Cognitive function and treatment response in a randomized clinical trial of computer-based training in cognitive-behavioral therapy

Performance-based attentional control, but not self-reported attentional control, predicts changes in depressive symptoms in short-term psychotherapy

OBJECTIVE

Although impairments in attentional control are pervasive across psychopathology, there is substantial individual differences. In the current study, we examined whether individual differences in self-reported and performance-based measures of attentional control predict changes in depressive symptoms and well-being in a diagnostically diverse sample of patients attending a CBT-based partial hospital program.

METHOD

Participants were 89 patients (56.2% men, 75.3% non-Hispanic White). At baseline, patients completed the self-reported Attentional Control Scale and the Rapid Serial Visual Presentation task (RSVP), a behavioral measure of attentional control. Depressive symptoms were assessed daily using the Patient Health Questionnaire and well-being was assessed using the Mental Health Continuum Short Form.

RESULTS

On average, greater self-reported attentional control was significantly associated with lower depressive symptoms, β = -0.49, t(52) = 4.84, p < .001, 95% CIs [-0.69, -0.29], and greater well-being, β = 0.45, t(53) = 3.90, p < .001, 95% CIs [0.22, 0.67]. More accurate task-based performance was associated with a decline in depressive symptoms over time, β = -0.02, t(32) = 2.50, p = .02, 95% CIs [-0.04, -0.01]. Neither self-reported nor performance-based measures of attentional control predicted changes in well-being. Finally, exploratory analyses suggest that depressive symptoms also improved over time for individuals who underestimated self-reported attentional control abilities relative to task-based performance, β = -0.19, t(32) = 2.23, p = .03, 95% CIs [-0.36, -0.02].

CONCLUSIONS

Results suggest that performance-based attentional control may be an important target for assessment and intervention, as well as a potential mechanism underlying risk and recovery.

Exploring user experiences of a text message-delivered intervention among individuals on opioid use disorder treatment in Kenya: A qualitative study

Opioid use disorder causes significant burden of disease and treatment comprises pharmacotherapy and psychosocial treatment. Cognitive behavioral therapy is an effective psychosocial intervention used in substance use disorders treatment and can be delivered using digital approach. There is limited use of digital treatment among individuals with opioid use disorder in Kenya. This study aimed to describe the experiences and feedback from participants with opioid use disorder enrolled in a text-message intervention in Kenya. Qualitative data was collected from participants in the intervention arm of a feasibility trial testing a text-message intervention based on cognitive behavioral therapy. Data was collected using open-ended questions in a questionnaire and structured in-depth interviews amongst those who received the intervention. Framework method was applied for analysis. Twenty-four participants (83.3% males) were enrolled with a mean age of 32.5 years (SD9.5). Five themes were identified namely: (1) Gain of cognitive behavioral therapy skills which included: identification and change of substance use patterns; drug refusal skills; coping with craving and self-efficacy; (2) Therapeutic alliance which included: development of a bond and agreement on treatment goals; (3) Feedback on intervention components and delivery such as: frequency, and duration of the text message intervention; (4) Challenges experienced during the intervention such as: technical problems with phones; and barriers related to intervention delivery; (5) Recommendations for improvement of intervention in future implementations. The findings demonstrated participants' satisfaction with intervention, gain of skills to change substance use patterns, highlighted challenges experienced and suggestions on improving the intervention among individuals with opioid use disorder. The feedback and recommendations provided by the participants can guide implementation of such interventions to allow acceptability, effectiveness and sustainability. Trial registration: This study was part of a randomized feasibility trial. Clinical trial registration: Pan African Clinical Trial Registry: Registration number: PACTR202201736072847. Date of registration: 10th January 2022.

Impulsivity Predicts Relapse—but Not Dropout—in Outpatients with SUD: a Longitudinal Study

The objective of this study was to compare performance on a comprehensive impulsivity battery of SUD outpatients who dropout versus those who do not dropout and of abstainers versus relapsers at 3 and 12 months of treatment follow-up. Impulsivity was measured at the start of treatment and adherence and relapse at 3 and 12 months. The participants are 115 outpatients with SUD. Motor impulsivity (Affective Go/No Go), attentional impulsivity (Stroop), delay discounting (Monetary Choice Questionnaire; MCQ), and decision making (Iowa Gambling Task; IGT) were assessed. Impulsivity was not associated with dropout. There were no relationships between treatment outcomes and the MCQ and IGT. Stroop and affective Go-No Go were associated with relapse at 3 and 12 months. Affective motor disinhibition and cognitive disinhibition predict relapse in outpatients. No cognitive aspect of impulsiveness is related to dropout.

Examining an In-Home Behavioral Parent Training Protocol Among Parents Who Use Substances Involved Child Welfare: Effectiveness of SafeCare

Given the detrimental impact of substance use (SU) on both parent and child outcomes including child maltreatment, research and service efforts have focused on incorporating parenting resources into integrated SU treatment programs. While promising, it is imperative to examine and test parenting programs in a variety of settings. This study examined whether SU moderated the relationship between treatment condition and parenting outcomes among parents who participated in SafeCare, and parent ratings of engagement, service satisfaction, and perceived cultural competency of services. Results indicated that SU did not moderate the relationship between treatment condition and abuse potential, but did moderate this relationship for depression and parental distress such that parents with higher levels of SU reported less improvement in depression and parental distress. Results underscore that SU problems may impact the effectiveness of SC on specific risk factors, such as depression and parental distress, potentially indicating unique treatment needs and the need to adapt interventions to ensure treatment success. In addition, this study found that SafeCare was not found to be beneficial for parents with SU problems above and beyond the treatment as usual condition. Finally, results indicated that parents with SU concerns and without SU concerns engaged very similarly in SafeCare.

Targeting white matter neuroprotection as a relapse prevention strategy for treatment of cocaine use disorder: Design of a mechanism-focused randomized clinical trial

Cocaine use continues to be a significant public health problem with limited treatment options and no approved pharmacotherapies. Cognitive-behavioral therapy (CBT) remains the mainstay treatment for preventing relapse, however, people with chronic cocaine use display cognitive impairments that are associated with poor response to CBT. Emerging evidence in animal and human studies suggests that the peroxisome proliferator-activated receptor-gamma (PPAR- γ) agonist, pioglitazone, improves white matter integrity that is essential for cognitive function. This project will determine whether adjunctive use of pioglitazone enhances the effect of CBT in preventing relapse during the early phase of recovery from cocaine use disorder. This paper describes the design of a mechanism-focused phase 2 randomized clinical trial that aims first to evaluate the effects of pioglitazone on targeted mechanisms related to white matter integrity, cognitive function, and cocaine craving; and second, to evaluate the extent to which improvements on target mechanisms predict CBT response. Positive results will support pioglitazone as a potential cognitive enhancing agent to advance to later stage medication development research.

Randomized Controlled Trials of a Psychosocial Intervention for Improving the Cognitive Function among Older Adults: A Scoping Review

Aim: The goal is to explore available evidence and provide greater clarity to what is described as psychosocial intervention to improve cognitive function among older population with MCI as well as identifying areas for future research. Methods: An electronic literature search of PubMed, Cochrane, Ebscohost, Medline, Scopus, and gray resource was conducted to find articles published in English language between 2010 and September 2020. This review focused on research undertaken using randomized clinical trials study design. We extracted information regarding the publication date, geographical location, study setting, intervention mechanism, type of cognitive measurement used, and outcome of the studies. References of this literature were also reviewed to ensure comprehensive search. Result: Out of 240 potential records found, a total of 27 articles were identified following the first round of screening and deletion of duplicates. Full-text article reviews and analysis in the second round of screening narrowed the selection down to four articles. Another three relevant articles obtained from references were also included making a total of seven articles in the final analysis. Findings: Psychosocial intervention strategies for improvement of cognitive function, done in various setting all over the globe, covered a range of approaches including art therapy, visual art therapy, therapeutic writing therapy, reminiscence activity, and cognitive behavioral approach. Most were conducted in weekly basis within 1-to-2-hour duration of session. Cognitive function of older adult in psychosocial intervention group was significantly improved in two studies. Three studies showed no significant improvement at all in the cognitive function, and another one reported success in improving cognitive function over time in the intervention group than in control group. One study did not describe the interaction effect. Different types of cognitive measurement also were used to quantify different domains of cognitive function in the reviewed studies. Conclusion: The idea of using psychosocial intervention for improving cognitive function has begun to increasingly accepted recently. Findings from the limited studies are encouraging, although the outcome of the cognitive function was mixed. Large-scale and longer duration of psychosocial intervention with bigger sample size is warranted for future studies.

Baseline executive functions and receiving cognitive rehabilitation can predict treatment response in people with opioid use disorder

BACKGROUND

Impaired cognitive functions, particularly executive function, predicts poor treatment success in people with substance use disorders. The current study investigated the effect of receiving adjunct cognitive rehabilitation and baseline executive function (EF) measures on treatment response among people with opioid use disorder (OUD).

METHOD

The analysis sample consisted of 113 participants with OUD who were discharged from a compulsory court-mandated methadone maintenance treatment (MMT) and followed for 3 months. We used the Backward digit span/Auditory verbal learning, Stroop, and Trail making tests to assess the three measures of EF, including working memory, inhibition, and shifting, respectively. Treatment response was operationalized as (1) treatment retention and (2) the number of positive urine tests for morphine during 3-month follow-up periods. The study used Cox's proportional hazards model and linear mixed model to identify predictive factors.

RESULTS

Lower Stroop interference scores predicted increased length of stay in treatment (χ² = 33.15, P < 0.001). The linear mixed model showed that scores on auditory verbal learning test and group intervention predicted the number of positive urine tests during a 3-month follow-up.

CONCLUSION

Working memory and inhibitory control, as well as receiving cognitive rehabilitation, could be potentially considered as predictors of treatment response for newly MMT admitted patients with OUD. Assessment of EF before treatment initiation may inform treatment providers about patient's cognitive deficits that may interfere with therapeutic interventions.

Lack of longitudinal changes in cognition in individuals with methamphetamine use disorder during the first 6 weeks after commencing treatment

Background: Methamphetamine use disorder (MUD) associates with cognitive impulsivity deficits. However, few studies have examined longitudinal changes in cognition, and it remains unclear if deficits resolve during early recovery.Objectives: To compare: (1) cognitive function of individuals with MUD at treatment onset and six-weeks later with controls tested over the same period; (2) cognitive changes in MUD-individuals who remained abstinent versus relapsed.Method: We recruited 108 participants meeting DSM-IV-TR criteria for methamphetamine dependence (81 males) and 50 demographically matched controls (38 males); 77 methamphetamine- dependent participants (59 males) and 48 controls (36 males) were retained at follow-up. We administered response inhibition, delay discounting and uncertainty-based decision-making tests at both endpoints. Relapse was defined as methamphetamine concentrations >0.4 ng/mg at follow-up in hair toxicology.Results: We found a significant time-by-group interaction on uncertainty-based decision-making (effect size: η² = .05), although post-hoc tests to disentangle this interaction yielded inconclusive results (p-range = .14-.40; BF₁₀-range = 0.43-1.67). There were no significant time-by-group interactions on response inhibition or delay discounting, with the former likely a null effect (η²-interaction = .003 and .02; BF_incl = 0.23 and 0.71). There were no significant differences in cognitive recovery between individuals who maintained abstinence (n = 12) versus relapsed (n = 65) (η²-range = .003-.04), although evidence was inconclusive toward whether findings reflected true null effects (BF_incl-range = 0.33-0.75).Conclusion: We did not find evidence that MUD-related cognitive impulsivity deficits improve beyond practice effects over 6 weeks. Findings do not support previous, albeit conflicting, evidence of early recovery of cognitive deficits in MUD.

Cognitive Impact of Calorie Restriction: A Narrative Review

The impairment of cognitive function can cause substantial emotional and financial burdens. A recent global increasing trend in cognitive impairment and associated disorders has been observed, which will continue to grow as the population ages rapidly. As a nonpharmaceutical approach, calorie restriction (CR) has received extensive research interests due to its health benefits, including maintaining cognitive function. In this narrative review, we first briefly introduce the role of cognitive function in activities of daily living and CR as a part of healthy lifestyle behaviors to protect against cognitive decline. Second, we present results from human studies demonstrating that CR might be beneficial for improving age-related cognitive decline and cognitive impairment in the clinical population such as obesity and type 2 diabetes. Third, the potential mechanisms regarding the protective effects of CR on cognition are discussed. Fourth, specific suggestions are highlighted to be considered in future human studies. Overall, although there are few data available from human studies, CR appears to be beneficial for cognitive protection for both healthy and clinical populations. Further scientific investigations are needed before a firm conclusion can be made.

Probabilistic Reversal Learning Deficits in Patients With Methamphetamine Use Disorder-A Longitudinal Pilot Study

Methamphetamine use disorder (MUD) is increasing worldwide and commonly associated with learning deficits. Little is known the about underlying trajectories, i.e., how the affected higher-order cognitive functions develop over time and with respect to abstinence and relapse. A probabilistic reversal learning (PRL) paradigm was implemented to uncover the microstructure of impulsive choice and maladaptive learning strategies in 23 patients with MUD in comparison with 24 controls. Baseline data revealed fewer optimal choices and a pattern of altered learning behavior from negative and positive feedback in patients suggesting impairments in flexibly-adapting behavior to changes of reward contingencies. Integrating longitudinal data from a follow-up assessment after 3 months of specific treatment revealed a group-by-time interaction indicating a normalization of these cognitive impairments in patients with MUD. In summary, our study demonstrates behavioral correlates of maladaptive decision-making processes in patients with MUD, which may recover after 3 months of MUD-specific therapy paving the way for further learning-based interventions. Limited by a small sample size, the results of this pilot study warrant replication in larger populations.

Clinical Trials for Stimulant Use Disorders: Addressing Heterogeneities That May Undermine Treatment Outcomes

In recent years, use of cocaine and amphetamines and deaths associated with stimulants have been on the rise, and there are still no FDA-approved medications for stimulant use disorders. One contributing factor may involve heterogeneity. At the neurobiological level, dual dopamine dysfunction may be undermining medication efficacy, suggesting a need for combination pharmacotherapies. At the population level, individual variability is expressed in a number of ways and, if left unaddressed, may interfere with medication efficacy. This chapter reviews studies investigating medications to address dopamine dysfunction, and it also identifies several prominent heterogeneities associated with stimulant (and other substance) use disorders. The chapter has implications for improving interventions to treat stimulant use disorders, and the theme of individual heterogeneity may have broader application across substance use disorders.

Computerized Cognitive Behavioral Therapy for Substance Use Disorders: A Summary of the Evidence and Potential Mechanisms of Behavior Change

Cognitive-behavioral therapy (CBT) is one of the most evaluated behavioral interventions for substance use disorders, with considerable empirical evidence supporting its efficacy. However, despite CBT's strong support from efficacy trials, broad dissemination and implementation have been challenging. Furthermore, there remains limited understanding regarding CBT's mechanisms of behavior change; the theory-driven assumption that individuals acquire new skills for coping with triggers for substance use has notoriously lacked statistical support. The emergence of computer-delivered interventions has the potential to address dissemination and implementation challenges, as well as offer advantages toward understanding treatment mechanisms. This article will provide a summary of the current evidence supporting one particular computerized CBT program, CBT4CBT. Multiple clinical trials in different treatment settings have indicated CBT4CBT's efficacy at reducing rates of alcohol and drug use when provided as an add-on to standard addiction treatment, as well as when provided with minimal clinical monitoring (i.e., virtual stand-alone). These effects have also been relatively durable after treatment termination, consistent with findings of traditional CBT. It is important to note that the evaluation of individuals' cognitive and behavioral coping skills prior and following treatment has indicated the acquisition/improvement of these skills may be a mechanism of behavior change for those who engage with CBT4CBT. Thus, computerized delivery may be a strategy for enhancing individuals' learning of cognitive and behavioral skills for successfully avoiding substance use. Future work should aim to identify the optimal type of setting, clinician role, and patient characteristics for targeted dissemination and implementation.

Modified cognitive behavioral therapy (M-CBT) for cocaine dependence: Development of treatment for cognitively impaired users and results from a Stage 1 trial

Cognitive impairments are associated with poor outcomes when treating cocaine dependent patients, but behavioral interventions to mitigate this impact have not been developed. In this Stage 1A/1B treatment development study, several compensatory strategies (e.g., content repetition, daily logs, diaries, visual presentation) were combined to create a modified cognitive behavioral therapy (M-CBT) for treating cocaine dependence. Initially, a select group of therapists, neuropsychology experts, and patients were asked to provide input on early drafts of the treatment manual and companion patient workbook. After an uncontrolled small trial (N = 15) and two rounds of manual development (Stage 1A), a pilot randomized clinical trial (N = 102) of cocaine dependent outpatients with and without cognitive impairments was conducted (Stage 1B). Participants were randomized to M-CBT (N = 52) or CBT (N = 50). Both treatments were individually delivered over 12 weeks with assessments conducted at baseline, end-of-treatment, and 3-month follow-up. The primary outcome was frequency of cocaine use, measured by number of days used in the prior 7 days. Participants in the two treatment groups did not differ significantly on drug use reduction or retention in treatment. However, among participants who completed at least 9 weeks of treatment, those in M-CBT showed a trend toward greater reduction in cocaine use compared to those in the CBT group. M-CBT is feasible for impaired and nonimpaired cocaine dependent participants. However, M-CBT treatment did not show significant superiority over standard CBT in the present sample. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Sustained attention but not effort-based decision-making predicts treatment motivation change in people with methamphetamine dependence

BACKGROUND

Early treatment motivation is a meaningful predictor of clinical outcomes in the context of methamphetamine dependence (MD). Cognitive deficits associated with MD can have a significant impact on motivational fluctuations during early treatment. We specifically examined if sustained attention and effort-based decision-making predict early treatment motivation change in individuals with MD. We hypothesised that both variables would be significant predictors of individual differences in treatment motivation change.

METHODS

We conducted a longitudinal, observational, cohort study on individuals with MD (N = 72, Age, M = 31.1, SD = 7.3, 29% female). Participants were assessed with cognitive tests of sustained attention (continuous performance test) and effort-based decision-making (effort expenditure for rewards task) within three weeks of entering treatment and rated their treatment motivation at baseline and at follow up six weeks later (n = 50). Multiple regression was used to examine the predictive value of cognitive variables after controlling for nuisance variables.

RESULTS

Cognitive measures significantly predicted change in treatment motivation after accounting for nuisance variables, F(5,43) = 2.89, p = .025. Analysis of individual predictors showed that sustained attention, but not decision-making, was a significant negative predictor of improvement in treatment motivation (β = -0.34, p = .015).

CONCLUSIONS

Poorer attentional function was associated with limited improvement in motivation during early treatment. These findings help to characterise cognitive predictors of treatment motivation and suggest directions for tailored treatment programs. Individuals entering treatment with attentional deficits may benefit from adjustments to therapy and/or cognitive remediation.

Cognitive functioning and treatment outcomes in a randomized controlled trial of internet-delivered drug and alcohol treatment

BACKGROUND AND OBJECTIVES

Substance use disorders are associated with lower cognitive functioning, and this impairment is associated with poorer outcomes. The Therapeutic Education System (TES) is an internet-based psychosocial intervention for substance use disorders that may provide enhanced treatment for individuals with cognitive deficits. This secondary analysis investigates the association between cognitive functioning and treatment outcomes in a large (N = 507) randomized controlled effectiveness trial of TES compared to treatment-as-usual conducted within outpatient programs in the National Drug Abuse Treatment Clinical Trials Network.

METHODS

All participants completed a computer-based cognitive assessment (Microcog™ short version) at baseline. Scores on subtests of attention, reasoning, and spatial perception were tested as moderators of the treatment effect on abstinence and retention at the end of the 12-week treatment phase using mixed effects logistic regression.

RESULTS

Cognitive functioning was not found to be a moderator of treatment on abstinence or retention. Post-hoc analysis of the main effect of cognitive functioning on retention and abstinence found impaired reasoning and cognitive flexibility were associated with lower retention. There were no other main effects of cognitive functioning on retention or abstinence.

CONCLUSIONS

The benefit of internet delivered treatment over standard care was unchanged across a range of cognitive functioning. Consistent with previous research, mild to moderate impairment in reasoning and cognitive flexibility were associated with lower retention across both treatment arms.

SCIENTIFIC SIGNIFICANCE

An internet-delivered cognitive behavioral intervention for substance use disorders, TES, is equally effective across a spectrum of cognitive functioning among diverse patients. (Am J Addict 2018;27:509-515).

Relations Between Cognitive Functioning and Alcohol Use, Craving, and Post-Traumatic Stress: An Examination Among Trauma-Exposed Military Veterans With Alcohol Use Disorder

Cognitive dysfunction is commonly observed among individuals with alcohol use disorder (AUD) and trauma exposure and is, in turn, associated with worse clinical outcomes. Accordingly, disruptions in cognitive functioning may be conceptualized as a trans-disease phenomenon representing a potential high-yield target for intervention. Less is known though about how different cognitive functions covary with alcohol use, craving, and post-traumatic stress symptom severity among trauma-exposed individuals with AUD. Sixty-eight male and female trauma-exposed military veterans with AUD, entering treatment trials to reduce alcohol use, completed measures assessing alcohol use and craving, post-traumatic stress symptom severity, and cognitive functioning. In multivariate models, after controlling for post-traumatic stress symptom severity, poorer learning and memory was associated with higher alcohol consumption and higher risk taking/impulsivity was associated with stronger preoccupations with alcohol and compulsions to drink. Alcohol consumption and craving, but not performance on cognitive tests, were positively associated with post-traumatic stress symptom severity. Findings suggest that interventions to strengthen cognitive functioning might be used as a preparatory step to augment treatments for AUD. Clinicians are encouraged to consider a standard assessment of cognitive functioning, in addition to post-traumatic stress symptom severity, in treatment planning and delivery for this vulnerable and high-risk population.

Adolescent Corticosterone and TrkB Pharmaco-Manipulations Sex-Dependently Impact Instrumental Reversal Learning Later in Life

Early-life trauma can increase the risk for, and severity of, several psychiatric illnesses. These include drug use disorders, and some correlations appear to be stronger in women. Understanding the long-term consequences of developmental stressor or stress hormone exposure and possible sex differences is critically important. So-called “reversal learning” tasks are commonly used in rodents to model cognitive deficits in stress- and addiction-related illnesses in humans. Here, we exposed mice to the primary stress hormone corticosterone (CORT) during early adolescence (postnatal days 31–42), then tested behavioral flexibility in adulthood using an instrumental reversal learning task. CORT-exposed female, but not male, mice developed perseverative errors. Despite resilience to subchronic CORT exposure, males developed reversal performance impairments following exposure to physical stressors. Administration of a putative tyrosine kinase receptor B (trkB) agonist, 7,8-dihydroxyflavone (7,8-DHF), during adolescence blocked CORT-induced errors in females and improved performance in males. Conversely, blockade of trkB by ANA-12 impaired performance. These data suggest that trkB-based interventions could have certain protective benefits in the context of early-life stressor exposure. We consider the implications of our findings in an extended “Discussion” section.

Chronic Δ9-THC in Rhesus Monkeys: Effects on Cognitive Performance and Dopamine D2/D3 Receptor Availability

Cannabis-related impairments to cognitive function may represent novel therapeutic targets for cannabis-use disorder, although the nature, persistence, and reversibility of such deficits remain unclear. Adult male rhesus monkeys (N = 6) responded in the morning on tasks designed to assess different cognitive domains using the Cambridge Neuropsychological Test Automated Battery (CANTAB) touchscreens followed by responding maintained under a fixed-ratio (FR) 10 schedule of food presentation in different operant chambers. First, the acute effects of Δ⁹-tetrahydrocannabinol (THC; 0.01-0.56 mg/kg, i.v.) on cognitive performance, FR responding, and body temperature were determined. Next, THC (1.0-2.0 mg/kg, s.c.) was administered daily after FR 10 sessions for 12 weeks, during which the residual effects of THC (i.e., 22 hours after administration) on cognition were examined and the acute effects of THC were redetermined. In a subgroup of monkeys, dopamine D2/D3 receptor availability was assessed after 4 weeks of chronic THC exposure and compared with drug-naive controls using positron emission tomography and [¹¹C]-raclopride (N = 4/group). Acute THC pretreatments dose-dependently decreased FR responding and body temperature, and impairment to cognitive performance was task specific. During chronic treatment, THC produced persistent residual impairment only to working memory; tolerance differentially developed to acute cognitive impairments. There was recovery from residual cognitive impairments to working memory within 2 weeks of abstinence. Compared with controls, D2/D3 receptor availability was not altered during chronic THC treatment. In conclusion, THC-induced disruptions in cognition were task-specific, as was tolerance development, and not related to changes in D2/D3 receptor availability. Intervention strategies for cannabis-use disorder that enhance working memory performance may facilitate positive treatment outcomes.

Neurocognitive Profiling of Adult Treatment Seekers Enrolled in a Clinical Trial of a Web-delivered Intervention for Substance Use Disorders

OBJECTIVE

This study is a secondary descriptive analysis that explores and compares the cognitive profiles of adults entering treatment at geographically diverse community-based substance use disorder treatment facilities.

METHODS

Performance on cognitive measures at baseline was compared across 5 primary substance subgroups of individuals (alcohol = 104; cocaine = 102; stimulants = 69; opioids = 108; marijuana = 114) enrolled in a web-based psychosocial treatment study conducted within the National Drug Abuse Treatment Clinical Trials Network. MicroCog subtests were used to assess cognitive domains of attention and mental control, reasoning and cognitive flexibility, and spatial processing.

RESULTS

The average age of onset for a substance use disorder was early to mid-20s, with marijuana users reporting the earliest age of onset (mean 19.9, SD 7.5) and stimulant users reporting the latest (mean 25.2, SD 9.9). Among the total sample, half (49.7%) demonstrated impairment in cognitive flexibility and reasoning, and over one-third (37.3%) had impairment in verbal learning and memory. Stimulant (37.68%) and cocaine (34.31%) users showed significantly greater clinical impairment in attention and mental control compared with alcohol users (17.31%) and opioid (21.30%) users (stimulant subgroup only) (χ [4] = 10.97, P = 0.027). Cocaine users showed the greatest overall impairment across total and proficiency subtest scores, although these were not statistically different from other subgroups.

CONCLUSIONS

These findings confirmed previous studies, indicating a high prevalence of significant cognitive dysfunction across all substance use categories among treatment-seeking adults, and found that cocaine use appears to be associated with the most impairment. Increasing knowledge of similarities and differences between primary substance subgroups can help guide substance use disorder treatment planning.

Self-reported cognitive scales in a US National Survey: reliability, validity, and preliminary evidence for associations with alcohol and drug use

AIMS

To evaluate relationships between measures of cognitive functioning and alcohol or drug use among adults (≥ 18 years) in the US general population.

DESIGN

Two cognitive scales were created based on dimensionality and reliability of self-reported Executive Function Index items. Relationships between the two scales and validators were evaluated. Associations between the cognitive scales and past-year frequency of alcohol or drug use were estimated with adjusted odds ratios (aOR).

SETTING

United States, using the 2012-13 National Epidemiologic Survey on Alcohol and Related Conditions-III, a nationally representative adult sample selected by multi-stage probability sampling.

PARTICIPANTS

36 085 respondents.

MEASUREMENTS

Past-year substance use outcome variables categorized binge drinking, marijuana, cocaine, opioid, sedative/tranquilizer and stimulant use as frequent (at least weekly to daily), infrequent (any to two to three times/month) or no use, assessed by the Alcohol Use Disorder and Associated Disabilities Interview Schedule-5. Key predictors were the two cognitive scales. Construct validators included education and functional impairment. Covariates included age, gender, income and race/ethnicity.

FINDINGS

Nine cognitive items fitted a two-factor model (comparative fit index = 0.973): attention (five items) and executive functioning (four items). Both scales were associated positively with higher education (Ps < 0.001) and negatively with functional impairment (Ps < 0.001), demonstrating construct validity. Poorer attention was associated with frequent and infrequent binge drinking and use of drugs [aOR range = 1.07 (binge drinking) to 1.72 (stimulants), Ps ≤ 0.01]. Poorer executive functioning was associated with frequent binge drinking and use of drugs [aOR range = 1.22 (binge drinking) to 2.03 (cocaine), Ps < 0.001] and infrequent use of all drugs [aOR range = 1.19 (marijuana) to 1.63 (cocaine), Ps < 0.001].

CONCLUSIONS

Impairments in attention and executive functioning are positively associated with substance use in the US general population.

Paternal cocaine taking elicits epigenetic remodeling and memory deficits in male progeny

Paternal environmental perturbations including exposure to drugs of abuse can produce profound effects on the physiology and behavior of offspring via epigenetic modifications. Here we show that adult drug-naive male offspring of cocaine-exposed sires have memory formation deficits and associated reductions in NMDA receptor-mediated hippocampal synaptic plasticity. Reduced levels of the endogenous NMDA receptor co-agonist d-serine were accompanied by increased expression of the d-serine degrading enzyme d-amino acid oxidase (Dao1) in the hippocampus of cocaine-sired male progeny. Increased Dao1 transcription was associated with enrichment of permissive epigenetic marks on histone proteins in the hippocampus of male cocaine-sired progeny, some of which were enhanced near the Dao1 locus. Finally, hippocampal administration of d-serine reversed both the memory formation and synaptic plasticity deficits. Collectively, these results demonstrate that paternal cocaine exposure produces epigenetic remodeling in the hippocampus leading to NMDA receptor-dependent memory formation and synaptic plasticity impairments only in male progeny, which has significant implications for the male descendants of chronic cocaine users.

Factors associated with attrition in substance using patients enrolled in an intensive outpatient program

BACKGROUND AND OBJECTIVES

Data suggest individuals with substance use disorders (SUD) have high rates of attrition from treatment and exhibit impairments on measures of executive functioning (EF). The primary aim of this pilot study was to investigate if EF is associated with attrition from a 1 month intensive outpatient program (IOP) for SUD, and examine the feasibility of implementing the project.

METHODS

Baseline neurocognitive functioning was assessed by the Cambridge Neuropsychological Test Automated Battery (CANTAB) and the self-reported Behavior Rating Inventory of Executive Functioning (BRIEF-A) questionnaire.

RESULTS

Thirty subjects enrolled in the pilot study: including 20 "completers" (age 39.5 ± 13.1 years) and 10 "drop-outs" who discontinued the IOP prior to completion (age 32 ± 11.1 years). IOP drop-out was associated with earlier age of substance use onset (all p-values <0.05) and male gender, as well as greater SUD, opiate use, and past week substance use. Overall a high level of executive dysfunction was found on the BRIEF-A and CANTAB assessments, and specific differences emerged between completers and drop outs. However, no statistically significant differences were found between these groups on measures of depression, anxiety, or ADHD.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Overall, findings from this pilot study suggest high levels of self-reported executive dysfunction, but EF's predictive association with drop-out was limited. Measures of addiction severity were more strongly associated with attrition, suggesting potential utility of brief motivational interventions prior to commencing an IOP may improve retention. Further investigations with larger and more diverse samples are warranted. (Am J Addict 2017;26:780-787).

Blending Face-to-Face and Internet-Based Interventions for the Treatment of Mental Disorders in Adults: Systematic Review

Background

Many studies have provided evidence for the effectiveness of Internet-based stand-alone interventions for mental disorders. A newer form of intervention combines the strengths of face-to-face (f2f) and Internet approaches (blended interventions).

Objective

The aim of this review was to provide an overview of (1) the different formats of blended treatments for adults, (2) the stage of treatment in which these are applied, (3) their objective in combining face-to-face and Internet-based approaches, and (4) their effectiveness.

Methods

Studies on blended concepts were identified through systematic searches in the MEDLINE, PsycINFO, Cochrane, and PubMed databases. Keywords included terms indicating face-to-face interventions (“inpatient,” “outpatient,” “face-to-face,” or “residential treatment”), which were combined with terms indicating Internet treatment (“internet,” “online,” or “web”) and terms indicating mental disorders (“mental health,” “depression,” “anxiety,” or “substance abuse”). We focused on three of the most common mental disorders (depression, anxiety, and substance abuse).

Results

We identified 64 publications describing 44 studies, 27 of which were randomized controlled trials (RCTs). Results suggest that, compared with stand-alone face-to-face therapy, blended therapy may save clinician time, lead to lower dropout rates and greater abstinence rates of patients with substance abuse, or help maintain initially achieved changes within psychotherapy in the long-term effects of inpatient therapy. However, there is a lack of comparative outcome studies investigating the superiority of the outcomes of blended treatments in comparison with classic face-to-face or Internet-based treatments, as well as of studies identifying the optimal ratio of face-to-face and Internet sessions.

Conclusions

Several studies have shown that, for common mental health disorders, blended interventions are feasible and can be more effective compared with no treatment controls. However, more RCTs on effectiveness and cost-effectiveness of blended treatments, especially compared with nonblended treatments are necessary.

Atomoxetine in abstinent cocaine users: Sex differences

Data presented are from a sex-differences secondary analysis of a human laboratory investigation of single doses of atomoxetine (40 mg and 80 mg) versus placebo in abstinent individuals with cocaine use disorders (CUD). Subjective drug effects, cognitive performance and cardiovascular measures were assessed. The primary atomoxetine dose analyses (which do not consider sex as a factor) are reported in full elsewhere (DeVito et al., 2017) [1].

Atomoxetine in abstinent cocaine users: Cognitive, subjective and cardiovascular effects

No pharmacotherapies are approved for the treatment of cocaine use disorders (CUD). Behavioral treatments for CUD are efficacious for some individuals, but recovery rates from CUD remain low. Cognitive impairments in CUD have been linked with poorer clinical outcomes. Cognitive enhancing pharmacotherapies have been proposed as promising treatments for CUD. Atomoxetine, a norepinephrine transporter inhibitor, shows potential as a treatment for CUD based on its efficacy as a cognitive enhancer in other clinical populations and impact on addictive processes in preclinical and human laboratory studies. In this randomized, double-blind, crossover study, abstinent individuals with CUD (N=39) received placebo, 40 and 80mg atomoxetine, over three sessions. Measures of attention, response inhibition and working memory; subjective medication effects and mood; and cardiovascular effects were collected. Analyses assessed acute, dose-dependent effects of atomoxetine. In addition, preliminary analyses investigating the modulation of atomoxetine dose effects by sex were performed. Atomoxetine increased heart rate and blood pressure, was rated as having positive and negative subjective drug effects, and had only modest effects on mood and cognitive enhancement.

Impact of general cognition and executive function deficits on addiction treatment outcomes: Systematic review and discussion of neurocognitive pathways

This systematic review aims to examine growing evidence linking cognitive-executive functions with addiction treatment outcomes, and to discuss significant cognitive predictors drawing upon addiction neuroscience theory. We conducted a systematic search to identify studies using measures of general cognition and executive functions in patients with substance use disorders for the purpose of predicting two treatment outcomes: therapeutic adherence and relapse. Forty-six studies were selected, and sample characteristics, timing of assessments, and cognitive measures were analyzed. We observed significant methodological differences across studies, resulting in substantial variability in the relationships between cognitive-executive domains and treatment outcomes. Notwithstanding this variability, we found evidence of associations, of medium effect size, between general cognition and treatment adherence, and between reward-based decision-making and relapse. The link between general cognition and treatment adherence is consistent with emerging evidence linking limited cognitive-executive resources with less ability to benefit from talk therapies. The link between reward-based decision-making and relapse accords with decision neuroscience models of addiction. Findings may inform preclinical and clinical research concerning addiction treatment mechanisms.

Effects of yohimbine and drug cues on impulsivity and attention in cocaine-dependent men and women and sex-matched controls

BACKGROUND

Deficits in executive function have been associated with risk for relapse. Data from previous studies suggest that relapse may be triggered by stress and drug-paired cues and that there are significant sex differences in the magnitude of these responses. The aim of this study was to examine the impact of the pharmacological stressor and alpha-2 adrenergic receptor antagonist yohimbine and cocaine cues on executive function in cocaine-dependent men and women.

METHODS

In a double-blind placebo controlled cross-over study, cocaine-dependent men (n=12), cocaine-dependent women (n=27), control men (n=31) and control women (n=25) received either yohimbine or placebo prior to two cocaine cue exposure sessions. Participants performed the Connors' Continuous Performance Test II prior to medication/placebo administration and immediately after each cue exposure session

RESULTS

Healthy controls had a significant increase in commission errors under the yohimbine condition [RR (95% CI)=1.1 (1.0-1.3), χ(2)1=2.0, p=0.050]. Cocaine-dependent individuals exhibited a significant decrease in omission errors under the yohimbine condition [RR (95% CI)=0.6 (0.4-0.8), χ(2)1=8.6, p=0.003]. Cocaine-dependent women had more omission errors as compared to cocaine-dependent men regardless of treatment [RR (95% CI)=7.2 (3.6-14.7), χ(2)1=30.1, p<0.001]. Cocaine-dependent women exhibited a slower hit reaction time as compared to cocaine-dependent men [Female 354 ± 13 vs. Male 415 ± 14; t89=2.6, p=0.012].

CONCLUSIONS

These data add to a growing literature demonstrating significant sex differences in behaviors associated with relapse in cocaine-dependent individuals.

Everyday problems with executive dysfunction and impulsivity in adults recovering from methamphetamine addiction

OBJECTIVES

Compared with non-addicted controls (CTLs), adults in remission from methamphetamine addiction (MA-REM) evidence impairments on objective measures of executive functioning and impulsivity.

METHODS

To evaluate the impact of these impairments in MA-REM adults, demographically matched groups (MA-REM, n=30; CTLs, n=24) completed objective and self-report measures of executive functioning and impulsivity.

RESULTS

MA-REM adults demonstrated significantly (p < 0.050) greater objective and subjective problems with executive functioning and impulsivity.

CONCLUSIONS

These results suggest that adults in MA-REM are aware of their deficits and that these deficits have significant impact in everyday life.

Technology-delivered adaptations of motivational interviewing for health-related behaviors: A systematic review of the current research

OBJECTIVES

The aims of this paper were to describe and evaluate the methods and efficacy of technology-delivered motivational interviewing interventions (TAMIs), discuss the challenges and opportunities of TAMIs, and provide a framework for future research.

METHODS

We reviewed studies that reported using motivational interviewing (MI) based components delivered via technology and conducted ratings on technology description, comprehensiveness of MI, and study methods.

RESULTS

The majority of studies were fully-automated and included at least one form of media rich technology to deliver the TAMI. Few studies provided complete descriptions of how MI components were delivered via technology. Of the studies that isolated the TAMI effects, positive changes were reported.

CONCLUSION

Researchers have used a range of technologies to deliver TAMIs suggesting feasibility of these methods. However, there are limited data regarding their efficacy, and strategies to deliver relational components remain a challenge. Future research should better characterize the components of TAMIs, empirically test the efficacy of TAMIs with randomized controlled trials, and incorporate fidelity measures.

PRACTICE IMPLICATIONS

TAMIs are feasible to implement and well accepted. These approaches offer considerable potential to reduce costs, minimize therapist and training burden, and expand the range of clients that may benefit from adaptations of MI.

Predictors of outcome from computer-based treatment for substance use disorders: Results from a randomized clinical trial

BACKGROUND

Although empirical evidence for the effectiveness of technology-mediated interventions for substance use disorders is rapidly growing, the role of baseline characteristics of patients in predicting treatment outcomes of a technology-based therapy is largely unknown.

METHOD

Participants were randomly assigned to either standard methadone maintenance treatment or reduced standard treatment combined with the computer-based therapeutic education system (TES). An array of demographic and behavioral characteristics of participants (N=160) was measured at baseline. Opioid abstinence and treatment retention were measured weekly for a 52-week intervention period. Generalized linear model and Cox-regression were used to estimate the predictive roles of baseline characteristics in predicting treatment outcomes.

RESULTS

We found significant predictors of opioid abstinence and treatment retention within and across conditions. Among 21 baseline characteristics of participants, employment status, anxiety, and ambivalent attitudes toward substance use predicted better opioid abstinence in the reduced-standard-plus-TES condition compared to standard treatment. Participants who had used cocaine/crack in the past 30 days at baseline showed lower dropout rates in standard treatment, whereas those who had not used exhibited lower dropout rates in the reduced-standard-plus-TES condition.

CONCLUSIONS

This study is the first randomized controlled trial, evaluating over a 12-month period, how various aspects of participant characteristics impact outcomes for treatments that do or do not include technology-based therapy. Compared to standard alone treatment, including TES as part of the care was preferable for patients who were employed, highly anxious, and ambivalent about substance use and did not produce worse outcomes for any subgroups of participants.

Treatment Outcome and Predictors of Internet Guided Self-Help for Obsessive-Compulsive Disorder

Internet-guided self-help (iGSH) has amassed significant empirical support for a variety of psychiatric conditions; however, it is not known who responds best to these treatments. This open trial examined the clinical outcomes and predictors of a 17-week iGSH program for obsessive-compulsive disorder (OCD). Therapist support was provided either in person or by phone 9 times for an average of 13minutes per session. Twenty-four patients initiated treatment, and 17 of these (70.8%) completed. Results of the intent-to-treat sample indicated statistically significant improvements at posttreatment with large treatment effects for OCD symptoms as assessed by the Yale Brown Obsessive-Compulsive Scale (d=0.87), and small to moderate improvements in depression (d=0.19), functioning (d=0.53), and quality of life (d=-0.18). These outcomes were largely maintained over a 6-month follow-up. Readiness to reduce avoidance of OCD triggers and attendance to therapist sessions were moderately associated with posttreatment response, and correctly classified the responder status (defined as clinically significant change) of nearly 9 out of 10 patients at posttreatment. These same variables did not predict responder status at 6-month follow-up. These results lend further empirical support to iGSH as a treatment for OCD and provide direction on the development of predictor models to identify patients who are and are not likely to acutely respond to iGSH.

Pharmacological interventions for drug-using offenders

BACKGROUND

The review represents one in a family of four reviews focusing on a range of different interventions for drug-using offenders. This specific review considers pharmacological interventions aimed at reducing drug use or criminal activity, or both, for illicit drug-using offenders.

OBJECTIVES

To assess the effectiveness of pharmacological interventions for drug-using offenders in reducing criminal activity or drug use, or both.

SEARCH METHODS

We searched Fourteen electronic bibliographic databases up to May 2014 and five additional Web resources (between 2004 and November 2011). We contacted experts in the field for further information.

SELECTION CRITERIA

We included randomised controlled trials assessing the efficacy of any pharmacological intervention a component of which is designed to reduce, eliminate or prevent relapse of drug use or criminal activity, or both, in drug-using offenders. We also report data on the cost and cost-effectiveness of interventions.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as expected by Cochrane.

MAIN RESULTS

Fourteen trials with 2647 participants met the inclusion criteria. The interventions included in this review report on agonistic pharmacological interventions (buprenorphine, methadone and naltrexone) compared to no intervention, other non-pharmacological treatments (e.g. counselling) and other pharmacological drugs. The methodological trial quality was poorly described, and most studies were rated as 'unclear' by the reviewers. The biggest threats to risk of bias were generated through blinding (performance and detection bias) and incomplete outcome data (attrition bias). Studies could not be combined all together because the comparisons were too different. Only subgroup analysis for type of pharmacological treatment were done. When compared to non-pharmacological, we found low quality evidence that agonist treatments are not effective in reducing drug use or criminal activity, objective results (biological) (two studies, 237 participants (RR 0.72 (95% CI 0.51 to 1.00); subjective (self-report), (three studies, 317 participants (RR 0.61 95% CI 0.31 to 1.18); self-report drug use (three studies, 510 participants (SMD: -0.62 (95% CI -0.85 to -0.39). We found low quality of evidence that antagonist treatment was not effective in reducing drug use (one study, 63 participants (RR 0.69, 95% CI 0.28 to 1.70) but we found moderate quality of evidence that they significantly reduced criminal activity (two studies, 114 participants, (RR 0.40, 95% CI 0.21 to 0.74).Findings on the effects of individual pharmacological interventions on drug use and criminal activity showed mixed results. In the comparison of methadone to buprenorphine, diamorphine and naltrexone, no significant differences were displayed for either treatment for self report dichotomous drug use (two studies, 370 participants (RR 1.04, 95% CI 0.69 to 1.55), continuous measures of drug use (one study, 81 participants, (mean difference (MD) 0.70, 95% CI -5.33 to 6.73); or criminal activity (one study, 116 participants, (RR 1.25, 95% CI 0.83 to 1.88) between methadone and buprenorphine. Similar results were found for comparisons with diamorphine with no significant differences between the drugs for self report dichotomous drug use for arrest (one study, 825 participants, (RR 1.25, 95% CI 1.03 to 1.51) or naltrexone for dichotomous measures of reincarceration (one study, 44 participants, (RR 1.10, 95% CI 0.37 to 3.26), and continuous outcome measure of crime, (MD -0.50, 95% CI -8.04 to 7.04) or self report drug use (MD 4.60, 95% CI -3.54 to 12.74).

AUTHORS' CONCLUSIONS

When compared to non-pharmacological treatment, agonist treatments did not seem effective in reducing drug use or criminal activity. Antagonist treatments were not effective in reducing drug use but significantly reduced criminal activity. When comparing the drugs to one another we found no significant differences between the drug comparisons (methadone versus buprenorphine, diamorphine and naltrexone) on any of the outcome measures. Caution should be taken when interpreting these findings, as the conclusions are based on a small number of trials, and generalisation of these study findings should be limited mainly to male adult offenders. Additionally, many studies were rated at high risk of bias.

Interventions for drug-using offenders with co-occurring mental illness

BACKGROUND

This is an updated version of an original Cochrane review published in Issue 3 2006 (Perry 2006). The review represents one from a family of four reviews focusing on interventions for drug-using offenders. This specific review considers interventions aimed at reducing drug use or criminal activity, or both for drug-using offenders with co-occurring mental illness.

OBJECTIVES

To assess the effectiveness of interventions for drug-using offenders with co-occurring mental illness in reducing criminal activity or drug use, or both.

SEARCH METHODS

We searched 14 electronic bibliographic databases up to May 2014 and 5 Internet resources (searched between 2004 and 11 November 2009). We contacted experts in the field for further information.

SELECTION CRITERIA

We included randomised controlled trials designed to reduce, eliminate, or prevent relapse of drug use and criminal activity, or both in drug-using offenders with co-occurring mental illness. We also reported data on the cost and cost-effectiveness of interventions.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

Eight trials with 2058 participants met the inclusion criteria. The methodological quality of the trials was generally difficult to rate due to a lack of clear reporting. On most 'Risk of bias' items, we rated the majority of studies as unclear. Overall, we could not statistically combine the results due to the heterogenous nature of the different study interventions and comparison groups. A narrative summary of the findings identified that the interventions reported limited success with reducing self report drug use, but did have some impact on re-incarceration rates, but not re-arrest. In the single comparisons, we found moderate-quality evidence that therapeutic communities determine a reduction in re-incarceration but reported less success for outcomes of re-arrest, moderate quality of evidence and self report drug use. Three single studies evaluating case management via a mental health drug court (very low quality of evidence), motivational interviewing and cognitive skills (low and very low quality of evidence) and interpersonal psychotherapy (very low quality of evidence) did not report significant reductions in criminal activity and self report drug use respectively. Quality of evidence for these three types of interventions was low to very low. The trials reported some cost information, but it was not sufficient to be able to evaluate the cost-effectiveness of the interventions.

AUTHORS' CONCLUSIONS

Two of the five trials showed some promising results for the use of therapeutic communities and aftercare, but only in relation to reducing subsequent re-incarceration. Overall, the studies showed a high degree of variation, warranting a degree of caution in the interpretation of the magnitude of effect and direction of benefit for treatment outcomes. More evaluations are required to assess the effectiveness of interventions for drug-using offenders with co-occurring mental health problems.

Interventions for female drug-using offenders

BACKGROUND

This is an updated version of a Cochrane review first published in Issue 3, 2006 (Perry 2006). The review represents one in a family of four reviews focusing on the effectiveness of interventions in reducing drug use and criminal activity for offenders. This specific review considers interventions for female drug-using offenders.

OBJECTIVES

To assess the effectiveness of interventions for female drug-using offenders in reducing criminal activity, or drug use, or both.

SEARCH METHODS

We searched 14 electronic bibliographic databases up to May 2014 and five additional Website resources (between 2004 and November 2011). We contacted experts in the field for further information.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) designed to reduce, eliminate or prevent relapse of drug use or criminal activity in female drug-using offenders. We also reported data on the cost and cost-effectiveness of interventions.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

Nine trials with 1792 participants met the inclusion criteria. Trial quality and risks of bias varied across each study. We rated the majority of studies as being at 'unclear' risk of bias due to a lack of descriptive information. We divided the studies into different categories for the purpose of meta-analyses: for any psychosocial treatments in comparison to treatment as usual we found low quality evidence that there were no significant differences in arrest rates, (two studies; 489 participants; risk ratio (RR) 0.82, 95% confidence interval (CI) 0.45 to 1.52) or drug use (one study; 77 participants; RR 0.65, 95% CI 0.20 to 2.12), but we found moderate quality evidence that there was a significant reduction in reincarceration, (three studies; 630 participants; RR 0.46, 95% CI 0.34 to 0.64). Pharmacological intervention using buprenorphine in comparison to a placebo did not significantly reduce self reported drug use (one study; 36 participants; RR 0.58, 95% CI 0.25 to 1.35). No cost or cost-effectiveness evidence was reported in the studies.

AUTHORS' CONCLUSIONS

Three of the nine trials show a positive trend towards the use of any psychosocial treatment in comparison to treatment as usual showing an overall significant reduction in subsequent reincarceration, but not arrest rates or drug use. Pharmacological interventions in comparison to a placebo did not significantly reduce drug use and did not measure criminal activity. Four different treatment comparisons showed varying results and were not combined due to differences in the intervention and comparison groups. The studies overall showed a high degree of heterogeneity for types of comparisons and outcome measures assessed, which limited the possibility to pool the data. Descriptions of treatment modalities are required to identify the important elements for treatment success in drug-using female offenders. More trials are required to increase the precision of confidence with which we can draw conclusions about the effectiveness of treatments for female drug-using offenders.

Effects of prior cocaine self-administration on cognitive performance in female cynomolgus monkeys

Cocaine use has been associated with cognitive impairments that may contribute to poor treatment outcomes. However, the degree to which these deficits extend into periods of abstinence has not been completely elucidated. This study tested whether prior experience self-administering cocaine affected acquisition of two cognitive tasks in 16 adult female cynomolgus monkeys. Seven monkeys had previously self-administered cocaine but had not had access to cocaine for 2 months at the start of this study. After monkeys were trained to respond on a touchscreen, associative learning and behavioral flexibility were assessed using a stimulus discrimination (SD) and reversal (SDR) task from the CANTAB battery. Performance on this task was monitored over the subsequent 3 months. Additionally, working memory was assessed with a delayed match-to-sample (DMS) task. Cocaine-naïve monkeys required fewer total trials and made fewer errors and omissions before acquiring the SD and SDR tasks compared with monkeys who had previously self-administered cocaine; two monkeys in the latter group did not acquire the task. However, this cognitive impairment dissipated over several months of exposure to the task. The number of sessions for touch training and delays required to establish a performance-based curve on the DMS task did not differ between groups. Results suggest that cocaine exposure can impair the ability to learn a novel task requiring behavioral inhibition and flexibility, even after an extended period of abstinence. However, this deficit did not extend to maintenance of the task or to acquisition of a working memory task.

Effectiveness of Computer-Assisted Therapy for Substance Dependence Using Breaking Free Online: Subgroup Analyses of a Heterogeneous Sample of Service Users

BACKGROUND

Substance misuse services within the United Kingdom have traditionally been oriented to opiate and crack users, and attended predominantly by male service users. Groups who do not fit this demographic, such as women or those whose primary drug of choice is neither heroin nor crack, have tended to be underrepresented in services. In addition, there can be stigma associated with traditional opiate and crack-centric services. Therefore, the computerized treatment and recovery program, Breaking Free Online (BFO), was developed to enable service users to access confidential support for dependence on a wide range of substances. BFO is delivered as computer-assisted therapy (CAT), or, where appropriate, used as self-help.

OBJECTIVE

The aim of this study was to report psychometric outcomes data from 393 service users accessing online support for substance misuse via BFO.

METHODS

Following initial referral to substance misuse services, all participants were supported in setting up a BFO login by a practitioner or peer mentor, and, where required, assisted as they completed an online baseline assessment battery contained within the BFO program. Following a period of engagement with BFO, all participants completed the same battery of assessments, and changes in the scores on these assessments were examined.

RESULTS

Significant improvements were found across the 393 service users in several areas of psychosocial functioning, including quality of life, severity of alcohol and drug dependence, depression, and anxiety (P=<.001 across all aspects of functioning). Additionally, significant improvements were found within specific subgroups of participants, including females (P=.001-<.001), males (P=.004-<.001), service users reporting alcohol dependence (P=.002-<.001), opiate and crack dependence (P=.014-<.001), and those seeking support for other substances that may be less well represented in the substance misuse sector (P=.001-<.001).

CONCLUSIONS

Data from this study indicates that BFO is an effective clinical treatment for a wide range of individuals requiring support for substance misuse. Further work is currently underway to examine more closely the clinical effectiveness of the program.

Guanfacine enhances inhibitory control and attentional shifting in early abstinent cocaine-dependent individuals

OBJECTIVES

Attenuation of adrenergic drive and cognitive enhancement, via stimulation of alpha2 pre- and post-synaptic receptors, may selectively enhance executive performance in early abstinent cocaine-dependent individuals. As these cognitive processes underpin important treatment-related behaviors, the alpha2 agonist, guanfacine HCl, may represent an effective pharmaco-therapeutic intervention.

METHODS

Twenty-five early abstinent cocaine-dependent individuals were administered a battery of neurocognitive tasks on entry into treatment (baseline) and again following 3 weeks of either placebo or guanfacine treatment (up to 3 mg). Tasks included: Stop Signal, Stroop, 3-Dimentional Intra-dimensional/Extra-dimensional (IDED) task, Spatial Working Memory (SWM), Paired Associates Learning (PAL), Verbal Fluency and the Rey Auditory Verbal Learning Test (RAVLT).

RESULTS

Compared with placebo, the guanfacine group demonstrated attenuated anxiety and negative affect as well as improved performance on selective executive tests. This included fewer directional errors on the stop signal task, fewer errors on the extra-dimensional shift component of the IDED task and better attentional switching during verbal fluency. Guanfacine did not improve strategic working memory or peripheral memory.

CONCLUSION

Guanfacine improves selective cognitive processes which may underlie salient treatment-related regulatory behaviors. Alpha2 agonists may therefore represent important agents for cocaine dependence.

Implementation of computer-assisted therapy for substance misuse: a qualitative study of Breaking Free Online using Roger's diffusion of innovation theory

Purpose

– The purpose of this paper is to explore the adoption and implementation of computer-assisted therapy (CAT) using Breaking Free Online (BFO) in a social care and health charity working with people affected by drugs and alcohol dependence, Crime Reduction Initiatives (CRI).

Design/methodology/approach

– Semi-structured interviews were conducted with service managers, practitioners, peer mentors and service users. Data were thematically analysed and themes conceptualised using Roger's Diffusion of Innovation Theory (Rogers, 1995, 2002, 2004).

Findings

– A number of perceived barriers to adoption of BFO throughout CRI were identified within the social system, including a lack of IT resources and skills. However, there were numerous perceived benefits of adoption of BFO throughout CRI, including broadening access to effective interventions to support recovery from substance dependence, and promoting digital inclusion. Along with the solutions that were found to the identified barriers to implementation, intentions around longer-term continuation of adoption of the programme were reported, with this process being supported through changes to both the social system and the individuals within it.

Research limitations/implications

– The introduction of innovations such as BFO within large organisations like CRI can be perceived as being disruptive, even when individuals within the organisation recognise its benefits. For successful adoption and implementation of such innovations, changes in the social system are required, at organisational and individual levels.

Practical implications

– The learning points from this study may be relevant to the substance misuse sector, and more widely to criminal justice, health and social care organisations.

Originality/value

– This study is the first of its kind to use a qualitative approach to examine processes of implementation of CAT for substance misuse within a large treatment and recovery organisation.

A cognitive-behavioral model of Internet gaming disorder: theoretical underpinnings and clinical implications

Cognitive contributions to the behaviors observed in substance and non-substance addictions have been investigated and characterized. Based on models of drug addictions and the extant literature on Internet gaming disorder (IGD), we propose a cognitive-behavioral model for conceptualizing IGD. The model focuses on three domains and their roles in addictive behaviors. The three domains include motivational drives related to reward-seeking and stress-reduction, behavioral control relating to executive inhibition, and decision-making that involves weighing the pros and cons of engaging in motivated behaviors. Based on this model, we propose how behavioral therapies might target these domains in the treatment of IGD.

Cannabis abstinence during treatment and one-year follow-up: relationship to neural activity in men

Cannabis is among the most frequently abused substances in the United States. Cognitive control is a contributory factor in the maintenance of substance-use disorders and may relate to treatment response. Therefore, we assessed whether cognitive-control-related neural activity before treatment differs between treatment-seeking cannabis-dependent and healthy individuals and relates to cannabis-abstinence measures during treatment and 1-year follow-up. Cannabis-dependent males (N=20) completed a functional magnetic resonance imaging (fMRI) cognitive-control (Stroop) task before a 12-week randomized controlled trial of cognitive-behavioral therapy and/or contingency management. A healthy-comparison group (N=20) also completed the fMRI task. Cannabis use was assessed by urine toxicology and self-report during treatment, and by self-report across a 1-year follow-up period (N=18). The cannabis-dependent group displayed diminished Stroop-related neural activity relative to the healthy-comparison group in multiple regions, including those strongly implicated in cognitive-control and addiction-related processes (eg, dorsolateral prefrontal cortex and ventral striatum). The groups did not differ significantly in response times (cannabis-dependent, N=12; healthy-comparison, N=14). Within the cannabis-dependent group, greater Stroop-related activity in regions including the dorsal anterior cingulate cortex was associated with less cannabis use during treatment. Greater activity in regions including the ventral striatum was associated with less cannabis use during 1-year posttreatment follow-up. These data suggest that lower cognitive-control-related neural activity in classic 'control' regions (eg, dorsolateral prefrontal cortex and dorsal anterior cingulate) and classic 'salience/reward/learning' regions (eg, ventral striatum) differentiates cannabis-dependent individuals from healthy individuals and relates to less abstinence within-treatment and during long-term follow-up. Clinically, results suggest that treatment development efforts that focus on enhancing cognitive control in addition to abstinence may improve treatment outcomes in cannabis dependence.

Brain structural substrates of cognitive procedural learning in alcoholic patients early in abstinence

BACKGROUND

Procedural learning allows for the acquisition of new behavioral skills. Previous studies have shown that chronic alcoholism is characterized by impaired cognitive procedural learning and brain abnormalities affecting regions that are involved in the automation of new cognitive procedures in healthy individuals. The goal of the present study was to investigate the brain structural substrates of cognitive procedural learning in alcoholic patients (ALs) early in abstinence.

METHODS

Thirty-one ALs and 31 control participants (NCs) performed the Tower of Toronto task (4 daily learning sessions, each comprising 10 trials) to assess cognitive procedural learning. We also assessed episodic and working memory, executive functions, and visuospatial abilities. ALs underwent 1.5T structural magnetic resonance imaging.

RESULTS

The initial cognitive phase was longer in the AL group than in the NC group, whereas the autonomous phase was shorter. In ALs, the longer cognitive phase was predicted by poorer planning and visuospatial working memory abilities, and by smaller gray matter (GM) volumes in the angular gyrus and caudate nucleus. ALs' planning abilities correlated with smaller GM volume in the angular gyrus.

CONCLUSIONS

Cognitive procedural learning was impaired in ALs, with a delayed transition from the cognitive to the autonomous phase. This slowdown in the automation of the cognitive procedure was related to lower planning abilities, which may have hampered the initial generation of the procedure to be learned. In agreement with this neuropsychological finding, a persistent relationship was found between learning performance and the GM volumes of the angular gyrus and caudate nucleus, which are usually regarded as markers of planning and initial learning of the cognitive procedure.

Neuropsychological Assessment Battery-Screening Module (S-NAB): performance in treatment-seeking cocaine users

Abstract Background: Cocaine use is associated with cognitive impairments, which can have a negative effect on treatment retention and drug use. Thus, there is an increasing demand for a screening cognitive battery can be used by clinicians to detect such impairments in cocaine patients so that treatment can be adapted to patients' specific cognitive strengths and deficits. The Neuropsychological Assessment Battery-Screening Module (S-NAB) test for adults takes approximately 35-45 min to administer, and assesses attention, language, memory (verbal and visual), visual spatial reasoning, and executive functioning.

OBJECTIVE

The purpose of this descriptive study was to present S-NAB score results for a sample of treatment seeking adult cocaine users to determine its potential utility for detecting cognitive impairments in this population.

METHODS

In the present sample, 145 adult cocaine users participated in screening to enroll in an intervention to decrease cocaine use (59% male; 73.1% African American); screening included the S-NAB and self-report questionnaires.

RESULTS

A substantial proportion of the sample (44%) met criteria for impairment, i.e. composite scores of one or more standard deviations below the mean. Furthermore, memory scores were significantly lower than language and spatial scores (p < 0.007).

CONCLUSIONS

The impairments detected by the S-NAB were generally consistent with those previously observed in samples of cocaine users completing other batteries, as well in other substance abusing samples completing the S-NAB. This suggests that the S-NAB can be considered an additional appropriate battery, as an alternative to other existing batteries, for assessment of the cognitive functioning of adult cocaine users.

Impulsivity as a vulnerability factor for poor addiction treatment outcomes: a review of neurocognitive findings among individuals with substance use disorders

With the current review, we explore the hypothesis that individual differences in neurocognitive aspects of impulsivity (i.e., cognitive and motor disinhibition, delay discounting and impulsive decision-making) among individuals with a substance use disorder are linked to unfavorable addiction treatment outcomes, including high drop-out rates and difficulties in achieving and maintaining abstinence. A systematic review of the literature was carried out using PubMed, PsycINFO and Web of Knowledge searches. Twenty-five unique empirical papers were identified and findings were considered in relation to the different impulsivity dimensions. Although conceptual/methodological heterogeneity and lack of replication are key limitations of studies in this area, findings speak for a prominent role of cognitive disinhibition, delay discounting and impulsive decision-making in the ability to successfully achieve and maintain abstinence during and following addiction treatment. In contrast, indices of motor disinhibition appear to be unrelated to abstinence levels. Whereas the relationship between impulsivity and treatment retention needs to be examined more extensively, preliminary evidence suggests that impulsive/risky decision-making is unrelated to premature treatment drop-out among individuals with a substance use disorder. The reviewed findings are discussed in terms of their clinical implications.

Interventions for female drug-using offenders

BACKGROUND

This is an updated version of a Cochrane review first published in Issue 3, 2006 (Perry 2006). The review represents one in a family of four reviews focusing on the effectiveness of interventions in reducing drug use and criminal activity for offenders. This specific review considers interventions for female drug-using offenders.

OBJECTIVES

To assess the effectiveness of interventions for female drug-using offenders in reducing criminal activity or drug use, or both.

SEARCH METHODS

We searched 14 electronic bibliographic databases (between 2004 and 21st March 2013) and five additional web resources (between 2004 and November 2011). We contacted experts in the field for further information.

SELECTION CRITERIA

We include randomised controlled trials designed to reduce, eliminate or prevent relapse in female drug-using offenders. We also report data on the cost and cost effectiveness of interventions.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by the Cochrane Collaboration.

MAIN RESULTS

We identified 76 trials across the four reviews. Following a process of prescreening, we judged that 11 trials met the inclusion criteria of the specified review; four of the 11 trials are awaiting classification in the review. The remaining seven trials cover 1236 participants. The interventions included in this review report on therapeutic communities (TCs), gender-responsive treatment (GRT), use of case management and cognitive skills, and a pharmacological intervention using buprenorphine. Trial quality and risks of bias varied across each study. The majority of studies were rated as being at 'unclear' risk of bias due to a lack of descriptive information. Overall the interventions showed statistically significant reductions in self-reported drug use, (four studies, 734 participants, risk ratio (RR) 0.68; 95% confidence interval (CI) 0.58 to 0.80) and re-incarceration, (four studies, 745 participants, RR 0.55; 95% CI 0.41 to 0.72). We found a statistically non-significant result for re-arrest (three studies, 803 participants, RR 0.80; 95% CI 0.53 to 1.19). Individual treatment results found that TCs and a GRT programme showed a statistically significant reduction in re-incarceration (one study, 509 participants, RR 0.42; 95% CI 0.29 to 0.60) but not for re-arrest, (one study, 314 participants, RR 0.73; 95% CI 0.52 to 1.03) and self-reported drug use (two studies, 825 participants, RR 0.47; 95% CI 0.14 to 1.53). Case management and cognitive skills programmes did not significantly reduce re-arrests, (one study, 183 participants RR 1.12; 95% CI 0.89 to 1.41) or self-reported drug use, (one study, 77 participants, RR 0.65; 95% CI 0.20 to 2.12), but did show a statistically significant reduction in re-incarceration, (three studies, 236 participants, RR 0.63; 95% CI 0.49 to 0.81). Buprenorphine did not significantly reduce self-reported drug use (RR 0.58; 95% CI 0.25 to 1.35), but this result came from a single study with only 36 participants. Due to the small number of studies we were unable to analyse the impact of treatment setting on outcome. No cost and cost effectiveness evidence was reported in the studies.

AUTHORS' CONCLUSIONS

The seven trials show some positive results for the use of treatments to reduce self-reported drug use and subsequent re-incarceration. However, the studies overall showed a high degree of statistical variation, requiring a degree of caution in the interpretation of the magnitude of effect and direction of benefit for treatment outcomes. Descriptions of treatment modalities are required to identify the important elements for treatment success in drug-using female offenders. More trials are required to increase the confidence with which we can draw conclusions about the effectiveness of treatments for female drug-using offenders.

Interventions for drug-using offenders with co-occurring mental illness

BACKGROUND

This is an updated version of an original Cochrane review published in Issue 3 2006 (Perry 2006). The review represents one from a family of four reviews focusing on interventions for drug-using offenders. This specific review considers interventions aimed at reducing drug use or criminal activity, or both for drug-using offenders with co-occurring mental illness.

OBJECTIVES

To assess the effectiveness of interventions for drug-using offenders with co-occurring mental illness in reducing criminal activity or drug use, or both.

SEARCH METHODS

We searched 14 electronic bibliographic databases (searched between 2004 and 21 March 2013) and five internet resources (searched between 2004 and 11 November 2009). We contacted experts in the field for further information.

SELECTION CRITERIA

We included randomised controlled trials designed to reduce, eliminate or prevent relapse in drug-using offenders with co-occurring mental illness. We also reported data on the cost and cost effectiveness of interventions.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

We identified 76 trials across the four reviews. Following a process of pre-screening, we judged eight trials to meet the inclusion criteria for this specific review (three of the five trials are awaiting classification). The five included 1502 participants. The interventions reported on case management via a mental health drugs court, a therapeutic community, and an evaluation of a motivational interviewing technique and cognitive skills in comparison to relaxation training. The methodological quality of the trials was generally difficult to rate due to a lack of clear reporting. On most risk of bias items, we rated the majority of studies as unclear. Overall, the combined interventions did not show a statistically significant reduction in self reported drug use (2 studies, 715 participants; risk ratio (RR) 0.82, 95% confidence interval (CI) 0.44 to 1.55). A statistically significantly reduction was shown for re-incarceration (4 studies, 627 participants; RR 0.40, 95% CI 0.24 to 0.67 and mean difference (MD) 28.72, 95% CI 5.89 to 51.54) but not re-arrest (2 studies, 518 participants; RR 1.00, 95% CI 0.90 to 1.12). A specific subgroup analysis combining studies using therapeutic community interventions showed a statistically significant reduction in re-incarceration (2 studies, 266 participants; RR 0.29, 95% CI 0.16 to 0.54) but not re-arrest (1 study, 428 participants; RR 0.90, 95% CI 0.61 to 1.33). Case management via a mental health court and motivational interviewing with cognitive skills did not show a statistically significant reduction in criminal activity (1 study, 235 participants; RR 1.05, 95% CI 0.90 to 1.22) or self reported drug misuse (1 study, 162 participants; MD -7.42, 95% CI -20.12 to 5.28). Due to the small number of studies, we were unable to analyse the impact of setting on outcome. Some cost information was provided in the trials but not sufficient to be able to evaluate the cost effectiveness of the interventions.

AUTHORS' CONCLUSIONS

This review highlights the paucity of evidence for drug misusing offenders with co-occurring mental health problems. Two of the five trials showed some promising results for the use of therapeutic communities and aftercare, but only in relation to reducing subsequent re-incarceration. The studies overall, showed a high degree of statistical variation demonstrating a degree of caution in the interpretation of the magnitude of effect and direction of benefit for treatment outcomes. More evaluations are required to assess the effectiveness of interventions for drug-using offenders with co-occurring mental health problems.

"Counselor in Your Pocket": Youth and Provider Perspectives on a Mobile Motivational Intervention for Marijuana Use

Previous interventions for marijuana use have been administered out of the real-life contexts in which use occurs. In 2010, we interviewed youth aged 15-24 years who use marijuana frequently (n = 8) and providers who treat them (n = 6) on the acceptability and utility of a mobile intervention involving momentary self-monitoring of use-related contexts and responsive motivational messaging following clinic-based brief motivational enhancement therapy. Thematic analysis was used to examine youth and provider perspectives on the mobile intervention. Results suggest that mobile technology is a promising tool for brief interventions to reduce youth marijuana use and warrants further development.

Pharmacological interventions for drug-using offenders

BACKGROUND

The review represents one in a family of four reviews focusing on a range of different interventions for drug-using offenders. This specific review considers pharmacological interventions aimed at reducing drug use and/or criminal activity for illicit drug-using offenders.

OBJECTIVES

To assess the effectiveness of pharmacological interventions for drug-using offenders in reducing criminal activity and/or drug use.

SEARCH METHODS

Fourteen electronic bibliographic databases (searched between 2004 and 21 March 2013) and five additional Web resources (searched between 2004 and 11 November 2011) were searched. Experts in the field were contacted for further information.

SELECTION CRITERIA

Randomised controlled trials assessing the efficacy of any pharmacological interventions for reducing, eliminating or preventing relapse in drug-using offenders were included. Data on the cost and cost-effectiveness of interventions were reported.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as expected by The Cochrane Collaboration.

MAIN RESULTS

A total of 76 trials across the four reviews were identified. After a process of prescreening had been completed, 17 trials were judged to meet the inclusion criteria for this specific review (six of the 17 trials are awaiting classification for the review). The remaining 11 trials contained a total of 2,678 participants. Nine of the eleven studies used samples with a majority of men. The interventions (buprenorphine, methadone and naltrexone) were compared to non pharmacological treatments (e.g., counselling) and other pharmacological drugs. The methodological trial quality was poorly described, and most studies were rated as 'unclear' by the reviewers. The biggest threats to risk of bias were generated through blinding (performance and detection bias) and incomplete outcome data (attrition bias). When combined, the results suggest that pharmacological interventions do significantly reduce subsequent drug use using biological measures, (three studies, 300 participants, RR 0.71 (95% CI 0.52 to 0.97)), self report dichotomous data (three studies, 317 participants, RR 0.42, (95% CI 0.22 to 0.81)) and continuous measures (one study, MD -59.66 (95% CI -120.60 to 1.28)) . In the subgroups analysis for community setting, (two studies, 99 participants: RR 0.62 (95% CI 0.35 to 1.09)) and for secure establishment setting, (one study, 201 participants: RR 0.76 (95% CI 0.52 to 1.10)), the results are no longer statistically significant. Criminal activity was significantly reduced favouring the dichotomous measures of re arrest, (one study, 62 participants, RR 0.60 (95% CI 0.32 to 1.14)), re-incarceration, (three studies, 142 participants, RR 0.33 (95% CI 0.19 to 0.56)) and continuous measures (one study, 51 participants, MD -74.21 (95% CI -133.53 to -14.89)). Findings on the effects of individual pharmacological interventions on drug use and criminal activity show mixed results. Buprenorphine in comparison to a non pharmacological treatment seemed to favour buprenorphine but not significantly with self report drug use, (one study, 36 participants, RR 0.58 (95% CI 0.25 to 1.35)). Methadone and cognitive behavioural skills in comparison to standard psychiatric services, did show a significant reduction for self report dichotomous drug use (one study, 253 participants, RR 0.43 (95% CI 0.33 to 0.56)) but not for self report continuous data (one study 51 participants) MD -0.52 (95% CI -1.09 to 0.05)), or re incarceration RR 1.23 (95% CI 0.53 to 2.87)). Naltrexone was favoured significantly over routine parole and probation for re incarceration (two studies 114 participants, RR 0.36 (95% CI 0.19 to 0.69)) but no data was available on drug use. Finally, we compared each pharmacological treatment to another. In each case we compared methadone to: buprenorphine, diamorphine and naltrexone. No significant differences were displayed for either treatment for self report dichotomous drug use (one study, 193 participants RR 1.23 (95% CI 0.86 to 1.76)), continuous measures of drug use MD 0.70 (95% CI -5.33 to 6.73) or criminal activity RR 1.25 (95% CI 0.83 to 1.88)) between methadone and buprenorphine. Similiar results were found for comparisons with Diamorphine with no significant differences between the drugs for self report dichotomous drug use for arrest (one study, 825 participants RR 1.25 (95% CI 1.03-1.51)) or Naltrexone for dichotomous measures of re incarceration (one study, 44 participants, RR 1.10 (95% CI 0.37 to 3.26)), and continuous outcome measure of crime MD -0.50 (95% CI -8.04 to 7.04)) or self report drug use MD 4.60 (95% CI -3.54 to 12.74)).

AUTHORS' CONCLUSIONS

Pharmacological interventions for drug-using offenders do appear to reduce overall subsequent drug use and criminal activity (but to a lesser extent). No statistically significant differences were displayed by treatment setting. Individual differences are displayed between the three pharmacological interventions (buprenorphine, methadone and naltrexone) when compared to a non pharmacological intervention, but not when compared to each other. Caution should be taken when interpreting these findings, as the conclusions are based on a small number of trials, and generalisation of these study findings should be limited mainly to male adult offenders. Additionally, many studies were rated at high risk of bias because trial information was inadequately described.

Performance of a computer-based assessment of cognitive function measures in two cohorts of seniors

BACKGROUND

Computer-administered assessment of cognitive function is being increasingly incorporated in clinical trials; however, its performance in these settings has not been systematically evaluated.

DESIGN

The Seniors Health and Activity Research Program pilot trial (N = 73) developed a computer-based tool for assessing memory performance and executive functioning. The Lifestyle Interventions and Independence for Elders investigators incorporated this battery in a full-scale multicenter clinical trial (N = 1635). We describe relationships that test scores have with those from interviewer-administered cognitive function tests and risk factors for cognitive deficits and describe performance measures (completeness, intraclass correlations [ICC]).

RESULTS

Computer-based assessments of cognitive function had consistent relationships across the pilot and full-scale trial cohorts with interviewer-administered assessments of cognitive function, age, and a measure of physical function. In the Lifestyle Interventions and Independence for Elders cohort, their external validity was further demonstrated by associations with other risk factors for cognitive dysfunction: education, hypertension, diabetes, and physical function. Acceptable levels of data completeness (>83%) were achieved on all computer-based measures; however, rates of missing data were higher among older participants (odds ratio = 1.06 for each additional year; p < 0.001) and those who reported no current computer use (odds ratio = 2.71; p < 0.001). ICCs among clinics were at least as low (ICC < 0.013) as for interviewer measures (ICC < 0.023), reflecting good standardization. All cognitive measures loaded onto the first principal component (global cognitive function), which accounted for 40% of the overall variance.

CONCLUSION

Our results support the use of computer-based tools for assessing cognitive function in multicenter clinical trials of older individuals.