Cognitive Function as a Transdiagnostic Treatment Target in Stimulant Use Disorders

Abstract

Stimulant use disorder is an important public health problem, with an estimated 2.1 million current users in the United States alone. No pharmacological treatments are approved by the U.S. Food and Drug Administration (FDA) for stimulant use disorder and behavioral treatments have variable efficacy and limited availability. Most individuals with stimulant use disorder have other comorbidities, most with overlapping symptoms and cognitive impairments. The goal of this article is to present a rationale for cognition as a treatment target in stimulant use disorder, and to outline potential treatment approaches. Rates of lifetime comorbid psychiatric disorders among people with stimulant use disorders are estimated at 65% - 73%, with the most common being mood disorders (13% - 64%) and anxiety disorders (21% - 50%), as well as non-substance induced psychotic disorders (under 10%). There are several models of addictive behavior, but the dual process model particularly highlights the relevance of cognitive impairments and biases to the development and maintenance of addiction. This model explains addictive behavior as a balance between automatic processes and executive control, which in turn are related to individual (genetics, comorbid disorders, psychosocial factors) and other (craving, triggers, drug use) factors. Certain cognitive impairments, such as attentional bias and approach bias, are most relevant to automatic processes, while sustained attention, response inhibition, and working memory are primarily related to executive control. These cognitive impairments and biases are also common in disorders frequently comorbid with stimulant use disorder, and predict poor treatment retention and clinical outcomes. As such, they may serve as feasible trans-diagnostic treatment targets. There are promising pharmacological, cognitive, and behavioral approaches that aim to enhance cognitive function. Pharmacotherapies target cognitive impairments associated with executive control and include cholinesterase inhibitors (e.g., galantamine, rivastigmine) and monoamine transporter inhibitors (e.g., modafinil, methylphenidate). Cognitive behavioral therapy and cognitive rehabilitation also enhance executive control, while cognitive bias modification targets impairments associated with automatic processes. Cognitive enhancements to improve treatment outcomes is a novel and promising strategy, but its clinical value for the treatment of stimulant use disorder, with or without other psychiatric comorbidities, remains to be determined in future studies.

Addiction, cognitive decline and therapy: seeking ways to escape a vicious cycle

“…These programs involve a program of cognitive exercises, which the client must engage in on a regular basis throughout the treatment period (McGurk ). Recently, it has become evident that it may also be useful in the fairly common situation where substance use is comorbid with schizophrenia (Sofuoglu et al ). For example, a recent study showed that CET improved the rate of substance abuse in patients with schizophrenia (Eack et al , ).…”

Effects of muscarinic M1 and M4 acetylcholine receptor stimulation on extinction and reinstatement of cocaine seeking in male mice, independent of extinction learning

“…Cocaine remains one of the most common substances to be used illegally, and there are no pharmacotherapies approved for treating addiction to cocaine or other psychostimulant drugs (Skolnick et al 2015; Czoty et al 2016). Improvement of cognitive functions through pharmacological agents, so called “cognitive enhancers”, have been proposed as adjunct treatments for psychostimulant addiction in conjunction with psychotherapeutic approaches, in the hopes of improving inhibitory control, decision-making, and other cognitive functions that may affect treatment outcome (Sofuoglu et al 2013, 2016). In addition, the use of cognitive enhancers to facilitate extinction of conditioned responses to drug-associated cues has been suggested as a potential treatment strategy for drug addiction (Kaplan et al 2011; Nic Dhonnchadha and Kantak 2011).…”

Working memory predicts methamphetamine hair concentration over the course of treatment: moderating effect of impulsivity and implications for dual‐systems model

“…developing strategies to adapt to patient-specific strengths and weaknesses) and rehabilitated (e.g. group-based cognitive remediation; Sofuoglu et al 2016) in treatment.…”