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

• Percent Days of Abstinence [ Time Frame: 3 months and 6 months ] [ Designated as safety issue: No ]
  Abstinence will be determined by toxicology screening, breathalizer and substance abuse calendar weekly during 3 months of active intervention. At 6 month follow-up, relapse will be determined by substance abuse calendar and clinical record review.
  
  

• Cognitive functioning and symptoms [ Time Frame: Baseline, 3 month and 6 month follow-up ] [ Designated as safety issue: No ]
  Neurocognitive assessments will measure attention, memory, executive function and impulsivity. Symptoms will be measured with the Brief Symptom Inventory
  
  

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. The investigators 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. The investigators 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.

The investigators 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 Positscience. 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.