A preliminary randomized controlled trial of contingency management for alcohol use reduction using a transdermal alcohol sensor

Wrist-worn alcohol biosensors: Strengths, limitations, and future directions

Wearable alcohol biosensors have emerged as a valuable tool for noninvasive, objective, and continuous monitoring of alcohol consumption. However, to date their research and clinical applications have been limited by several factors including large size, high cost, and social stigma. In contrast, recently developed wrist-worn alcohol biosensors are smaller, less expensive, and may be more acceptable for daily use. However, these devices are at the prototype phase and have just begun to be tested for research applications. In this paper, we describe our experiences with two prototypes of these new wrist-worn alcohol biosensors (i.e., Quantac Tally and BACtrack Skyn) and their associated smartphone applications in both a controlled laboratory setting and the real-world environment. Our preliminary experiences with these devices highlight their advantages including comfort, high participant acceptability, and good compliance. However, there are various limitations that should be addressed prior to future research applications of these biosensors, including large interpersonal variations in transdermal alcohol readings, lack of immediately applicable data analysis/interpretation software, and poor battery life after a few months. More research is also needed to further validate the new biosensors, and investigate individual (e.g., skin thickness, gender differences) and environmental factors (e.g., humidity, temperature) contributing to the variations in transdermal alcohol readings measured by wrist-worn alcohol biosensors.

Monitoring alcohol use in heavy drinking soup kitchen attendees

Rates of heavy alcohol use in soup kitchen attendees range from 30% to 38%, but these data are based entirely on self-reported drinking. Little is known about the intensity or frequency of drinking in this population. We assessed alcohol use transdermally every 30 min over a 3-week period among heavy drinkers who attended local soup kitchens. In addition to transdermal alcohol monitoring, participants were randomly assigned to daily breath alcohol monitoring with or without reinforcement for alcohol-negative breath samples (BrAC). Analyses assessed feasibility of transdermal monitoring and examined alcohol use based on BrAC, transdermal, and self-report data, as well as effect sizes for these metrics based on group assignment. Nineteen participants completed the 21-day monitoring period in full; three persons removed the anklet 3-16 days early due to hospitalization, impending hospitalization, or incarceration. Participants reported minimal impacts of the monitors, and severity ratings of side effects were mild. When using BrAC, transdermal, and self-report data, the percentage of non-drinking days was 93%, 58%, and 57%, and the longest duration of consecutive non-drinking days averaged 10.3, 7.2, and 5.7 days, respectively. About half of drinking days involved heavy drinking (5 + drinks). Self-report and transdermal drinking days correlated significantly, p < .001, but neither index was associated with BrAC. Group comparisons indicate small-to-moderate sized effects of reinforcement compared to no reinforcement for increasing the proportion of alcohol-negative breath samples and durations of consecutive non-drinking samples during the study when BrAC was the metric. Transdermal data and self-report data indicated a more complex pattern. Reinforcement participants drank more often but at lower quantities than monitoring (control) participants per both transdermal and self-report data. These data suggest that transdermal monitors are well tolerated and document substantial heavy drinking in this population. Soup kitchens users are in need of alcohol interventions, and soup kitchens may represent a novel opportunistic setting for intervention delivery for an important and growing health disparities population.

Therapeutic efficacy of environmental enrichment for substance use disorders

Addiction to drug and alcohol is regarded as a major health problem worldwide for which available treatments show limited effectiveness. The biggest challenge remains to enhance the capacities of interventions to reduce craving, prevent relapse and promote long-term recovery. New strategies to meet these challenges are being explored. Findings from preclinical work suggest that environmental enrichment (EE) holds therapeutic potential for the treatment of substance use disorders, as demonstrated in a number of animal models of drug abuse. The EE intervention introduced after drug exposure leads to attenuation of compulsive drug taking, attenuation of the rewarding (and reinforcing) effects of drugs, reductions in control of behavior by drug cues, and, very importantly, relapse prevention. Clinical work also suggests that multidimensional EE interventions (involving physical activity, social interaction, vocational training, recreational and community involvement) might produce similar therapeutic effects, if implemented continuously and rigorously. In this review we survey preclinical and clinical studies assessing the efficacy of EE as a behavioral intervention for substance use disorders and address related challenges. We also review work providing empirical evidence for EE-induced neuroplasticity within the mesocorticolimbic system that is believed to contribute to the seemingly therapeutic effects of EE on drug and alcohol-related behaviors.

Developing neuroscience-based treatments for alcohol addiction: A matter of choice?

Excessive alcohol use is the cause of an ongoing public health crisis, and accounts for ~5% of global disease burden. A minority of people with recreational alcohol use develop alcohol addiction (hereafter equated with "alcohol dependence" or simply "alcoholism"), a condition characterized by a systematically biased choice preference for alcohol at the expense of healthy rewards, and continued use despite adverse consequences ("compulsivity"). Alcoholism is arguably the most pressing area of unmet medical needs in psychiatry, with only a small fraction of patients receiving effective, evidence-based treatments. Medications currently approved for the treatment of alcoholism have small effect sizes, and their clinical uptake is negligible. No mechanistically new medications have been approved since 2004, and promising preclinical results have failed to translate into novel treatments. This has contributed to a reemerging debate whether and to what extent alcohol addiction represents a medical condition, or reflects maladaptive choices without an underlying brain pathology. Here, we review this landscape, and discuss the challenges, lessons learned, and opportunities to retool drug development in this important therapeutic area.

Technology-Based Contingency Management in the Treatment of Substance-Use Disorders

Contingency management is one of the most efficacious interventions to promote drug abstinence. Contingency management has traditionally been delivered in person so that clinicians could confirm drug abstinence and provide access to additional therapeutic services. Now, new technologies not only permit remote confirmation of abstinence, but also remote delivery of incentives. We discuss several technology-based tools to assess substance use, and new ways to deliver contingency management to promote tobacco, alcohol, and cannabis abstinence. These new tools have the potential to dramatically increase access while maintaining high levels of treatment fidelity. Technology-based methods also allow arranging group contingencies that harness online communities, and they permit targeting multiple health-risk behaviors with a combination of sensor-based technologies. Overall, there are unprecedented opportunities to link technology with contingency management to promote drug abstinence.

Considerations for Implementing Contingency Management in Substance Abuse Treatment Clinics: The Veterans Affairs Initiative as a Model

Contingency management (CM) is an efficacious intervention for the treatment of substance use disorders that is widely applicable across a range of client populations and characteristics. Despite its strong evidence base, CM remains underutilized in real world practice. This article introduces CM for clinicians interested in adopting CM and briefly reviews this research evidence. In addition, CM protocols are described, with emphasis on the specific design considerations important to CM's efficacy. The recent Department of Veterans Affairs (VA) initiative, which represents the first successful large-scale implementation effort, is presented. It provides a model for the training and supervision components that may be critical to implementation with fidelity. Continued research in this area, as well as further demonstrations of successful dissemination and implementation, will be critical for improving the adoption of this intervention in clinical, nonresearch settings.

What Do Real Alcohol Outpatients Expect about Alcohol Transdermal Sensors?

Objective: Little is known about the potential acceptability of alcohol transdermal sensors among alcohol-dependent outpatients in routine clinical settings. The aim of the present study was to investigate patients’ attitudes towards alcohol transdermal sensors, as well as features associated with enhanced acceptability and usability. Methods: A cross-sectional survey among routine alcohol outpatients was conducted. The Drug Attitude Inventory (DAI-10) was adapted to the field of alcohol transdermal sensors for attitudes assessment. Likert-type and multiple-choice questions were used for acceptability and usability evaluation. Results: 68 patients completed the questionnaire, and the DAI-10 mean score was 3 (standard deviation (SD) = 6.5). Internal consistency revealed a Cronbach alpha of 0.613. The score of a single The score of a single Likert-type question about overall perceived value was 7.4 (SD = 2.6). Its correlation with mean DAI-10 scores was r = 0.633, with p < 0.001. Relapse prevention and a stricter treatment control from therapists were the main reported advantages. Perceived stigma was the main disadvantage. Features increasing device discretion would enhance its acceptability. Conclusions: The data suggest that transdermal sensors could play a role in the clinical treatment of alcohol outpatients and concerns regarding stigma should be taken into account. Future designs should try to minimize size and visibility and stigma concerns should be discussed with patients.

Assessment of Alcohol Use in the Natural Environment

The current article critically reviews 3 methodological options for assessing drinking episodes in the natural environment. Ecological momentary assessment (EMA) typically involves using mobile devices to collect self-report data from participants in daily life. This technique is now widely used in alcohol research, but investigators have implemented diverse assessment strategies. This article focuses on "high-resolution" EMA protocols that oversample experiences and behaviors within individual drinking episodes. A number of approaches have been used to accomplish this, including using signaled follow-ups tied to drinking initiation, asking participants to log entries before and after individual drinks or drinking episodes, and delivering frequent signaled assessments during periods of the day when alcohol use is most common. Transdermal alcohol sensors (TAS) are devices that are worn continuously and are capable of detecting alcohol eliminated through the skin. These methods are appealing because they do not rely upon drinkers' self-report. Studies using TAS have been appearing with greater frequency over the past several years. New methods are making the use of TAS more tractable by permitting back-translation of transdermal alcohol concentration data to more familiar estimates of blood alcohol concentration or breath alcohol concentration. However, the current generation of devices can have problems with missing data and tend to be relatively insensitive to low-level drinking. An emerging area of research investigates the possibility of using mobile device data and machine learning to passively detect the user's drinking, with promising early findings. EMA, TAS, and sensor-based approaches are all valid, and tend to produce convergent information when used in conjunction with one another. Each has a unique profile of advantages, disadvantages, and threats to validity. Therefore, the nature of the underlying research question must dictate the method(s) investigators select.

Consumption outcomes in clinical trials of alcohol use disorder treatment: Consideration of standard drink misestimation

Background. The Food and Drug Administration recently added a new clinical endpoint for evaluating the efficacy of alcohol use disorder (AUD) treatment that is more inclusive of treatment goals besides abstinence: no heavy drinking days (NHDD). However, numerous critiques have been noted for such binary models of treatment outcome. Further, there is mounting evidence that participants inaccurately estimate the quantities of alcohol they consume during drinking episodes (i.e., drink size misestimation), which may be particularly problematic when using a binary criterion (NHDD) compared to a similar, continuous alternative outcome variable: percent heavy drinking days (PHDD). Yet, the impact of drinking misestimation on binary (e.g., NHDD) versus continuous outcome variables (e.g., PHDD) has not been studied. Objectives. Using simulation methods, the present study examined the potential impact of drink size misestimation on NHDD and PHDD. Methods. Data simulations were based on previously published findings of the amount of error in how much alcohol is actually poured when estimating standard drinks. We started with self-reported daily drinking data from COMBINE study participants with complete data (N = 888; 68.1% male), then simulated inaccuracy in those estimations based on literature on standard drink size misestimation. Results. Clinical trial effect sizes were consistently lower for NHDD than for PHDD. Drink size misestimation further lowered effect sizes for NHDD and PHDD. Conclusions. Drink size misestimation may lead to inaccurate conclusions about drinking outcomes and the comparative effectiveness of AUD treatments, including inflated type-II error rates, particularly when treatment "success" is defined by binary outcomes such as NHDD.

Protective Effects of Pregnancy on Risk of Alcohol Use Disorder

OBJECTIVE

The authors sought to clarify the etiology of the association between pregnancy and reduced risk of alcohol use disorder.

METHODS

The authors used data from longitudinal population-wide Swedish medical, pharmacy, and criminal registries to evaluate whether rates of alcohol use disorder are lower during pregnancy. They compared pregnant women born between 1975 and 1992 (N=322,029) with matched population controls, with female relatives discordant for pregnancy, and with pre- and postpregnancy periods within individuals. They further compared rates of alcohol use disorder between pregnant women and their partners.

RESULTS

Pregnancy was inversely associated with alcohol use disorder across all analyses (odds ratios, 0.17-0.32). In co-relative analyses, the strength of the association increased among more closely related individuals. Within individuals, rates of alcohol use disorder were substantially decreased during pregnancy relative to the prepregnancy period (odds ratios, 0.25-0.26), and they remained reduced during postpartum periods (odds ratios, 0.23-0.31). Results were similar for second pregnancies (odds ratio, 0.23). The partners of pregnant women also exhibited reductions in alcohol use disorder (odds ratio, 0.45). Among women who became pregnant at earlier ages and those with a history of criminal behavior, the negative association between pregnancy and alcohol use disorder was especially pronounced, but no moderation was observed for a personal or maternal parental history of alcohol use disorder.

CONCLUSIONS

The findings suggest that pregnancy plays a critical, and likely causal, motivational role in reducing alcohol use disorder risk among women and, to a lesser extent, their partners. These results extend our understanding of the relationship between pregnancy and alcohol use, demonstrating that even a severe condition such as alcohol use disorder is subject to the protective effects of pregnancy.

Remote Alcohol Monitoring to Facilitate Incentive-Based Treatment for Alcohol Use Disorder: A Randomized Trial

Background

The delivery of monetary incentives contingent on verified abstinence is an effective treatment for alcohol use disorder. However, technological barriers to accurate, frequent biochemical verification of alcohol abstinence have limited the dissemination of this technique.

Methods

In the present randomized parallel trial, we employed a breathalyzer that allows remote, user‐verified collection of a breath alcohol sample, text messaging, and reloadable debit cards for remote delivery of incentives to evaluate a contingency management treatment for alcohol use disorder that can be delivered with no in‐person contact. Treatment‐seeking participants with alcohol use disorder (n = 40) were recruited from the community and randomized to either a contingent or a noncontingent group (n = 20 each). The contingent group received nearly immediate monetary incentives each day they remotely provided negative breathalyzer samples. The noncontingent group received matched monetary payments each day they successfully provided samples independent of alcohol content. Groups were not masked as awareness of group contingencies was an essential intervention component.

Results

The primary outcome of the intent‐to‐treat analyses (analyzed n = 40) was percent days abstinent as measured by the remote breathalyzer samples. Abstinence rates in the contingent group were 85%, which was significantly higher than the 38% recorded in the noncontingent group, corresponding to an odds ratio of 9.4 (95% CI = 4.0 to 22.2). Breathalyzer collection adherence rates were over 95%, and participant ratings of acceptability were also high.

Conclusions

These results support the efficacy, acceptability, and feasibility of this remotely deliverable abstinence reinforcement incentive intervention for the initiation and near‐term maintenance of abstinence from alcohol in adults with alcohol use disorder. Due to low provider and participant burden, this procedure has the potential for broad dissemination.

Translating transdermal alcohol monitoring procedures for contingency management among adults recently arrested for DWI

Recent developments in alcohol monitoring devices have made it more feasible to use contingency management (CM) procedures to reduce alcohol use. A growing body of literature is demonstrating the effectiveness of CM to reduce alcohol use among community recruited adults wearing transdermal alcohol concentration (TAC) monitoring devices. This article describes the quality improvement process aimed at adapting TAC-informed CM aimed at minimizing alcohol use and maximizing treatment completion. This extends literature to a high-risk population; adults arrested and awaiting trial (pretrial) for criminal charge of driving while intoxicated (DWI). Participants were enrolled during their orientation to pretrial supervision conditions of DWI bond release. At enrollment, participants completed a screening, brief intervention, and referral to treatment; those with high risk alcohol histories were enrolled in an 8-week CM procedure to avoid TAC readings. Four Plan-Do-Study-Act (PDSA) quality improvement cycles were conducted where the TAC cutoff for determining alcohol use, the quantity of reinforcer, and handling of tampers on the transdermal alcohol monitor were manipulated. Across four PDSA cycles, the retention for the full 8-weeks of treatment was increased. The proportion of weeks with alcohol use was not decreased across cycles, the peak TAC values observed during drinking weeks were significantly lower in Cycles 1 and 4 than 3. CM may be developed as a tool for pretrial supervision to be used to increase bond compliance of those arrested for DWI and for others as a method to identify the need for additional judicial services.

Wearable Electrochemical Alcohol Biosensors

The rapid development of wearable sensing platforms in recent years has led to an array of viable monitoring applications for various target analytes. As a significant biomarker with high impact in diverse areas, the reliable on-body detection and continuous monitoring of alcohol has become a focus of many such systems. Currently, several commercial sensing platforms are available that are capable of transdermal monitoring of alcohol consumption using insensible sweat. Drawbacks of existing alcohol sensing platforms that apply this sensing strategy have led to efforts in developing wearable biosensors capable of real-time alcohol detection in sampled biofluids such as sensible sweat and skin interstitial fluid. This review discusses the current trends in wearable electrochemical alcohol biosensing and highlights recent advances in such systems toward continuous, real-time monitoring of alcohol consumption. Our perspective on this important field is given with an outlook on the future of wearable electrochemical alcohol biosensors.

Combining ecological momentary assessment with objective, ambulatory measures of behavior and physiology in substance-use research

Whereas substance-use researchers have long combined self-report with objective measures of behavior and physiology inside the laboratory, developments in mobile/wearable electronic technology are increasingly allowing for the collection of both subjective and objective information in participants' daily lives. For self-report, ecological momentary assessment (EMA), as implemented on contemporary smartphones or personal digital assistants, can provide researchers with near-real-time information on participants' behavior and mood in their natural environments. Data from portable/wearable electronic sensors measuring participants' internal and external environments can be combined with EMA (e.g., by timestamps recorded on questionnaires) to provide objective information useful in determining the momentary context of behavior and mood and/or validating participants' self-reports. Here, we review three objective ambulatory monitoring techniques that have been combined with EMA, with a focus on detecting drug use and/or measuring the behavioral or physiological correlates of mental events (i.e., emotions, cognitions): (1) collection and processing of biological samples in the field to measure drug use or participants' physiological activity (e.g., hypothalamic-pituitary-adrenal axis activity); (2) global positioning system (GPS) location information to link environmental characteristics (disorder/disadvantage, retail drug outlets) to drug use and affect; (3) ambulatory electronic physiological monitoring (e.g., electrocardiography) to detect drug use and mental events, as advances in machine learning algorithms make it possible to distinguish target changes from confounds (e.g., physical activity). Finally, we consider several other mobile/wearable technologies that hold promise to be combined with EMA, as well as potential challenges faced by researchers working with multiple mobile/wearable technologies simultaneously in the field.

The Role of Technology-Based Interventions for Substance Use Disorders in Primary Care: A Review of the Literature

The burden of alcohol and drug use disorders (substance use disorders [SUDs]) has intensified efforts to expand access to cost-effective psychosocial interventions and pharmacotherapies. This article provides an overview of technology-based interventions (eg, computer-based and Web-based interventions, text messaging, interactive voice recognition, smartphone apps, and emerging technologies) that are extending the reach of effective addiction treatments both in substance use treatment and primary care settings. It discusses the efficacy of existing technology-based interventions for SUDs, prospects for emerging technologies, and special considerations when integrating technologies in primary care (eg, privacy and regulatory protocols) to enhance the management of SUDs.

mHealth for the Detection and Intervention in Adolescent and Young Adult Substance Use Disorder

Purpose of review

The goal of this review is to highlight recent research in mHealth based approaches to the detection and treatment of substance use disorders in adolescents and young adults.

Recent findings

The main methods for mHealth based detection include mobile phone based self-report tools, GPS tracking, and wearable sensors. Wearables can be used to detect physiologic changes (e.g., heart rate, electrodermal activity) or biochemical contents of analytes (i.e. alcohol in sweat) with reasonable accuracy, but larger studies are needed. Detection methods have been combined with interventions based on mindfulness, education, incentives/goals and motivation. Few studies have focused specifically on the young adult population, although those that did indicate high rates of utilization and acceptance.

Summary

Research that explores the pairing of advanced detection methods such as wearables with real time intervention strategies is crucial to realizing the full potential of mHealth in this population.

Patients' Experiences of Using a Cellular Photo Digital Breathalyzer for Treatment Purposes

OBJECTIVES

The field of eHealth systems is rapidly developing and is now expanding into alcohol treatment settings. Despite a growing public and professional interest, cellular photo digital breathalyzers (CPDBs) have not been investigated in a clinical context so far. In this study, we aimed to investigate the experiences of patients in alcohol treatment who had been using a CPDB-TripleA- for a minimum of three months. What are their personal experiences of using the CPDB? Do the patients think it supports them to change their drinking habits, and if so, in what way?

METHODS

A qualitative interview study with individuals who had been using the CPDB TripleA, for at least 3 months as complement to treatment (12-step program or hospital-based outpatient care). A thematic analysis with an inductive approach was used to identify, analyze, and interpret patterns within data.

RESULTS

In all, 12 interviews were conducted with 8 men and 4 women. Participants were generally enthusiastic about the CPDB and found it convenient and useful, even though it created a need for privacy when using the device. Although technical problems were substantial, participants were tolerant to those. The system was perceived to support self-control and to restore relations, but did not replace the need for close contact with caregivers. Self-motivation to change drinking habits was essential, and could not be reached by solely using the CPDB.

CONCLUSIONS

Participants perceived the CPDB as a convenient and useful tool that was supportive under the circumstances that it was used in a context that included personal contact with a caregiver; and the user felt more than just a minimum of motivation to reduce drinking. Technical stability needs to be achieved to secure long-term use.

Experiences with SCRAMx alcohol monitoring technology in 100 alcohol treatment outpatients

BACKGROUND

Transdermal alcohol monitoring technology allows for new research on alcohol use disorders. This study assessed feasibility, acceptability, and adherence with this technology in the context of two clinical research trials.

METHODS

Participants were the first 100 community-based alcohol treatment outpatients enrolled in randomized studies that monitored drinking with the secure continuous remote alcohol monitor (SCRAMx®) for 12 weeks. Study 1 participants were randomized to usual care (n=36) or usual care with contingency management incentives for treatment attendance (CM-Att; n=30). Study 2 participants were randomized to usual care (n=17) or usual care with CM for each day of no drinking per SCRAMx (CM-Abst; n=17). After 12 weeks, participants completed a survey about the bracelet.

RESULTS

Nine percent of individuals screened (54 of 595) declined participation because of the bracelet. Of participants, 84% provided 12weeks of data, and 96% of bracelets were returned fully intact. Ninety-four equipment tampers occurred, affecting 2% of monitoring days; 56% (67) of tampers coincided with detected drinking. Common concerns reported by participants were skin marks (58%), irritation (54%), and interfered with clothing choices (51%), but severity ratings were generally mild (60%-94%). Eighty-one percent of participants reported that the bracelet helped them reduce drinking, and 75% indicated that they would wear it for longer. A common suggestion for improvement was to reduce the size of the bracelet.

CONCLUSIONS

Results support the viability of transdermal monitoring in voluntary substance abuse treatment participants for an extended duration. Issues to consider for future applications of this technology are discussed.

Predictors of detection of alcohol use episodes using a transdermal alcohol sensor

The objective of this investigation was to establish the ability of the Secure Continuous Remote Alcohol Monitoring (SCRAM) alcohol sensor to detect different levels of self-reported alcohol consumption, and to determine whether gender and body mass index, alcohol dependence, bracelet version, and age of bracelet influenced detection of alcohol use. Heavy drinking adults (N = 66, 46% female) wore the SCRAM for 1-28 days and reported their alcohol use in daily Web-based surveys. Participant reports of alcohol use were matched with drinking episodes identified from bracelet readings. On days when bracelets were functional, 690 drinking episodes were reported and 502 of those episodes (72.8%) were detected using sensor data. Using generalized estimating equations, we found no gender differences in detection of reported drinking episodes (77% for women, 69% for men). In univariate analyses, at the level of fewer than 5 drinks, women's episodes were more likely to be detected, likely because of the significantly higher transdermal alcohol concentration levels of these episodes, whereas at the level of 5 or more drinks, there was no gender difference in detection (92.6% for women, 93.4% for men). In multivariable analyses, no variables other than number of drinks significantly predicted alcohol detection. In summary, the SCRAM sensor is very good at detecting 5 or more drinks; performance of the monitor below this level was better among women because of their higher transdermal alcohol concentration levels. Individual person characteristics and bracelet features were not related to detection after number of drinks was included. Minimal bracelet malfunctions were noted.