Dismantling MBRP: Identifying Critical Neuroimmune Mechanisms of Action.
Phase: NA
Conditions: Alcohol Use Disorder
Sponsor: University of Colorado, Denver

Title: Dismantling MBRP: Identifying Critical Neuroimmune Mechanisms of 
Action 
NCT#: NCT02994043 
Version Date: 14 JULY 2020 

 
 
 
 
 
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TITLE: Mindfulness Based Relapse Prevention  
 
PROTOCOL VERSION DATE: 14 July 2020 
VERSION: 17 
PRINCIPAL INVESTIGATOR (PI):  
Name: Kent Hutchison, Ph.D. 
Address: Department of Psychology and Neuroscience, 345 UCB 
Telephone: 303-492-8163  
Email: kent.hutchison@colorado.edu 
KEY PERSONNEL 
Name: Angela Bryan, Ph.D.   
Role in project: Co-PI  
 
Name: Jarrod Ellingson Ph.D.   
Role in project: Research Coordinator  
 
Name: Nicholas Gonyea   
Role in project: Research Assistant  
 
Name: Suzanne Taborsky-Barba  
Role in project: Co-PI  
 
Name: Jamie Cavanaugh 
      Role in project: Co-I with Edit 
 
 
In addition to the individuals listed above, undergraduate and professional research assistants will play 
an active role in the data collection phase of this study. Research assistants will assist with the study 
appointments and procedures (i.e., conducting phone screens to determine participant eligibility, 
collecting informed consent, running the MRI scan, performing the required laboratory techniques, 
questionnaire administration and blood draw). Therapists will be selected from the graduate program in 
clinical psychology at the University of Colorado and will have a master’s degree in clinical 
psychology and previous training in the fundamentals of psychological intervention provided by Dr. 

 
 
 
 
 
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Hutchison or Dr. Dimidjian. All personnel have completed CITI training, and have been trained in 
responsible conduct of research, biosafety training and study specific procedures/guidelines. 
I. 
OBJECTIVES 
Please note that the grant supporting this project is funded by the NIAAA and IRB approval of 
the protocol is needed as soon as possible.  
The goal of this study is to examine the effectiveness of Mindfulness Based Relapse Prevention 
(MBRP) versus Relapse Prevention (RP) for the treatment of Alcohol Use Disorders (AUD) by 
examining neurobiological, immunological, epigenetic, and microbial characteristics of AUD. We will 
compare the effectiveness of MBRP compared to RP by examining changes in DNA methylation of 
key genes implicated in alcohol dependence, expression of inflammatory cytokines, changes in number 
and diversity of microbial populations found in the gut, liver function tests, and connectivity and cue-
elicited BOLD activation within reward and control circuits of the brain. In addition, we will explore 
how expression of inflammatory cytokines might influence the relationship between alcohol 
consumption, brain activation and connectivity within reward and control regions. This research will 
dismantle the effects of MBRP from the effects of RP in the treatment of AUDs and elucidate the 
mechanisms that mediate the effects of MBRP. From a larger perspective, the findings of this 
investigation will increase the body of knowledge about how MBRP works and will advance a 
biobehavioral conceptualization of the development and maintenance of alcohol dependence. 
Ultimately, this work should lead to the development of interventions that target epigenetic and 
immune system changes. 
Specific Aim 1.  
Comparing the effectiveness of MBRP (n=113) to RP (n=113).  
• Hypothesis 1.  It is hypothesized that MBRP will demonstrate superior effectiveness, as 
compared to RP, by reductions in heavy drinking days at the end of treatment (8 weeks) and 
longer term (20 and 32 weeks) decreases in liver function tests (8, 20, and 32 weeks). 
Specific Aim 2.  
Examining the putative molecular mechanisms underlying the effects of MBRP versus RP. 
• Hypothesis 2.  Based on studies suggesting that MBIs alter epigenetic regulation of key genes 
implicated in alcohol dependence (i.e., DRD2, SLC6A3, DBH) and reduce inflammatory 
pathway activation (i.e., IL-8, IL-6, TNFa), it is hypothesized that MBRP treatment will 
demonstrate significant decreases in methylation of key genes as well as decreases in 
inflammation biomarkers. 
• Hypothesis 3. It is also hypothesized that individuals who receive MBRP, as compared to RP, 
will demonstrate greater LECN/RECN connectivity as well as reduced cue-elicited BOLD 
response in the striatum.  
Specific Aim 3.  
The third specific aim will determine whether the effectiveness of MBRP vs. RP on clinical outcomes 
is mediated by the effect of MBRP on molecular mechanisms, and, in turn, their effects on network 
connectivity and BOLD response. 
• Hypothesis 4. It is hypothesized that the effects of MBRP on clinical outcomes (Hypothesis 1) 
will accrue through two routes: the effects of MBRP on reductions in inflammatory markers 

 
 
 
 
 
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(Hypothesis 2) which in turn influence LECN/RECN connectivity; and the effect of MBRP on 
methylation of key genes which in turn influence cue-elicited BOLD activation in the striatum 
(Hypothesis 3). These effects will be tested in the context of a structural equation modeling 
framework. 
Exploratory Aim 1.  
Comparing gut microbiota populations pre and post intervention for MBRP vs. RP 
• Hypothesis 5. We will test the hypothesis that there will be differences in gut microbiota 
between MBRP and RP groups both before and after 8 weeks of treatment, as measured by 
microbial DNA collected from fecal samples.   
 
II. 
BACKGROUND AND SIGNIFICANCE  
Alcohol use disorders (AUDs) are associated with socioeconomic costs of approximately $234 
billion in the United States alone (Rehm et al., 2009). Despite decades of research, the best treatments 
have proven to be only modestly successful. Meta-analyses suggest that common psychosocial 
treatments, such as 12 step facilitation, motivational enhancement approaches, and cognitive 
behavioral therapies lead to 12 month abstinence rates of 17 to 35% (Miller, Walters, & Bennett, 
2001). Results from Project COMBINE, one of the largest, most carefully controlled clinical trials to 
date, indicated that naltrexone and medication management and a combined behavioral intervention 
were superior to other conditions, but only produced a 12 month abstinence rate of approximately 20% 
(Anton et al., 2006).  
Clearly, there is room for improvement. While a number of psychosocial treatments are modestly 
effective, it is largely unknown how these treatments exert their effects. New studies designed to probe 
the therapeutic mechanisms that drive the efficacy of existing treatments are needed to further refine 
efforts to more effectively target those mechanisms. Information about the active mechanisms may 
also be used to develop measures that will provide an early signal about whether a given treatment is 
working, which could be instrumental in deciding whether to switch treatments. Finally, knowledge 
about the mediating mechanisms can be used to identify critical associated domains of patient 
heterogeneity, which in turn can be used to identify the patients most likely to respond to a particular 
treatment.  
Recent funding announcements from NIAAA have acknowledged the significance of research on 
treatment mechanisms. For example, PAR 14-051 “Mechanisms of Behavior Change” is an 
acknowledgement of the need for exactly this type of research, as it calls for “research that bridges the 
gap between basic science processes and clinical treatment by increasing our understanding of how 
treatment impacts specific mechanisms operating at the cognitive, neurobiological or genetic level of 
analysis in relation to alcohol-related outcomes.” The current protocol will first review the critical 
neurobiological factors that underlie the etiology and maintenance of AUDs with an emphasis on 
cutting edge research published in the last few years as well as our own preliminary data. This 
framework will then be used to discuss how existing treatments may impact these neurobiological 
mechanisms. In the context of this critical review, we will argue that Mindfulness Based Relapse 
Prevention (MBRP) emerges as the candidate with the strongest support as a treatment that impacts 
these mechanisms.  
 
Mechanistic Framework - Perturbations in Control and Reward Regions in the Brain. 

 
 
 
 
 
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In order to provide a conceptual foundation for the aims and hypotheses of the present application, 
it is important to contextualize the putative effects of existing treatments in a broader conceptual model 
that integrates molecular, neural, and clinical constructs associated with relapse. For a number of years 
now, scientists have emphasized neuroadaptations in the control and reward networks of the brain and 
the interplay between the two (Karoly, Harlaar, & Hutchison, 2013; Koob & Volkow, 2010). The 
model presented below (see Figure 1) is grounded in both basic animal neuroscience and human 
cognitive neuroscience and identifies two primary brain networks that influence an individual’s alcohol 
and drug use behavior. The control network (top of Figure 1) consists of prefrontally distributed areas, 
including the orbitofrontal cortex (OFC), dorsolateral prefrontal cortex (DLPFC), and inferior frontal 
gyrus (IFG). The cognitive neuroscience literature has consistently implicated these areas in reflection 
and control over impulsive decisions, evaluation of the magnitude of reward, and the urge to drink or 
use drugs (Bechara & Van Der Linden, 2005; Goldstein & Volkow, 2002; Wong et al., 2006). The 
reward network (bottom of Figure 1) is involved in the anticipation and processing of reward and has 
been studied extensively in the animal and human literature (Berridge & Robinson, 1998; Kalivas & 
Volkow, 2005). Research has repeatedly implicated specific structures (e.g., striatum, anterior 
cingulate, precuneus) in the motivation to use drugs and the attribution of incentive salience to drug 
cues, and this is consistent with our own human neuroimaging studies (Claus et al., 2011). While there 
has been substantial research on reward and control networks and how they may be related to treatment 
outcomes, there has been much less work on the molecular mechanisms that underlie the 
neuroadaptations in these networks, especially in clinical settings. In this application, we argue that the 
molecular precursors of these adaptations should be primary targets for intervention development. 
 
Molecular Mechanisms Underlying Alcohol-Induced Adaptations in Reward and Control 
Circuitry.  
As described in Figure 1, emerging evidence suggests that molecular mechanisms such as 
epigenetic regulation and changes in immune system function, particularly inflammatory processes, are 
involved in the effects of alcohol on control and reward circuits. We will discuss the evidence for the 
immune system first, followed by the role of 
epigenetic regulation.  
At first glance, the link between AUDs and 
immune processes may not be obvious. 
However, recent studies have suggested that 
perturbation of the immune system is a critical 
mechanism in the etiology of AUDs (for 
reviews see Mayfield, Ferguson, & Harris, 
2013;  Leclercq et al., 2012; Leclercq et al, 
2014). More specifically, alcohol produces 
deleterious effects on peripheral and central 
immune signaling pathways, particularly 
through activation of lipopolysaccharide (LPS)-
induced TLR4 signaling cascades that span the 
gut, liver, and brain, and coincide with the 
release of cytokines and other pro-inflammatory 
pathways in the brain (Fernandez-Lizarbe, 
Pascual, & Guerri, 2009). Repeated activation 
of pro-inflammatory pathways and microglia is 
Figure 1. Summary of the rationale for 
the proposal. Chronic alcohol exposure leads 
to changes in the immune system via TLR4 
mediated increases in cytokines and 
microglial activation, which in turn lead to 
damage to the executive control networks 
and diminished control. At the same time, 
alcohol exposure leads to epigenetic 
modification of key dopamine genes, leading 
to sensitized reward responding and craving. 
MBRP putatively reduces cytokine signaling 
and neuroinflammation and mitigates or 
reverses epigenetic changes, thereby 
restoring balance in the control and reward 
networks and reducing relapse after 
treatment. This research proposes to test 
these mechanisms and pathways.   
The image part with relationship ID rId9 was not found in the file.

 
 
 
 
 
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associated with increased neuroinflammation and neural damage in frontal brain regions involved in 
executive function and control (Alfonso-Loeches et al.,  2010; Guerri & Pascual, 2010). These 
neuroinflammatory processes have also been implicated in the etiology of a number of other 
neurodegenerative diseases as well as the deleterious effects of aging on cognitive function (Smith, 
Das, Ray, & Banik, 2012; Ownby, 2010; Lyman et al., 2014).  
While animal models have indicated that acute and chronic alcohol use is associated with 
increased levels of LPS circulating in the blood, there have also been studies in humans demonstrating 
that acute binge drinking releases LPS which in turn ligates TLR4 and activates the release of 
cytokines and inflammation. Specifically, a recent study in humans tested the effects of an acute binge 
episode on circulating LPS levels (Bala et al., 2014). The study estimated that the physiological dose of 
LPS after a binge episode was 100 pg/ml. As part of the study, peripheral blood mononuclear cells 
(PBMCs) were isolated from subjects and challenged ex-vivo with a 100 pg/ml dose of LPS. The study 
observed significant induction of cytokines (TNFa, IL-6, MCP1). Thus, these data are also consistent 
with the notion that the alcohol/LPS/TLR4/neuroinflammation pathway is a central mechanism in the 
etiology of AUDs.  
While the neuroinflammatory effects of alcohol likely underlie changes in control circuits, 
epigenetic regulation of genes and proteins involved in the reward system are also clearly important 
factors in the etiology of AUDs. Epigenetics is a term that refers to the potentially reversible 
biochemical processes that regulate gene transcription and expression without altering the DNA 
sequence. Recent studies in animals and humans have suggested that epigenetic mechanisms may 
mediate the effect of alcohol and drugs on long lasting adaptations in the brain (Nestler, 2014; 
Starkman, Sakharkar, & Pandey, 2012; Warnault & Ron, 2013). Modern epigenetic research has 
focused primarily on how changes to DNA influence chromatin structure (Goldberg, Allis, & 
Bernstein, 2007). DNA methylation and histone acetylation are two epigenetic processes that have 
been shown to modify chromatin and exert downstream effects on gene transcription. DNA 
methylation tends to occur at unmethylated cytosine guanine (CpG) dinucleotides, clusters of which 
are often located in promoter, or 5’ regions, of many human genes, and have come to be known as 
CpG islands (Jones & Takai, 2001). Unusual patterns of methylation in humans have been associated 
with numerous diseases (Santos, Mazzola, & Carvalho, 2005), including cancer, schizophrenia, and a 
variety of other psychiatric conditions including AUDs (Shukla et al., 2008). While still a nascent area 
of research, there are a growing number of studies on epigenetics and alcohol abuse in humans that 
have focused on DNA methylation. With respect to AUDs, previous research has observed increased 
methylation levels in alcohol-dependent patients compared with controls in a number of genes (e.g., 
Hillemacher et al., 2009; Zhang et al., 2013). In addition, a recent genome-wide methylation study in 
our lab implicated methylation of the DRD2 promoter (Harlaar et al., 2014).  
Our most recent data suggest that epigenetic changes in the DRD2 promoter are strongly 
associated with DA D2 receptor binding in vivo using [C11] raclopride PET, associated with BOLD 
response to alcohol cues using fMRI, and associated with clinical measures of impaired control over 
alcohol use (see preliminary studies). This is critical because mesolimbic dopamine activation has long 
been implicated as a major mechanism in alcohol and drug-related reward (Koob & Volkow, 2010). 
Even more specifically, the DA D2 receptor and the DRD2 gene are arguably the most important 
targets in this system. DRD2 expression is reduced in the nucleus accumbens among high-alcohol-
preferring mice (Bice et al., 2008) while over-expression is associated with low-ethanol self-
administration (Thanos et al., 2001). In humans, positron emission tomography (PET) studies have 
found that decreased striatal DA D2 receptor availability is associated with substance abuse more 
generally and alcohol dependence specifically (Volkow et al., 2009; Heinz et al., 2004) Alterations in 

 
 
 
 
 
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dopamine function have also been linked to downstream endophenotypes associated with reward 
processing, inhibitory control, and learning (Koob & Volkow, 2010). Thus, findings across animal and 
human studies, using PET and fMRI, suggest that changes in D2 receptor availability and function are 
related to substance abuse and may underlie changes in reward response and impaired control, 
hallmarks of addiction. Treatments that have the potential to reverse or mitigate changes in the 
epigenetic regulation of the DRD2 and other genes could have substantial impact. 
 
Treatment Targets: Immune System Inflammation and Epigenetic Regulation.  
To summarize, epigenetic regulation and immune system activation are two critical molecular 
mechanisms that lead to changes in reward and control neural systems that have long been 
acknowledged as central to the development and maintenance of AUDs. In our reading of the extant 
literature, we examined existing medications and psychosocial interventions that have at least some 
efficacy in the treatment of AUDs and have also demonstrated safety. Naltrexone, varenicline, 
gabapentin, acamprosate, and topiramate were scrutinized. While many of these putatively target the 
neural reward system by virtue of their action at key receptor sites, there is little evidence to suggest 
that any of these medications target the underlying molecular mechanisms (i.e., epigenetic gene 
regulation) and/or inflammatory pathways. Topiramate is one possible exception given that one study 
has suggested that topiramate may have HDAC inhibitory activity (Eyal et al., 2004). However, the 
evidence is not particularly strong. In terms of medications that are known to alter epigenetic 
regulation and inflammation but have yet to be studied in the context of AUDs, most have extremely 
undesirable side effect profiles (e.g., voronistat). Finally, many of the existing anti-inflammatory 
medications also have serious side effects, which make them less attractive as candidate medications. 
For example, medications like diclofenac and vioxx (now withdrawn) are known to be associated with 
substantial increased risk of heart attacks and strokes (McGettigan & Henry, 2011). With respect to 
existing psychosocial treatments, many (e.g., motivational interventions, CBT) directly target cognitive 
control over alcohol use. Thus, existing pharmacotherapies and psychosocial treatments do not appear 
to target epigenetic regulation and immune system function. However, there is one relatively new 
psychosocial treatment with an increasingly robust evidence base suggesting effects on immune system 
function as well as epigenetic regulation.  
A growing number of studies indicate that Mindfulness Based Interventions (MBIs) are associated 
with alterations in inflammatory genes and proteins (e.g., IL-6, IL-8, TNF-a) and epigenetic regulation 
(e.g., histone deacetylases) across a range of patient populations (Rosenkranz et al., 2013; Roberts et 
al., 2014; Antoni et al., 2012; Black et al., 2013; Bower et al., 2014; Pace et al., 2009; Carlson, 2003; 
Bhasin et al., 2013; Carlson et al., 2007; Kaliman et al., 2014; Witek-Janusek et al., 2008). For 
example, mindfulness based stress reduction (MBSR) has been shown to reduce inflammatory 
cytokine activation and increase anti-inflammatory cytokine activation in cancer patients (Carlson, 
2003; Bhasin et al., 2013) with effects persisting up to 1 year (Carlson et al., 2007). Finally, a few 
studies have also suggested a dose effect, such that more frequent mindfulness practice appears to 
increase the longevity of intervention effects on inflammatory biomarkers such as TNF-a (Kaliman et 
al., 2014), which is consistent with other studies demonstrating associations between increased 
mindfulness practice and cytokine reductions (Bower et al., 2014).  
It is important to note that this research has been conducted across a range of patient populations, 
rather than specifically with AUD patients. In addition, these studies have used a range of assays for 
immune system function. Some assays are more sophisticated and others less so. Finally, the choice of 
immune targets has not always been consistent. The most recent studies on the effects of MBIs have 
begun to incorporate more sophisticated methods for measuring immune system changes by examining 

 
 
 
 
 
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changes in gene and protein expression in PBMCs. In fact, three recent studies used procedures very 
similar to those proposed in this application and deserve a more thorough review including the 
observed effect sizes (expressed as Cohen’s d). One of these studies was focused on the effects of MBI 
on cytokine production in PBMCs without a lipopolysaccharide (LPS) challenge (Witek-Janusek et al., 
2008). In this study, an 8-week MBSR intervention (n=38) was compared to a control intervention 
(n=28) in a sample of breast cancer survivors. The results indicated that MBSR resulted in significantly 
lower levels of inflammatory cytokines in PBMCs across the trial (IL-4, d=.89 ; IL-10, d=.55).  The 
effects were most pronounced immediately after the intervention and at the 4-week follow-up. There 
was no effect on IL-6. Another study examined the acute effects of a mindfulness meditation condition 
(n=19) versus a control condition (n=21) on expression of genes involved in epigenetic regulation (i.e., 
HDAC inhibitor genes) and inflammatory pathways in PBMCs (Kaliman et al., 2014). In this study, 
mindful meditation produced robust changes in genes involved in epigenetic regulation (HDAC2, 
d=.71; HDAC3, d=1.0; HDAC9, d=.92) and pro-inflammatory genes (RIPK2, d=.95; COX2, d=.52). 
Finally, the last study examined the effect of an MBI for the treatment of insomnia (Irwin et al., 2015). 
Unlike the first two studies, PBMCs were isolated and TLR4 receptors were stimulated with LPS 
before assaying for inflammatory markers. The MBI condition (n=48), compared to the control 
condition (n=25), reduced inflammatory biomarkers at 4 months (TNFa, d=.59 ; IL-6, d=.57) and 7 
months (TNFa, d=.64 ; IL-6, d=.64) after the intervention. These studies were selected because they 
are most similar to the proposed study in terms of testing the effect of MBIs on immune system 
biomarkers in PBMCs. In all three studies, the effect sizes for the impact of MBIs on inflammatory 
biomarkers and epigenetic regulation ranged from moderate to large, indicating that MBIs may have 
strong effects on inflammation and epigenetic regulation. Finally, it is important to note that the last 
study described above is particularly relevant to the proposed work because it utilized LPS stimulation 
of TLR4 receptors, which is exactly the pathway that has been implicated in the development and 
maintenance of AUDs (see Figure 1 above). Thus, the proposed research will feature a vertically 
integrated assessment of epigenetic regulation, neurogenic inflammation including basal and LPS 
stimulated changes in inflammatory gene expression in PBMCs, immunoassays of cytokines in 
PBMCs, and downstream effects on structure and function of control circuits in the brain. 
In sum, our literature review yielded close to a dozen studies suggesting that MBIs may influence 
two key neurobiological mechanisms that are critical to the etiology and maintenance of AUDs. Given 
the growing body of evidence suggesting that MBIs impact mechanisms that appear to be critical in the 
maintenance of AUDs, the question becomes whether there is an MBI that has demonstrated efficacy 
in the treatment of AUDs. In fact, a recent review of 24 clinical studies on substance use disorders 
suggests that MBIs represent a promising intervention (Chiesa & Serretti, 2014). One specific MBI, 
known as Mindfulness Based Relapse Prevention (MBRP) combines mindfulness components with 
relapse prevention and was manualized several years ago (Bowen, Chawla, & Marlatt, 2011). Perhaps 
most importantly, recent randomized control trials (RCTs) testing the effects of MBRP have provided 
the best evidence to date that MBRP is an efficacious treatment (Bowen et al., 2014; Witkiewitz et al., 
2014). For example, in a large (n=286) RCT published in JAMA Psychiatry, MBRP resulted in 
superior alcohol and substance use outcomes as compared to a relapse prevention (RP) intervention 
only, and treatment as usual (Witkiewitz et al., 2014). The effect sizes for the MBRP versus RP in 
these two RCTs ranged from d=.2 to d=.4. (small to moderate). Thus, there is clearly a strong evidence 
base emerging around the efficacy of MBRP over and above RP in isolation, although much work 
remains to be done.  
 
Alcohol and the Gut Microbiome 

 
 
 
 
 
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Prior research suggests that bacteria in the gut may influence numerous aspects of human 
health. The effects of alcohol on gut microbiota are currently not well understood, however several 
recent human and animal studies have linked chronic alcoholism with altered microbiota composition 
in the gut (Mutlu et al., 2012; Yan et al., 2011). Further, progressive changes in the gut microbiome 
appear to coincide with the progression of liver cirrhosis caused by inflammation (Bajaj et al., 2014). 
Not surprisingly, the gut microbiome may represent a potential treatment target for alcohol-related 
liver disease (Hartmann, Chen, & Schnabl, 2012). This field of research is still in its infancy, thus 
further investigation is needed. In particular, studies controlling for factors such as age, gender and diet 
may shed further light on the possible influence of heavy alcohol consumption on the microbiota 
composition of the gut.   
 
Summary of Significance, Impact, and Innovation 
For the last two decades, the conventional wisdom has underscored the importance of targeting 
dopamine circuits, either directly or indirectly, by using medications that act as antagonists, agonists, 
or mixed agonists at dopamine receptors (e.g., aripiprazole, quetiapine) or other receptor systems that 
may modulate dopamine function indirectly (e.g., naltrexone, ondansetron, varenicline). Given the 
extant body of work, the results have been somewhat disappointing, as only naltrexone eventually 
received FDA approval as a treatment for AUDs. Rather than targeting receptors that influence neural 
circuits, it may be more effective to target the molecular mechanism, at the level of transcription, 
which underlies changes in dopamine receptors and the function of the reward circuit (e.g., epigenetic 
modifications). Likewise, perturbation in immune system function is just now emerging as an 
important target. 
Importantly, what has been largely overlooked in most research on AUDs is that there may be 
psychosocial interventions that exert top down control over epigenetic and inflammatory mechanisms 
and could be equally or more effective than medications while having fewer side effects. Although this 
has been largely untested in the alcohol field, there are close to a dozen studies in other patient 
populations to suggest that MBIs may have exactly this type of effect. If psychosocial interventions, 
such as MBRP, are demonstrated to be efficacious and the active ingredients can be harnessed and 
focused, the field will potentially see much greater success.  
Thus, the significance and impact of the first aim of the proposed research stems from the simple 
notion that understanding how a given treatment may be effective informs efforts to increase the 
effectiveness of that treatment. The proposed study will serve to dismantle the effects of the 
mindfulness components from the relapse prevention components and test innovative and unique 
hypotheses about how the mindfulness components work in an AUD patient population. Specifically, 
the first aim will isolate the effect of Mindfulness from Relapse Prevention by comparing MBRP to RP 
only. Two published studies to date suggest that MBRP is more effective than RP only (Bowen et al., 
2014; Witkiewitz et al., 2014). However, these two studies were conducted in samples of individuals 
with a variety of substance use disorders, rather than AUDs specifically. Thus, the first aim is 
significant because it will be the first large, randomized trial to dismantle the effect of MBRP from RP 
in a sample of individuals with a primary diagnosis of AUD. The second aim will isolate the effects of 
mindfulness on key neurobiological mechanisms by determining whether MBRP influences epigenetic 
regulation of key genes and influences immune system function as compared to RP. The third aim will 
determine whether the effect of mindfulness on drinking outcomes is mediated by the effect of 
mindfulness on epigenetic regulation and immune system function. Because no other clinical scientists 
are targeting epigenetic and immune system changes in AUD treatment trials (to our knowledge), this 
study and this program of research are highly innovative. In addition, our vertical integration of 

 
 
 
 
 
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epigenetic regulation, immune system function including an ex-vivo LPS challenge of PBMCs, a 
neuroimaging assessment of changes at the neural circuit level, and clinical assessments is innovative 
and unique from a methodological perspective.  
From a clinical perspective, identification of the molecular mechanisms that mediate the effects of 
mindfulness in AUD patients can then be leveraged in a variety of ways. This information may be used 
in future studies to test how MBIs might be refined to increase the effect of the intervention on these 
mechanisms. For example, does increasing the dose/practice of mindfulness increase the effects of the 
intervention on inflammatory pathways and/or epigenetic regulation of key genes? Would booster 
sessions at regular intervals after the initial 8-week training increase the effects of mindfulness practice 
on the immune system? Would combining MBRP with other interventions that putatively target the 
same mechanisms (e.g., exercise) increase the effects? All of these questions can be asked and 
answered once we have verified the underlying mechanisms and identified measurable biomarkers. 
Finally, knowledge about the mechanisms may also be used to develop an important intermediate and 
inexpensive test of treatment success. For example, if changes in immune system function or 
epigenetic regulation at 4 weeks are highly predictive of relapse after treatment, tests of immune 
system function or epigenetic regulation could be used to determine whether the treatment is having an 
effect early in the process, allowing treatment providers to alter the dose and/or treatment for non-
responders. As an analogy, a primary care physician will prescribe a treatment to prevent heart disease 
(e.g., a statin) and then order a cholesterol test to determine if the statin is working. If not, the dose is 
increased or a different treatment is prescribed. In the same way, tests of immune function or 
epigenetic regulation may be used to check on the effect of the AUD treatment early in the process.  
 
Due to the COVID-19 situation we are collecting remote data only and will return to our original 
protocol when it is safe to do so. The remote version of this study will use telehealth therapy and thus 
the following references have been included for  BACKGROUND AND SIGNIFICANCE: 
 
Although in-person psychotherapies have always been the norm, telehealth is increasingly becoming a 
more common, convenient and effective alternative. A study of evidence-based psychotherapy for 
PTSD and depression found that home-based telehealth is a treatment with clinical outcomes matching 
those of in-person clinic-based delivery systems (Acierno et al., 2016). A more recent systematic 
review of numerous studies looking at telemedicine’s effectiveness in substance use disorders showed 
this method of therapy had high patient satisfaction and was an effective alternative to in-person 
psychotherapy (Lin, Casteel, Shigekawa, et al., 2019). Finally, a study looking at the increasing use 
of telemedicine versus in-person therapy for opioid use disorder revealed that patients treated via 
telemedicine were more likely to stay in therapy than patients treated in-person (n = 1590; aOR = 1.27; 
95% CI 1.14–1.41; p < 0.001). At the one-year mark, telemedicine patient’s retention rate was 50%, 
while in-person patients were at 39% retention (Eibl et al., 2017). 
 
 
III. 
PRELIMINARY STUDIES 
 
Epigenetic Mechanisms.  

 
 
 
 
 
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To date, we have performed a number of experiments to validate our epigenetic approach and 
determine whether epigenetic modifications play a role in the etiology of AUDs. The results suggest 
that our approach is feasible and that epigenetics is involved in the etiology of AUD.  
In order to validate that DRD2 methylation changes are functionally significant and that DNA 
methylation in peripheral tissue like blood is correlated with protein levels in the brain, we conducted a 
series of studies in which we sequenced bisulfite 
treated DNA to estimate the amount of methylation in 
a 655 base amplicon in the promoter region of the 
DRD2 that previously demonstrated an effect. These 
data and the data described below have been bundled 
into one manuscript and have been submitted for peer 
review. The first experiment examined the association 
between D2 binding potential using PET and the 
degree of methylation in this amplicon. To reduce 
Type I error, the first analysis examined the average 
methylation across the amplicon in relation to 
[11C]raclopride binding (BPND) reflecting DA D2/D3 
receptor availability in the nucleus accumbens. The 
correlation between DRD2 methylation and average 
of right and left accumbens BPND was r = 0.650, p = 
0.022 (correlations for left and right individually were 
r = 0.55 and r = 0.72).   
Representation of the functional relationship 
between the average methylation of these CpGs and 
striatal BPND are shown in the brain map and scatter 
plots in Figure 2.   
 
DRD2 Methylation and BOLD Response to Alcohol 
Cues.  
BOLD response to alcohol cues in the nucleus accumbens and caudate were extracted from each 
individual in a previously collected data set (n=78). Correlations between the BOLD response to 
alcohol cues in these structures and the average methylation of the 17 CpGs were calculated. Negative 
correlations were found between the average methylation of the 17 CpGs and the bilateral caudate 
(left: r = -0.273, p = 0.027; right: r = -0.305, p = 0.013) and nucleus accumbens (left: r = -0.247, p = 
0.045; right: r = -0.241, p = 0.052).  
 
DRD2 Methylation and Clinical Measures of Alcohol Dependence.  
Again using the clinical sample (n=78), three commonly used measures of severity were 
negatively correlated with average methylation of the 17 DRD2 CpGs, controlling for age (AUDIT: r = 
-0.276 p = 0.015; Alcohol Dependence Scale: r = -0.295, p = 0.008). 
Finally, our most recent epigenome-wide analyses indicate that the dopamine transporter gene 
(SLC6A3) and dopamine beta hydroxylase gene (DBH) are also important epigenetic targets, and thus, 
we have included these additional genes. 
To identify treatment implications, we also examined DRD2 methylation as a predictor of 
treatment outcome in a subsample of 50 individuals from a previous trial with olanzapine (Littlewood 
et al., 2014). Methylation in the DRD2 promoter was associated with less ability to control alcohol use 
The image part with relationship ID rId9 was not found in the file.
The image part with relationship ID rId9 was not found in the file.
Figure 2. The correlation between 
methylation across 17 CpGs in the DRD2 
promoter region and DA D2/D3 binding.   

 
 
 
 
 
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over 12 weeks of treatment, regardless of treatment condition (unpublished data). These results also 
add support to the notion that epigenetic changes may play a role in relapse. Directly targeting these 
epigenetic changes may be beneficial. Finally, it is important to note that we have also conducted a 
number of clinical trials with AUD patients and tobacco users over the last 10 years (Hutchison et al., 
2006; Littlewood et al., 2014). Our demonstration of the importance of epigenetic regulation of reward 
related genes, and our success with clinical trials, provides evidence regarding feasibility of the 
proposed trial in terms of recruitment, data collection, and study completion. 
 
Immune Function.  
While our program of research has focused more on epigenetic regulation, there is a substantial 
amount of data in the literature to suggest the importance of the LPS/TLR4 signaling cascade in the 
etiology and maintenance of AUDs (Mayfield et al., 2013). Based on this literature, we recently 
examined the association between cytokines and key alcohol phenotypes, including connectivity in the 
left and right executive control networks (LECN/RECN). Our previous work suggests that these two 
networks are important in the etiology of AUDs (Karoly, Weiland, Sabbineni, & Hutchison, 2014). To 
generate effect sizes on the association between cytokines (TNF, IL-6, IL-8) and neural network 
connectivity, we assayed these markers in the plasma of 30 subjects in one of our existing datasets. 
The correlations with connectivity in the LECN and RECN ranged from r = -.24 to r = -.55 for TNF 
and IL-8.  It is also important to note that the samples were not fresh, and the measures were not as 
sophisticated as the proposed approach that involves the collection of PBMCs. We now routinely 
collect PBMCs in one of our studies on aging and inflammation (PI: Bryan) and we routinely utilize an 
assay that involves stimulating the PBMCs with LPS to examine the effects of LPS on inflammatory 
gene expression and cytokines. Given the superiority of these methods, we expect to see larger effect 
sizes in the proposed study.   
 
IV. 
RESEARCH STUDY DESIGN  
 
Overview and Design of the Proposed Study.  
A 2 (Treatment: 8 weeks of MBRP vs. 8 weeks of RP) x 5 (Time: Baseline, 4, 8, 20, 32 weeks) 
mixed factorial design, where treatment is a between-subjects factor and time is a within-subjects 
factor, will be used to test the treatment outcome hypothesis in Aim 1. Subjects will be randomly 
assigned to receive MBRP or RP for a period of 8 weeks such that there are equal numbers of patients 
in each group. An intermediate assessment of the effects of treatment on immune system function and 
epigenetic regulation of dopamine genes will be collected at 4 weeks. Follow-up assessments will be 
obtained at 8 weeks (the end of treatment), 20 weeks (12 weeks after the end of treatment), and 32 
weeks (24 weeks after the end of treatment).  
 
Treatment: 
 
Rationale for Treatment Conditions.  
MBRP was chosen as the experimental treatment because there is mounting evidence that MBIs 
have a significant effect on immune system function, including on targets that have been implicated in 
the maintenance of AUDs. To our knowledge, there are no other examples of psychosocial 

 
 
 
 
 
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interventions or pharmacotherapies that influence the immune system and epigenetics that are as well 
supported as MBRP. RP was chosen as the control condition in order to dismantle the effects of MBRP 
from RP, thereby isolating the effects of the mindfulness components. Our decisions regarding the 
overall length of treatment (8 weeks), length and content of individual sessions, subject selection, 
assessments, and follow-ups at 5 and 8 months after the end of treatment were based on recent trials of 
MBRP and RP (Bowen et al., 2014; Witkiewitz et al., 2014).  
 
MBRP and RP Implementation.  
Consistent with the treatment manuals and previously published papers, a goal of abstinence is 
encouraged but not required (see Bowen et al., 2014). For scheduling logistics, we will not have a 
group format but instead each treatment will be provided individually. As noted in the budget 
justification, the consultants (Dr. Sarah Bowen and Dr. Katie Witkiewitz) along with Dr. Sona 
Dimidjian (Co-I), will be on-site at the inception of the study to provide feedback on the refinement 
and implementation of MBRP and RP. Dr. Bowen and Dr. Witkiewitz will continue to provide expert 
supervision and consultation throughout the study. Dr. Sona Dimidjian, who is widely known for her 
expertise with MBIs, will be onsite for supervision and training throughout the trial. Therapists will be 
selected from the graduate program in clinical psychology at the University of Colorado and will have 
a master’s degree in clinical psychology and previous training in the fundamentals of psychological 
intervention provided by Dr. Hutchison or Dr. Dimidjian. At the inception of the study, Dr. Bowen will 
travel to Boulder to provide a two-day workshop on MBRP. At a separate time, Dr. Witkiewitz will 
travel to Boulder to provide a two-day workshop on RP. In advance of the training workshops, 
prospective therapists will study the relevant manual (MBRP or RP). The workshops will contain both 
didactic and role-play exercises.   Therapists will be cross-trained in the interventions and will lead an 
equal number of both conditions to prevent therapist effects. After training, prospective therapists will 
be required to demonstrate competency in MBRP or RP by submitting audio recordings of pilot 
therapy sessions with patients recruited through the University of Colorado training clinic, who will 
not be part of the proposed study. The recordings will be reviewed by Dr. Bowen and either Dr. 
Dimidjian or Dr. Hutchison and rated using both the Yale Adherence and Competence Scale as well as 
the MBRP competence scale, using a 7-point Likert scale as described in previous reports (Bowen et 
al., 2014). Therapists who demonstrate an average rating of 5 across the duration of the 8-week 
treatment will be certified to be a therapist for the trial. During the course of the trial, weekly 
supervision meetings will be convened and an on-site supervisor (Dr. Hutchison or Dr. Dimidjian) will 
review at least one audio recording per week using the same rating scales to ensure consistency in the 
treatment throughout the duration of the trial. Dr. Bowen will visit Boulder once per year to assess 
overall fidelity and progress of the trial. MBRP will consist of 8 weekly 1-hour sessions provided in an 
individual format, whereas RP will consist of the same format, time, location, and amount of assigned 
homework but will not contain the mindfulness content provided during MBRP.  
Participants will be instructed to arrive at the CINC 10 minutes prior to their scheduled 
appointment and meet in Room 129. Participants will fill out a quick check-in survey on an iPad before 
their appointment begins in order to inform therapists of the extent to which they completed their home 
practice the week before. The check-in survey will also allow participants to record any questions they 
have for their therapist before the appointment begins. The room will have two chairs with a coffee 
table in between the chairs, along with meditation cushions. Water will be available in the room. At 
each session, the therapist will engage and guide the participant in a discussion and exercise. The 
session will last one hour.   
 

 
 
 
 
 
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MRI and Connectivity: 
 
MRI Data Collection (Baseline and Week 32).  
Before treatment begins and at the 6 month follow-up appointment (week 32), subjects will 
participate in an fMRI cue exposure session (Claus et al., 2011). Participants who are determined 
eligible to have an MRI scan will undergo a structural scan, using a Siemens 3T Trio, followed by a 
functional MRI scan that involves alcohol cue exposure. Our cue procedure is consistent with NIAAA 
guidelines and less risky than previous studies that have examined this mechanism in a sample 
receiving treatment (e.g., Myrick et al., 2008; Spagnolo et al., 2014; see protection of human subjects 
section). Structural MRI (sMRI): We will acquire a high-resolution protocol sufficient to permit 
accurate tissue classification and anatomical parcellation. For optimal contrast between gray matter 
(GM), white matter (WM) and cerebral spinal fluid (CSF) at 3T, we will use a multi-echo MPRAGE 
(MEMPR) sequence with the following parameters: TR/TE/TI = 2300/2.74/900 ms, flip angle = 8°, 
FOV = 256x256 mm, Slab thickness = 176 mm, Matrix = 256x256x176, Voxel size =1x1x1 mm, 
Number of echos = 4, Pixel bandwidth =650 Hz, Total scan time = 6 min. Functional MRI (fMRI) – 
Cue-Elicited BOLD: fMRI scans will be collected with single-shot full k-space echo-planar imaging 
(EPI) with ramp sampling correction using the intercomissural line (AC-PC) as a reference (TR: 2.0 s, 
TE: 27ms, a: 70o, matrix size: 64 ´ 64, 32 slices, voxel size: 3 ´ 3 ´ 4 mm3). Image-based higher order 
automatic shimming will be employed. FMRI data will be acquired with a 32-channel coil. Scanner 
instability and signal-to-noise ratio during fMRI scanning on a phantom will be monitored weekly 
throughout the project period. Automated analysis of scanner instability with the Weiskoff method is 
routinely performed. We have used our alcohol cue task successfully in over 600 individuals (Claus et 
al., 2011). It is reliable and well validated. The task compares the taste of an individual’s favorite 
alcoholic beverage with a sweet, appetitive control taste (litchi juice). The task was designed to 
minimize movement by only administering 1 ml of each beverage through Teflon tubing that is 
attached to a computer controller gustometer, over each 24 second trial. It is important to note that the 
total amount of the alcoholic beverage is only 12 ml (less then a teaspoon). The task itself involves a 
block design with twelve pseudorandomly ordered alcohol and control trials that are presented in two 
consecutive runs. In order to examine whether the effects of MBRP differ from those of RP, we will 
calculate the signal change for alcohol minus the control condition in the precuneus, putamen, and 
anterior cingulate and use the signal in these regions of interest (ROIs) in the structural equation 
models (see analysis section).  
 
Resting State Connectivity (Baseline and Week 32).  
Before treatment begins and at the 6 month follow-up appointment (week 32), a 10 minute resting 
state scan will be collected to derive measures of functional connectivity in the left and right executive 
control networks (LECN/RECN) following our previously published procedures (Weiland et al., 
2014). These networks will be identified using functionally defined ROIs/nodes. The nodes for the 
LECN include: dorsolateral prefrontal cortex (DLPFC), left middle/superior frontal gyrus (MFG), left 
superior parietal gyrus/angular gyrus (PAR), left inferior/middle temporal gyri (TL), right crus I/crus 
II/Lobule VI (CE), and left thalamus (TH). The RECN nodes include: right DLPFC, right MFG, right 
PAR, right medial superior frontal gyrus (mSFG), left CE, and right caudate (CU). Functional 
connections between nodes, each pairwise correlation defined as an edge, will be calculated and used 
to create a correlation matrix between the time-series of all nodes within each network for each subject. 
A Fisher r-to-z transformation will be applied to r-values to yield z-scores. Connectivity strength as a 
primary global measure of connectivity for each network will be calculated as the mean of all pairwise 

 
 
 
 
 
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correlations between nodes within each network as well as other graph theory metrics (e.g., degree, 
efficiency, centrality). The framewise displacement (FD) for each subject will be calculated across the 
entire resting state run from the image motion parameter and used a covariate in the analyses. 
 
Blood Collection and DNA Methylation: 
 
DNA Collection, Extraction, Storage, and Sequencing (Baseline, Week 4, 8, 20, 32). 
We will retain an aliquot of whole blood (approximately 10 mL) for DNA extraction. After 
extraction, DNA will be quantified and stored at -80° for future analysis. DNA will be collected at 
baseline, 4, 8, 20, 32 weeks so that we can monitor epigenetic changes over time. 
 
Bisulfite Sequencing / Estimation of Methylation.  
Bisulfite specific PCR primers will be designed using MethPrimer primer design software freely 
available at http://www.urogene.org/methprimer/. PCR amplification will use Accuprime™ Taq DNA 
Polymerase High Fidelity (Life Technologies™) in 50 ul reactions according to the manufacturer’s 
instructions using 20 ng of converted genomic DNA with a final forward and reverse primer 
concentration of 200 nm each. PCR products will be purified using DNA Clean and Concentrator™-5 
(Zymo Research) and quantified. Dual indexed libraries will be prepared using Illumina Nextera XT 
DNA Sample Preparation kit. Denatured and diluted libraries will be sequenced on the Illumina MiSeq 
benchtop sequencer with the sequencing by-synthesis technology per manufacturer’s protocol. Data 
will be demultiplexed on the MiSeq instrument automatically, and zipped FASTQ files will be 
generated per sample, per read. Data will be accessed either in the run analysis folder locally on the 
instrument, or through BaseSpace beta. Custom scripts then determine the ration of methylation at each 
CpG in the amplicon. Average methylation across the CpGs identified in of our preliminary data will 
be used as the primary methylation measure in the analyses below. 
 
Blood Draw Collection and LPS Stimulation: 
 
Blood Levels of Cytokines (Baseline, Week 4, 8, 20, 32).  
As noted in the background and in our description of our preliminary studies, we expect that 
MBRP will reduce biomarkers related to inflammation during the course of treatment and it is 
hypothesized that changes in inflammation will mediate the effects of MBRP on changes in 
connectivity in the brain, neurocognition, and drinking outcomes. Blood samples drawn at each 
assessment (baseline, 4, 8, 20, 32 weeks) will be assayed for IFNg, IL-1a, IL-1b, IL-6, IL-2, IL-4, IL-8, 
IL-10, IL-12, and TNF. Previous studies in animals (Mayfield et al., 2013) and humans (Bala et al., 
2014), as well as our own preliminary data, suggest that cytokine activation is associated with the 
pathophysiology of AUDs. This is the same assay used in our preliminary studies. 
 
Liver Function Panel Tests (Baseline, Week 8, 20, 32). 
 
As stated in the study background, LPS-induced pro-inflammatory cascades span the brain, gut, 
and liver (Fernandez-Lizarbe, Pascual, & Guerri, 2009). Additionally, enzyme levels detected in a liver 
function panel (LFT) can indicate possible liver damage and cirrhosis cause by alcohol abuse 
(Bellentani et al., 1997). We expect to see changes in liver function tests as a result of decreased 
alcohol consumption and pro-inflammatory markers associated with RP and MBRP therapy. The LFT 
will also provide an additional objective measure of alcohol consumption to supplement the self-report 
measures we will collect. To detect differences pre and post-treatment as well as differences between 

 
 
 
 
 
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RP and MBRP treatment groups, we will have a liver function panel test performed on a 2mL sample 
of each participant’s blood collected at baseline, 4, 8, 20, and 32 weeks. Liver function panels will be 
performed by Boulder Community Hospital Reference Lab.  
 
Lipopolysaccharide (LPS)-PBMC challenge.  
We also expect MBRP to impact the responses of blood monocyte cells to an LPS challenge. This 
may represent a more accurate test of the effects of the treatment, since LPS stimulation of PBMCs 
simulates the TLR4 inflammation cascade that putatively mediates the neuroinflammatory effects of 
alcohol. To that end, 40 ml of whole blood will be drawn at each assessment point. Peripheral blood 
mononuclear cells (PBMC) will be separated using density gradient centrifugation. Cells will be 
counted and viability assessed using trypan blue exclusion. PBMCs will be exposed to LPS (0, 0.1, 1, 
10 and 100 ng/ml) for 20h in a 96 well v-bottom plate. Protein levels of cytokines and chemokines 
(IL1,TNF, IL6, IL4, IL10, IFNg, MIP-1a) will be measured in supernatant using a multiplex ELISA 
assay (Aushon Biosystems, Billerica MA). mRNA levels of the same cytokines and chemokines will 
be measured in cell lysates using real-time PCR. We have successfully performed the PMBC isolation 
and LPS challenge in other projects. 
 
Gut Microbiome Sample Collection and Microbial DNA Extraction: 
 
Fecal Sample Collection, Storage, Extraction, and Sequencing (Baseline, Week 8) 
 
We expect to see changes in both the number and diversity of microbiota populations found in 
the gut as a result of treatment and reduced alcohol consumption. Because inflammation, liver 
function, and the gut microbiome are heavily intertwined, we will examine the relationship between 
changes in the gut microbiome with changes in inflammatory biomarkers in the blood (cytokines and 
blood monocyte cell response to LPS challenge) and liver function as a result of both RP and MBRP 
therapy. Fecal samples will be collected from participants using at-home kits and then stored at -80°. 
Microbial DNA will be extracted from fecal samples and then analyzed to determine how many and 
which bacterial species are present in the gut. Gut microbiome data will be collected at baseline and 8 
weeks so that we can monitor changes in number and diversity of microbial DNA pre and post-
intervention. 
 
Due to the COVID-19 situation we are collecting remote data only and will return to our original 
protocol when it is safe to do so. The remote RESEARCH STUDY DESIGN will be as follows: 
 
Because of the remote nature of the study, we will not be collecting the data mentioned above: MRI 
data, microbiome samples, or blood data. 
 
We will be administering the parts of this study that can be done remotely through contact with a 
research assistant: All therapy sessions (mentioned above), and the Validating Self-report Measures 
listed directly below.  
 
Additionally, due to the necessity of the remote nature attributable to COVID: All participants will 
need access to the internet whether by computer, smartphone, or other device such that they can 
complete this study. A research assistant will send unique links to participants that they will simply 
click on in order to participate, applications such as: Zoom (an internet application that allows us to see 

 
 
 
 
 
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and talk with the participant), Qualtrics and REDCap (online survey platforms), and DocuSign (an 
internet application that allows us to send forms for signatures). 
 
Validating Self-report Measures: 
 
Biochemical Outcome Measures (Baseline, Week 8, 20, 32).  
Following the procedures and recommendations outlined in a report on biochemical verification of 
abstinence, tests of plasma %CDT and GGT will be used as an unbiased, biological outcome variable 
that will be used to validate self-report measures (Anton, Lieber, & Tabakoff, 2002) (Martínez-Raga et 
al., 2002). 
 
Measures and Assessments: 
 
Individual Difference Measures (Baseline).  
• A Demographics Questionnaire will be used to collect information on age, sex, marital status, 
SES, occupation, income, education, and race.  
• The Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES) will be used to 
measure individual differences in motivation at baseline.  
• Drinking History is measured with 12 items assessing lifetime drinking history such as current 
drinking, age of onset, and number of previous of attempts to quit/reduce drinking.  
• A Smoking History Questionnaire will be used to collect information on frequency and 
quantity of nicotine use and will be used to determine whether the treatment groups differ on 
nicotine consumption. 
• A Cannabis Self-Treatment questionnaire will be used to better characterize our population in 
case participants are self-treating with cannabis. 
 
 
Self-Report Outcome Measures (Baseline, Week 4, 8, 20, 32).  
• Heavy Drinking Days (HDD), Drinks per Drinking Day (DDD), and Percent Days 
Abstinent (PDA) as well as any comorbid drug use (e.g., tobacco use) will be obtained at 
each assessment using the Timeline Follow Back (TLFB), which is a calendar-based 
assessment of daily alcohol and drug use (Sobell et al., 1979). The TLFB has been shown 
to have good psychometric characteristics among a variety of drinker groups and can 
generate variables that provide a wide range of information about an individual's drinking 
(e.g., pattern, variability, and magnitude of drinking). HDD is the primary behavioral 
outcome that will be analyzed. However, secondary outcome measures of interest will also 
be collected.  
• The Impaired Control Scale – Failed Control (ICS-FC) is a 25-item scale that is used to 
measure the severity of alcohol dependence with respect to dimensions such as impaired 
control over drinking, awareness of compulsion to drink, etc. (Heather, Booth, & Luce, 
1998).  
• The Alcohol Dependence Scale (ADS) has been used widely and found to have excellent 
predictive value with respect to DSM diagnosis (Kivlahan, Sher, & Donovan, 1989).  
• The Pennsylvania Alcohol Craving Scale (PACS) is a 5-item measure of craving that will 
be completed at baseline and at each follow-up session to provide a measure of craving 
(Flannery, Volpicelli, & Pettinati, 1999). In a recent study, the PACS was found to be a 

 
 
 
 
 
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slightly better predictor of drinking as compared to the OCDS and AUQ (Flannery, Poole, 
Gallop, & Volpicelli, 2003).  
• The Drug Use Questionnaire assesses individual behavior with regard to frequency and 
quantity of drug use. This measure will be used to assess whether smoking and drug use 
behavior changes during the course of clinical trial.  
• The Beck Depression Inventory-II (BDI-II) consists of 21 scaled statements designed to 
assess symptoms of depression, with a coefficient alpha of .91 (Beck, Steer, & Carbin, 
1988) The BDI-II will be administered at baseline and at last follow-up to examine 
changes in comorbid depression and covary baseline differences if necessary.  
• The Beck Anxiety Inventory (BAI; Beck et al., 1988) consists of 21 items, each describing 
a common symptom of anxiety. The items are summed to obtain a total score that can 
range from 0 to 63. The BAI will be administered to examine comorbid anxiety and covary 
baseline differences if necessary.  
• The Five Facet Mindfulness Questionnaire (Baer et al., 2006) will determine the extent to 
which MBRP increases mindfulness practice as a proximal mediator of the effects of the 
intervention. These data will be used as a manipulation check.  
• The extent to which patients engage in key aspects of mindfulness will be collected using 
the 10 item Mindfulness Practice Questionnaire (e.g., Witkiewitz, Lustyk, & Bowen, 2013) 
on a weekly basis. 
• The CHIME (Bergomi, Tschacher, & Kupper, 2015) consists of three items and will 
determine the number of minutes of mindfulness practice per week each patient is 
currently engaging in. Minues of current meditation practice will be calculated using the 
following compound variable: (weekly frequency x average session duration). The data 
will be used to co-vary for patients who are already engaging in frequent mindfulness 
meditation practice at baseline if necessary. 
• The Multidimensional Personality Questionnaire (Tellegen, 1982, Tellegan & Waller, 
2008) consists of 18 True/False items of statements describing negative emotionality and 
stress reaction. The questionnaire will be administered to examine comorbid negative 
emotionality and used to co-vary baseline differences if necessary.  
• The Ruminative Response Scale (Treynor, Gonzalez, & Nolen-Hoeksema, 2003) consists 
of 22 items scoring how often the patient engages in ruminative thinking associated with 
depression. The data will be used to examine comorbid negative emotionality and used to 
co-vary baseline differences if necessary.  
• The Effortful Control Scale Derryberry & Rothbart, 1988, Evans & Rothbart, 2007) 
consists of 35 items that measure the degree to which the patient exhibits behavioral 
control. The data will be used to co-vary baseline differences in behavioral control if 
necessary.  
• The Drinking Motives Questionnaire (Cooper, 1994, Kuntsche et al., 2006, Young-Wolff 
et al., 2009) consists of 20 items used to assess patients’ varying motives for drinking 
alcohol. The Drinking Motives Questionnaire will be used to assess whether motives for 
drinking alcohol change from baseline following treatment.  
• Alcohol use will be evaluated with a variation of the measure used by White and Labouvie 
(1989).  First, participants will be asked if they have ever had an alcoholic drink (with 
instructions that define one alcoholic drink as “one beer, one glass of wine, or one serving 
of hard liquor either by itself or in a mixed drink”). Those (likely well over 90%) who 

 
 
 
 
 
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answer that they have previously had alcohol before will be asked to rate: (1) their 
frequency of use in the last three months on a 9-point scale ranging from “never” to “every 
day”, (2) their typical quantity of drinks in one sitting on a 10-point scale ranging from “no 
drinks” to “more than 20 drinks”, and (3) their frequency of getting drunk when drinking 
in the past three months on a 5-point scale ranging from “never” to “always.” 
• The AUDIT (Saunders, Aasland, Babor, De La Fuente & Grant, 1993) is used to detect 
less severe problem drinkers and addresses both current problems (problems within the last 
3 months) and problems across an individual’s lifetime.  The AUDIT consists of ten 
questions that cover such domains as alcohol consumption, drinking behavior, adverse 
psychological reactions, and alcohol-related problems. 
• Participants will be asked about their engagement in any 12-step programs (Tonigan, 
Miller & Conners, 1997), psychological services for alcohol and other problems, and use 
of other self-help materials. At baseline, participants will be asked about lifetime 
engagement in treatment. Because this study will be recruiting a population of heavy 
drinkers, it will be important for us to know whether or not any of our participants have 
previously received treatment for alcohol abuse. In future analyses, this information (e.g., 
prior treatment history) will be used as a covariate. 
• The AUQ  (Bohn et al., 1995) will be used to assess craving. The AUQ consists of eight 
items related to urge drink that are rated on a 7-point Likert scale with the extremes 
anchored by "Strongly Disagree" and "Strongly Agree." The AUQ has demonstrated 
internal consistency and reliability. 
• The ImpSS (Zuckerman, 1996) consists of 19 items measuring impulsivity and sensation 
seeking that may predict responses to alcohol and drug problems. The sum of the 
symptoms endorsed is a proxy measure of dependence. 
• The Fruits and Vegetable Screener is a 10-item measure that was developed by the 
National Cancer Institute to assess how many times in the previous month subjects 
consumed different types of fruits and vegetables, including potion size questions for every 
food item. This measure was shown to be a useful estimate for obtaining median intakes of 
fruit and vegetable servings in U.S. populations (Thompson et al., 2002). Fruit and 
vegetable consumption has been shown to influence inflammation (e.g., Holt et al., 2009), 
and dietary factors have also been linked with epigenetic changes (see Hardy & Tollefsbol, 
2011). Thus, the inclusion of this measure allows fruit and vegetable consumption to be 
controlled for in inflammation and epigenetic analyses.  
• The single-item, self-rated diet quality measure (Loftfield et al., 2015) consists of a single 
question asking “In general, how healthy is your overall diet?” Participants can respond 
with (1) excellent, (2) very good, (3) good, (4) fair, or (5) poor. The item is significantly 
associated with variation in objective measures of dietary intake (P<.001). 
• The VAEQ assesses levels of voluntary exercise (Bryan and Rocheleau, 2002). 
Participants indicated how frequently they engaged in exercise activities in the past 3 
months and past week. The exercise composite score used in these analyses was composed 
of 4 items: (i) “In the past 3 months, what is the average number of days per week that you 
engaged in aerobic exercise?” (ii) “In the past 3 months, what is the average number of 
total minutes per week that you engaged in aerobic exercise?” (iii) “In the past week, how 
many days did you engage in aerobic exercise?” and (iv) “In the past week, what is the 
total number of minutes that you engaged in aerobic exercise?” This measure has been 
used to quantify exercise participation in our previous alcohol studies (Karoly et al., 2013). 

 
 
 
 
 
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Given that exercise may impact inflammation (see Woods, Vieira, & Keylock, 2009) and 
epigenetics (seeNtanasis-Stathopoulos, Tzanninis, Philippou, & Koutsilieris, 2013), this 
measure (either alone or in combination with the Godin, see below) will allow us to control 
for exercise behavior in inflammation and epigenetic analyses. 
• The Godin Leisure-Time Exercise Questionnaire (QLTEQ; Godin & Shephard, 1985) is 
used to generate ‘activity scores’ based on how many separate times (occasions) in a 
typical week participants engage in mild, moderate, or vigorous exercise for more than 15 
minutes of their leisure time. The three levels of intensity are defined as follows: (1) mild 
exercise, defining features include, slightly elevated heartbeat, slightly elevated breathing 
rate (able to carry on a conversation effortlessly); (2) moderate exercise, defining features 
include accelerated heartbeat, moderately elevated breathing rate (able to carry on a 
conversation), and mild physical exhaustion; and (3) vigorous exercise, defining features 
include rapid heartbeat, heavy breathing (difficult or unable to carry on conversation), and 
physical exhaustion. Participants will be asked to answer how many separate times they 
engaged in mild, moderate, and vigorous intensity exercise over the past week (for each 
data collection time point). This measure could be used alone or in combination with the 
VAEQ to control for exercise participation in inflammation analyses. 
• The PSS (Cohen, Kamarck, & Mermelstein,1983) is a 14-item scale that measures (1) the 
degree to which situations in someone’s life are perceived as stressful. Stress is a known 
correlate of substance use and abuse and it will be crucial for us to obtain a measure of our 
participants’ perceived stress levels, which may be associated with inflammatory processes 
(e.g., Hart & Kamm, 2002) and epigenetic changes (see Eric J Nestler, 2012). Thus, this 
measure will be used to control for stress in epigenetic and inflammation analyses. 
• The PSQI (Buysse, Reynolds, Monk, Berman, & Kupfer, 1989) is a 19-item self-report 
scale that measures sleep quality over the past month. The 19 self-related items are 
combined to form seven “component” scores, each of which has a range of 0-3 points. In 
all cases, a score of “0” indicates no difficulty, while a score of “3” indicates severe 
difficulty. The seven component scores are then added to yield one “global” score, with a 
range of 0-21 points. In the present study, it will be important to control for sleep duration 
and/or quality, given that sleep is known to be associated with inflammation (e.g., Patel et 
al., 2009) and epigenetic factors (see Qureshi & Mehler, 2014). Thus, component scores, 
global scores and single item scores could all potentially be used as covariates in later 
analyses of these data. Scores from this measure will be included as covariates in 
inflammation and epigenetic analyses. 
• The Leisure-Time Categorical Item (L-Cat) is a single item comprised of six descriptive 
categories ranging from inactive to very active (Kiernan, Schoffman, Lee, Brown, Fair, 
Perri, & Haskell, 2013). Each category consists of 1–2 sentences describing common 
activity patterns differing in frequency, intensity, duration, and types of activities, thus 
encompassing content validity (van Poppel, Chinapaw, Mokkink, van Mechelen, & 
Terwee, 2010). Respondents pick the category best describing their activity during the past 
month. It assesses national activity recommendations as well as multiple clinically relevant 
categories below and above recommendations, and incorporates critical methodological 
principles that enhance psychometrics (reliability, validity, sensitivity to change). 
• The Pain Interference item bank is from the National Institutes of Health (NIH) and is part 
of the Patient Reported Outcomes Measurement Information System (PROMIS). The Pain 
Interference SF-8a, is a 8-item short-form questionnaire that measures the self-reported 

 
 
 
 
 
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consequences of pain on relevant aspects of one’s life. This includes the extent to which 
pain hinders engagement with social, cognitive, emotional, physical, and recreational 
activities (Amtmann et al., 2010).  
• Emotion Regulation Questionnaire (ERQ) is a 10-item scale that is designed to assess 
individual differences in the habitual use of two emotion regulation strategies: cognitive 
reappraisal and expressive suppression (Gross, John, 2003).  
 
Because of the COVID-19 situation and the remote nature of the study, we will not be collecting the 
Neurocognitive data: 
 
Neurocognitive NIH Toolbox Measures (Baseline & Week 8). 
• Flanker Inhibitory Control & Attention Test: Tests inhibitory control and attention. The 
participant focuses on a particular stimulus while ignoring other stimuli. Five arrows are 
displayed in the middle of the screen, each pointing left or right. The participant selects the 
arrow that matches the middle arrow in the sequence. 
• Dimensional Change Card Sort Test: Measures cognitive flexibility and attention. Two 
target pictures are presented that vary along two dimensions (e.g., shape and color). 
Participants are asked to match one of the two bottom cards to the card displayed at top, by 
either color or shape. 
• Pattern Comparison: Measures processing speed. The test takes less than 90 seconds and 
requires participants to discern whether two side-by-side pictures are the same or not. 
• Picture Sequence Memory Test: Tests episodic memory. Participants are asked to 
reproduce the sequence of pictures that is shown on the screen. 
• Picture Vocabulary Test: A measure of receptive vocabulary administered in a computer-
adaptive test (CAT) format. Participant matches picture with spoken word. 
• List Sorting Working Memory Test: Participants have to say back the list of images they 
are given. 
 
 
Power Analysis: 
 
Sample Size Requirements. 
Sample size was selected to permit analysis of the hypotheses at a two-tailed alpha of .05 and 
power level of at least .80 following Cohen (Cohen, 1988). G*Power 3.0.3 (Erdfelder, Faul, & 
Buchner, 1996) was utilized for some power calculations, while Monte Carlo simulation strategies 
formed the basis of our power analysis for the mediational model (Bryan, Schmiege, & Broaddus, 
2007; Mackinnon & Dwyer, 1993).  
 
The impact of attrition.  
It is anticipated that some attrition will occur in this population, though we do not anticipate 
differential attrition by condition. A conservative estimate of 20% attrition over the course of data 
collection is assumed. Recently published evidence suggests an attrition rate of approximately 20% for 
other trials. In our own previous trials, we have seen attrition of around 20%. Thus, sample size will 
need to be increased by 20% over minimum requirements. After final attrition has been calculated, 
pretest differences on alcohol use and problems will be compared among individuals who finished the 
study versus those who did not and by condition, to determine whether these two groups differed in 

 
 
 
 
 
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systematic ways and whether these differences were related to treatment condition.  
With respect to attrition during the follow-up period, all participants will update their address and 
phone number as well as the name and number of an individual who always knows how to reach them 
at every visit. The project coordinator will also contact each patient in between follow-up visits.   
 
Power for Specific Aim 1 - Detecting Treatment Effects on Alcohol Use Outcomes.  
The analyses of treatment effects will proceed via random coefficient regression utilizing a 2 
(Treatment: 8 weeks of MBRP vs. 8 weeks of RP) x 5 (Time: Baseline, 4, 8, 20, 32 weeks) mixed 
general linear model. The primary outcome variable tested will be heavy drinking days (HDD), 
consistent with previous MBRP trials (Bowen et al., 2014).  Secondary analyses will explore related 
outcomes such as drinks per drinking day, scores on the ICS, and liver function tests, with appropriate 
control of Type I error. In each model, the key effect of interest will be the treatment X time 
interaction. Given the effect sizes in previous trials (small d=.23 or f <.10 to moderate d=.45 or f=.20), 
we conservatively estimate a small effect size (e.g., f = .10). A mixed model testing the between 
(treatment) X within (time) subjects interaction with a total of 180 participants (90 per treatment 
group) will give us well over .90 power, assuming alpha of .05 and a correlation of approximately .50 
between repeated assessments. Given that we expect 20% attrition over the course of the trial, we will 
initially recruit ~226 participants. 
 
Power for Specific Aim 2 - Detecting Treatment Effects on Putative Molecular Mechanisms.  
As reviewed above, the effect sizes for the impact of MBIs (and thus likely MBRP) on 
inflammatory biomarkers and epigenetic regulation ranged from moderate to large. Thus, for tests of 
the hypotheses under Specific Aim 2, that there will be treatment effects on both inflammatory markers 
and epigenetics, the effect sizes are in all cases larger than our estimated effects of treatment on 
outcomes. Thus, 226 participants are more than adequate for Hypothesis 2 of Specific Aim 2. In terms 
of Hypothesis 3 of Specific Aim 2, there are no data available to estimate the size of the direct effects 
of MBRP on cue-elicited BOLD activation or on network connectivity. With 226 participants, we will 
be able to detect a direct effect as small as d=.38 (a small to moderate effect) on change in BOLD 
activation and network connectivity as a result of MBRP versus RP.  
 
Power for Specific Aim 3 – Mediational Analysis.  
Aim 3 will involve a test of the hypothesis that the effectiveness of MBRP vs. RP on clinical 
outcomes is mediated by the effect of MBRP on the molecular mechanisms, and, in turn, their effects 
on network connectivity and BOLD response. This analysis will involve the use of structural equation 
modeling (Bryan et al., 2007)  techniques of the mediational model posited in Figure 4. Based on our 
review of the literature (see above for details and effect sizes), we expect moderate to large paths 
(d=.60) for the effect of MBRP on epigenetics and inflammation. We expect small to moderate 
relationships between epigenetics and cue-elicited BOLD activation and between inflammation and 
network connectivity strength (d=.30). Finally, for paths relating BOLD activation and network 
connectivity strength to drinking outcomes we expect paths in the small to moderate range (d=.30). We 
expect moderate to large (d=.75) loadings of all indicators for their respective latent constructs (for 
example, the loadings of heavy drinking days, drinks per drinking day, and impaired control on the 
Drinking Outcomes latent variable). Power analyses for these hypotheses were conducted in Mplus and 
then in SAS following procedures for estimating the power of the likelihood ratio test of the 
significance of parameters in structural equation models (Muthén  & Muthén, 2002). We utilized 
Monte Carlo simulation to generate a population covariance matrix based on the hypothesized 

 
 
 
 
 
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parameters in the model. For the smallest path in the model, assuming two-tailed alpha of .05, our 
power to detect a significant parameter estimate is .71 with 150 participants and .83 with 200 
participants; with 226 participants we have .87 power. For the moderate to large paths, we have well 
over .99 power with 226 participants.  
 
Data Analysis Plan: 
 
Analyses will be conducted using SAS Version 9.3 and EQS for Windows Version 5.7b. We will 
conduct extensive analyses of any attrition encountered in the project to determine bias. However, note 
that in each of the analyses described herein, we will have the capability of using modern approaches 
to the handling of missing data (Schafer & Graham, 2002) including full information maximum 
likelihood (FIML) estimation of missing data within Proc Mixed in SAS and within EQS.  
Descriptive analyses. The distributional properties of all continuously scaled variables will be 
examined for skewness and kurtosis to determine the need for normalizing transformations or for 
alternations to our analysis plan (i.e., generalized estimating equations in SAS or robust estimation in 
EQS) prior to the primary analyses.  
Pretest equivalence. To confirm the validity of random assignment, pretest equivalence of the two 
treatment conditions across demographics, drinking history, smoking, and all other baseline measures 
will be assessed via t-tests on continuous items and c2 tests of categorical items. We will use the 
Bonferroni approach (Keppel, 1991) to correct for alpha inflation with a familywise alpha of .05. Any 
variables on which the two groups are unequal at pretest will be covariates in all further analyses. 
 
Specific Aim 1 - Detecting Treatment Effects on Drinking Outcomes.  
The effect of the treatment on alcohol use outcomes (HYPOTHESIS 1) will be analyzed with a 2 
(Treatment: 8 weeks of MBRP vs. 8 weeks of RP) x 5 (Time: Baseline, 4, 8, 20, 32 weeks) mixed 
general linear model with Heavy Drinking Days (HDD) as the primary outcome variable. We will also 
examine drinks per drinking day, ICS score, and liver function tests as dependent measures in each of 
2 additional models, respectively. In the main analysis with HDD, a significant overall test of the 
treatment X time interaction will be followed by planned contrasts within the mixed model that allow 
us to test the superiority of MBRP over RP at the 8, 20, and 32 week follow-up points specifically. The 
FIML estimation procedure implemented in these analyses will allow us to utilize an “intent to treat” 
approach such that all subjects who are randomized will be included in the analyses (Schafer & 
Graham, 2002). It may be that the treatments are equally effective on drinking outcomes, and thus we 
will not see a direct effect of treatment on outcomes. Even in this case, it is possible that the 
mechanisms through which the treatments had their impact may differ. Thus, tests of Specific Aims 2 
and 3 are still important and warranted. 
 
Specific Aim 2 - Detecting Treatment Effects on Molecular Mechanisms.  
The effect of the treatment on methylation and inflammation (HYPOTHESIS 2) will be analyzed 
with one 2 (Treatment: 8 weeks of MBRP vs. 8 weeks of RP) x 5 (Time: Baseline, 4, 8, 20, 32 
weeks) mixed multivariate general linear model with methylation outcomes of DRD2, SLC6A3, and 
DBH and a second model with peripheral inflammation outcomes of IL-6, IL-8, and TNFα. The effect 
of the treatment on cue-elicited BOLD activation and network connectivity (HYPOTHESIS 3) will be 
analyzed with a 2-way multivariate analysis of variance (MANOVA; Treatment: 8 weeks of MBRP 
vs. 8 weeks of RP) with BOLD activation in the accumbens, caudate, putamen, and anterior cingulate 
regions as separate outcomes in the same analysis, and a second MANOVA with network connectivity 

 
 
 
 
 
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in the RECN and LECN as the 
outcomes. Note, again, that FIML 
estimation will be used to allow full 
utilization of available data in an intent 
to treat framework. It is also possible 
that the treatments are equally effective 
on drinking outcomes, and thus we will 
not see a differential effect of treatment 
on the mediators. Yet it is still important 
to know whether levels of methylation 
or inflammation post-treatment have 
any impact on changes in 
neurocognitive outcomes. Thus, the test of Specific Aim 3 is still critical, even in the case that both 
treatments are equally effective on both the mediators and drinking outcomes. 
 
Specific Aim 3 - Mediational analyses.  
Mediational analyses based on structural equation modeling with latent variables will be used to 
examine the mechanisms by which MBRP has its effects on behavioral outcomes related to alcohol use 
and dependence (See Figure 4; HYPOTHESIS 4) (Baron & Kenny, 1986; Bryan et al., 2007). 
Mediational analyses will utilize the methylation and inflammation data collected at 4 weeks, and 
changes in cue-elicited BOLD activation and network connectivity strength at 8 weeks as the 
mediators, and drinking outcome data collected at 20 weeks. The exogenous variable in the model is 
the contrast that compares MBRP to RP. Methylation, inflammation, and drinking outcomes are all 
conceptualized as latent variables, which means that they are not directly measured, but are rather 
inferred via the measurement of variables thought to be a consequence of the latent variable. Latent 
variables have advantages over measured variables in that they are more reliable and thus allow for 
higher power for the test of relationships between the underlying construct and other variables (Kline, 
2010).  
The model is then estimated in EQS, and both the fit of the model and the significance of the path 
coefficients are examined. If HYPOTHESIS 4 is supported, we will see significant paths from the 
treatment contrast to methylation and inflammation. Further, there will be significant paths from 
methylation to cue-elicited BOLD activation and from inflammation to network connectivity. Finally, 
we expect significant relationships between BOLD activation and network connectivity to drinking 
outcomes. Importantly, tests for the completeness of mediation of the treatment differences in drinking 
outcomes are employed through a one degree of freedom c2 test where a path directly from the 
treatment contrast to drinking outcomes is added to the model. A nonsignificant direct path and a 
nonsignificant change in c2 suggest that treatment effects on drinking outcomes were mediated through 
the series of molecular and brain-based mechanisms. A secondary test of mediation will utilize 
bootstrap methods to test the significance of, and confidence limits around, the mediated effect 
(Mackinnon & Dwyer, 1993). Similar mediational analyses have been widely used by Co-I Dr. Bryan 
(Bryan et al., 2007).  
 
Exploratory Aim 1. 
 
We will also conduct an additional exploratory analysis comparing populations of microbial 
DNA pre and post-intervention. We will control for age, gender, and diet, because these factors can 
differentially influence the gut microbiome as well. To do this, we will run a series of OLS multiple 
The image part with relationship ID rId9 was not found in the file.

 
 
 
 
 
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regression models regression microbiome values on age, gender, fruit and vegetable consumption, and 
the contrast coded intervention (MBRP or RP) group variable both pre and post intervention. A follow-
up analysis may include looking within an intervention group, and regressing age, gender, fruit and 
vegetable consumption and a continuous measure of alcohol use (i.e., total AUDIT score or TLFB 
drinks per drinking day) on the microbiome values to determine whether there is a dose-response 
relationship between alcohol intake and changes to the microbiome. We will also explore interactions 
between changes in the gut microbiome and changes in inflammation and liver function. 
 
Differential attrition analyses.  
Attrition analyses will be conducted after each follow-up data collection effort to provide 
assurance that differential attrition by treatment condition has not occurred. Following previously 
published procedures (Jurs & Glass, 1971), a series of ANOVAs of treatment (MBRP versus RP) X 
retention (retained, not retained) will be conducted on continuous baseline measures. Significant 
treatment X retention interactions identify measured variables on which differential attrition may have 
occurred. The logit model analog procedure will be applied to categorical baseline measures to test for 
differential attrition on categorical variables such as gender and ethnicity (Agresti, 1990). We will 
conduct these analyses to assure that differential attrition by treatment condition does not account for 
any of the effects of the treatments.  
 
Secondary analyses.  
 
In the context of the test of the model in Figure 4, we will conduct secondary analyses to test 
whether there are effects of methylation on network connectivity and of inflammation on BOLD 
activation. We will also conduct exploratory analyses to determine whether the treatments are 
differentially effective by gender, age, or race/ethnicity, and we will explore interactions between 
mechanisms with appropriate Type I error correction. Finally, we will examine the relationship of early 
changes in drinking behavior (within the first 2 weeks) and neural adaptations in the analysis plan and 
how the degree of mindfulness uptake relates to neural and clinical outcomes. 
 
Project Timeline.  
 
The proposed timetable for all data collection, analysis, and manuscript preparation is five years. 
Because the protocol is similar to clinical protocols we have used in previous studies and because we 
have existing experienced staff, we will only need 3 months to refine and implement the protocols. 
Thus, data collection will begin in earnest in April 2016. Consistent with previous trials, we expect to 
enroll about 6 patients per month during the first year and about 4 per month thereafter. Thus, we 
expect to enroll 50 patients during each of the first 4 years and 26 patients in the last year, for a total of 
226 patients. The remainder of year 5 will involve data analysis and manuscript preparation.  
V. 
FUNDING 
This study is funded by a grant from NIAAA. 
 

 
 
 
 
 
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VI. 
ABOUT THE SUBJECTS  
Participants for the proposed research are 226 individuals with an alcohol use disorder who will 
be recruited from the greater Denver/Boulder metropolitan area in the state of Colorado using the 
exclusionary criteria described below.   
 
Criteria for inclusion in the study are:  
1. Must be between the ages of 21 and 60 and provide informed consent; 
2. Have a primary DSM-V diagnosis of alcohol use disorder;  
3. Must be within 10 days of last drink;  
4. Must have been drinking heavily (criteria dependent upon individual’s age, gender, and 
BMI) for a consistent period of time; 
5. Must have a breath alcohol level of 0 at screening (to sign consent form); 
6. Not currently taking any medications for the treatment of psychiatric disorders, 
including substance use disorders, mood disorders, and psychosis; 
7. Female subjects must not be pregnant, as indicated by a pregnancy test which will be 
administered at baseline (tests will be re-administered at the 32 week session prior to 
the MR scan); 
8. Must not be positive for sedatives, opiates, cocaine, or amphetamine on drug screen at 
baseline; 
9. Must not meet criteria for psychotic disorder, bipolar disorder, or a major depressive 
episode; 
10. Must not have a Beck Depression Inventory (BDI) score of more than 28 (29-63 
indicates severe depression); 
11. Must not rate 2 or higher on BDI question 9 (assessment of suicidality); 
12. Must have a Clinical Institute Withdrawal Assessment (CIWA) score less than 8 
(indicating no need for medical detox). If CIWA is greater than 8, patient will be 
referred to detox and only accepted into study after detox is successfully completed. 
13. Must have expressed a desire during their initial screen to reduce the number of drinks 
they regularly consume  
VI. 
VULNERABLE POPULATIONS 
This study does not include any vulnerable populations.  
VII. 
RECRUITMENT METHODS 
Advertisements in mass media outlets (e.g., newspaper, radio); through social media (e.g., 
Facebook); using online recruitment tools (e.g., ResearchMatch); via flyers given to local mental 
health providers, who offer limited or no substance use treatment (e.g., referrals for alternative 
treatment options [when alcohol is the primary presenting concern] or as an adjunct alcohol 
treatment [when the provider is addressing other mental health issues]); and direct mailings 
targeting the greater Front Range metropolitan area, which includes Boulder County, Denver, and 
suburbs of Denver, will be the primary sources of participants. Additionally, participants will be able 
to fill out an online screening showing their interest that will be directly advertised via a link to Redcap 

 
 
 
 
 
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on the mailings sent out. The online screening will be administered through Redcap and is password 
protected. Only the research team knows the password to this Redcap screening. This recruitment 
strategy is based on the successful recruitment in our previous trials. All of these advertisements will 
describe the opportunity to earn a maximum of $340 by participating in a study exploring mindfulness 
and biological mechanisms related to alcohol use. Men and women of all ethnic backgrounds will be 
recruited into the study. We expect that the proposed study will reflect the ethnic diversity of the 
greater Denver metropolitan area, such that approximately 25-35% of the final sample will represent 
Latino and non-Caucasian individuals. We will recruit 226 individuals. Our previous experience with 
clinical trials (e.g., Littlewood et al., 2014), as well as the experience of our research team members 
(Bowen, Witkiewitz, Dimidjian) with this specific intervention supports the feasibility of recruiting 
approximately 50 patients per year (see Bowen et al., 2014) 
During the phone or online interview, participants will be screened for the inclusion criteria 
outlined above. Before asking any eligibility questions, the interviewer will obtain verbal consent from 
the potential participant. For the online interview, participants will be marking their electronic written 
consent to participate in the screening at the beginning of the survey. The potential participant will also 
be informed that some of the questions asked will concern their use of substances including alcohol, 
cannabis and illegal drugs. They will be told that they do not have to answer any question that makes 
them feel uncomfortable; however, not answering some or all of the questions on the phone or on the 
online screening, may result in their being ineligible to participate in the study. In accordance with the 
IRB’s guidelines for pre-screening potential participants () only first names or initials will be collected 
to identify the potential participant during this phone screen (pre-screen). In regards to the online 
phone screen, the potential participant will be contacted on the phone after they complete the screen in 
order to receive an explanation about the study and to schedule them for their first appointment. For 
participants that do not meet criteria, they will be sent an email stating their ineligibility and will 
receive resources for alcohol and mindfulness therapies in their area. In order to protect participant 
confidentiality, the first eight pages of the phone screen form will be shredded immediately after the 
phone screen (pre-screen) is complete. Only the information relevant to contacting the participant on 
the phone screen will remain. This contact information will be important for us to retain so that we can 
reach participants concerning their appointments. Participant contact information will be stored in a 
separate research folder, apart from all other study documents. This folder will be stored in a locked 
filing cabinet CU CHANGE research lab at the Center for Innovation and Creativity (CINC). Each 
contact information sheet will be destroyed at the end of the study, which will minimize any risk of 
loss of confidentiality. For the online phone screen, the participant information will be kept on a 
password protected Excel document on a computer in Dr. Hutchison’s laboratory which will be 
destroyed at the end of the study.  
Due to the COVID-19 situation we are collecting remote data only and will return to our original 
protocol when it is safe to do so. The remote RECRUITMENT METHODS will be as follows: 
Participants will be recruited using social media advertising and will go through a phone screen 
with a research assistant to confirm their eligibility and answer any questions they may have. If 
the participant is eligible, they will be scheduled for their next Zoom appointment. 
 
VIII. COMPENSATION  

 
 
 
 
 
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We estimate that the completion of assessments and procedures across the duration of the trial, 
including therapy sessions, will total approximately 16 hours of time (an additional 2 hours for MRI). 
To compensate subjects for their time and travel costs, subjects who will not be scanning will be paid a 
maximum of $280 if they complete all therapy sessions and appointments and those subjects who will 
be scanned will be paid a maximum of $340. As a breakdown for compensation participants will be 
given: 
• $30 for completing the Baseline Session (an additional $30 will be given to participants 
who under to the first MRI scan) 
• $30 at the Intermediate Session (week 4) 
• $30 for completing the End of Treatment Session (week 8) 
• $15 for each therapy session they attended (week 1-3 and 5-7) ($90 total; will be given 
in total to participants at week 8) 
• $50 for completing the full week 20 follow-up ($30 will be given for completing 
surveys, whether completed in our laboratory or remotely; $20 will be given for blood 
sample collection, which can only occur in our laboratory)  
• $50 for completing self-report measures for the week 32 follow-up ($30 will be given 
for completing surveys, whether completed in our laboratory or remotely; $20 will be 
given for blood sample collection, which can only occur in our laboratory; an 
additional $30 will be given to participants who undergo the second MRI scan) 
 
 
Due to the COVID-19 situation we are collecting remote data only and will return to our original 
protocol when it is safe to do so, the remote COMPENSATION will be as follows: 
Compensation (via Amazon gift cards) for each study appointment goes as follows:  
• Baseline session: $30 
• Therapy sessions (weeks 1-3, 5-7): $15 per session ($90 total given at week 8) 
• Intermediate session (week 4): $30 
• End of treatment session (week 8): $30  
• Follow-up session I (week 20): $50 for surveys 
• Follow-up session II (week 32): $50 for surveys 
 
IX. 
CONSENT PROCESS 
 
Given that the phone screen portion of the study presents no more than minimal risk of harm to 
subjects and involves no procedures for which written consent is normally required outside of the 
research study, the study team is requesting a waiver of written consent for the phone screen portion of 
the study. The member of the research team who is conducting the phone screen will say the following 
prior to asking any screening questions, in order to obtain verbal consent to conduct the screen: “Thank 
you for your interest in our research study investigating alcohol and mindfulness. Do I have your 
verbal consent for me to ask you a few questions to verify that you are qualified and tell you about the 
requirements before you come to the lab? It will take about 10-15 minutes of your time. If you have 
any questions you can contact Kent Hutchison at 303-492-8163 or the Institutional Review Board at 
303-735-3702. Your participation in this pre-screening is voluntary.” The member of the study team 
will be available to answer any questions regarding the phone screen process, and the phone screen 

 
 
 
 
 
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will be immediately discontinued if the potential participant does not give verbal consent to answer the 
eligibility questions. For the online screening, the participant has the choice to exit out of the screening 
at any point without completing it. The study team will track individuals who give verbal consent to 
the phone screen in a non-identifiable manner (i.e., subjects who consent to be phone screened will be 
referred to as Subject-01, Subject-02, etc. on the tracking log). This tracking log will be stored in a 
password-protected file on a computer in Dr. Hutchison’s laboratory.  
When a participant arrives for his/her first session at the Center for Innovation and Creativity 
(CINC), a member of the research team (i.e., a trained research assistant or graduate student) will greet 
him/her in the first-floor lobby. The research assistant will take the participant to a private room and 
provide the participant with a copy of the informed consent document. A description of the MRI 
procedures is included in the consent form, and all participants will be given a verbal description of the 
MRI screening process and potential risks of MRI studies. Prior to asking the participant to sign the 
consent form, the trained research assistant and the participant will have a discussion regarding the 
research study. Additionally, the research assistant or graduate student will be available to answer any 
questions he or she may have about the study.  Participation will be clearly stated as voluntary, with 
the option to withdraw at any time. There will be no deception involved with this study. After 
discussing the study and going over the consent form with the researcher, the participant will initial 
and sign the informed consent document.  
Separate signatures will be obtained for participation in the study and broadly sharing gut 
metagenomic and phenotypic data. Individuals who opt not to have their gut metagenomic and 
phenotypic data broadly shared will still be allowed to proceed with participation in the study.  
 
Due to the COVID-19 situation we are collecting remote data only and will return to our original 
protocol when it is safe to do so. The remote CONSENT PROCESS will be as follows: 
 
When a participant arrives via Zoom for his/her first remote Baseline & consent session a member of 
the research team (i.e., a trained research assistant or graduate student) will greet him/her and welcome 
them to the study. The research assistant will provide the participant with a copy of the informed 
consent form via a link to the DocuSign document. Prior to asking the participant to sign the consent 
form, the trained research assistant and the participant will have a discussion regarding the research 
study. Additionally, the research assistant or graduate student will take the participant through the 
informed consent document, step by step, and give them an opportunity to ask any questions about 
their participation in the study. Participation will be clearly stated as voluntary, with the option to 
withdraw at any time. There will be no deception involved with this study. After discussing the study 
and going over the consent form with the researcher, and after all questions have been resolved, the 
participant will then show their ID to the researcher, over Zoom, to the confirm they are between 21-60 
years old. Then the research assistant will use DocuSign to electronically sign the consent form and 
send it to the participant to sign. The participant will then send the signed DocuSign informed consent 
form back to the researcher. Signed consent forms will be stored securely on our server in a password 
protected folder.  
 
X. 
PROCESS TO DOCUMENT CONSENT IN WRITING 

 
 
 
 
 
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In accordance with 45 CFR 46.117, an unsigned copy of the form used to document consent 
will also be given to the study participant.  
XI. 
PROCEDURES  
Screening for Eligibility/Scheduling 
Participants will contact the researchers with their interest by phone, e-mail or by filling out the 
online screening. The researcher will respond with an overview of the study and answer any questions 
the potential participant has before screening the caller for preliminary eligibility. In the case that a 
potential participant requests more information via e-mail, the research assistant responding to the e-
mail will ask the participant to call the lab phone number (same phone number provided on all study 
advertisements) for more information, or e-mail the study team a phone number at which the potential 
participant could be reached at and a desirable time for the research staff to call. Prior to being asked 
the phone screen questions, potential participants will be required to give their verbal consent, or in the 
case of the electronic online screening, written consent. They will be asked to state that they are 
willing to answer questions over the phone or through the online survey which will help researchers to 
determine their eligibility to take part in the study. The phone screening process will help to ensure 
participants have ample opportunity to be informed of the main study components, ask questions, and 
decide if they are willing to participate before they sign up for the study. For participants that complete 
the online screening, a research assistant will follow up with the participant on the phone to answer any 
questions and ask if the participant is willing to take part in the study. If the participants meet the study 
criteria during the initial phone interview or online screening, they will be invited to come to the CINC 
for the initial consenting session. They will be given the option of combining this session with the 
experimental baseline session. If participants choose to do a separate session for consenting, they will 
schedule their experimental baseline session upon completion of the consent/orientation session. Upon 
scheduling their first appointment, participants will be provided, via an e-mail attachment (see pre-
appointment e-mail template), a letter that will include the time and date of the appointment. If 
participants are electing to combine both appointments, they will be instructed ahead of time not to 
drink alcohol within 48 hours, smoke marijuana within 48 hours, or consume caffeine or smoke 
cigarettes within 3 hours of the session. They will receive an email containing this information upon 
scheduling the session (see “Instructions for Appointment” document). If participants are doing the 
consent/orientation and study appointments on two separate visits, they will be given these instructions 
during the consent/orientation session.  
 
COVID-19: Before interacting with research assistants, eligible participants will be asked 
additional questions related to COVID-19. These questions will be administered prior to any in-person 
appointment and by a research assistant over the phone (or at a distance of at least 6-feet if the 
participant is unable to complete the questions over the phone). These questions will be administered 
to protect staff and participants from the spread of COVID-19. The questions are a precaution based on 
current university and Centers for Disease Control and Prevention guidelines and may need to be 
updated as the understanding of COVID-19 evolves. These procedural questions are temporary in 
nature and will be lifted once university guidelines deem it unnecessary. 
 
 
Informed Consent Appointment  

 
 
 
 
 
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Upon arrival for the informed consent appointment, participants will be met by a research 
assistant or graduate student who will escort them to a private consultation room where participants 
will be asked to complete and sign the informed consent form. If the participant is doing the consent 
and experimental baseline session in two separate visits, he or she will be informed at the consent 
session to refrain from drinking alcohol within 48 hours, smoking marijuana within 48 hours, or 
consuming caffeine or smoking cigarettes within 3 hours of the experimental baseline session, and the 
baseline session will be scheduled at the end of the consent appointment. The participant will also be 
given a copy of the Instructions for Appointment Document at the end of the consent visit. If the 
participant is doing the consent session and experimental session in the same visit, he or she will 
proceed with the study procedures after completing the informed consent process with the trained 
research assistant or graduate student.  
 
Baseline Session 
After arriving at the lab, qualified participants will (1) complete an informed consent form, and 
then (at either the same session or a separate session), participants will (2) complete a breath alcohol 
test, (3) complete a urine toxicology screen, (4) provide a blood sample for assays of peripheral 
inflammatory markers and DNA methylation, (5) fill out the baseline questionnaires, (6) and take 
several neurocognitive tasks. Participants will also be given a gut microbiome sample collection kit at 
the end of the session and will return it to their first scheduled session (7). 
Subjects will be breathalyzed before every session starts, including all therapy sessions. Any 
subject that has a positive BAL or who reports drinking will be rescheduled for that appointment. A 
participant who blows a BAC over 0.00 will be given one chance to reschedule his/her appointment for 
the next day. If s/he comes in the next day with a breath alcohol greater than 0.00 then this session will 
be counted as “missed.” If a subject accumulates more than one “missed” session, they will be 
automatically dropped from the study on the grounds that they failed to follow explicit study directions 
properly. Participants will not receive compensation if a session is terminated due to failure to follow 
the abstinence instructions. They will be informed of this contingency during the phone screen, consent 
visit and is stated the consent form.  
A urine toxicology screen will be administered to insure that subjects have not recently used illicit 
drugs including, sedatives, opiates, cocaine, or amphetamines.  
A member of our research team who has completed a certified training in phlebotomy will collect 
the blood sample. The blood draw procedures will involve collecting venous blood (40 ml) 
venipuncture of a peripheral arm vein using standard, sterile phlebotomy techniques. The samples will 
be tested for cytokine levels and epigenetics using equipment at the CINC.   
Subjects will then complete baseline questionnaires related to their demographics, history of 
drinking, smoking and drug use, and alcohol craving (measures listed below). Also, subjects will take 
six neurocognitive tests using the NIH toolbox application, which will assess their cognitive function 
in terms of memory and attention. If not eligible for the MRI, subjects will be randomly assigned to 
receive MBRP or RP for the next 8 weeks at the end of their baseline session and will also be given 
their microbiome sample collection kits at the end of the session. They will return the sample kits at 
their next scheduled session. Subjects will be compensated $30 for completion of the baseline 
appointment. 
 
MRI Scan I 
All subjects who are eligible will undergo a structural scan, using a Siemens 3T Trio, followed by 
an fMRI scan that involves alcohol cue exposure. Female participants will be asked to take a 

 
 
 
 
 
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pregnancy test free of charge and must have a negative result in order to continue with participation in 
the study. Female participants may opt out of the urine pregnancy test and sign a waiver (one of the 
standard INC MRI scanning forms) indicating they understand that the risks associated with MRI and 
unborn fetuses is unknown and that they are confident that they are not currently pregnant.  
The research assistant will go over the contraindications for fMRI screening form again with the 
participant to ensure that eligibility has not changed since the phone screen; if there is any question 
that a participant might not be safe to go into the scanner the appointment will be cancelled and 
rescheduled if possible. 
Prior to going into the MRI scanner, the MRI technologist on duty will ask participants to remove 
all jewelry and metal objects from their pockets. Participants will be required to change into scrubs to 
prevent any possible risk from metallic objects or decorations in their clothing. Eligible participants 
will be escorted to a changing room where they will be asked to change into the hospital scrubs 
provided, and to lock up their belongings in the locker.  
A trained MRI technician will position participants in the scanner and ensure that all safety 
procedures are followed. In an MRI scan, the subject lies down on a table and is placed into a long 
donut-shaped magnet.  A specially designed coil will be placed around the head to provide better 
images (as is done with standard clinical examinations).  As the MRI scan is performed, the subject 
will hear loud rapping and knocking noises that are normal for a MRI scan. 
During the scanning session, we will acquire anatomical images for subsequent analysis as well as 
functional images during an alcohol cue task. The alcohol cue task compares the taste of an 
individual’s favorite alcoholic beverage with a sweet, appetitive control taste (litchi juice). Subjects 
will be administered 1 ml of each beverage through Teflon tubing that is attached to a computer 
controller gustometer, over each 24-second trial. The total amount of the alcoholic beverage is only 1 
ml (less than a teaspoon).  
After the scan, a research assistant will escort the participants back to the changing room where 
their belongings are locked. Subjects in this group will be given their MBRP or RP condition 
assignment after the scan is complete in order to minimize any expectancy effects that may occur as a 
result of knowing their condition assignment before all pre-treatment measures have been taken.  
Subjects will be compensated $30 for completion of the MRI scan I appointment. 
 
Goal-setting Session 
 
Subjects will have a 1-hour individual session with a trained therapist before starting the 8-
week long program, resulting in a total of 9 individual therapy sessions. The purpose of this being a 
chance for the participant to discuss with their therapist their goals for the next 8 weeks in terms of 
drinking reduction goals or abstinence goals. Subjects will take a BAC test before the session starts.  
 
MBRP (or RP) Weekly Sessions  
Subjects will meet with a trained therapist for 1-hour individual therapy sessions once a week for 
8 weeks at the CINC in a private consultation room.  
Subjects will be breathalyzed and complete their check-in survey before every session starts. If 
subjects are dropped due to accumulated “missed” sessions due to failure to follow the abstinence 
instructions, they will not be compensation for previous attended therapy sessions. They will be 
informed of this contingency during the phone screen, consent visit and is stated the consent form. 
Subjects will be compensated $15 for each therapy session they complete (payment for each 
completed session is given to participants at week 8).  
 

 
 
 
 
 
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Intermediate Session (4 weeks) 
 
At the intermediate session, subjects will continue with their usual session with a therapist 
(including a BAC test), and either before or after their appointment, complete a set of self-report 
outcome measures, and provide a blood sample. Subjects will be compensated $30 for completion of 
this session. 
 
End of Treatment (8 weeks) 
 
At the end of treatment session, subjects will continue with their usual session with a therapist 
(including a BAC test), and either before or after their appointment, complete a set of follow-up 
outcome measures including questionnaires and neurocognitive tests, and provide a blood sample. 
Subjects will be compensated $30 for completion of this session, plus an additional $15 for completing 
each therapy session (weeks 1-3 and 5-7), for a total of $90 if they have attended all 6 sessions. 
Participants will receive their second gut microbiome sample collection kits at the end of the session 
and will return them using a pre-paid, pre-addressed envelope that we will provide for them.  
 
Follow-up Assessment I (20 weeks) 
 
At this follow-up session, all subjects will take a BAC test, complete a set of self-report 
outcome measures and provide a blood sample. Subjects will be compensated $50 for completing this 
assessment ($30 for completing self-report measures and $20 for providing blood samples). For 
subjects who are unable to come into the laboratory, the option of completing self-report measures 
online (via Qualtrics) will be provided for a $30 compensation.  
 
Participants who are unable to come into the laboratory will be sent an email, with an 
anonymous link to the same Qualtrics survey that would is administered at the follow-up assessments. 
All surveys are administered via Qualtrics and, thus, participants will already be familiar with 
navigating this online survey. The email will include the following instructions:  
 
As our study staff noted, your progress since finishing treatment is extremely important for 
us to understand how alcohol treatments work, and why they may work better for some 
individuals than others. Therefore, regardless of whether you feel you have improved, declined, 
or had no changes since completing treatment, your responses are equally valuable. To 
reimburse you for your time, we will provide a $30 gift card. 
 
If you choose to proceed, here is the link to your survey: [INSERT LINK] 
 
After clicking the link, please enter your study ID and treatment condition (see below). 
Please fill out this survey alone to ensure focus and anonymity. In addition, you may 
discontinue participation or refuse to answer any questions without penalty. Once you have 
completed the survey, study staff will be notified and you will receive your compensation 
within one week.  
 
Your study ID is: [INSERT ID] 
Your treatment condition is: [INSERT MBRP or RP] 
 
Follow-up Assessment II (32 weeks) and MRI Scan II 
 
At this follow-up session, all subjects will take a BAC test, complete a set of self-report 
outcome measures and provide a blood sample. Subjects will be compensated $50 for completing this 

 
 
 
 
 
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assessment ($30 for completing self-report measures and $20 for providing blood samples). For 
subjects who are unable to come into the laboratory, the option of completing self-report measures 
online (via Qualtrics) will be provided for a $30 compensation. The same email will be sent for the 
second follow-up assessment as provided above.  
All subjects who are eligible and selected to participate in the MRI scan portion of the study, will 
complete the second MRI scan during this appointment and receive an additional $30 for completion 
of the second scan. Female participants will be asked to take a second pregnancy test free of charge 
and must have a negative result in order to go in the MRI. Following the MRI scan, a therapist will 
conduct an assessment with each participant after the cue exposure session to determine whether there 
is any residual craving or anxiety before leaving the session. Participants will also be provided with 
contact information for local AA and support groups for aftercare.  
 
Check-in Session (33 weeks) 
 
Those subjects who participated in the MRI scan will return for a visit with a therapist one 
week after their second follow-up session. Before this session starts, participants will take a BAC test. 
During this session, the therapist will assess whether there were any adverse events, including lapses 
that may have resulted from the alcohol cues administered during the MR scan. Any adverse events 
will be addressed in the session and reported to the PI. At the end of their last session (33 weeks), 
participation in the study is complete. 
 
 
Name of 
instrument/tool/procedure 
Purpose (i.e. what data is being 
collected? 
Time to 
Complete 
 
Questionnaire Measures 
Collected at Baseline Only 
 
 
10 minutes 
Demographics 
• A demographics questionnaire 
will be used to collect 
information on age, sex, marital 
status, SES, occupation, income, 
education, and race. 
 
 
The Stages of Change 
Readiness and 
Treatment Eagerness 
Scale (SOCRATES) 
• SOCRATES (Miller & Tonigan, 
1996) is an experimental 
instrument designed to assess 
readiness for change in alcohol 
abusers. The instrument yields 
three factorially-derived scale 
scores: Recognition (Re), 
Ambivalence (Am), and Taking 
Steps (Ts). It will be used to 
measure individual differences in 
motivation at baseline. 
 
 

 
 
 
 
 
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Drinking History 
Questionnaire 
• Drinking history is measured with 
12 items assessing lifetime 
drinking history such as current 
drinking, age of onset, and 
number of previous of attempts to 
quit/reduce drinking. 
 
 
Smoking History 
Questionnaire  
• Smoking History Questionnaire 
will be used to collect 
information on frequency and 
quantity of nicotine use and will 
be used to determine whether the 
treatment groups differ on 
nicotine consumption.  
 
 
 
Questionnaire Measures 
Collected at Baseline, 4, 8, 20, 
32 weeks  
 
 
30 minutes 
Timeline Follow Back 
(TLFB) 
• The TLFB (Sobell, Maisto, 
Sobell, & Cooper, 1979) is an 
assessment method that obtains 
estimates of daily alcohol, 
cigarette, and drug use. The 
TLFB has been shown to have 
good psychometric characteristics 
with a variety of drinker groups 
and can generate variables that 
provide a wide range of 
information about an individual's 
drinking (e.g., pattern, variability, 
and magnitude of drinking). This 
instrument requires subjects to 
recall from memory the number 
of drinks consumed for each day 
over the prior 30 days as well as 
their use of tobacco products and 
recreational drugs. Studies with 
alcoholics have shown this 
instrument to be reliable in 
assessing drinking frequencies 
and other behaviors such as 
arrests and hospitalizations 
(Sobell et al., 1979). 
 
 

 
 
 
 
 
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Heavy Drinking Days 
(HDD); Drinks per 
Drinking Day (DDD); 
Percent Days Abstinent 
(PDA)  
• All three measures will be 
obtained at each assessment using 
the Timeline Follow Back 
(TLFB), a calendar-based 
assessment of daily alcohol and 
drug use (Sobell et al., 1979). The 
TLFB has been shown to have 
good psychometric characteristics 
among a variety of drinker groups 
and can generate variables that 
provide a wide range of 
information about an individual's 
drinking (e.g., pattern, variability, 
and magnitude of drinking). HDD 
is the primary behavioral 
outcome that will be analyzed.  
 
 
Impaired Control Scale-
Failed Control (ICS-FC) 
• The Impaired Control Scale is a 
25-item scale that is used to 
measure the severity of alcohol 
dependence with respect to 
dimensions such as impaired 
control over drinking, awareness 
of compulsion to drink, etc. 
(Heather, Booth, & Luce, 1998).  
 
 
Alcohol Dependence 
Scale (ADS) 
• The ADS has been used widely 
and found to have excellent 
predictive value with respect to 
DSM diagnosis (Kivlahan, Sher, 
& Donovan, 1989) and will be 
used to assess severity of alcohol 
use symptoms. 
 
 
Pennsylvania Alcohol 
Craving Scale (PACS) 
• The PACS (Flannery, Volpicelli, 
& Pettinati, 1999) is a 5-item 
measure that will provide a 
measure of craving at each 
session.  
 
 
Drug Use Questionnaire  
 
• The Drug Use Questionnaire 
assesses individual behavior with 
regard to frequency and quantity 
of drug use. This measure will be 
used to assess whether smoking 
 

 
 
 
 
 
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and drug use behavior changes 
during the course of clinical trial. 
 
Beck Depression 
Inventory-II (BDI-II) 
• The BDI-II (Beck et al., 1996) is 
a 21-item measure of depression 
symptom severity in the past two 
weeks. BDI-II scores range 
between 0 and 63, with 
categorical depression ratings of 
“minimal” (0–13), “mild” (14–
19), “moderate” (20–28), and 
“severe” (29–63). The BDI-II 
will be administered at baseline 
and at last follow-up to examine 
changes in comorbid depression 
and co-vary baseline differences 
if necessary.  
 
 
Beck Anxiety Inventory 
(BAI) 
• The BAI (Beck & Steer, 1990) 
consists of 21 items, each 
describing a common symptom of 
anxiety. The items are summed to 
obtain a total score that can range 
from 0 to 63. The BAI will be 
administered to examine 
comorbid anxiety and co-vary 
baseline differences if necessary. 
 
 
Pain Interference - SF 8a 
• The Pain Interference item bank 
is from the National Institutes of 
Health (NIH) and is part of the 
Patient Reported Outcomes 
Measurement Information System 
(PROMIS). The Pain Interference 
SF-8a, is a 8-item short-form 
questionnaire that measures the 
self-reported consequences of 
pain on relevant aspects of one’s 
life. This includes the extent to 
which pain hinders engagement 
with social, cognitive, emotional, 
physical, and recreational 
activities (Amtmann et al., 2010).  
 
 

 
 
 
 
 
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The Five Facet 
Mindfulness 
Questionnaire  
 
• The Five Facet Mindfulness 
Questionnaire (Baer et al., 2006) 
will determine the extent to 
which MBRP increases 
mindfulness practice as a 
proximal mediator of the effects 
of the intervention. These data 
will be used as a manipulation 
check.  
 
 
Mindfulness Practice 
Questionnaire 
• The extent to which patients 
engage in key aspects of 
mindfulness will be collected 
using the 10 item Mindfulness 
Practice Questionnaire (e.g., 
Witkiewitz, Lustyk, & Bowen, 
2013) on a weekly basis.  
 
 
Comprehensive 
Inventory of 
Mindfulness Experiences 
(CHIME) 
• The CHIME (Bergomi, 
Tschacher, & Kupper, 2015) 
consists of three items and will 
determine the number of minutes 
of mindfulness practice per week 
each patient is currently engaging 
in. Minues of current meditation 
practice will be calculated using 
the following compound variable: 
(weekly frequency x average 
session duration). The data will 
be used to co-vary for patients 
who are already engaging in 
frequent mindfulness meditation 
practice at baseline if necessary. 
  
 
Multidimensional 
Personality 
Questionnaire – Stress 
Reaction 
• The Multidimensional Personality 
Questionnaire (Tellegen, 1982, 
Tellegan & Waller, 2008) 
consists of 18 True/False items of 
statements describing negative 
emotionality and stress reaction. 
The questionnaire will be 
administered to examine 
comorbid negative emotionality 
and used to co-vary baseline 
differences if necessary.  
 
 

 
 
 
 
 
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Response Styles 
Questionnaire - 
Ruminative Response 
Scale 
• The Ruminative Response Scale 
(Treynor, Gonzalez, & Nolen-
Hoeksema, 2003) consists of 22 
items scoring how often the 
patient engages in ruminative 
thinking associated with 
depression. The data will be used 
to examine comorbid negative 
emotionality and used to co-vary 
baseline differences if necessary.  
 
 
Emotion Regulation 
Questionnaire (ERQ) 
• Emotion Regulation 
Questionnaire (ERQ) is a 10-item 
scale that is designed to assess 
individual differences in the 
habitual use of two emotion 
regulation strategies: cognitive 
reappraisal and expressive 
suppression (Gross, John, 2003).  
 
Effortful Control Scale – 
Full Scale  
• The Effortful Control Scale 
Derryberry & Rothbart, 1988, 
Evans & Rothbart, 2007) consists 
of 35 items that measure the 
degree to which the patient 
exhibits behavioral control. The 
data will be used to co-vary 
baseline differences in behavioral 
control if necessary.  
 
 
Drinking Motives 
Questionnaire 
• The Drinking Motives 
Questionnaire (Cooper, 1994, 
Kuntsche et al., 2006, Young-
Wolff et al., 2009) consists of 20 
items used to assess patients’ 
varying motives for drinking 
alcohol. The Drinking Motives 
Questionnaire will be used to 
assess whether motives for 
drinking alcohol change from 
baseline following treatment.  
 
 

 
 
 
 
 
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Quantity/Frequency of 
Alcohol use 
• Alcohol use will be evaluated 
with a variation of the measure 
used by White and Labouvie 
(1989).  First, participants will be 
asked if they have ever had an 
alcoholic drink (with instructions 
that define one alcoholic drink as 
“one beer, one glass of wine, or 
one serving of hard liquor either 
by itself or in a mixed drink”). 
Those (likely well over 90%) 
who answer that they have 
previously had alcohol before 
will be asked to rate: (1) their 
frequency of use in the last three 
months on a 9-point scale ranging 
from “never” to “every day”, (2) 
their typical quantity of drinks in 
one sitting on a 10-point scale 
ranging from “no drinks” to 
“more than 20 drinks”, and (3) 
their frequency of getting drunk 
when drinking in the past three 
months on a 5-point scale ranging 
from “never” to “always.” 
 
 
Alcohol Use Disorders 
Identification Test 
(AUDIT) 
 
 
 
 
 
 
 
• The AUDIT (Saunders, Aasland, 
Babor, De La Fuente & Grant, 
1993) is used to detect less severe 
problem drinkers and addresses 
both current problems (problems 
within the last 3 months) and 
problems across an individual’s 
lifetime.  The AUDIT consists of 
ten questions that cover such 
domains as alcohol consumption, 
drinking behavior, adverse 
psychological reactions, and 
alcohol-related problems. 
 
 
 
 
 
 
 
 
Prior Treatment 
Experiences 
Questionnaire (PTEQ) 
• Participants will be asked about 
their engagement in any 12-step 
programs (Tonigan, Miller & 
Conners, 1997), psychological 
services for alcohol and other 
 

 
 
 
 
 
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problems, and use of other self-
help materials. At baseline, 
participants will be asked about 
lifetime engagement in treatment. 
Because this study will be 
recruiting a population of heavy 
drinkers, it will be important for 
us to know whether or not any of 
our participants have previously 
received treatment for alcohol 
abuse. In future analyses, this 
information (e.g., prior treatment 
history) will be used as a 
covariate. 
 
Alcohol Urge 
Questionnaire (AUQ) 
• The AUQ  (Bohn et al., 1995) 
will be used to assess craving. 
The AUQ consists of eight items 
related to urge drink that are rated 
on a 7-point Likert scale with the 
extremes anchored by "Strongly 
Disagree" and "Strongly Agree." 
The AUQ has demonstrated 
internal consistency and 
reliability. 
 
 
Impulsivity and 
Sensation Seeking Scale 
(ImpSS) 
• The ImpSS (Zuckerman, 1996) 
consists of 19 items measuring 
impulsivity and sensation seeking 
that may predict responses to 
alcohol and drug problems. The 
sum of the symptoms endorsed is 
a proxy measure of dependence. 
 
 
Fruit and Vegetable 
Intake Screener (the 
“All-Day” version) 
• This 10-item measure was 
developed by the National Cancer 
Institute to assess how many 
times in the previous month 
subjects consumed different types 
of fruits and vegetables, including 
potion size questions for every 
food item. This measure was 
shown to be a useful estimate for 
obtaining median intakes of fruit 
and vegetable servings in U.S. 
populations (Thompson et al., 
 

 
 
 
 
 
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2002). Fruit and vegetable 
consumption has been shown to 
influence inflammation (e.g., Holt 
et al., 2009), and dietary factors 
have also been linked with 
epigenetic changes (see Hardy & 
Tollefsbol, 2011). Thus, the 
inclusion of this measure allows 
fruit and vegetable consumption 
to be controlled for in 
inflammation and epigenetic 
analyses. 
 
Self-Rated Diet Quality 
• This single-item, self-rated diet 
quality measure (Loftfield et al., 
2015) consists of a single 
question asking “In general, how 
healthy is your overall diet?” 
Participants can respond with (1) 
excellent, (2) very good, (3) 
good, (4) fair, or (5) poor. The 
item is significantly associated 
with variation in objective 
measures of dietary intake 
(P<.001).  
 

 
 
 
 
 
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Voluntary Aerobic 
Exercise Questionnaire 
(VAEQ) 
• The VAEQ assesses levels of 
voluntary exercise (Bryan and 
Rocheleau, 2002). Participants 
indicated how frequently they 
engaged in exercise activities in 
the past 3 months and past week. 
The exercise composite score 
used in these analyses was 
composed of 4 items: (i) “In the 
past 3 months,what is the average 
number of days per week that you 
engaged in aerobic exercise?” (ii) 
“In the past 3 months, what is the 
average number of total minutes 
per week that you engaged in 
aerobic exercise?” (iii) “In the 
past week, how many days did 
you engage in aerobic exercise?” 
and (iv) “In the past week, what 
is the total number of minutes 
that you engaged in aerobic 
exercise?” This measure has been 
used to quantify exercise 
participation in our previous 
alcohol studies (Karoly et al., 
2013). Given that exercise may 
impact inflammation (see Woods, 
Vieira, & Keylock, 2009) and 
epigenetics (see Ntanasis-
Stathopoulos, Tzanninis, 
Philippou, & Koutsilieris, 2013), 
this measure (either alone or in 
combination with the Godin, see 
below) will allow us to control 
for exercise behavior in 
inflammation and epigenetic 
analyses. 
 
 

 
 
 
 
 
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Godin Leisure Time 
Exercise Questionnaire 
• The Godin Leisure-Time 
Exercise Questionnaire (QLTEQ; 
Godin & Shephard, 1985) is used 
to generate ‘activity scores’ based 
on how many separate times 
(occasions) in a typical week 
participants engage in mild, 
moderate, or vigorous exercise 
for more than 15 minutes of their 
leisure time. The three levels of 
intensity are defined as follows: 
(1) mild exercise, defining 
features include, slightly elevated 
heartbeat, slightly elevated 
breathing rate (able to carry on a 
conversation effortlessly); (2) 
moderate exercise, defining 
features include accelerated 
heartbeat, moderately elevated 
breathing rate (able to carry on a 
conversation), and mild physical 
exhaustion; and (3) vigorous 
exercise, defining features 
include rapid heartbeat, heavy 
breathing (difficult or unable to 
carry on conversation), and 
physical exhaustion. Participants 
will be asked to answer how 
many separate times they 
engaged in mild, moderate, and 
vigorous intensity exercise over 
the past week (for each data 
collection time point). This 
measure could be used alone or in 
combination with the VAEQ to 
control for exercise participation 
in inflammation analyses. 
 
 
Perceived Stress Scale 
• The PSS (Cohen, Kamarck, & 
Mermelstein,1983) is a 14-item 
scale that measures (1) the degree 
to which situations in someone’s 
life are perceived as stressful. 
Stress is a known correlate of 
substance use and abuse and it 
will be crucial for us to obtain a 
 

 
 
 
 
 
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measure of our participants’ 
perceived stress levels, which 
may be associated with 
inflammatory processes (e.g., 
Hart & Kamm, 2002) and 
epigenetic changes (see Eric J 
Nestler, 2012). Thus, this 
measure will be used to control 
for stress in epigenetic and 
inflammation analyses. 
 
Pittsburgh Sleep Quality 
Index (PSQI) 
• The PSQI (Buysse, Reynolds, 
Monk, Berman, & Kupfer, 1989) 
is a 19-item self-report scale that 
measures sleep quality over the 
past month. The 19 self-related 
items are combined to form seven 
“component” scores, each of 
which has a range of 0-3 points. 
In all cases, a score of “0” 
indicates no difficulty, while a 
score of “3” indicates severe 
difficulty. The seven component 
scores are then added to yield one 
“global” score, with a range of 0-
21 points. In the present study, it 
will be important to control for 
sleep duration and/or quality, 
given that sleep is known to be 
associated with inflammation 
(e.g., Patel et al., 2009) and 
epigenetic factors (see Qureshi & 
Mehler, 2014). Thus, component 
scores, global scores and single 
item scores could all potentially 
be used as covariates in later 
analyses of these data. Scores 
from this measure will be 
included as covariates in 
inflammation and epigenetic 
analyses. 
 
 
The Leisure-Time 
Categorical Item (L-Cat) 
• The Leisure-Time Categorical 
Item (L-Cat) is a single item 
comprised of six descriptive 
categories ranging from inactive 
 

 
 
 
 
 
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to very active (Kiernan, 
Schoffman, Lee, Brown, Fair, 
Perri, & Haskell, 2013). Each 
category consists of 1–2 
sentences describing common 
activity patterns differing in 
frequency, intensity, duration, 
and types of activities, thus 
encompassing content validity 
(van Poppel, Chinapaw, 
Mokkink, van Mechelen, & 
Terwee, 2010). Respondents pick 
the category best describing their 
activity during the past month. It 
assesses national activity 
recommendations as well as 
multiple clinically relevant 
categories below and above 
recommendations, and 
incorporates critical 
methodological principles that 
enhance psychometrics 
(reliability, validity, sensitivity to 
change). 
 
Neurocognitive NIH Toolbox 
Measures Collected at Baseline 
& End of Treatment (week 8) 
 
20 minutes 
 
Flanker Inhibitory Control & 
Attention Test 
 
 
• Inhibitory control and attention. 
The participant focuses on a 
particular stimulus while ignoring 
other stimuli. Five arrows are 
displayed in the middle of the 
screen, each pointing left or right. 
The participant selects the arrow 
that matches the middle arrow in 
the sequence. 
 
 
Dimensional Change Card Sort 
Test 
• Measures cognitive flexibility 
and attention. Two target pictures 
are presented that vary along two 
dimensions (e.g., shape and 
color). Participants are asked to 
match one of the two bottom 
 

 
 
 
 
 
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cards to the card displayed at top, 
by either color or shape. 
 
Pattern Comparison 
 
• Measures processing speed. The 
test takes less than 90 seconds 
and requires participants to 
discern whether two side-by-side 
pictures are the same or not.  
 
 
Picture Sequence Memory Test  
 
• Episodic memory. Participants 
are asked to reproduce the 
sequence of pictures that is 
shown on the screen. 
 
 
Picture Vocabulary Test 
 
• A measure of receptive 
vocabulary administered in a 
computer-adaptive test (CAT) 
format. Participant matches 
picture with spoken word. 
 
 
List Sorting Working Memory 
Test  
 
• Participants have to say back the 
list of images they are given. 
 
 
 
MRI/fMRI Scan Collected at 
Baseline and 8 weeks 
 
 
 
MRI/fMRI In-task 
Measures 
• The MRI data collection will take 
place at the CU Boulder’s INC 
MRI Suite in the CINC. We will 
utilize a 2011 3T research-only 
Siemens Trio system (Erlangen, 
Germany) with a 32-channel head 
coil, multinuclear support, 
clinical features (extremity coil, 
shoulder array coil, spectrus 
injector), and additional software 
(e.g., BLADE, inline 
diffusion/BOLD, spectroscopy, 
cardiac, advanced functional 
software). Scanner instability and 
quality control on a phantom will 
be monitored weekly. All 
participants will undergo a 
structural scan, followed by a 
functional MRI scan, which 
 

 
 
 
 
 
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includes the alcohol cue task. 
 
Structural MRI (sMRI) 
• For this sequence, participants 
will be asked to just lie still and 
stay awake. No other actions on 
their behalf are needed. We will 
collect high-resolution anatomical 
images to permit accurate tissue 
classification and anatomical 
parcellation. For optimal contrast 
between gray matter (GM), white 
matter (WM) and cerebral spinal 
fluid (CSF) at 3T, we will use a 
multi-echo MPRAGE (MEMPR) 
sequence with the following 
parameters: TR/TE/TI = 
2300/2.74/900 ms, flip angle = 
8°, FOV = 256x256 mm, Slab 
thickness = 176 mm, Matrix = 
256x256x176, Voxel size =1x1x1 
mm, Number of echos = 4, Pixel 
bandwidth =650 Hz, Total scan 
time = 6 min. 
 
6 minutes 
Functional MRI (fMRI) 
• fMRI scans will be collected with 
single-shot full k-space echo-
planar imaging (EPI) with ramp 
sampling correction using the 
intercomissural line (AC-PC) as a 
reference (TR: 2.0 s, TE: 27ms, 
a: 70o, matrix size: 64 ´ 64, 32 
slices, voxel size: 3 ´ 3 ´ 4 mm3). 
Image-based higher order 
automatic shimming will be 
employed. fMRI data will be 
acquired with a 32-channel coil. 
Scanner instability and signal-to-
noise ratio during fMRI scanning 
on a phantom will be monitored 
weekly throughout the project 
period. Automated analysis of 
scanner instability with the 
Weiskoff method is routinely 
performed. We have used our 
alcohol cue task successfully in 
over 600 individuals (Claus et al., 
6 minutes 

 
 
 
 
 
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2011). It is reliable and well 
validated. The task compares the 
taste of an individual’s favorite 
alcoholic beverage with a sweet, 
appetitive control taste (litchi 
juice). The task was designed to 
minimize movement by only 
administering 1 ml of each 
beverage through Teflon tubing 
that is attached to a computer 
controller gustometer, over each 
24 second trial. It is important to 
note that the total amount of the 
alcoholic beverage is only 12 ml 
(less then a teaspoon). The task 
itself involves a block design 
with twelve pseudorandomly 
ordered alcohol and control trials 
that are presented in two 
consecutive runs. In order to 
examine whether the effects of 
MBRP differ from those of RP, 
we will calculate the signal 
change for alcohol minus the 
control condition in the 
precuneus, putamen, and anterior 
cingulate and use the signal in 
these regions of interest (ROIs) in 
the structural equation models 
(see analysis section).  
 
Resting State 
Connectivity  
• For this sequence, participants 
will be asked to just lie still and 
stay awake. No other actions on 
their behalf are needed. This 
resting state scan will be 
collected to derive measures of 
functional connectivity in the left 
and right executive control 
networks (LECN/RECN) 
following our previously 
published procedures (Weiland et 
al., 2014). These networks will be 
identified using functionally 
defined ROIs/nodes. The nodes 
for the LECN include: 
10 minutes 

 
 
 
 
 
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dorsolateral prefrontal cortex 
(DLPFC), left middle/superior 
frontal gyrus (MFG), left superior 
parietal gyrus/angular gyrus 
(PAR), left inferior/middle 
temporal gyri (TL), right crus 
I/crus II/Lobule VI (CE), and left 
thalamus (TH). The RECN nodes 
include: right DLPFC, right 
MFG, right PAR, right medial 
superior frontal gyrus (mSFG), 
left CE, and right caudate (CU). 
Functional connections between 
nodes, each pairwise correlation 
defined as an edge, will be 
calculated and used to create a 
correlation matrix between the 
time-series of all nodes within 
each network for each subject. A 
Fisher r-to-z transformation will 
be applied to r-values to yield z-
scores. Connectivity strength as a 
primary global measure of 
connectivity for each network 
will be calculated as the mean of 
all pairwise correlations between 
nodes within each network as 
well as other graph theory metrics 
(e.g., degree, efficiency, 
centrality). The framewise 
displacement (FD) for each 
subject will be calculated across 
the entire resting state run from 
the image motion parameter and 
used a covariate in the analyses. 
 
 
 
 
Visit/Session  
           Procedures/Tools 
Location 
Time to Complete 
Baseline Session  
• Informed consent; 
Study orientation; 
BAC test; Urine 
drug test; 
Questionnaires; 
Neurocognitive 
CINC 
2 hours and 30 
minutes 

 
 
 
 
 
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tests; Blood draw; 
receive microbiome 
kit 
 
MRI Scan I 
• BAC test; 
Pregnancy test; MRI 
 
CINC 
1 hour 
Goal-setting Session 
• BAC test; a goal 
setting session with 
a therapist to discuss 
drinking reduction 
goals for the next 8 
weeks; return 
microbiome kit  
 
CINC 
1 hour 
MBRP (or RP) 
Therapy Sessions 
(weeks 1-3 and 5-7) 
 
• BAC test; 
Mindfulness 
Relapse Prevention 
or Relapse 
Prevention therapy 
session with a 
trained therapist  
 
CINC 
1 hour each session 
(6 hours total) 
Intermediate Session 
(week 4) 
• BAC test; MBRP 
(or RP) therapy 
session; 
Questionnaires; 
Blood draw 
 
CINC 
2 hours  
End of Treatment 
Session (week 8) 
• BAC test; MBRP 
(or RP) therapy 
session; 
Questionnaires; 
Neurocognitive 
tests; Blood draw; 
receive microbiome 
kit 
 
CINC 
2 hours 
Mail-in Sample from 
Home 
• Subject will mail-in 
their collection kit 
back to our lab in a 
pre-paid, pre-
addressed envelope. 
At Home 
5 minutes 

 
 
 
 
 
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Follow-up Session 
(week 20) 
 
• BAC test; 
Questionnaires; 
Blood draw 
CINC 
1 hour  
Follow-up Session 
(week 32) & MRI 
Scan II 
• BAC test; 
Questionnaires; 
Blood draw; 
Pregnancy test; MRI 
scan 
CINC 
1 hour (2 hours with 
scan)  
Check-In Session 
(week 33) 
• BAC test; a check-
in session with a 
therapist to discuss 
potential relapse.  
CINC 
30 minutes 
 
TOTAL TIME 
 
 
 
Approximately 16 
hours (18 hours with 
MRI) 
 
 
 
 
 
Due to the COVID-19 situation we are collecting remote data only and will return to our original 
protocol when it is safe to do so. The remote PROCEDURES will be as follows: 
 
BASELINE SESSION: The first study appointment is an orientation and consent session, also referred 
to as the Baseline session. For this appointment, the participant will meet with a research assistant who 
will take them through the informed consent document and give them an opportunity to ask any 
questions about their participation in the study. The participant will show their ID over Zoom to the 
confirm they are between 21-60 years old. Then a research assistant will use Docusign to electronically 
sign the consent form and send it to the participant to sign. Signed consent forms will be stored 
securely on our server in a password protected folder.  
 
The research assistant will then email the participant a link to the questionnaires. The participant will 
answer these questions while on Zoom with the research assistant. Participants will complete 
computerized questionnaires asking about substance use, psychological functioning and health 
behaviors. Then, each participant will be assigned to receive either MBRP or RP for an 8-week long 
program, and will be compensated with at $30 Amazon gift card for completing this appointment.  
 
GOAL-SETTING SESSION: Participants will then be given some instructions about how to prepare 
for their next study session, which is called the Goal-setting Session. Before starting the 8-week long 
program, each participant will meet with a therapist for a 1 hour Goal-setting Session, resulting in a 
total of 9 individual therapy sessions. This will be an informational session where they will be 
introduced to their therapist, talk about goals for treatment, and learn about what they will be doing 
over the next 8 weeks. 
 
THERAPY SESSIONS: For the therapy sessions, participants will meet with a therapist via Zoom 
once a week for 1 hour individual sessions. The therapist will guide each session by engaging the 
participant in an exercise and a discussion. Participants will be compensated $15 in Amazon gift 

 
 
 
 
 
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cards for every therapy session they attend. This compensation will be totaled for therapy sessions 1-3 
and 5-7, and given to them at the end of their End of Treatment Session, at week 8 (see study table 
and compensation chart below). 
 
INTERMEDIATE SESSION - 4 WEEKS: At the Intermediate Session, 4-week therapy session, 
participants will have their regular meeting with a therapist, and complete similar computerized 
questionnaires. The research assistant will again email the participant a link to the questionnaires. The 
participant will answer these questions while on Zoom with the research assistant. They will be 
compensated with a $30 Amazon gift card for this appointment.  
 
END OF TREATMENT SESSION - 8 WEEKS: At the End of Treatment Session, week 8, participants 
will have their final session with their therapist and fill out questionnaires via a link sent by a research 
assistant over Zoom, and the research assistant will remain with the participant until they are finished. 
They will be compensated for all therapy sessions and receive an additional $30 Amazon gift card at 
the completion of this appointment.  
 
FOLLOW-UP SESSIONS I & II: At the end of this week 8 session, they will schedule their final two 
follow-up appointments with the research assistant. These will be scheduled at 20 weeks (3 months 
post-treatment) and 32 weeks (6 months post-treatment). At these two appointments, participants will 
fill out questionnaires via a link, and will be compensated with a $50 Amazon gift card for completing 
the questionnaires at each of these two follow-up appointments. After this 32-week appointment, 
participation in this study will be complete.  
 
Visit/Session 
Procedures/Tools 
Location 
Time to Complete 
Baseline 
Session 
Informed 
consent; Study 
orientation; 
Questionnaires. 
Remote/Zoom 
1 hours and 30 
minutes 
Goal-setting 
Session 
An introduction 
and goal-setting 
session with your 
therapist. 
Remote/Zoom 
1 hour 
MBRP or RP, 
Individual Therapy 
Sessions (weeks 1-
3 and 5-7) 
Mindfulness 
Based Relapse 
Prevention or 
Relapse Prevention 
therapy session with 
a trained therapist. 
Remote/Zoom 
1 hour sessions (6 
hours total) 

 
 
 
 
 
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Visit/Session 
Procedures/Tools 
Location 
Time to Complete 
Intermediate 
Session (at 4 
weeks) 
MBRP or RP 
therapy session; 
Questionnaires.  
Remote/Zoom 
2 hours 
End of 
Treatment Session 
(at 8 weeks) 
MBRP or RP 
therapy session; 
Questionnaires. 
Remote/Zoom 
2 hours 
Follow-up 
Session I (at 20 
weeks) 
Questionnaires 
Remote/Zoom 
1 hour  
Follow-up 
Session II (at 32 
weeks) 
Questionnaires 
Remote/Zoom 
1 hour  
TOTAL TIME 
 
 
Approximately 15 
hours  
 
XII. 
SPECIMEN MANAGEMENT  
Specimen data will be stored indefinitely in locked freezers on site within the PI’s laboratory 
designed specifically for storing biological specimens. All stored data will be coded with randomly 
generated numbers, and the master list linking the numbers to participants’ names will be stored on a 
password protected server.  For blood specimens being used for liver function tests, only research 
assistants who are authorized to work on the study will transport blood specimens from the CINC to 
Boulder Community Hospital Reference Laboratory in a sealed cooler. Identifying information 
associated with blood specimens will be removed before being transferred to BCH. Each specimen will 
be labeled with a general name (e.g. Research, P###), a randomly generated subject ID number, and a 
randomly generated date of birth to ensure confidentiality during specimen transport. At study closure, 
all links between participant name and number will be destroyed, at which point the specimen will be 
considered de-identified.  
XIII. DATA MANAGEMENT  
 
Strict standards of confidentiality will be maintained. MRI data will be electronically stored and 
analyzed using ID codes. If the data are published subjects will remain anonymous in all publications.  
Data will be stored indefinitely and will not be shared with other investigators without explicit 
permission from the CU Boulder IRB. 
Signed consent forms will be stored in a locked filing cabinet in the PI’s lab at the CINC. Liver 
function test results will be stored in the same locked filing cabinet. Electronically entered data from 
liver function test results will only be associated with the participant’s subject ID number. All data 
from self-report and interview measures will be stored on password protected computers and on the 
PI’s password protected server in the Department of Psychology & Neuroscience in Muenzinger Hall, 

 
 
 
 
 
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both of which are only accessible to research staff.  Any identifying information will be destroyed after 
the follow-up session. After this, there will be no way to connect participant’s names with participant 
data, at which point they will be considered de-identified.  
Individuals who will have access to subject data include Dr. Kent Hutchison, research assistants 
working on the study, and personnel involved with scanning procedures at CINC and Georgia State 
University (see below). 
Basic identifying information (name, address, phone number/email address) is collected from every 
research participant for the purpose of research logistics (schedule visits, etc.) and mailing of the 
radiological review letter, as appropriate. Participant names and other identifying information will be 
maintained in this restricted database, available only to authorized members of the research team for 
the duration of the study protocol. 
Brain researchers within the Intermountain Neuroimaging Consortium (INC) are located at the 
University of Colorado Boulder in Boulder, CO and Georgia State University (GSU) in Atlanta, GA. 
COINS, a common tool utilized by researchers at INC, is a Neuroinformatics website used to register 
and store MR data. The COINS web service employs the highest security for registering participants, 
and requires each researcher to gain permission before being allowed access to COINS. Each 
researcher is given a portal where they may register participants for their own studies. Each researcher 
and/or their staff will be responsible for registering participants in COINS. Unique research subject 
identifiers (URSIs) are created for each participant in order to de-identify their imaging and research 
data according to good clinical practice. The URSIs are generated via the COINS database. Every 
participant is given an URSI, and all MR data are stored at INC and GSU using the URSI. Participants 
are asked to register for the MRI with personal information including their names, birthdate, phone 
number and address. This information is necessary in cases of incidental findings where GSU 
radiological review requires that the participant be contacted.  GSU will maintain information 
associated with the URSI but not the scanning data (e.g., participant names and contact information) in 
a highly secure cloud computing service such as Amazon Web Services. 
CU Boulder and GSU are currently involved in the storage and security of imaging data. Research 
staff at GSU will not be engaged in the research (they will not be interacting or intervening with 
subjects, nor will they obtain subject’s private, identifiable data).  Staff at GSU may be involved in 
helping researchers interpret the data collected during the protocol, but will not receive personal or 
identifiable data about the subjects. De-identified data will be managed through the COINS system. 
Access to personal information is restricted to PIs and project staff for the specific study in which the 
participant is enrolled and senior GSU and INC staff (for cases of incidental findings where a 
radiological review and letter to the participant would be necessary). 
Microbiome and Alcohol Data Sharing: 
We plan to generate approximately 150 human gut microbiota metagenomes (i.e., microbiome). 
Per NIH policy of Genomic Data Sharing for this number of samples of non-human genetic data 
generated, data will be broadly shared for participants who consent. Specifically, de-identified gut 
metagenome data and phenotype data for consenting participants will be shared through GenBank, an 
NIH genetic sequence database at the National Center for Biotechnology Information that provides an 
annotated collection of publicly available DNA sequences. Data submission to GenBank will include 
individual-level microbiome data and phenotypic data related to alcohol use and depression. Separate 
signatures will be obtained for permission to broadly share these data. 
XIV. WITHDRAWAL OF PARTICIPANTS   

 
 
 
 
 
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Situations in which the entire study may be terminated early include the following:  If the 
Principal Investigator or other governing official discovers serious concerns about subjects' safety, 
inadequate performance or rate of enrollment (this includes a missed study session); because study 
objectives have been obtained according to pre-established statistical guidelines; or in the unlikely 
event that the Principal Investigator retires and no other additional investigators are able to succeed his 
role within the research project. 
Though highly unlikely, the circumstances under which a participant would be withdrawn 
without his or her consent include: obviously not following instructions or behavior that is verbally or 
physically abusive towards research staff. Those who experience early withdrawal will receive 
prorated payment based on the number of sessions they completed.  
XV. 
RISKS TO PARTICIPANTS 
 
Risks Associated with Venipuncture. 
 
 
 
There is a small risk of local hematoma, infection, and syncope associated with phlebotomy. 
 
Risks Pertaining to the Collection of Genetic Material.  
The collection of genetic material (i.e. from the blood) entails risks to confidentiality. Ethical 
guidelines for the collection and use of genetic material continue to develop; however, set guidelines 
for these purposes have yet to be officially set forth. The collection of genetic material has become 
common-place within several research disciplines, and entails only minimal risk to study participants. 
 
Risks Pertaining to Liver Function Panel Tests. 
 
There is a risk that the liver function panel test will reveal a result concerning an individual 
research participant beyond the scope of the study protocol due to a critical value level obtained from 
the blood work. In the event of Boulder Community Hospital Reference Laboratory obtaining a critical 
value level result, personnel from BCH will contact Dr. Kent Hutchison with the subject number and 
test results. Dr. Kent Hutchison will then share this information with the participant, which will likely 
be distressing to them.  
 
Risks Pertaining to fMRI Scans.  
The MRI scanning procedure in a 3 Tesla system has been approved by the FDA and is safe for 
use in healthy human populations and there are no known risks associated with the visual or auditory 
stimuli presented during recording of functional MRI. There are however, several risks both physical 
and psychological, involved in the use of fMRI. These shall be explained to the participants during 
screening and consent processes: 
 
Physical Risks and Discomforts. 
• The magnetic field of the MR environment has the potential to cause burns or bodily injury if 
ferrous metal objects are implanted in the body, or if personal articles containing ferrous 
material are brought into the environment. 
• Participants who could suffer potential risks include those with metal implants (pacemaker, 
metal rods, bone screws, orthodontics, metal flakes from metalworking).  

 
 
 
 
 
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• Participants who might be pregnant may be at risk during the MRI procedure. The risk of MRI 
to pregnant women and fetuses is currently unknown.   
• Participants have the potential to experience discomfort due to scanner noise.  
• Participants will be told that they may experience discomfort from lying in one position for a 
long time. The discomfort should subside once the scan is complete, but some subjects may be 
sore for a more extended duration. 
• Participants will be informed about peripheral nerve stimulation (PNS/tingling) that they may 
experience during the scan. At sufficient exposure levels, peripheral nerve stimulation is 
perceptible as “tingling” or “tapping” sensations.  
 
Psychological Risks and Discomforts. 
• There is some risk of feeling nervous or claustrophobic while participants are in the scanner. 
• There is a risk that the image will reveal an observation concerning an individual research 
participant that has potential clinical importance but is beyond the aims of this protocol. In the 
event of the confirmation of a significant anomaly in a participant’s brain image, this 
information will likely be distressing to the participant. 
 
Exposure to Alcohol. 
During the fMRI scan at baseline and the second follow-up visit, participants are exposed to 
less than a teaspoon of an alcoholic beverage, there is a risk that participants may experience an urge to 
drink or it might cause cravings or anxiety. This risk is particularly relevant during the second MRI 
scan because many patients may have established abstinence or reduced their alcohol consumption 
substantially. 
  
Risks Pertaining to Loss of Confidentiality and Privacy. 
Confidentiality of participants is a priority for research staff and must be maintained unless the 
investigator obtains the express permission of the subject to do otherwise. Risks from breach of 
confidentiality include invasion of privacy, as well as social and economic risks. Economic risks 
include alterations in relationships with others that are to the disadvantage of the subject, and may 
involve embarrassment, loss of respect of others, labeling with negative consequences, or diminishing 
the subject's opportunities and status in relation to others. These risks include payment by subjects for 
procedures, loss of wages or income, and/or damage to employability or insurability. 
Participants will be asked about illegal activities that they may have been involved in (i.e. illicit 
drug use). Participants will also be warned that there are some things that they might tell us that we 
CANNOT promise to keep confidential. Participants will be informed that we are required to report 
information like child abuse or neglect, crimes that they tell us they or others plan to commit, or harm 
planned against yourself or others. 
Self-report data will be collected via individual laptop computers. Theft of the study computers 
is also a possibility, but an extremely unlikely risk.  
Participants must be 21 years of age in order to participate in the study. For this reason, 
participants’ driver’s licenses will be checked at the beginning of the first study session to ensure that 
they are 21 years of age. In order to protect confidentiality, a copy of the license will not be retained.  
 
Unanticipated risks. 
Any experiment may involve risks that cannot be anticipated.  If unanticipated risks occur, the 
investigators will follow the IRB guidelines for adverse event reporting the risks, discomforts, hazards 

 
 
 
 
 
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or inconveniences to the participants.  
XVI. MANAGEMENT OF RISKS 
Participants are informed of all procedures beforehand, and they must read the informed 
consent form and sign the consent form stating that they understand and agree to the procedures before 
beginning the study. 
 
Protection against risks associated with Venipuncture. 
The risks of hematoma and infection are minimized by having trained phlebotomist perform all 
blood draws along with using standard and sterile phlebotomy techniques. 
 
Risks Pertaining to the Collection of Genetic Material. 
The collection of genetic material has become commonplace within several research 
disciplines, and entails only minimal risk to study participants. All genetic material will be coded and 
stored with a randomly generated number. The master list linking the numbers to participants’ names 
will be stored on a password-protected server.  At study closure, all links between participant name and 
URSI will be destroyed, at which point the specimen/data will be considered de-identified. Participants 
will be informed, both verbally and in writing upon initial consent, of the risks of genetic research. 
 
Risks Pertaining to Liver Function Panel Tests. 
 
In the unlikely event of a critical value level test result, BCH will inform Dr. Kent Hutchison of 
the participant’s randomly generated participant number and abnormal test result. Dr. Hutchison will 
immediately inform the participant of the test results and share a copy of the results for the participant 
to give to their primary care physician or a referred specialist. Participants will be informed of this risk 
associated with the liver function test during the consenting process and made aware that we will be 
unable to clinically interpret the results past informing them that they indicate critical value levels.   
 
Risks Pertaining to fMRI Scans. 
This protocol will be performed using an MR scanner employing pulse sequences and hardware 
that have been approved by the FDA for human clinical use. The field strength is 3 Tesla and all 
relevant operating characteristics (RF power deposition, rate of change of the field gradients, coil 
design) fall within the limits of FDA guidelines for NMR exposure.  
 
In the case of an anomalous finding in a brain image, the following procedure is followed: 
1. The technologist and/or research personnel flag potential abnormalities. 
2. The MRI technologist notifies the INC Director of Operations, appropriate Georgia State 
University (GSU) personnel, and the P.I.  
3. The scan gets queued to the radiologist worklist in COINS.  All cases of suspected incidental 
findings are sent for formal neuroradiologic review at GSU. 
4. The radiology review contains a written summary of the findings and classifies the referral 
status into one of these categories: 
o There is not enough information from the MRI scan to complete a full review. No 
obvious abnormalities found. 
o MRI shows nothing obvious that needs medical attention.  

 
 
 
 
 
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o MRI shows something that may or may not be of medical concern.  Participants should 
consider discussing the enclosed report with their doctor.  
o MRI shows something that needs to be brought to the attention of your 
doctor. Participants may also be contacted by the study team and/or appropriate GSU 
personnel about this report. 
5. The PI will get an electronic copy of the radiology review (coded via URSI) as soon as the 
review is completed. If an urgent referral is recommended, the PI should discuss the review 
with the Medical Director prior to contacting the participant. 
6. If a referral is recommended, the PI will contact the participant and explain that an unusual 
feature was observed in their scan. The PI provides the contact information for the Medical 
Director who reviewed the image (this information is in the letter mailed to the participant as 
well). Routine referrals are handled on a case by case basis and up to the PI/Medical Director to 
determine if the participant should receive a call in advance. 
7. All cases reviewed will generate a formal radiology report, which is printed on letterhead and a 
copy of which is mailed to the participant. In the case of an urgent referral, someone from the 
study team or the Medical Director will contact the participant prior to the letter being mailed 
 
Physical Risks and Discomforts. 
• Participants who could suffer potential risks include those with metal implants (pacemaker, 
metal rods, bone screws, orthodontics, metal flakes from metalworking). Participants are 
carefully screened for these types of metal implants or any other bodily exposure to metal during 
informed consent, and again prior to the MR scan, using an MRI safety screening checklist. It 
will be clearly explained to participants that the magnetic field of the MR environment has the 
potential to cause burns or bodily injury if ferrous metal objects are implanted in the body, or if 
personal articles containing ferrous material are brought into the environment. MR Facility rules 
strictly forbid staff from entering the magnet room carrying metal objects. 
 
• Female participants will be warned that the risk of MRI to pregnant women and fetuses is 
currently unknown. Study staff will explicitly inform all female participants of this fact and 
they will be given the option to complete a free urine pregnancy test. Female subjects who test 
positive will not be allowed to participate in the study. The pregnancy test will be strongly 
recommended by the study staff. If the participant wishes to dismiss the request to complete a 
urine pregnancy test, they must sign an agreement to acknowledge the risk and indicate that 
they do not believe they are currently pregnant. This will be required immediately prior to the 
MRI scan.  
 
• Participants will be informed about potential discomfort they may experience due to scanner 
noise. This risk will be minimized by providing participants with earplugs and headphones. 
Ultimately, the volume of the noise is not great enough to pose a health risk, with or without 
earplugs/headphones.  
 
• Participants will be told that they may experience discomfort from lying in one position for a 
long time. The discomfort should subside once the scan is complete, but some subjects may be 
sore for a more extended duration.  
 

 
 
 
 
 
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• Participants will be informed about peripheral nerve stimulation (PNS/tingling) that they may 
experience during the scan. At sufficient exposure levels, peripheral nerve stimulation is 
perceptible as “tingling” or “tapping” sensations. It will be made clear to participants that PNS 
symptoms usually subside shortly after the scan is completed. In addition, participants are 
given a squeeze ball to use in case of an emergency. They are informed that if they experience 
PNS related sensations or are otherwise uncomfortable, they can alert the MRI technologist via 
the squeeze ball and the technologist will stop the scan immediately. 
 
Psychological Risks and Discomforts. 
• There is some risk of feeling nervous or claustrophobic while participants are in the scanner. 
This risk will be minimized by (1) including exclusion criterion for claustrophobia in the phone 
pre-screen, (2) informing participants before they enter the scanning room that they may stop 
the scan at any time, (3) providing participants ear protection with headphones, a mirror to see 
out, a button to signal distress, and an intercom and (4) making sure the subject is lying 
comfortably with head and neck supported.  Scan time will be kept to a minimum.   
 
 
• There are psychological risks associated with potential incidental findings that may show up in 
the scan images.  For example, there is a risk that an image may reveal an observation 
concerning an individual research participant that has potential clinical importance but is 
beyond the aims of the study.  In the event of the confirmation of a significant anomaly in a 
participant’s brain image, this information will likely be distressing to the subject and 
constitutes a psychological risk.  
 
Exposure to Alcohol.  
During the fMRI session, participants may experience a reaction to the alcohol presented to them 
during the scan. Such a reaction might manifest as craving or anxiety. These effects are almost always 
only temporary. We have used the same cue exposure task in over 600 participants; many of who were 
treatment-seeking patients who had established some measure of abstinence (required to be in our 
studies) prior to scanning.  We have not observed any adverse effects from our cue exposure protocol 
in these individuals. It is important to understand that the entire task uses less than 1 tsp of an alcohol 
beverage. The consent form clearly notes that the cue exposure session takes place at baseline and at 
the second follow-up session (week-32) and clearly notes that patients can opt out of the cue exposure 
part of the study. The patients will be reminded again about the option to opt out of the MR scan. As 
we have done previously, we will conduct an assessment with each participant after the cue exposure 
session to determine whether there is any residual craving or anxiety. We also allow each patient to 
process his or her reaction to the alcohol cues with a therapist before leaving the experiment. Thus, the 
therapist and study staff will know immediately if there is an adverse reaction to the cues. The therapist 
will address any adverse reactions to the cues at that time. In addition, therapists will now see all 
patients for an additional week of therapy. Thus, a plan is also in place for follow-up with these 
patients. During this session at week-33, the therapist will assess whether there were any adverse 
events, including a lapse that may have resulted from the cues.  Any adverse events will be addressed 
in the session and reported to the PI. These procedures ensure that the patient does not leave the lab in 
a vulnerable state. If more than five individuals during the entire trial report having a lapse within 48 
hours of the cue exposure session, we will discontinue the cue exposure assessment. 
 
 

 
 
 
 
 
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Risks Pertaining to Loss of Confidentiality and Privacy.  
Identifying information will be collected only for the purpose of contacting participants for their 
longitudinal follow-up assessments. All study computers are password protected and housed in the PI’s 
lab space at either Muenzinger Hall or the CINC, which are both kept locked unless researchers or 
students are currently using the space. Further, there is no identifying information contained on the 
laptops. All identifying information (e.g., consent forms, contact information) is kept separate and 
secure from the data files and never on the same laptop and this information will be destroyed 
immediately after the last follow-up.  
Participants will be informed that we are required to report information like child abuse or neglect, 
crimes that they tell us they or others plan to commit, or harm planned against yourself or others. 
XVII. POTENTIAL BENEFITS  
These studies are expected to add to the knowledge base of information on the development 
and treatment of alcohol use disorder. Given only a slight risk to participants and the greater possibility 
of long-term benefits to the knowledge base and to treatment interventions for alcoholics, the 
risks/benefits ratio seems reasonable. As a part of this study, all participants will have the opportunity 
to examine their own alcohol use behavior in the context of completing measurement instruments, and 
will have the opportunity to work with a trained therapist over the course of the trial.  Participants will 
also receive the added benefit of a treatment (either MBRP or RP) that has demonstrated efficacy in 
the treatment of AUD. The risks associated with participating have been minimized via the procedures 
described above. Finally, a demonstration that MBRP is superior to RP and the identification of the 
mechanisms of action has great potential to benefit others. 
XVIII. PROVISIONS TO MONITOR THE DATA FOR THE SAFETY OF PARTICIPANTS 
We have taken a number of measures to ensure the confidentiality of the data and the safety of 
the participants. All data from the proposed study will be identified by a numerical ID code only.  The 
information linking the numerical ID code to identifying information will be maintained separate and 
secure from the data themselves.  At the conclusion of the final follow-up data collection, the list 
linking the ID code to identifying information will be destroyed.  
It will be the responsibility of the PI to obtain and maintain approval of all procedures from the 
Internal Review Board (IRB). Study staff will report to the PI on a weekly basis regarding the 
procedures being employed in the protocol to assure that all IRB-approved procedures are being 
followed. Any adverse events will be reported to the PI immediately. The PI will immediately call the 
IRB to inform the secretary and the committee of the adverse event. The PI will submit a detailed 
description using the HRP-214 New Information Form in eRA to report all adverse events consistent 
instructions of CU Boulder IRB’s List of Standard Operating Procedures document: 
(http://www.colorado.edu/vcr/sites/default/files/IRB-Policies-and-Procedures_05012013.pdf). 
Consistent with IRB policy, the reporting will occur immediately (within 24 hours) upon learning of a 
study-related death, study personnel will notify the IRB via e-mail by providing a brief summary of the 
event. Then, within 1 week (five business days), the PI or designee will submit a Reportable Event in 
eRA. (2) For any other problem or event requiring reporting to the IRB, the PI or designee will submit 
to the IRB a Reportable Event or Deviation in eRA as soon as possible, but no later than 10 working 
days from notification of event. 

 
 
 
 
 
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In addition, the proposed study will form and utilize a Data Safety and Monitoring Board 
(DSMB) at the University of Colorado.  This DSMB is will consist of individuals with broad range of 
clinical and research experience.  The DSMB members will include a psychiatrist (e.g., Dr. Chris 
Schenck) a clinical psychologist working in a non-profit addiction center (e.g., Dr. Annie Peters), and 
individual with extensive experience in research ethics who is also a member of the IRB (e.g.,  Dr. 
Thomas Kuntsman). The DSMB is intended to ensure the safety of our research participants, the 
validity of the data, and the appropriate termination of the proposed study based on any emergent 
significant benefits or risks.  For these reviews the DSMB will review any adverse events and any 
safety differences that are emerging between the randomized arms at intervals of every three months.  
To facilitate this review, the PI will provide the DSMB with the data related to safety and efficacy. If 
the DSMB determines that there are significant emergent risks, the DSMB will make a 
recommendation to the PI and IRB that the study be closed for accrual of participants until a more 
detailed review can be conducted in conjunction with the PI and IRB.  Ultimately, the study may be 
terminated depending on the outcome of this review. 
The MRI technologists are not trained to identify potentially significant clinical anomalies in 
the brain images. Should the MRI technologist notice something he or she believes to be a potential 
anomaly in a brain image, he or she will follow the procedure noted in section XVII to ensure 
appropriate radiological review. The participant will be contacted if the radiologist recommends a scan 
to determine the clinical significance of any anomaly.  
Lastly, a potential risk that the study team will be prepared to manage is participant 
endorsement of thoughts of suicide on the Beck Depression Invention (BDI-II). The BDI-II is used to 
measure depression symptomatology. Item number 9 from the BDI-II inquires about “suicidal thoughts 
or wishes” that participants may or may not be experiencing. In order to ensure the safety of our 
participants, a staff member will check the participant’s response to item number 9 of the BDI-II 
before the participants leaves the building. If a participant has either responded “I would like to kill 
myself” or “I would kill myself if I had the chance,” the research team member will immediately notify 
Dr. Hutchison (a licensed clinical psychologist). Dr. Hutchison or a master’s-level clinician will 
immediately assess the participant for imminent suicide risk and provide him/her with a list of 
psychological services referral contacts. After the participant has been assessed for risk, the study 
coordinator will use the CU CHANGE lab’s previously IRB approved ‘Suicide Ideation Protocol’ to 
connect the participant with an appropriate referral resource (i.e., 911 if in imminent danger, Boulder 
County Mental Health Center (BCMHC) if the participant is a community member, or Wardenburg 
Health Center and/or BCMHC if the participant is a CU Boulder student, staff, or faculty member). Dr. 
Hutchison himself or a research team member will follow up with Dr. Hutchison to ensure that all of 
the necessary measures had been taken to protect the safety of the participant and determine whether or 
not it is safe for the participant to continue their involvement in the study. If it is determined that the 
participant is at imminent risk and should not continue participating in the study, Dr. Hutchison will 
contact the participant and explain that for their safety, the research team does not feel that it is safe for 
him/her to continue participating in the study and will also answer any questions the participant may 
have about this decision.   
XIX. PROVISIONS TO PROTECT THE PRIVACY INTERESTS OF PARTICIPANTS  
Fully informed consent will be sought to ensure that participants are aware of any possible 
risks. Subjects will be aware of all study procedures, measures, and data being collected throughout the 

 
 
 
 
 
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study. Data and observations will not be collected or obtained without their knowledge or consent. 
Participation in the research is completely voluntary, as is answering each particular question in all of 
the measures and providing each physiological measure. 
XX. 
MEDICAL CARE AND COMPENSATION FOR INJURY 
 Participants will be informed to contact Dr. Hutchison immediately by phone (303-735-1304) 
should they feel that they have been harmed while participating in this study. They will be told that the 
cost for any treatment will be billed to them or their medical or hospital insurance. Information 
regarding compensation for injury is included in the informed consent document.  
XXI. COST TO PARTICIPANTS  
There are no costs to the participant for participation in this study aside from those accrued 
from transportation to and from study appointments. Participants will be compensated throughout the 
study, with a total of $280 if they complete all sessions. For those subjects who are eligible and 
selected to participate in the MRI scan portion of the study, they will be compensated an addition $60 
($30 per scan) with a total of $340 if they complete all sessions. At each session they will be 
compensated a given amount (described in IX.) that should cover all travel costs and parking is free at 
the CINC.   
XXII. DRUG ADMINISTRATION 
Not Applicable.  
XXIII. INVESTIGATIONAL DEVICES 
Not applicable.  
XXIV. MULTI-SITE STUDIES 
Not applicable.  
XXV. SHARING OF RESULTS WITH PARTICIPANTS 
 There are no plans to share results of the study with individual participants. 
 
 
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