Contingency management is one of the most helpful behavior change strategies for people with substance use disorder, yet its impact varies at different stages of the disorder. This study examined its utility for patients admitted to the hospital for alcohol-related liver disease, showing just how difficult it is to intervene at the later stages.
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Alcohol-related liver disease comprises several conditions beginning with fatty liver, alcoholic hepatitis (i.e., liver inflammation), and ultimately irreversible alcoholic cirrhosis characterized by scar tissue in the liver. These conditions doubled from 1999 to 2020, with women and young adults showing the largest proportionate increases. Half of individuals with alcohol use disorder and one-quarter with hazardous drinking (e.g., meeting NIAAA guidelines for “risky” drinking) have these alcohol-related clinical conditions. People with alcohol-related liver disease can be hard to engage in treatment. Contingency management – motivational incentives for a targeted behavior – is among the most potent substance use disorder interventions, but little is known regarding its impact in certain groups of alcohol patients, such as those with liver disease. This study examined whether contingency management helped individuals with alcohol-related liver disease engage with integrated liver care, a comprehensive outpatient approach to the treatment of liver disease.
This was a randomized controlled trial with 30 adults with alcohol use disorder and alcohol-related liver disease presenting to the emergency department or admitted to the hospital with an acute liver episode. It compared the effects of providing an integrated liver care intervention plus contingency management to integrated liver care alone measuring effects both after the hospital visit at 12 weeks post-treatment and again 12 weeks later (i.e., 24-week follow-up). Alcohol use disorder was determined by electronic health record or a screening instrument and alcohol-related liver disease was determined by clinical examination or labs. Integrated liver care consisted of 4 outpatient appointments with comprehensive alcohol use disorder care over 12 weeks (see graphic below for more details). Contingency management provided motivational incentives which took the form of vouchers for material goods up to a value of 120 UK pounds based on attendance at the integrated liver care sessions; the greater the number of sessions the patients attended the more vouchers they could earn.
As is common with initial investigations like this study, findings focused both on how feasible the intervention was to deliver as well as preliminary clinical outcomes. Of note, the study did not use formal tests to compare attendance in each group. They also did not examine alcohol-related outcomes of randomized groups, only the participants who went to 2+ appointments in each randomized group – a select group of engaged participants. All outcomes should be considered descriptive and preliminary given this was a small study conducted at an early stage of investigation.
The study was very challenging to implement – 8 participants died in the hospital before discharge and 11 attended 0 or 1 appointment. Because only 11 participants fully engaged with the trial, study results should be interpreted with caution. That said, these fully engaged participants were twice as likely to be in the contingency management than the usual care group.
All 4 usual care participants (who attended 2+ sessions) were abstinent throughout the 24-week study and the 7 contingency management participants had 75% days abstinent 12 weeks post treatment and 71% days abstinent 12 weeks later. While no formal statistical tests were conducted, among the 11 participants with 2+ sessions, alcohol problems declined in both groups while liver functioning improved in both groups.
This study reflects the challenges of clinical interventions with people with a history of alcohol-related liver disease admitted to the hospital for an acute liver episode, and the substantial lethal risks related to these conditions. Also, because the study sample was small to begin with – not uncommon for these types of early investigations – and many patients died it is difficult to appraise the impact of the contingency management intervention.
That said, it is somewhat promising that those who received contingency management were twice as likely as those who did not to engage in integrated liver care after their hospital visit. It is possible that this advantage could have been even higher had the monetary incentive been larger than the 120 UK pound reward. This relatively low amount may be related to the stigma around severe, chronic alcohol and other drug use disorders. Future studies may try and increase the monetary incentive to promote greater integrated live care attendance. In addition, future studies might target individuals with higher likelihood of survival and better functioning (e.g., during one’s first alcohol-related hospital consequence), albeit still at major risk for alcohol-related liver conditions, to determine if contingency management improves engagement in care. Finally, the study indirectly highlights the health benefits of intervening earlier in the disease course of alcohol use disorder and ongoing recovery monitoring, given the challenges of intervening at this late clinical stage.
It is challenging to engage people with substantial alcohol-related liver conditions in outpatient care before they require hospital admissions; earlier intervention is needed. For people at this later stage of liver disease, rewards for attending specialized care may help improve engagement and decrease mortality risk. The preliminary results from this small, pilot study should be replicated in larger trials.
Hemrage, S., Kalk, N., Shah, N., Parkin, S., Deluca, P., & Drummond, C. (2025). Contingency management to promote treatment engagement in comorbid alcohol use disorder and alcohol-related liver disease: Findings from a pilot randomized controlled trial. Alcohol, Clinical & Experimental Research, 49(4), 893–910. doi: 10.1111/acer.70018.
l
Alcohol-related liver disease comprises several conditions beginning with fatty liver, alcoholic hepatitis (i.e., liver inflammation), and ultimately irreversible alcoholic cirrhosis characterized by scar tissue in the liver. These conditions doubled from 1999 to 2020, with women and young adults showing the largest proportionate increases. Half of individuals with alcohol use disorder and one-quarter with hazardous drinking (e.g., meeting NIAAA guidelines for “risky” drinking) have these alcohol-related clinical conditions. People with alcohol-related liver disease can be hard to engage in treatment. Contingency management – motivational incentives for a targeted behavior – is among the most potent substance use disorder interventions, but little is known regarding its impact in certain groups of alcohol patients, such as those with liver disease. This study examined whether contingency management helped individuals with alcohol-related liver disease engage with integrated liver care, a comprehensive outpatient approach to the treatment of liver disease.
This was a randomized controlled trial with 30 adults with alcohol use disorder and alcohol-related liver disease presenting to the emergency department or admitted to the hospital with an acute liver episode. It compared the effects of providing an integrated liver care intervention plus contingency management to integrated liver care alone measuring effects both after the hospital visit at 12 weeks post-treatment and again 12 weeks later (i.e., 24-week follow-up). Alcohol use disorder was determined by electronic health record or a screening instrument and alcohol-related liver disease was determined by clinical examination or labs. Integrated liver care consisted of 4 outpatient appointments with comprehensive alcohol use disorder care over 12 weeks (see graphic below for more details). Contingency management provided motivational incentives which took the form of vouchers for material goods up to a value of 120 UK pounds based on attendance at the integrated liver care sessions; the greater the number of sessions the patients attended the more vouchers they could earn.
As is common with initial investigations like this study, findings focused both on how feasible the intervention was to deliver as well as preliminary clinical outcomes. Of note, the study did not use formal tests to compare attendance in each group. They also did not examine alcohol-related outcomes of randomized groups, only the participants who went to 2+ appointments in each randomized group – a select group of engaged participants. All outcomes should be considered descriptive and preliminary given this was a small study conducted at an early stage of investigation.
The study was very challenging to implement – 8 participants died in the hospital before discharge and 11 attended 0 or 1 appointment. Because only 11 participants fully engaged with the trial, study results should be interpreted with caution. That said, these fully engaged participants were twice as likely to be in the contingency management than the usual care group.
All 4 usual care participants (who attended 2+ sessions) were abstinent throughout the 24-week study and the 7 contingency management participants had 75% days abstinent 12 weeks post treatment and 71% days abstinent 12 weeks later. While no formal statistical tests were conducted, among the 11 participants with 2+ sessions, alcohol problems declined in both groups while liver functioning improved in both groups.
This study reflects the challenges of clinical interventions with people with a history of alcohol-related liver disease admitted to the hospital for an acute liver episode, and the substantial lethal risks related to these conditions. Also, because the study sample was small to begin with – not uncommon for these types of early investigations – and many patients died it is difficult to appraise the impact of the contingency management intervention.
That said, it is somewhat promising that those who received contingency management were twice as likely as those who did not to engage in integrated liver care after their hospital visit. It is possible that this advantage could have been even higher had the monetary incentive been larger than the 120 UK pound reward. This relatively low amount may be related to the stigma around severe, chronic alcohol and other drug use disorders. Future studies may try and increase the monetary incentive to promote greater integrated live care attendance. In addition, future studies might target individuals with higher likelihood of survival and better functioning (e.g., during one’s first alcohol-related hospital consequence), albeit still at major risk for alcohol-related liver conditions, to determine if contingency management improves engagement in care. Finally, the study indirectly highlights the health benefits of intervening earlier in the disease course of alcohol use disorder and ongoing recovery monitoring, given the challenges of intervening at this late clinical stage.
It is challenging to engage people with substantial alcohol-related liver conditions in outpatient care before they require hospital admissions; earlier intervention is needed. For people at this later stage of liver disease, rewards for attending specialized care may help improve engagement and decrease mortality risk. The preliminary results from this small, pilot study should be replicated in larger trials.
Hemrage, S., Kalk, N., Shah, N., Parkin, S., Deluca, P., & Drummond, C. (2025). Contingency management to promote treatment engagement in comorbid alcohol use disorder and alcohol-related liver disease: Findings from a pilot randomized controlled trial. Alcohol, Clinical & Experimental Research, 49(4), 893–910. doi: 10.1111/acer.70018.
l
Alcohol-related liver disease comprises several conditions beginning with fatty liver, alcoholic hepatitis (i.e., liver inflammation), and ultimately irreversible alcoholic cirrhosis characterized by scar tissue in the liver. These conditions doubled from 1999 to 2020, with women and young adults showing the largest proportionate increases. Half of individuals with alcohol use disorder and one-quarter with hazardous drinking (e.g., meeting NIAAA guidelines for “risky” drinking) have these alcohol-related clinical conditions. People with alcohol-related liver disease can be hard to engage in treatment. Contingency management – motivational incentives for a targeted behavior – is among the most potent substance use disorder interventions, but little is known regarding its impact in certain groups of alcohol patients, such as those with liver disease. This study examined whether contingency management helped individuals with alcohol-related liver disease engage with integrated liver care, a comprehensive outpatient approach to the treatment of liver disease.
This was a randomized controlled trial with 30 adults with alcohol use disorder and alcohol-related liver disease presenting to the emergency department or admitted to the hospital with an acute liver episode. It compared the effects of providing an integrated liver care intervention plus contingency management to integrated liver care alone measuring effects both after the hospital visit at 12 weeks post-treatment and again 12 weeks later (i.e., 24-week follow-up). Alcohol use disorder was determined by electronic health record or a screening instrument and alcohol-related liver disease was determined by clinical examination or labs. Integrated liver care consisted of 4 outpatient appointments with comprehensive alcohol use disorder care over 12 weeks (see graphic below for more details). Contingency management provided motivational incentives which took the form of vouchers for material goods up to a value of 120 UK pounds based on attendance at the integrated liver care sessions; the greater the number of sessions the patients attended the more vouchers they could earn.
As is common with initial investigations like this study, findings focused both on how feasible the intervention was to deliver as well as preliminary clinical outcomes. Of note, the study did not use formal tests to compare attendance in each group. They also did not examine alcohol-related outcomes of randomized groups, only the participants who went to 2+ appointments in each randomized group – a select group of engaged participants. All outcomes should be considered descriptive and preliminary given this was a small study conducted at an early stage of investigation.
The study was very challenging to implement – 8 participants died in the hospital before discharge and 11 attended 0 or 1 appointment. Because only 11 participants fully engaged with the trial, study results should be interpreted with caution. That said, these fully engaged participants were twice as likely to be in the contingency management than the usual care group.
All 4 usual care participants (who attended 2+ sessions) were abstinent throughout the 24-week study and the 7 contingency management participants had 75% days abstinent 12 weeks post treatment and 71% days abstinent 12 weeks later. While no formal statistical tests were conducted, among the 11 participants with 2+ sessions, alcohol problems declined in both groups while liver functioning improved in both groups.
This study reflects the challenges of clinical interventions with people with a history of alcohol-related liver disease admitted to the hospital for an acute liver episode, and the substantial lethal risks related to these conditions. Also, because the study sample was small to begin with – not uncommon for these types of early investigations – and many patients died it is difficult to appraise the impact of the contingency management intervention.
That said, it is somewhat promising that those who received contingency management were twice as likely as those who did not to engage in integrated liver care after their hospital visit. It is possible that this advantage could have been even higher had the monetary incentive been larger than the 120 UK pound reward. This relatively low amount may be related to the stigma around severe, chronic alcohol and other drug use disorders. Future studies may try and increase the monetary incentive to promote greater integrated live care attendance. In addition, future studies might target individuals with higher likelihood of survival and better functioning (e.g., during one’s first alcohol-related hospital consequence), albeit still at major risk for alcohol-related liver conditions, to determine if contingency management improves engagement in care. Finally, the study indirectly highlights the health benefits of intervening earlier in the disease course of alcohol use disorder and ongoing recovery monitoring, given the challenges of intervening at this late clinical stage.
It is challenging to engage people with substantial alcohol-related liver conditions in outpatient care before they require hospital admissions; earlier intervention is needed. For people at this later stage of liver disease, rewards for attending specialized care may help improve engagement and decrease mortality risk. The preliminary results from this small, pilot study should be replicated in larger trials.
Hemrage, S., Kalk, N., Shah, N., Parkin, S., Deluca, P., & Drummond, C. (2025). Contingency management to promote treatment engagement in comorbid alcohol use disorder and alcohol-related liver disease: Findings from a pilot randomized controlled trial. Alcohol, Clinical & Experimental Research, 49(4), 893–910. doi: 10.1111/acer.70018.
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