Financial Rewards for Reducing Alcohol Use in Patients With Liver Disease

Official title

Randomized Evaluation of Incentives FOR Clinical Effectiveness in Liver Recovery (REINFORCE Trial): A PEth-Based Contingency Management Pilot Randomized Controlled Trial for Alcohol Use Disorder in Patients With Alcohol-Associated Liver Disease

Overview

This study tests whether providing financial rewards based on a blood test result can help people with alcohol-associated liver disease (ALD) stop or reduce their drinking. The blood test is called phosphatidylethanol (PEth), which can detect alcohol use over the past three to four weeks. The financial reward program is called contingency management (CM). The study has two parts. Part 1 involves one-time interviews and surveys with patients and healthcare providers to understand how a PEth-based CM program could best be delivered in a liver disease clinic. Part 2 is a pilot randomized controlled trial (the REINFORCE Trial) in which participants are randomly assigned to one of two groups: (1) a rewards group that receives escalating financial incentives when PEth results show reduced or no alcohol use, or (2) a monitoring group that receives fixed payments regardless of PEth results. Both groups receive PEth testing and continue their usual medical care. The study will assess whether the rewards program improves alcohol abstinence and reduction at 12 and 24 weeks.'

Detailed description

Alcohol-associated liver disease (ALD) accounts for approximately 50% of liver-related deaths in the United States and is the leading indication for liver transplantation. Despite the clear benefits of alcohol use disorder (AUD) treatment, fewer than 15% of ALD patients receive any evidence-based AUD treatment. Contingency management (CM) is one of the most effective behavioral interventions for substance use disorders, providing tangible incentives contingent on verifiable behavior change. Its application in ALD has been limited by the lack of reliable alcohol monitoring methods with sufficient detection windows.

Phosphatidylethanol (PEth) is a direct alcohol biomarker with a detection window of up to four weeks, high sensitivity, and high specificity. PEth testing can now be conducted via at-home dried blood spot (DBS) sampling, reducing burden for medically complex patients. Integrating PEth-based monitoring with CM in the hepatology clinic offers a novel strategy to improve AUD treatment engagement and promote sustained alcohol abstinence in ALD patients.

Aim 1 (Months 1-9): A mixed-methods formative study enrolling 15 ALD patients and 15 hepatology/addiction providers. Semi-structured interviews and surveys will assess feasibility, acceptability, and preferences for PEth-based CM delivery, guided by the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework. Findings will inform the Aim 2 intervention design.

Aim 2 (Months 7-36): A pilot randomized controlled trial (REINFORCE Trial) enrolling 90 participants with ALD and AUD (45 per arm), randomized 1:1 stratified by AUD severity and gender. The CM arm receives escalating financial incentives based on PEth results (up to $615 over 12 weeks) and treatment engagement. The control arm receives fixed non-contingent payments on the same PEth testing schedule (up to $330 over 12 weeks). Both arms receive treatment as usual. The primary outcome is alcohol abstinence at 12 weeks (PEth \<8 ng/mL). Secondary outcomes include alcohol use reduction at 12 weeks, abstinence or reduction at 24 weeks, and AUD treatment engagement. Exploratory analyses will examine treatment effect modifiers including AUD severity, liver disease stage, psychiatric comorbidities, age, and gender.'

Interventions

• Behavioral PEth Based Contingency Management
  Participants receive a contingency management intervention designed to promote alcohol abstinence among patients with alcohol use disorder and alcohol associated liver disease. Alcohol use is monitored using serial phosphatidylethanol (PEth) testing from dried blood spot samples. Participants receive financial incentives contingent on alcohol abstinence or substantial reduction in alcohol consumption as measured by PEth levels. Incentives escalate with consecutive negative PEth results during th
• Behavioral PEth Monitoring with Fixed Incentives
  Participants undergo serial phosphatidylethanol (PEth) testing using dried blood spot samples at the same schedule as the intervention group. Participants receive fixed incentives for completing testing visits, but incentives are not contingent on alcohol use outcomes. This condition controls for study participation, monitoring, and compensation while isolating the effect of contingency management.

Primary outcome measures

• Alcohol Abstinence Measured by PEth [Time frame: 12 weeks]

Secondary outcome measures (4)

• Changes in Alcohol Use Measured by PEth [Time frame: Baseline to 12 weeks]
• Intervention Feasibility [Time frame: 12 weeks]
• Participant Acceptability of the Intervention [Time frame: 12 weeks]
• Sustained Alcohol Abstinence After Intervention [Time frame: 24 weeks]

Eligibility criteria

Inclusion criteria

• Adults aged 18 years or older
• Diagnosis of alcohol use disorder based on DSM 5 criteria
• Diagnosis of alcohol associated liver disease or clinically suspected alcohol related liver injury
• Evidence of recent alcohol use or at risk for alcohol relapse
• Receiving care in hepatology or liver disease clinic at the participating institution
• Willingness to undergo serial phosphatidylethanol (PEth) testing using dried blood spot samples
• Ability to provide informed consent
• Willingness to participate in the contingency management intervention and follow study procedures

Exclusion criteria

• Severe cognitive impairment or medical condition that prevents participation in study procedures
• Active psychosis or severe psychiatric instability that would interfere with participation
• Current enrollment in another contingency management program targeting alcohol use
• Medical instability requiring hospitalization at the time of enrollment
• Inability to communicate in English (if study materials are only available in English)
• Any condition that, in the opinion of the investigators, would make participation unsafe or interfere with completion of the study

Criteria are shown verbatim from the registry (in English). Final eligibility is always assessed by the study center.

Healthy volunteers: No

Study design

Allocation

Randomized

Model

Parallel assignment

Masking

Open label

Primary purpose

Treatment

Study locations

Center list to be confirmed — check the primary protocol.

Publications

• Crabb DW, Im GY, Szabo G, Mellinger JL, Lucey MR. Diagnosis and Treatment of Alcohol-Associated Liver Diseases: 2019 Practice Guidance From the American Association for the Study of Liver Diseases. Hepatology. 2020 Jan;71(1):306-333. doi: 10.1002/hep.30866. No abstract available. PMID 31314133
• Beck O, Kenan Moden N, Seferaj S, Lenk G, Helander A. Study of measurement of the alcohol biomarker phosphatidylethanol (PEth) in dried blood spot (DBS) samples and application of a volumetric DBS device. Clin Chim Acta. 2018 Apr;479:38-42. doi: 10.1016/j.cca.2018.01.008. Epub 2018 Jan 5. PMID 29309773
• Edelman EJ, Dziura J, Deng Y, DePhilippis D, Fucito LM, Ferguson T, Bedimo R, Brown S, Marconi VC, Goetz MB, Rodriguez-Barradas MC, Simberkoff MS, Molina PE, Weintrob AC, Maisto SA, Paris M, Justice AC, Bryant KJ, Fiellin DA. Contingency management with stepped care for unhealthy alcohol use among individuals with HIV: Protocol for a randomized controlled trial. Contemp Clin Trials. 2023 Aug;131:1 PMID 37230168
• Petry NM, Alessi SM, Olmstead TA, Rash CJ, Zajac K. Contingency management treatment for substance use disorders: How far has it come, and where does it need to go? Psychol Addict Behav. 2017 Dec;31(8):897-906. doi: 10.1037/adb0000287. Epub 2017 Jun 22. PMID 28639812
• Lee BP, Witkiewitz K, Mellinger J, Anania FA, Bataller R, Cotter TG, Curtis B, Dasarathy S, DeMartini KS, Diamond I, Diazgranados N, DiMartini AF, Falk DE, Fernandez AC, German MN, Kamath PS, Kidwell KM, Leggio L, Litten R, Louvet A, Lucey MR, McCaul ME, Sanyal AJ, Singal AK, Sussman NL, Terrault NA, Thursz MR, Verna EC, Radaeva S, Nagy LE, Mitchell MC. Designing clinical trials to address alcohol PMID 38849555
• Jett JD, Beck R, Tyutyunnyk D, Sanchez J, Weeks DL, Javors MA, Hill-Kapturczak N, Lopez-Cruzan M, Kriegel L, Ginsburg BC, Cabassa L, McDonell MG. Feasibility of a telehealth-based contingency management intervention for alcohol use disorders using the phosphatidylethanol (PEth) 16:0/18:1 alcohol biomarker: a pilot randomized trial. Am J Drug Alcohol Abuse. 2024 Mar 3;50(2):162-172. doi: 10.1080/00 PMID 38284925
• McDonell MG, Skalisky J, Leickly E, Orr MF, McPherson S, Roll J, Hill-Kapturczak N, Javors M. Pilot investigation of a phosphatidylethanol-based contingency management intervention targeting alcohol use. Psychol Addict Behav. 2017 Aug;31(5):608-613. doi: 10.1037/adb0000293. Epub 2017 Jul 17. PMID 28714726

Identifiers

NCT: NCT07465588 · 2026P000556 · 1R34AA032300-01A1

Primary sources (government registries)

• ClinicalTrials.gov (US NIH)

View this study on ClinicalTrials.gov ↗