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

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 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.