Rewarding Adolescent Abstinence
Adolescents function within family units that have a large sway over engagement and follow-up in treatment. That being said, many parents lack the knowledge for how best to motivate their adolescents or may even undermine their engagement. To help their adolescents engage in substance use treatment parents may benefit from training to create incentives to help achieve and maintain abstinence.
WHAT PROBLEM DOES THIS STUDY ADDRESS?
Providing incentives for abstinence has been shown to be useful in a variety of disorders including adolescents with cannabis misuse (see Stewart et al 2015; Stanger et al, 2015). Less is known about the effectiveness of including abstinence-based motivational incentives (also known as contingency management) in the treatment of adolescent alcohol use disorder and other types of harmful drinking.
HOW WAS THIS STUDY CONDUCTED?
In this study, Stanger and colleagues randomized adolescent participants with alcohol misuse already receiving alcohol treatment to additionally receive either treatment attendance incentives (control condition) or a combination of abstinence incentives together with a weekly behavioral parent training.
- READ MORE ON STUDY METHODS
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The participants (n=75, ages 12-18) all met criteria for alcohol use disorder or recent binge drinking (>5 drinks in 1 day during the past 90 days), and 77% met criteria for cannabis use disorder. All participants received weekly individualized treatment (motivational enhancement therapy + cognitive behavior therapy, MET/CBT) together with weekly alcohol breath and urine drug tests for 14 weeks with an additional 12 weeks of urine monitoring and endpoint data collection at 36 weeks following treatment completion. The control condition included, in addition to the MET/CBT, an attendance-based initiative (increasing chances to win prizes with increased attendance).
The experimental arm, in addition to MET/CBT, included both an abstinence-based incentive as well as a home-based program with parental involvement. Abstinence was defined as abstinence from all substances determined by both urine screen, including assessment of ethyl glucuronide (an indicator of alcohol consumption remaining in the urine up to 80 hours after drinking), and teen/parental report. The abstinence-based incentive was similar to the attendance-based initiative used in the control condition, with the difference that the opportunities to win prizes are obtained through abstinence not participation.
The parental component included both parent training and also parents developing a contract with the teen specifying both negative and positive consequences for substance use and abstinence, with in-home saliva alcohol testing. The contract is also a contingency management approach and was intended here to extend the abstinence-based incentives provided at the clinic.
WHAT DID THIS STUDY FIND?
There were no differences in the rates for complete abstinence with home-based parental training. Approximately 35% of the teens remained abstinent from alcohol six months after completion of therapy using abstinence-based incentives (regardless of whether their parents were receiving specific training). For the subset of teens also using cannabis, 30% of those in the parental-training condition achieved abstinence versus 50% in the incentive-based-only condition. This may be explained by this study potentially selecting for already good parenting by virtue of parental willingness to participate.
For those continuing to use, the abstinence incentives treatment group showed fewer days of using alcohol or cannabis. The treatments were effective even in those not achieving abstinence. Those not abstaining were using alcohol on average 8% of the days in experimental and 12% of the days in the control condition.
Treatment focused on alcohol use also resulted in reductions of cannabis use. 30-50% of participants were still abstinent at six months after therapy completion. Of those not abstinent, participants had used cannabis on 27% of the days (in the treatment arm) vs 35% days (in the control arm).
Retention rates were high using this study design – Using abstinence-based incentives may appeal to adolescents and increase their sustained participations. There was >85% participation at week 14 and >75% for the follow-up measures. Note that adolescent retention in treatment is generally more challenging than in adults.
WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?
Adolescents with problematic alcohol use, with or without cannabis use disorder, achieve high levels of abstinence with a 12 week individual treatment combining motivational enhancement and cognitive behavior therapy, with 35-50% still abstinent six months later. The focus of this particular study was the added benefit of including incentives for abstinence both in the clinic and at home involving parental participation. There was not a significant additional benefit when those components were added in terms of total abstinence, though among those not abstinent, adolescents receiving the more intensive treatment had fewer drinking and cannabis use days. This study adds to the growing body of evidence that focusing treatment on one substance (alcohol in this study) also significantly decreases use of other substances (cannabis in this case).
- LIMITATIONS
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- Of the 75 participants included, complete data was obtained from only 58 participants. Given the small sample size, the true magnitude of the effect of these interventions may differ than reported.
- The experimental arm of this study includes both the abstinence incentives for the adolescent as well as the parent training intervention, confounding the results as to which of these two interventions is driving the effect. Furthermore, the control arm includes attendance incentives, not included in the treatment arm.
- There was a high percentage of patients (approximately 25%) with enough missing data on alcohol and cannabis use that percentage days used could not be calculated.
- The sample was 75% male affecting the generalizability of conclusions. This is a limitation of many studies of adolescent substance use.
BOTTOM LINE
- For individuals & families seeking recovery: Individual treatment combining motivation enhancement and cognitive behavior therapy (a state-of-the-art, empirically supported intervention for adolescents) can be quite effective in adolescents with alcohol use disorder or combined alcohol and cannabis use disorders. The treatment studied here shows high retention rates, which is always a challenge with adolescents, and sustained abstinence six months following treatment completion. This study also included a parent intervention (parents were trained and developed a contract with their child including positive and negative reinforcements for abstinence or use) but the data suggests that the added benefit of this intervention is small compared with the 12 week individual therapy component.
- For scientists: The authors point out that they attribute some of the success of the study to including a novel urine test for an alcohol metabolite, ethyl glucuronide. This allows an 80 hour detection window which exceeds that seen with breath or saliva testing. 25% of all instances of alcohol use were detecting using the ethyl glucuronide tests and not by parent or self-report, which they suggest in turn contributed to more accurate self-reporting. Inclusion of this type of urine testing could allow alcohol use to be monitored in a manner more comparable to other drug testing in clinical studies.
- For policy makers: Given the success of attendance and abstinence incentives in clinical research, a similar type of motivational incentive’s program (e.g., earning chances to win prizes via a fish-bowl draw for prizes) could be introduced more routinely in the juvenile court system or even in the school system for cases of school truancy.
- For treatment professionals and treatment systems: The parental component in this study has not been tested on its own, but given that it also includes abstinence incentives and home testing, perhaps a parental home intervention could be designed as an alternative to hard-to-find substance use treatment. Families might be assisted with implementing the parental component (contract development, home testing and abstinence incentives) as a first line prior to more intensive and individualized treatment.
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