Neurocognitive Factors in Substance Use Treatment Response: The Ways of Rewarding Abstinence Project

Cocaine Use Disorder Clinical Trial

— WRAP  

Official title:

Electrophysiological Predictors and Indicators of Contingency Management Treatment Response

Clinical Trial Details — Status: Active, not recruiting

Administrative data

• NCT number: NCT03799341
• Other study ID #: NURA-002-18S
• Secondary ID: CX001807-01A1
• Status: Active, not recruiting
• Phase: N/A
• Start date: November 13, 2019
• Est. completion date: December 31, 2024

Study information

• Verified date: February 2024
• Source: VA Office of Research and Development
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

The proposed work will investigate changes in brain signaling and cognitive functioning that support recovery from addiction, as well as use of pretreatment neurocognitive functioning to inform substance use treatment planning. Substance use disorders are prevalent amongst Veterans. Cocaine addiction, in particular, has been shown to complicate treatment of other high priority behavioral health problems in the Veteran population (e.g., PTSD, opioid addiction). While there are currently no approved medications to support recovery from cocaine addiction, research indicates that Contingency Management (CM) - a behavioral intervention for cocaine users - can be effective. However, individual responses are variable and long-term benefits are limited. This CDA will test a new model of how CM works by examining brain-based predictors and indicators of treatment response. Results will have immediate implications for measurement-based implementation of existing CM variants within the VA, supporting access to the version of CM that is best aligned with each Veteran's needs.

Description:

Electrophysiological methods, including event-related potential and functional connectivity approaches, have potential to clarify mechanisms of substance use treatment response and characterize individual differences therein. Veterans are disproportionately affected by disorders of addiction, of which cocaine use disorder (CUD) is particularly problematic due to high relapse rates and the absence of approved pharmacotherapy options. Behavioral interventions for CUD have therefore become an important focus and Contingency Management (CM) has emerged as the best-supported approach. CM involves reinforcing cocaine abstinence (established through objective testing) with reliable, short-term reward, such as chances to win prizes (i.e., Prize-Based CM or PBCM). Given robust empirical support, nationwide dissemination of PBCM has been supported by a VHA initiative since 2011. However, PBCM response rates are variable and long-term benefits are limited - problems magnified by the cost of implementation with respect to staffing and prizes. Measurement-based approaches to PBCM implementation have promise to improve the effectiveness and efficiency of CM programming but have not yet been investigated within the VA or considered in relation to promising neuromarkers. Importantly, two versions of PBCM are already utilized at VA sites and may differentially benefit individuals with distinct neurocognitive profiles. Specifically, VA PBCM programs employ either abstract (voucher prize) or concrete (tangible prize) incentives, the latter of which may more effectively incentivize abstinence in Veterans with poor future-oriented thinking and planning ability. While selection between existing PBCM variants currently reflects practical considerations only, pretreatment neurocognitive functioning could meaningfully and realistically inform clinical decision-making in this regard.

This project aims to advance measurement-based implementation of CM by testing a novel neurocognitive model with immediate implications for the use of abstract versus concrete PBCM incentives within the VA. Specifically, the future-minded decision-making (FMDM) model posits that CM scaffolds future-oriented goal representation and self-control to support abstinence during in the moment use-related decision-making. For individuals with greater FMDM impairment, concrete, readily-accessible incentives may be more effective than abstract voucher-based rewards (which require future-oriented thinking and planning to acquire value). To test this model, neurocognitive substrates of FMDM will be examined as predictors of differential treatment response in voucher (VoucherPBCM) versus tangible prize (TangiblePBCM) versions of PBCM. Treatment-related change in neural and cognitive-behavioral correlates of FMDM will also be evaluated in PBCM-adherent versus non-adherent subgroups. Veterans with CUD will be allocated to VoucherPBCM or TangiblePBCM conditions and followed for a 12-week treatment interval. Pre- and post-treatment electroencephalography (EEG) and cognitive-behavioral assessments will be used to measure FMDM-related constructs (working memory, self-control, future-oriented decision-making, future reward representation) and related neuromarkers. These measures will be investigated as predictors of differential treatment response in VoucherPBCM versus TangiblePBCM, as well as maintenance of gains during a post-treatment follow-up period. Change in FMDM-related neural and cognitive measures over the course of treatment will also be evaluated for evidence of neuroadaptation (e.g., changes in functional connectivity) and enhancement of FMDM function through PBCM. Taken together, results of the current research project will represent a first step toward precision implementation of CM within the VA.

Recruitment information / eligibility

• Status: Active, not recruiting
• Enrollment: 59
• Est. completion date: December 31, 2024
• Est. primary completion date: December 31, 2023
• Accepts healthy volunteers: No
• Gender: All
• Age group: 18 Years to 75 Years

Eligibility

Inclusion Criteria:

• Military Veterans

• DSM-5 Criteria for Cocaine Use Disorder (Mild, Moderate, or Severe)

• Cocaine Use Within Past 60 Days

• Stated Goal of Cocaine Abstinence or Reduced Cocaine Use

• Normal or Corrected-to-Normal Vision

• Average or Corrected Hearing

Exclusion Criteria:

• History of Severe Traumatic Brain Injury, Seizure Disorder, or other Neurological Illness

• Severe or Unstable Medical or Psychiatric Condition

• Pregnant or Lactating Women

• Moderate-to-Severe Neurocognitive Impairment per Medical Record, SLUMS < 21, or Mini MoCA < 11

• In Ongoing Residential Treatment or Imminently Expected to Enter Residential Treatment During the Study Interval at Time of Screening

Related Conditions & MeSH terms

• Cocaine Use Disorder

Intervention

Behavioral:
• Prize-Based Contingency Management
Participants assigned to Prize-based Contingency Management (PBCM) conditions will receive PBCM as an adjunct to TAU. PBCM will involve twice weekly one-on-one sessions with a provider for 12-weeks. During each session, a urine specimen provided by the patient will be tested for cocaine using a point-of-care dip-test. Results of point-of-care testing will be shared with the patient and negative results will be reinforced with draws from a fish bowl containing 500 paper slips, 250 of which award small, large, or jumbo prizes (remaining slips deliver words of encouragement). Patients will be reinforced with a single prize draw for their first negative specimen; an additional prize draw will be added for each consecutive negative result (up to 8 prize draws per session). Abstinence-contingent prize draws will be reset to one upon either a positive test result or unexcused, missed appointment.
• Treatment As Usual Outpatient Substance Use Treatment
All participants will receive treatment as usual outpatient substance use services during the 12-week treatment interval. TAU will specifically entail recommended participation in at least two outpatient group and/or individual psychotherapy encounters per week within the Center for Treatment of Addictive Disorders (CTAD) at VA Pittsburgh Healthcare System. Participants will additionally continue any previously prescribed pharmacotherapy for substance use and/or other mental health conditions, if applicable.

Locations

Country	Name	City	State
United States	VA Pittsburgh Healthcare System University Drive Division, Pittsburgh, PA	Pittsburgh	Pennsylvania

Sponsors (1)

Lead Sponsor	Collaborator
VA Office of Research and Development

Country where clinical trial is conducted

United States, 

Outcome

Type	Measure	Description	Time frame	Safety issue
Other	Pre- to Post-Treatment Change in Theta Synchronization	Treatment-related change in theta synchronization between anterior cingulate cortex and lateral prefrontal cortex during high conflict events in the Parametric Conflict Flankers task.	12-Week Treatment Interval
Other	Pre- to Post-Treatment Change in Executive Working Memory	Treatment-related change in Brown-Peterson working memory scores. We will specifically use a modified Brown-Peterson test (Auditory Consonant Trigrams) for which both age- and Veteran-specific norms exist. Summary scores for this measure (including 9-, 18-, and 36-second delay conditions) can range from 0-45, with higher scores indicating improved executive working memory performance.	12-Week Treatment Interval
Other	Pre- to Post-Treatment Change in Episodic Future Thinking Effect (Delay Discounting)	Treatment-related change in the difference in delay discounting slopes (ln(k)) estimated for discounting conditions with and without personally meaningful event tags.	12-Week Treatment Interval
Other	Pre- to Post-Treatment Change Spontaneous Eyeblink Rate	Treatment-related change in spontaneous eyeblink rate at rest.	12-Week Treatment Interval
Primary	% Cocaine-Negative Urine Specimens	Proportion of urine specimens provided during the 12-week treatment interval that test negative for cocaine.	12-Week Treatment Interval
Primary	Longest Duration of Cocaine Abstinence	Longest period of objectively verified abstinence from cocaine during treatment.	12-Week Treatment Interval
Secondary	% Contingency Management (CM) Sessions Attended (CM Groups Only)	Proportion of CM treatment sessions attended.	12-Week Treatment Interval
Secondary	Total Non-CM Treatment Encounters	Number of non-CM treatment encounters during treatment (documented in chart and/or self-reported)	12-Week Treatment Interval
Secondary	% Self-Reported Cocaine-Abstinent Days During Treatment	Proportion of self-reported cocaine-abstinent days during the 12-week treatment interval.	12-Week Treatment Interval
Secondary	% Self-Reported Drug- and Alcohol-Abstinent Days During Treatment	Proportion of self-reported drug- and alcohol-abstinent days during the 12-week treatment interval.	12-Week Treatment Interval
Secondary	% Self-Reported Stimulant-Abstinent Days at Post-Treatment (CM Groups Only)	Proportion of self-reported stimulant-abstinent days during the 6 month post-treatment interval.	6 Month Post-Treatment Interval
Secondary	% Self-Reported Drug- and Alcohol-Abstinent Days at Post-Treatment (CM Groups Only)	Proportion of self-reported drug- and alcohol-abstinent days during the 6 month post-treatment interval.	6 Month Post-Treatment Interval