Working Memory Training and High Magnitude Incentives for Youth Cannabis Use: A SMART Pilot Trial

The purpose of this sequential multiple-assignment randomization treatment pilot study was to examine if (a) adding working memory training to contingency management (CM) for youth with cannabis use disorder (CUD) and (b) switching nonresponding youth to higher magnitude CM incentives boosts outcomes. In Phase 1, youth with CUD (n = 59, M age = 16, male = 71%) attending an intensive outpatient program were randomly assigned to 14 weeks of CM only or CM plus working memory training (WMT). In Week 4, a Phase 2 treatment was assigned. Those with negative urine drug tests (responders) continued in their Phase 1 treatment. Those who were drug positive (nonresponders) were randomly assigned to remain in their Phase 1 treatment or to higher magnitude CM. Zero-inflated negative binomial models comparing those assigned to CM versus CM + WMT indicated no differences in the likelihood of having ≥1 week of continuous abstinence or longer abstinence duration. Those assigned to WMT showed greater but nonsignificant improvements in working memory (n = 35; β = .69, p = .06). Working memory improvements were associated with achieving any abstinence (odds ratio = 3.50, 95% CI [1.01, 12.10], p = .05). Phase 2 randomization to higher magnitude CM did not boost outcomes. Overall results suggest that WMT appears promising, but the sample size was small, attrition was high, and replication is important. Alternative strategies should continue to be explored to improve outcomes for adolescent substance use disorders, such as different approaches for nonresponders, tailoring to other baseline or response characteristics, or more robust first-line interventions.