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）对公共卫生有重大影响，每年在美国花费数十亿美元用于治疗和生产力损失，并且在退伍军人中非常普遍。1 -4心理和行为干预具有一定的疗效，但正如一项大型VA合作多地点药物增强研究所揭示的那样，（纳曲酮），研究的所有组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方法可能是解决神经认知障碍，特别是在恢复的早期阶段，但通常持续多年7，干扰新的认知能力的获得。 学习（例如注意力和记忆力）和更好的决策（执行功能）。事实上，酒精相关的认知障碍可能会影响患者从治疗中获益的能力8并损害其日常社区功能，进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，认知补救治疗（CRT）可能会改善精神分裂症和相关疾病的注意力、记忆力和执行功能，16由于许多AUD治疗也需要获得技能，例如学习应对渴望的新方法，学习更好的方法来忍受痛苦，以及使用解决问题的策略，改善注意力，工作记忆和执行功能可以让患者从他们的康复治疗中获得更多。 国家药物滥用研究所（NIDA）充分受到CRT的初步发现以及关于物质使用障碍（SUD）对认知影响的大量神经科学文献的鼓舞，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，我们的团队（PI：Bell）获得了这些奖项之一。我们的研究比较了CRT与工作疗法（WT）单独WT在退伍军人与物质使用障碍，并发现显着更大的改善执行功能和工作记忆在训练结束（3个月）和随访（6个月）。此外，AUD患者从CRT中获益最多，他们在语言学习方面有显着改善，这是一个在AUD中尤其受损的认知领域。在两种情况下均发现了极好的SUD结局。 拟议的研究是一项双臂、意向治疗、双盲随机对照试验，将重点关注AUD，并将联合收割机CRT与手动个体药物咨询（IDC）相结合，后者目前正由我们的合作研究者用于NIDA资助的研究，而不是继续进行工作治疗。将CRT与IDC相结合将增加对任何门诊病人的普遍性，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。将CRT+IDC条件与游戏安慰剂+IDC条件进行比较。游戏安慰剂条件目前正用于DoD申办的mTBI退伍军人CRT的双臂、双盲研究（研究中心-PI：Bell）。我们假设CRT将改善神经认知，从而促进IDC治疗。 在AUD恢复早期（戒断后30天内）转诊的90例受试者将随机分配至不同状况，并按基线时的神经认知功能分层。参与者和评估者一样，对自己的状况一无所知。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AUD结果是活动期内饮酒天数和重度饮酒天数。次要AUD结局是6个月随访前30天内饮酒天数和重度饮酒天数。次要结局包括3个月和6个月随访时的神经认知变化。

 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.