ISTANBUL, TURKEY — Remediation of the cognitive deficits often present in chronic substance abusers offers an exciting new opportunity to treat addictive disorders.
Two approaches are under investigation: computer-assisted cognitive rehabilitation using structured exercises to improve cognitive flexibility and, more recently, pharmacologic manipulation of various neurotransmitter systems involved in the cognitive impairment, Frank Vocci, Ph.D., said at the annual congress of the European College of Neuropsychopharmacology.
Numerous studies have established that although vocabulary and verbal skills are preserved in substance abusers, deficits in many other areas of cognition are common.
“The deficits have a high prevalence and are oftentimes as severe as those seen in traumatic brain injury. They evolve over an extended period of time. They usually go unrecognized by providers. You can't tell who's cognitively impaired based upon a clinical interview; you have to run neuropsychologic batteries. And the patient behaviors are often attributed to personality and character, not cognitive impairment,” explained Dr. Vocci, corporate president of the Friends Research Institute, Baltimore.
This misinterpretation of cognitive dysfunction as a fixed characterologic issue often sets up a poor therapeutic alliance and patient/therapist mismatch. The therapist views the substance abuse patient as unmotivated to participate fully in the learning experience, which cognitive-behavioral therapy or its variants is supposed to be.
Cognitive impairment has been shown to be adversely related to treatment engagement, which in turn is related to length of stay in a treatment program, which in turn is strongly related to treatment outcome, he continued.
The cognitive impairment will gradually improve spontaneously during the first 6 months or so of sobriety. But treatment programs in the United States are becoming shorter, which means that patients may not be in treatment long enough to achieve significant cognitive improvement.
“Spontaneous recovery may be too little, too late to be of any real consequence,” according to Dr. Vocci. “We end up with a terrible mismatch: The greatest amount of therapy may be given at a time when a person is cognitively impaired and has the least ability to learn from it.”
This is the impetus for accelerating cognitive recovery. The initial success came with computer-assisted cognitive rehabilitation (CACR). William Fals-Stewart, Ph.D., and his colleagues at the State University of New York, Buffalo, Research Institute on Addictions showed in the late 1990s and early part of this decade that CACR designed to address attention, memory, executive function, and problem-solving skills led to improvement in multiple cognitive domains in participants in a 6-month residential recovery program.
In a 120-patient study, patients randomized to three 50-minute CACG sessions per week for 2 months plus standard treatment stayed in the treatment program for an average of 200 days, significantly longer than the 128 and 132 days in two control groups. And CACG made a real difference in treatment outcomes: The CACG group had more than twice the program graduation rate, fewer subsequent problems in employment, better family and social functioning, and less medical problems, all of which were fully mediated by the differences in length of stay in the treatment program.
But most of the work with CACG has been done in residential treatment settings, which are becoming increasingly rare. Much research remains to be done before it is known how well CACG will translate to the outpatient setting.
Turning to pharmacologic strategies for accelerating cognitive remediation in substance abusers, Dr. Vocci said the big news is that a large, double-blind, placebo-controlled, National Institute on Drug Abuse–sponsored, multicenter randomized trial of modafinil (Provigil) at 200-400 mg/day in methamphetamine abusers has just been completed. The data are now being analyzed in preparation for presentation of the results in 2010.
Beyond modafinil, numerous other pharmacologic agents are under study in pharmacology laboratories as selective modulators of a multiplicity of neurotransmitter systems believed to play key roles in the cognitive deficits characteristic of substance abusers.
Dr. Vocci disclosed serving as a paid consultant to multiple pharmaceutical companies.
'The greatest amount of therapy may be given at a time when a person is cognitively impaired.'
Source DR. VOCCI