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Impaired Decision Making In Substance Use Disorders

Claire Wilcox MD

UNM Dept of Psychiatry

Alcohol Medical Scholars Program

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Case 55 y.o. male Physician High intelligence Methamphetamine dependent Multiple prior treatments Negative consequences: unemployed Repeated relapses Wants to quit

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This Lecture Will Cover

Neurocognitive aspects

Neurochemical systems

Malfunction in substance use disorder (SUD)

Treatment implications

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How Are Decisions Made?

Mental process Neurocognitive

Involves 3 stages

• Interconnected

• Experience-driven© AMSP

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Stage 1: Stimulus Assessment

Preference

Valence

Salience

Context

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Stage 1:Assessment

Stage 2:Execution

Action selection

Action performance

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Stage 3: EFFECT!!

Evaluation/feedback: pros and cons of choice© AMSP

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Stage 1:Assessment

Stage 2:Execution

Stage 3:Effect

Stage 3: Learning

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Stages in the Case

Stage 2 (Execution)• Became obsessed• Unable to fight impulse

Stage 3 (Effect & Learning)• Use pleasure, relief drug use reinforced

Stage 1 (Assessment)• Saw friend use• Frustrated/stressed

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Lecture

Neurocognitive aspects

Neurochemical systems

Malfunction in substance use disorder (SUD)

Treatment implications© AMSP

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Dopamine

Salience Cost benefit analysis

Action Inhibitory control

‘High’ Learning

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Stage 1: Assessment

Stage 2: Execution

Stage 3: Effect & Learning

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Glutamate

Learning

Stimulus Preference

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Stage 1: Assessment

Stage 2: Execution

Stage 3: Learning

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Noradrenaline Stress response

• Sympathetic NS• CRF release

Focus on task Exploration

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Stage 1:Assessment

Stage 2: Execution

Stage 3: Learning

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Lecture

Neurocognitive aspects

Neurochemical systems

Malfunction in substance use disorder (SUD)

Treatment implications© AMSP

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Decision Making In SUDs

Failure at any of 3 stages Biological root Possible pre-morbid deficits Worsened by drug use

• DA release to reward• DA receptor density • NA and CRF to stress

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Assessment Deficits

Response to cue

Preference,short-term reward/”high”

Stress, cue salience

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Execution Deficits

Habitual actions favored

• Can’t see other options

Inhibitory control

• Can’t hold back

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Effect/Learning Deficits

Imbalanced reward encoding• First drug use, reward • Once dependent

o Drug rewardo Further drug consumption

Learning from negative © AMSP

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Case

Assessment: preference for drug

Execution: inhibitory control

Effect: / response to drug

Learning: response neg consequence

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Lecture

Neurocognitive aspects

Neurochemical systems

Malfunction in substance use disorder (SUD)

Treatment implications© AMSP

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Prevention

Exposure

Target high-risk

• Adolescents

• Genetically vulnerable

• Cognitive probs (schizophrenia, brain injury)

• Stress reactive (depressed/anxious)© AMSP

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Medications

Drug cue effect

Naltrexone (AUDs), opioid blocker

DA release

Craving

Relapse

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Medications

Negative emotional states drug craving

Methadone (opioid use disorder)

Withdrawal/craving

Brain stress response/ anxiety

Treat co-occurring disorders© AMSP

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Medications

Cognitive functioninhibitory control

Experimental

• Varenicline (Nicotine Use Disorders)

• Memantine (Alzheimer’s Disease)© AMSP

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Medications

Drug reward

Under development

Cocaine & nicotine vaccines

Abs block drug entry into brain © AMSP

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Psychotherapies

Contingency Management Therapy

• Reward changes behaviors

• Learn abstinence earn $$$

Relapse Prevention Therapy

• Identify triggers

• Learn avoidance

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This lecture covered

Neurocognitive aspects of decision making

Neurochemical systems

How systems can malfunction in SUD

Treatment implications © AMSP

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Thanks to:

Dr. Ann Manzardo (a power point genius)

Dr. Marc Schuckit (for an excellent learning

experience, and all of his help and time)

Alcohol Medical Scholars Program (for the yummy

food and spectacular hotels)© AMSP