Project #1 Cognitive dysfunction is increasingly considered to be a defining feature of addiction. The cognitive functions most commonly found to be impaired among substance users (attention, working memory, and inhibitory control) are precisely those functions that may be necessary for engaging and benefiting in behavioral therapies. This may be particularly relevant for cognitive behavioral approaches (CBT), as these functions are needed in order to (1) engage in and attend to treatment, (2) acquire new cognitive and behavioral skills and strategies, and (3) implement them effectively. This project will evaluate the extent to which training designed to enhance those target functions (attention, working memory, inhibitory control) delivered prior to a trial of computerized CBT (CBT4CBT) improves treatment engagement and outcome: Treatment will be delivered in 2 phases. In the first phase, 150 individuals with cocaine use disorder, all of whom are attending an intensive outpatient program, will be randomized to one of the following 4-week 'preparatory'conditions: (1) no training (treatment as usual only, TAU);(2) 4 weeks of a rapid abstinence initiation procedure (RAI), or (3) 4 weeks of RAI plus cognitive control training (CCT) with monetary incentives for improved performance. In the second phase, all participants will receive an 8-week trial of CBT4CBT (12 weeks total). Changes in the targeted cognitive functions and cocaine use will be assessed at baseline, after the 4 week preparatory phase, after the 8-week CBT4CBT trial, and at 1-, 3, and 6-month follow-up interviews. Neuroimaging using tasks selected to assess cognitive correlates of working memory, cognitive control, and regulation of craving (N-Back, Stroop, Regulation of Craving) will be done at 3 time points (baseline, post preparatory'phase, post CBT4CBT phase). These will be used to evaluate (1) neurocognitive predictors of treatment response in both phases, (2) effects of preparatory procedures on neurocognitive targets, and (3) changes in neural function associated with the preparatory conditions and CBT4CBT. We hypothesize improved function in attention, working memory, and inhibitory control will be associated with better learning and implementation of CBT skills and hence to reduced cocaine use. A six-month follow-up is included to evaluate the durability of intervention effects. The novel strategy of providing incentives contingent on improved performance on cognitive training tasks is likely to substantially improve CCT's effectiveness within this sample. The strategy of cognitive enhancement prior to initiation of treatment goes beyond previous research in this area by evaluating the effect of cognition as a modifiable mediator of a response to treatment, rather than testing direct effects of improving cognitive function on drug use outcomes. If shown to be effective, the strategy of enhancing cognitive function prior to initiation of treatment may generalize to other substance use disorders as it targets cognitive dysfunction as a defining feature of addiction.
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