Cognitive Training in the Treatment of Alcohol Use Disorders in Older Veterans

 描述(由申请人提供)： 酒精使用障碍(AUD)具有重大的公共健康影响，在美国每年花费数十亿美元用于治疗和丧失生产力，在退伍军人中非常普遍。1-4心理社会和行为干预措施具有一定的疗效，但正如退伍军人协会对一种药物增强剂(纳曲酮)的大型合作多点研究所揭示的那样，研究的所有分支中有很高比例在一年内复发。5因此，迫切需要继续探索改善退伍军人AUD治疗的方法。改善AUD治疗结果的一种可能的方法可能是解决神经认知障碍，尤其是在康复的早期阶段，但通常会持续多年，干扰新的 学习(如注意力和记忆力)和更好的决策(执行功能)。事实上，与酒精相关的认知障碍可能会影响个人从治疗中获益的能力，并损害他们的日常社区功能，从而增加压力和随后的复发，从而导致AUD的进展。9，10最近的研究表明，认知补救疗法(CRT)可能会改善精神分裂症和相关障碍的注意力、记忆和执行功能，11-15并可能导致结构性群体获得更好的技能。16因为许多AUD治疗也需要技能获得，如学习应对渴望的新方法，学习更好的忍受痛苦的方法，以及使用解决问题的策略，提高注意力，工作记忆和执行功能可以让患者从以康复为导向的治疗中获得更多。国家药物滥用研究所(NIDA)受到CRT的初步发现以及关于物质使用障碍(SODS)对认知影响的大型神经科学文献的充分鼓舞，发布了题为“改善药物滥用治疗结果的认知补救方法(R21)”的RFA，我们小组(PI：BELL)获得了这些奖项之一。在有物质使用障碍的退伍军人中，我们的研究比较了CRT和工作疗法(WT)与单独的WT，发现在训练结束(3个月)和随访(6个月)时，执行功能和工作记忆有显著改善。此外，患有AUD的人从CRT中受益最大，他们在语言学习方面有了显著的改善，这是AUD中尤其受损的一个认知领域。在这两种情况下都发现了良好的SUD结果。这项拟议的研究是一项双武装、意向治疗、双盲随机对照试验，将重点放在AUD上，并将CRT与手册个人药物咨询(IDC)相结合，该方法目前正由我们的联合调查员在NIDA资助的一项研究中使用，而不是继续工作治疗。CRT与IDC的结合将增加对任何门诊患者的普适性，无论他们是否想参与工作治疗，并将提供标准化的门诊酒精治疗。CRT+IDC的情况将与游戏安慰剂+IDC的情况进行比较。游戏安慰剂条件目前正被用于国防部赞助的一项双臂、双盲研究，用于患有mTBI的退伍军人CRT(SITE-PI：BELL)。我们假设CRT将改善神经认知，从而促进IDC的治疗。在AUDS康复的早期阶段(戒烟30天内)的90名参与者将被随机分配到不同的情况，按基线时的神经认知功能进行分层。参赛者对自己的状况视而不见，评估员也是如此。参与者进行为期3个月的积极治疗，每周评估酒精使用情况。在积极治疗结束时和6个月随访时进行神经认知测试。主要的AUD结果是活动期饮酒天数和大量饮酒天数。二次AUD结果是在6个月随访前30天内饮酒天数和大量饮酒天数。次要结果包括3个月和6个月随访时的神经认知改变。

 DESCRIPTION (provided by applicant): Alcohol Use Disorders (AUDs) have a significant public health impact, cost billions of dollars in the US each year for treatment and lost productivity, and are highly prevalent in Veterans.1-4 Psychosocial and behavioral interventions have some efficacy, but as revealed in a large VA cooperative multi-site study of a pharmacological augmentation (naltrexone), a high proportion in all arms of the study relapsed within one year.5 There is, therefore, a critical need to continu to explore ways to improve AUD treatment in Veterans. One possible way to improve AUD treatment outcomes may be to address neurocognitive impairments especially common in the early phase of recovery but often persisting over years7 that interfere with the acquisition of new learning (e.g. attention and memory) and with better decision making (executive functioning). Indeed, alcohol related cognitive impairments may contribute to the progression of AUD by affecting the individual's ability to benefit from treatment8 and impairing their daily community functioning, which in turn increases stress and subsequent relapse.9,10 Recent research has suggested that cognitive remediation therapy (CRT) may improve attention, memory and executive function in schizophrenia and related disorders,11-15 and may lead to better skill acquisition in structured groups.16 Since many AUD treatments also require skill acquisition such as learning new ways of coping with craving, learning better methods for tolerating distress, and using problem-solving strategies, improving attention, working memory and executive functioning could allow patients to get more out of their recovery-oriented treatments. The National Institute of Drug Abuse (NIDA) was sufficiently encouraged by preliminary findings of CRT as well as the large neuroscience literature on the effects of substance use disorders (SUDs) on cognition to issue an RFA entitled "Cognitive Remediation Approaches to Improve Drug Abuse Treatment Outcomes (R21)", and our group (PI: Bell) received one of these awards. Our study compared CRT with work therapy (WT) to WT alone in Veterans with substance use disorders and found significantly greater improvement in executive functioning and working memory at the conclusion of training (3 months) and at follow-up (6 months). Moreover those with AUD benefitted most from CRT, and they had significant improvements in verbal learning, a cognitive domain especially impaired in AUDs. Excellent SUD outcomes were found for both conditions. The proposed study is a two armed, intent-to-treat, double-blind randomized controlled trial that will focus on AUD and will combine CRT with manualized Individual Drug Counseling (IDC), which is currently being used in a NIDA funded study by our Co-Investigator, rather than continuing with work therapy. Combining CRT with IDC will increase generalizability to any outpatient, whether or not they want to be involved in work therapy, and will provide standardized outpatient alcohol treatment. The CRT+IDC condition will be compared to a Game-Play Placebo+IDC condition. The Game-Play Placebo condition is currently being used in a DoD sponsored two-armed, double-blind study of CRT for Veterans with mTBI (site-PI: Bell). We hypothesize that CRT will improve neurocognition and thereby facilitate IDC treatment. Ninety participants referred in the early phase of recovery from AUDs (within 30 days of abstinence) will be randomized to condition, stratified by neurocognitive function at baseline. Participants are blind to their condition as is the assessor. Participants engage in their active treatment for 3 months with weekly assessments of alcohol use. Neurocognitive testing is performed at the conclusion of active treatment and at 6 month follow-up. Primary AUD outcomes are number of days of alcohol use and heavy drinking days during the active phase. Secondary AUD outcomes are number of days of alcohol use and heavy drinking days in the 30 days prior to 6 month follow-up. Secondary outcomes include neurocognitive change at 3 month and 6 month follow-up.