month of discharge after an initial hospitalization., Methods: This cohort study of all community hospitals in Washington state evaluated data from 82,060 adults discharged in the state of Washington with any International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis indicating diabetes mellitus between 2010 and 2011. Data on medical-surgical hospitalizations were obtained from the Washington State Comprehensive Hospital Abstract Reporting System. Co-morbid serious mental illness diagnoses were identified based on International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes indicating bipolar disorder, schizophrenia, or other psychotic disorders. Logistic regression analyses identified factors independently associated with rehospitalization within a month of discharge. Cox proportional hazard analyses estimated time to rehospitalization for the entire study period., Results: After adjusting for demographics, medical co-morbidity, and characteristics of the index hospitalization, co-morbid serious mental illness diagnosis was independently associated with increased odds of rehospitalization within 1 month among patients with diabetes who had a medical-surgical hospitalization (odds ratio: 1.24, 95% confidence interval: 1.07, 1.44). This increased risk of rehospitalization persisted throughout the study period (up to 24 mo)., Conclusions: Co-morbid serious mental illness in patients with diabetes is independently associated with greater risk of early medical-surgical rehospitalization. Future research is needed to define and specify targets for interventions at points of care transition for this vulnerable patient population., (© 2014 Published by Academy of Psychosomatic Medicine on behalf of Academy of Psychosomatic Medicine.)

This study assessed the effects of a contingency management (CM) intervention for alcohol consumption in 10 alcohol-dependent participants. An ABCA design was used. Vouchers were provided contingent on results of ethyl glucuronide (EtG) urine tests (an alcohol biomarker with a 2-day detection period) and alcohol breath tests during the C phase. The percentage of negative urines was 35% during the first baseline phase, 69% during the C phase, and 20% during the return-to-baseline phase. Results suggest that EtG urine tests may be a feasible method to deliver CM to promote alcohol abstinence.