Clinical translation of expert‐endorsed cognitive rehabilitation interventions for substance use disorders
Authors: Antonio Verdejo‐Garcia, Jamie Berry, Alfonso Caracuel, Marc L. Copersino, Matt Field, Eric L. Garland, Valentina Lorenzetti, Leandro Malloy‐Diniz, Victoria Manning, Ely M. Marceau, David L. Pennington, Tara Rezapour, Justin C. Strickland, Reinout W. Wiers, Hamed Ekhtiari
Journal: World Psychiatry (2024)

In a recent Delphi consensus1, we endorsed the application of four cognitive rehabilitation interventions as adjuncts to the treatment of substance use disorders: cognitive bias modification, contingency management, cognitive remediation, and emotion regulation training. This innovative portfolio is poised to cover the unaddressed need of tackling cognitive alterations that can hinder the efficacy of current treatments for substance use disorders2. Here, we summarize the therapeutic mechanisms of these four interventions, discuss barriers to their translation into clinical practice, and provide recommendations on how to overcome these barriers. Cognitive bias modification is a family of interventions that aim to reset drug-related biases using different varieties of computerized cognitive training. One example redirects tendencies to approach the drug toward alternative targets (e.g., from a tendency to approach alcohol to a tendency to approach a non-alcoholic drink). Contingency management provides tangible incentives (e.g., monetary payments) in exchange for therapeutic goal achievement (e.g., treatment attendance, abstaining or reducing drug use). Both cognitive bias modification and contingency management target addiction-related alterations in the incentive salience system by reducing the value of drug rewards and increasing the value of alternative reinforcers3. Cognitive remediation trains mental strategies aimed to restore or circumvent cognitive deficits, with a view to improving everyday function. For example, a "pause – check your goal – choose" strategy can be used to thwart impulsive choices within high-risk scenarios such as social engagements (especially those involving people who use drugs) or family gatherings, which can be highly confrontational for people in recovery. Emotion regulation training also uses a variety of mental strategies, in this case focused on improving management of negative emotions (e.g., cognitive reappraisal) and enhancing positive affect (e.g., savouring of natural reinforcers). Both cognitive remediation and emotion regulation interventions target addiction-related alterations in the executive control system by strengthening top-down control of behavior and emotions3. The Delphi experts recommended applying these interventions after acute detoxification, and maintaining them weekly for at least three months. The selection of the specific intervention/s should be based on individualized neuropsychosocial assessments, with the caveat that some interventions are best suited for particular substance use disorders (e.g., cognitive bias modification for alcohol use disorder). Different interventions can be combined to enhance treatment efficacy, as shown for the combination of cognitive remediation and contingency management4. Although the four expert-endorsed interventions are evidence-informed, multiple factors hamper their translation into clinical practice. These factors include the controversies around the concept of addiction, the divide between the research and clinical worlds, the lack of availability of technology and other resources, and the intricate policy landscape. Cognitive rehabilitation interventions are anchored in neuroscience evidence, but this approach is at risk of being equated with reductionist "brain disease" models of addiction, which have been criticized for neglecting the social aspects of the disorder and their limited contribution to help-seeking and treatment5. This may create a tension between the scientists and practitioners within the social and behavioral treatment space and the proponents of neuroscience-based approaches. An additional gap exists between the research community that develops cognitive rehabilitation interventions and those who train the treatment workforce that could implement them. These groups have different forums and priorities, also underpinned by disparate institutional incentive structures and performance indicators. To compound this problem further, there are limited opportunities to train addiction clinicians on neuroscience principles and approaches6. Cognitive rehabilitation interventions also require specific technology and material resources, such as computers and cloud-based services, and dedicated budgets for incentives, which may be prohibitive for mainstream treatment services. The broader policy and service provision landscape may pose additional challenges by opposing resistance (e.g., to contingency management) or lacking resources and/or agility to integrate these novel approaches within accessible, government-supported treatment plans. Notwithstanding these barriers, progress in scientific collaboration practices and translational science now provide a novel springboard to enable integration of cognitive rehabilitation in addiction clinical care. We previously referred to the "tension" between the behavioral/social and neuroscience approaches, but we argue that this tension is artificial, because cognitive rehabilitation interventions: a) leverage both neuroplasticity and learning principles to promote not only brain health but also adaptive changes in behavior and social function; b) should be understood and applied as add-ons rather than replacements for existing treatments. This integrative view is aligned with recent recommendations from the World Health Organization to nurture brain health in the context of its manifold individual and social determinants7, and relates back to the bio-psycho-social model of addiction. As many other psychiatric disorders, substance use disorders require a complexity-based approach that aims to optimize brain health by creating feedback loops with community resources and environmental mechanisms8. The more pragmatic gap between research and clinical worlds can be tackled with effective approaches derived from translational science, such as co-location and co-production. Co-location can start as early as during graduate clinical training, in masters and doctoral level programs, in which students can act as translators of research knowledge to become early-adopter clinicians. Co-production – which involves partnerships between researchers, clinicians and service providers towards the design of specific treatment solutions – provides unique opportunities for engagement of the addiction treatment workforce. It allows, for example, to develop case examples that are tailored to the individual and contextual needs, as well as delivery modalities and business models that are suitable and feasible. Furthermore, collaboration with industry partners can be leveraged to develop health technology solutions to optimize the user experience and engagement with interventions. Co-location and co-production also enable multiple opportunities for shared discussion forums among researchers, clinicians and decision-makers, which can facilitate coalescence of indicators of success across the research and clinical worlds (e.g., greater emphasis on translational outcomes for researchers, and greater opportunities for clinicians to participate in research). Moreover, changes in incentive structures can increase capacity and motivation for neuroscience training within the addiction treatment workforce, which can be expedited using e-learning and train-the-trainer approaches. Support from funding bodies is critical to bridge the technology and resources gap. Over $1.4 billion per annum is currently spent in addiction research only in the US; however, it has been estimated that only 15% of funded medical research is eventually translated into clinical practice9. It makes both good financial and public health sense to devote a significant proportion of that funding to enable service providers to catch up with evidence-based interventions. Specific funding schemes for non-governmental organizations and not-for-profit institutions to acquire the technology and resources needed for implementation of cognitive rehabilitation interventions would be a practical solution to reduce the current translation gap. These novel technologies and resources could also be used to monitor the outcomes of cognitive rehabilitation delivery in real-world clinical settings, as well as to analyze its impact on value-based health outcomes directly informed by consumers. In so doing, we envision a future in which cognitive rehabilitation is embedded in standard treatment pathways to maximize the health and well-being of individuals with addiction.