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

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

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

Inclusion Criteria:

- Military Veterans

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

- Cocaine Use Within Past 60 Days

- Stated Goal of Cocaine Abstinence or Reduced Cocaine Use

- Normal or Corrected-to-Normal Vision

- Average or Corrected Hearing

Exclusion Criteria:

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

- Severe or Unstable Medical or Psychiatric Condition

- Pregnant or Lactating Women

- Moderate-to-Severe Neurocognitive Impairment per Medical Record or SLUMS < 21

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