Cognitive Remediation and Work Therapy in the Initial Phase of Substance Abuse Tr

描述(由申请人提供)：这项建议旨在试点测试认知补救疗法(CRT)与工作疗法(WT)相结合，作为门诊药物滥用治疗初始阶段的辅助手段。有充分的研究证据表明，药物滥用障碍中存在认知障碍，特别是在康复的早期阶段。认知障碍与较差的药物滥用治疗结果有关，可以通过针对这些障碍的练习计划来补救。我们之前已经报道了一种在门诊环境下为精神病患者提供CRT与工作治疗(WT)的模式，该模式显示出执行功能和工作记忆以及工作表现和持续工作活动等重要功能结果的显著改善。我们建议将同样的方法应用于从开始康复的药物滥用者的30天住院计划中招募的参与者样本。当他们出院后，他们将能够继续接受治疗，这可能会鼓励他们参与CRT和药物滥用门诊服务。我们的具体目标是：1.在药物滥用治疗的早期阶段测试CRT和WT的可行性和耐受性。2.获得CRT和WT与单独WT在未来R01随机对照试验提交的主要药物滥用结果测量(戒酒天数百分比，PDA)上的效果大小。3.获得次要结果的效果大小(认知、心理社会、职业)。3.审查可能与确定纳入/排除随机对照试验标准有关的调节因素的影响，如年龄、药物滥用类型和认知功能。4.检测神经心理变化和治疗依从性等影响疗效的中介因素，了解治疗效果的机制。我们建议通过将50名希望接受WT服务的参与者随机分为两种情况来实现这些目标：25名被分配到15小时的WT+每周5小时的CRT(CRT+WT)，25名被分配到20小时的WT的主动控制。积极干预将持续13周。CRT将由来自位置科学的循序渐进的视觉和听觉练习的层级重复训练组成。WT将在他们选择的医疗中心校园内进行有偿工作活动。参与者在CRT和WT的时间将获得相同的时薪(联邦最低工资的一半)。全面评估将在入学时、3个月和6个月进行。这些将包括药物滥用、认知和心理社会后果以及坚持治疗。在为期3个月的积极干预期间，参与者将接受每周观察的尿毒学筛查、呼气分析测试和PDA评估，以及每月的工作表现评估。数据分析将包括随机效应回归模型，以及调节和中介效应对PDA主要结果的模型。如果发现有意义的影响，这些结果将指导后续的R01提交。 公共卫生相关性：这项研究将初步测试认知补救疗法与工作疗法相结合的使用，以了解患有初级物质使用障碍的门诊患者是否会进行这种治疗，以及它是否会比没有认知补救的工作疗法带来更好的认知和物质滥用结果。研究结果可能会为进一步测试一种新的治疗模式提供指导，这种模式可能会更有效地吸引门诊患者，并导致更快的康复。

DESCRIPTION (provided by applicant): This proposal aims to pilot test a cognitive remediation therapy (CRT) combined with work therapy (WT) as an adjunct to the initial phase of outpatient substance abuse treatment. There is ample research evidence of cognitive impairment across substance abuse disorders, particularly in the early phase of recovery. Cognitive impairment has been associated with poorer substance abuse treatment outcomes and may be remediated through programs of exercises that target these impairments. We have previously reported on a model of providing CRT with work therapy (WT) in an outpatient context for people with psychotic disorders, which showed significant improvements in executive function and working memory, and in important functional outcomes such as work performance and sustained work activity. We propose to apply this same approach to a sample of participants recruited from a 30-day residential program for substance abusers who are beginning their recovery. When they are discharged, they will be able to continue WT, which may encourage their engagement in CRT and in substance abuse outpatient services. Our Specific Aims are: 1. Test the feasibility and tolerability of CRT & WT in the early phase of substance abuse treatment. 2. Obtain effect size for CRT & WT compared to WT alone on a primary substance abuse outcome measure (Percent Days of Abstinence, PDA) for a future R01 RCT submission. 3. Obtain effect sizes for secondary outcomes (cognitive, psychosocial, vocational). 3. Examine effects of moderators such as age, type of substance abuse, and cognitive functioning that may be relevant for determining inclusion/exclusion criteria for an RCT. 4. Examine mediators of outcome such as neuropsychological change and treatment adherence to understand the mechanisms of treatment effects. We propose to accomplish these aims by randomizing 50 participants who wish to receive WT services into two conditions: 25 will be assigned to 15 hours of WT plus 5 hours of CRT each week (CRT+WT) and 25 will be assigned to an active control of 20 hours of WT. The active intervention will be for 13 weeks. CRT will be comprised of a repetitive training on a hierarchy of progressive visual and auditory exercise from Posit science. WT will involve paid work activity in a placement of their choosing on the medical center campus. Participants will be paid the same hourly rate (half federal minimum wage) for their time in CRT and WT. Comprehensive assessments will be performed at intake, 3 months and 6 months. These will include substance abuse, cognitive, and psychosocial outcomes as well as adherence to treatment. During the 3 months of active intervention participants will have weekly observed urine toxicology screens, breathalyzer tests and PDA assessments, as well as monthly work performance evaluations. Data analyses will include random effects regression models, as well as models of moderator and mediator effects on the primary outcome of PDA. If meaningful effects are found, these results will guide a subsequent R01 submission. PUBLIC HEALTH RELEVANCE: This study will pilot test the use of cognitive remediation therapy combined with work therapy to learn whether outpatients with primary substance use disorders will engage in this treatment and whether it will lead to better cognitive and substance abuse outcomes than having work therapy without cognitive remediation. Findings may offer guidance for further testing a new model of treatment that may engage outpatients more effectively and lead to more rapid recovery.