Ethyl glucuronide in urine (uEtG) is a biomarker that objectively detects alcohol consumption. However, what uEtG values represent regarding the last drinking event remains unclear. This study investigated whether the recency or amount consumed at the last event are associated with multiple uEtG cutoffs indicative of light to heavy drinking. Adults (n = 349) recruited for an alcohol use disorder clinical trial submitted urine samples and self-reported alcohol measures at baseline and twice weekly during a 4-week observation period prior to treatment. The ThermoFisher DRI immunoassay was used to quantify uEtG levels (0-2000 ng/mL). Self-report measures included the number of hours since last drink (Hours), number of standard drinks at that event (Amount), and ratios of these measures (Hours:Amount and Amount:Hours). Three uEtG cutoffs were assessed (100, 500, and 2000 ng/mL) and generalized linear mixed modeling applied to compare self-report measures below versus above each uEtG cutoff. A total of 1676 uEtG samples with self-reported data were included. Comparisons across cutoffs were significant for Hours (p < 0.001), while Amount was only significant at the 2000 ng/mL cutoff (p = 0.001). Hours also had the strongest association with uEtG results across cutoffs (pseudo-R2 range = 0.474-0.530). Higher uEtG results indicated more recent drinking, rather than higher levels of alcohol consumption, and the period of detection of uEtG was shorter than previously reported. Even at the low threshold of 100 ng/mL, uEtG was best conceptualized as a measure of alcohol consumption in the prior 24 h, with higher uEtG levels being associated with fewer hours since last drink.

Background: Formerly incarcerated people with serious mental illnesses (SMI) experience the criminal legal system unequally and have elevated rates of recidivism, homelessness, general medical problems, and substance use disorders. Permanent supportive housing (PSH) can be used during reentry, but it has limited resources for addressing community integration, a key component of reentry. PSH are often located in high-poverty environments with increased criminogenic risk. The geography of PSH also includes public spaces, which are associated with positive outcomes. The risk environment framework provides a structure for understanding the geography of PSH through its focus on the physical, social, economic, and policy influences on the micro and macro environments of reentry. Methods: This is a novel QUAL + QUAN (spatial) concurrent mixed-methods study that will examine how individual, interpersonal, and environmental factors interact with public and private spaces to inform reentry wellbeing. Eighty multimethod interviews (i.e., qualitative, quantitative, and participatory mapping methods) will be conducted with formerly incarcerated clients with SMI. Go-along interviews will be conducted with 20 of these participants. Participatory mapping will be geocoded and sites identified as places of importance, frequent participation, and belonging will be evaluated in relation to objective features of spaces to develop a community resilience index. Findings will ultimately be integrated into an intervention development codesign process with a community advisory board. Discussion: During reentry, individual, interpersonal, and environmental factors can interact with these environments to produce or reduce risk. If addressed, these factors can contribute to reentry wellbeing, through improved community participation and treatment engagement and reduced psychiatric distress and substance use.

Contingency Management (CM) is an evidence-based intervention with demonstrated efficacy for stimulant use disorder, yet its uptake has been largely limited to clinical settings. This project examined the implementation of a stimulant-focused CM protocol within a Permanent Supportive Housing (PSH) setting. Using thematic analysis of meeting notes collected over 16 months of implementation meetings we identified four themes related to implementation: philosophical alignment of CM and the PSH, barriers and facilitators, implementation adaptations and support, and broader organizational changes. These themes provide insight into implementing clinical interventions within non-clinical sites, like PSH. Despite implementation challenges (e.g., physical space limitations; enrollment and engagement difficulties), CM was launched in the PSH setting with 28 residents enrolled. Lessons learned highlight that sustained high touch technical assistance is critical, which can be further strengthened by engaging in early CM model development and maintaining ongoing conversations about the organizational landscape.

Background:In a recent randomized trial, six months of financial incentives contingent for recent alcohol abstinence led to lower levels of hazardous drinking, while incentives for recent isoniazid (INH) ingestion had no impact on INH adherence, during TB preventive therapy among persons with HIV (PWH). Whether the short-term incentives influence long-term alcohol use and HIV viral suppression post-intervention is unknown. Methods:We analyzed twelve-month HIV viral suppression and alcohol use in the Drinkers' Intervention to Prevent Tuberculosis study, a randomized controlled trial among PWH with latent TB and unhealthy alcohol use in south-western Uganda. We randomly assigned 680 participants (1:1:1:1) initiating six months of INH to: Arm 1, no incentives (control); Arm 2, financial incentives contingent on recent alcohol abstinence; Arm 3, incentives contingent on recent INH use; and Arm 4, incentives for recent alcohol abstinence and INH use, rewarded separately. The 6 months post-intervention outcomes evaluated were pre-specified and included: HIV viral suppression (<200 copies/mL) and no/low alcohol use, defined as Alcohol Use Disorders Identification Test-Consumption negative (<3: women, <4: men) and phosphatidylethanol, an alcohol biomarker, <35 ng/mL. We estimated adjusted risk differences (aRD) for alcohol reduction and INH adherence interventions using multivariable logistic regression adjusting for randomization stratification factors (sex and study site), and baseline alcohol use (alcohol intervention model only). Clinicaltrials.gov registration: NCT03492216, Registered 04/10/2018. Findings:Of 600 participants with 12-month viral load results, 556/585 (95%) with baseline results were virally suppressed, and 583/600 (97%) were virally suppressed at 12-months. Twelve-month viral suppression did not differ significantly between either intervention group versus control (alcohol reduction incentives versus control aRD = -0.9% (95% CI: -3.6 to 1.7); INH adherence incentives versus control aRD = 2.2% (95% CI: -0.4 to 4.9)). Of the 617 participants with 12-month alcohol use measures, alcohol reduction incentives led to a significantly greater proportion with no/low alcohol use at 12-months (20.2% [64/317]) versus no alcohol reduction incentives (11.0% [33/300]); aRD = 8.4%, (95% CI: 3.3-13.4), p = 0.001. Interpretation:Viral suppression was high (>95%) at baseline and at 12 months: we found no effect of either 6-month alcohol reduction or INH adherence incentives on long-term viral suppression. Six months of alcohol reduction incentives were effective at promoting no/low alcohol use at 12 months, demonstrating persistent effects post-intervention. Funding:National Institutes of Health (NIH/NIAAA) U01AA026223 (PI: Hahn) and U01AA026221 (PI: Chamie), NIH/NIAAAK24 AA022586 (PI: Hahn), NIH/NIAAAK24 AA031211 (PI: Chamie), Providence/Boston Center for AIDS ResearchP30AI042853 (PI: Sara Lodi).

BACKGROUND:Contingency management (CM) is an intervention for alcohol use disorder (AUD) that reinforces abstinence, as confirmed by alcohol biomarkers. CM is usually brief (12-16 weeks) despite evidence that longer interventions have better long-term outcomes. Most CM models are in-person which can also be a barrier for treatment. Studies of longer duration telehealth-based CM models are needed. AIMS:To determine if a telehealth-based CM model that utilizes phosphatidylethanol (PEth) to confirm abstinence is effective at reducing alcohol use during a 26-week intervention and 12-month follow-up. We will evaluate the impact of CM on alcohol-related outcomes, determine if Addiction Neuroclinical Assessment variables are associated with outcomes in follow-up, and whether savings related to decreased alcohol use offset intervention costs. METHODS:Adults with AUD residing in the United States will be recruited via online advertising. Research procedures will be conducted virtually. Participants who submit a PEth-positive blood sample (≥20 ng/mL) at enrollment will be randomized to 26 weeks of either 1) online cognitive behavior therapy (CBT4CBT) with rewards not contingent on PEth results (Control group) or 2) CBT4CBT with a maximum of $1,820 of rewards contingent on PEth results (CM group). Efficacy outcomes of PEth-negative tests (primary) and PEth-defined excessive drinking (≥200 ng/mL; secondary) will be assessed. Predictors of intervention outcomes and economic viability will also be investigated. DISCUSSION:If this telehealth-delivered PEth-based CM intervention reduces alcohol use and is cost-effective, it could be used to provide effective treatment to millions of individuals with AUD who do not receive in-person care.

BACKGROUND:Alcohol and tobacco are often used together, and their co-use is directly associated with a high incidence of morbidity and mortality. While there are currently no guidelines for treating co-addiction to alcohol and tobacco, studies suggest that integrated approaches may effectively reduce the use of both substances. Grounded in the Addiction Neuroclinical Assessment (ANA) framework, this study aims to evaluate the effectiveness of combining Contingency Management (CM) for Alcohol Use Disorder (AUD) with Varenicline for smoking cessation to significantly reduce alcohol and tobacco use among individuals with an AUD who smoke and are seeking treatment. In addition, the study will evaluate the mediator effect of the ANA domains, systematically measured and evaluated to determine their role in treatment outcomes. METHODS:Study will take place in Spokane-WA. After a two-week induction period, a total of 205 eligible participants will be randomized into one of two 12-week treatment conditions in equal proportions: CM + varenicline (experimental condition) and Non-Contingent (NC) + varenicline (control condition). Participants in the CM + varenicline group will receive rewards contingent on the submission of negative alcohol samples, while the NC + varenicline group will receive rewards for submitting urine samples, independent of alcohol positivity. Primary outcomes include objective verification of abstinence during the 12-week intervention phase (measured thrice-weekly). Follow-up evaluations will be conducted during the first, third, and sixth months. CONCLUSIONS:If demonstrated to be efficacious, this treatment approach has the potential to produce important health benefits for a highly prevalent population in desperate need for an integrated treatment. It may also assist in identifying how different ANA-based responses impact treatment outcomes.

Despite evidence supporting the involvement of family members in early-intervention services for psychosis, rates of family engagement have been relatively low, and disparities exist. This study investigated the acceptability, feasibility, and preliminary impact of Family Motivational Engagement Strategy (FAMES) with family members of clients enrolled in coordinated specialty care (CSC). A feasibility and acceptability pilot study of FAMES was conducted in five CSC programs for FEP using a modified stepped-wedge design. FAMES consists of brief weekly contacts based on communication preferences (i.e., phone, text messages, email) and the use of culturally responsive strategies over 12 weeks. Assessments were completed at baseline and weeks 4, 8, and 12. Primary outcomes were feasibility and acceptability, and secondary outcomes were engagement in FAMES and CSC. Forty-three participants were recruited (approximately 85% of the target recruitment sample of 50) and 72% (n = 31) completed all 12 weeks. Participants reported high rates of satisfaction with FAMES. Regarding engagement, 86% of scheduled FAMES appointments were attended, and no significant ethnoracial differences in engagement were observed. Exploratory analyses revealed engagement in FAMES was associated with engagement in CSC. Findings demonstrated the feasibility and acceptability of delivering FAMES within CSC settings for family members/support persons. A subsequent study is needed to examine the efficacy and real-world implementation of FAMES.

Background:Alaska Native and American Indian (ANAI) communities in Alaska have disproportionately high commercial tobacco smoking rates and face barriers to accessing cessation treatment. We beta-tested the feasibility of a remotely delivered, ANAI family-based financial incentive cessation intervention. Methods:We enrolled 10 "dyads" (i.e., one adult ANAI person who smokes [PWS] and one adult family member of their choice) across Alaska into a culturally tailored 6-month intervention (NCT05209451). PWS completed expired carbon monoxide, salivary cotinine, and self-reported abstinence measures at home during six smoking status check-ins. Both dyad members received financial incentives in escalating amounts for confirmed PWS abstinence. Participants completed baseline and end-of-study surveys. Results:Eight of the 10 PWS were women, their average age was 45 years (range = 34-57), and mean daily cigarettes smoked was 13 (range = 3-20). Five of the 10 family members were women, and four currently also smoked. Of the 60 check-ins possible among PWS participants, 41 (68 %) were completed; five (50 %) completed all check-ins. Despite minor difficulties with PWS internet connection, lost test kits, and delayed payment receipt, all participants were able to complete check-ins and received payments earned. Five PWS were abstinent at the final 6-month check-in, and two PWS were abstinent at all check-ins. Five PWS completed the end-of-study survey; four reported the intervention was helpful and would recommend it to others. Conclusion:A family-based financial incentive intervention for smoking cessation with ANAI families appears feasible. Next, a randomized controlled trial will be conducted statewide to evaluate effectiveness and inform future implementation needs.

Introduction:Screening, Brief Interventions and Referral to Treatment (SBIRT) programs reduce unhealthy alcohol use among adolescents. However, self-report screening alone may lead to false negatives and low service use, especially in HIV care settings. This study explored the contextual implementation factors and strategies of an alcohol biomarker-augmented SBIRT program for HIV-affected adolescents in Zambia, where alcohol use and HIV prevalence are high. Methods:We conducted key informant interviews (n=7) with mental health providers and policymakers and focus groups (n=16 groups; 10-11 participants each) with healthcare providers, adolescents, and caregivers, guided by a case vignette of the biomarker-augmented SBIRT program. Thematic analysis followed the implementation frameworks Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) and Practical, Robust Implementation and Sustainability Model (PRISM). Results:Participants perceived the SBIRT program as appropriate for adolescent alcohol use. Key contextual factors included: lack of alcohol treatment programs, community stigma against HIV and alcohol use, and robust implementation infrastructure through HIV healthcare. Strategies to enhance acceptability included making alcohol screening universal to avoid labeling adolescents, privacy and confidentiality during biomarker sampling, and peer-led age-matched counseling at screening. To enhance reach, participants suggested designing the program with attention to gender-specific needs and integrating it into HIV healthcare and alcohol use hotspots (e.g. schools). Conclusions:Implementation strategies should be designed to reduce stigma, build trust, engage adolescents across genders, and reach youth through clinical and community channels. Future research should define how to select, train, and evaluate peer counselors and assess the effectiveness of alcohol biomarkers within SBIRT programs in motivating behavior change.

IntroductionCannabis has been decriminalized by many states and shows promise in treating both neuropathic and non-neuropathic pain through its interaction with the endocannabinoid system and anti-inflammatory effects. This study examines differences in cannabis use for adults whose most bothersome chronic pain condition is neuropathic vs. non-neuropathic.Materials and methodsSurvey data were collected from adults receiving care at a pain clinic. Participants completed demographic questions and standardized self-report measures (PROMIS Pain Intensity/Interference and the ID-Pain tool). Participants' most bothersome pain condition(s) were categorized as neuropathic or non-neuropathic pain based on ID-Pain scores. Linear regression models assessed differences in frequency and duration of cannabis product use between groups, adjusting for age and sex.ResultsA total of 113 individuals were recruited; following exclusions and missing data, 104 participants (61.5% female) were included in the final analysis. Of these, 36.5% reported neuropathic pain as their most bothersome, and 63.5% reported non-neuropathic pain. Those with neuropathic pain reported significantly more days per month of Tetrahydrocannabinol/Cannabidiol (THC/CBD) combination (b = 5.96, p = 0.02), Cannabidiol-only (CBD-only) (b = 8.82, p = 0.03), and Tetrahydrocannabinol-only (THC-only) products (b = 7.04, p = 0.02). They also used THC-only (b = 0.97, p < 0.05) and THC/CBD (b = 1.09, p < 0.01) products more frequently per day. Neuropathic pain was positively associated with pain intensity (b = 4.10, p < 0.001) and interference (b = 4.95, p < 0.001).DiscussionAdults whose most bothersome pain condition(s) were neuropathic used cannabis, especially THC and THC/CBD combination products, more frequently than those whose most bothersome pain was non-neuropathic. Participants with neuropathic pain also reported higher levels of pain intensity and interference. Further longitudinal research is needed to confirm whether increased use of THC-rich cannabis provides symptom relief for adults with neuropathic pain.

Importance:Interest in contingency management (CM) as a treatment for opioid and stimulant use disorders has increased because of the ongoing dual opioid/stimulant crisis, rising stimulant drug deaths, and demand for effective treatments for stimulant use disorder. The success of the US Department of Veterans Affairs nationwide rollout and the launch of California's Recovery Incentives Program provide evidence that this treatment can be translated into effective clinical practice. Objective:To provide data-driven inflation-adjusted incentive estimates for modern CM protocols that can be customized for intervention duration. It is essential for CM protocols implemented in clinical care to use efficacious, research-supported parameters, including incentive magnitude. Evidence Review:This review included 112 published CM protocols that involved reinforcement of stimulant- and/or opioid-negative urine drug tests, categorized each protocol in terms of impact (small/medium/large effect size) relative to a non-CM comparator condition, and computed weekly inflation-adjusted incentive magnitudes for voucher- and prize-based CM protocols. Findings:Drawn from protocols with medium to large impacts on patient outcomes, weekly median magnitude estimates are $128/week for voucher protocols and $55/week for prize protocols. For the most common duration of 12 weeks, these estimates translate to $1536 for voucher and $660 for prize protocols. Conclusions and Relevance:These incentive magnitude estimates can be used to inform clinical, policy, and advocacy related to CM implementation. Practical suggestions (eg, starting values, escalation) for building protocols that meet these incentive magnitudes are provided and implications are discussed.

OBJECTIVE:To determine if adults with an alcohol use disorder (AUD), who had a preintervention urine ethyl glucuronide (uEtG) level predictive of nonresponse to contingency management (CM), would respond to two intervention modifications (https://clinicaltrials.gov/ ID: NCT03481049). METHOD:One hundred fifty-eight adults (53.2% female) with AUD, serious mental illness, and a mean uEtG ≥ 350 ng/mL over a 4-week induction period were randomized to (a) usual CM (uEtG-negative [<150 ng/mL] samples reinforced with $1,686); (b) high magnitude CM (uEtG-negative samples reinforced with $2,983); or (c) shaping CM (reduced drinking [uEtG < 500 ng/mL] samples reinforced for 4 weeks, then uEtG-negative samples reinforced for 12 weeks with $1,686). The primary outcome was uEtG-negative samples during induction and Weeks 5-16 of CM. The relationship between outcomes and uEtG-defined heavy drinking (≥ 500 ng/mL) immediately prior to randomization was assessed. RESULTS:CM conditions did not differ in uEtG-negative samples during the intervention period, Wald, χ²(2) = 1.96, p = .46. Participants were 4.2 times (95% CI [3.02, 5.92], p < .01) more likely to submit a uEtG-negative sample during CM, relative to induction. Those with a heavy drinking uEtG result immediately before randomization were less likely to submit uEtG-negative samples during CM, Wald, χ²(1) = 15.33, p < .01. CONCLUSIONS:CM modifications were not associated with lower levels of alcohol use. Participants engaged in less alcohol use during CM, relative to induction. Two patterns of response to CM were observed based on uEtG-defined heavy drinking immediately prior to CM. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

The opioid overdose epidemic has significantly impacted rural communities. Rural settings present unique challenges to addressing opioid misuse. The purpose of the current study was to understand the similarities and differences between rural and urban-based providers serving rural communities. Washington state-based opioid-related service providers who serve rural communities (N = 75) completed an online survey between July and September 2020. Chi-square tests of association were used to examine significant differences in proportions between rural providers and rural-serving urban providers across opioid prevention, treatment, and recovery training topics. Rural providers reported receiving significantly less opioid treatment and recovery training on the criminal legal system, workplace-based education on treatment and recovery, and co-occurring disorder treatment; and significantly higher prior opioid prevention training on the prevention programs for youth and accessing prevention funding. Differences between rural and rural-serving urban providers demonstrate ways in which rural–urban partnerships can be strengthened to enhance public health.

The American Indian Enculturation Scale (AIES) was developed for American Indian populations to measure connection to traditional culture, but it has not been evaluated in Alaska Native people. While American Indian and Alaska Native individuals are grouped together, significant differences exist between groups. As a part of a randomized controlled trial for contingency management to reduce alcohol use, 160 Alaska Native adults completed the AIES. The confirmatory factor analysis indicated that a one-factor, 15-item version of the AIES, removing items 1 and 2 and correlating items 8 and 10, was a reliable (15 items; α = 0.896) and valid measure in this sample (χ2 [89] = 155.788, p<.001; CFI = 0.903; TLI = 0.886; RMSEA = 0.068 [90% confidence interval {CI} 0.050-0.086]; p<.001; SRMR = 0.060). The study provides limited evidence of enculturation's structural validity, as measured by the AIES, for Alaska Native adults. Future confirmatory work and potential adaptation is needed to evaluate the empirical utility of the AIES for Alaska Native individuals seeking help to reduce alcohol use.

INTRODUCTION:Alaska Native and American Indian (ANAI) peoples in Alaska currently experience a disproportionate burden of morbidity and mortality from tobacco cigarette use. Financial incentives for smoking cessation are evidence-based, but a family-level incentive structure has not been evaluated. We used a community-based participatory research and qualitative approach to culturally adapt a smoking cessation intervention with ANAI families. AIMS AND METHODS:We conducted individual, semistructured telephone interviews with 12 ANAI adults who smoke, 12 adult family members, and 13 Alaska Tribal Health System stakeholders statewide between November 2022 and March 2023. Through content analysis, we explored intervention receptivity, incentive preferences, culturally aligned recruitment and intervention messaging, and future implementation needs. RESULTS:Participants were receptive to the intervention. Involving a family member was viewed as novel and aligned with ANAI cultural values of commitment to community and familial interdependence. Major themes included choosing a family member who is supportive and understanding, keeping materials positive and encouraging, and offering cash and noncash incentives for family members to choose (eg, fuel, groceries, activities). Participants indicated that messaging should emphasize family collaboration and that cessation resources and support tips should be provided. Stakeholders also reinforced that program materials should encourage the use of other existing evidence-based cessation therapies (eg, nicotine replacement, counseling). CONCLUSIONS:Adaptations, grounded in ANAI cultural strengths, were made to the intervention and recruitment materials based on participant feedback. Next steps include a beta-test for feasibility and a randomized controlled trial for efficacy. IMPLICATIONS:This is the first study to design and adapt a financial incentives intervention promoting smoking cessation among ANAI peoples and the first to involve the family system. Feedback from this formative work was used to develop a meaningful family-level incentive structure with ANAI people who smoke and family members and ensure intervention messaging is supportive and culturally aligned. The results provide qualitative knowledge that can inform future family-based interventions with ANAI communities, including our planned randomized controlled trial of the intervention.