StuDy AimED at Increasing AlCohol AbsTinEnce (DEDICATE) - The overall goals of this project in the R00 phase are to (1) test the efficacy of CM-PST vs CM alone in a 2-arm pilot RCT, and (2) assess neural mechanisms associated with CM-PST treatment effects in young adults with Alcohol Use Disorder (AUD). AUD is a chronic disease of impaired ability to stop or control alcohol use,1 and is a major public health problem, most prevalent in young adults (aged18-24 yr).2 AUD cost about 95,000 lives and $249B annually in the US as of 2010.3 About 70% of young adults engage in risky drinking,1,4 predisposing them to AUD.5 AUD has adverse whole-life health implications, especially among young adults, by virtue of their age. Heavy alcohol consumption impairs brain structure and function, more severely in young adults than in older adults.6 However, evidence-based treatments for AUD in young adults are lacking, and the neural mechanisms following available behavior treatments are poorly understood. The proposed study therefore aims to begin to overcome these gaps, by developing and testing an integrated AUD intervention, among young adults, to improve treatment efficacy, and inform about the neural mechanisms of treatment. One recommended treatment for AUD is contingency management (CM), a behavior therapy that rewards individuals for evidence of positive change,7 but CM has never been specifically tested in young adults. Prior randomized clinical trials (RCTs) of CM in AUD8–11 have shown only modest effects, but we hypothesize this is because CM is mediated by reward circuitry,12 a system impaired in persons with AUD.13–15 Therefore, to overcome this barrier so as to improve treatment efficacy, we will innovate by combining CM with a complementary approach that engages a neural circuit that may not rely on the reward system, but rather, involves reframing using cognitive control. To do so, we will integrate CM with Problem-Solving Therapy (PST), a brief psychotherapy proven beneficial in multiple health problems across different age groups, including young adults.16–20 Ma et al.’s mechanistic pilot trial showed that PST can engage both negative affect and cognitive control circuits.21,22 PST has been tested as enhancement strategy in combination with behavioral treatments such as motivational interviewing in related patient populations with substance (smoking, alcohol) use disorders,23,24 but these studies have not specifically assessed the efficacy of combining PST with CM. The proposed study's goal (StuDy AimED at Increasing AlCohol AbsTinEnce; DEDICATE) is to test the preliminary efficacy of CM-PST, vs. CM alone, to improve treatment efficacy and inform about neural mechanisms of treatment effects in young adults with AUD. Central hypothesis: Combined CM-PST can 1) improve alcohol abstinence (tested by urine alcohol screening; primary outcome) and other AUD outcomes (e.g., AUDIT, RAPI scores), and 2) increase activity in positive affect and cognitive control regions, decrease activity in negative affect regions, and enhance connectivity between these regions (exploratory outcome).
