People struggling with substance use disorders often have difficulties with memory, attention, planning, and decision-making.
New research explores how these cognitive deficits relate to treatment outcomes and whether targeting them could improve addiction recovery.
Key Facts:
- Cognitive deficits are common in people with substance use disorders, especially relating to memory, attention, self-control, and reward-based decision-making.
- The inability to make good decisions and restrain impulsive behavior predicts worse treatment outcomes like dropping out of therapy or relapsing.
- Computerized training to retrain attention biases shows promise for improving alcohol recovery. Goal management training that teaches people to make deliberate decisions aligned with recovery goals also helps.
- Memory and attention can potentially be improved with existing dementia medications like galantamine, as well as stimulants like modafinil. More research is needed.
- Non-invasive brain stimulation techniques can also alter cognitive abilities and craving, but more studies are needed to clarify their clinical usefulness.
Source: Dialogues Clin Neurosci.
The Cognitive Aspects of Addiction
Addiction has traditionally been viewed as a disorder of poor self-control and social factors.
But increasing research implicates cognitive deficits as both risk factors for developing problematic substance use as well as barriers to overcoming it in treatment.
Specific mental capacities relating to memory formation, attentional biases, self-control, and decision-making appear especially relevant.
For example, people addicted to various substances often show reduced working memory and cognitive flexibility to shift between tasks.
Their attention involuntarily fixates on drug-related stimuli in their environment.
They display more impulsive and risky choices motivated by the prospect of immediate reward.
Brain imaging studies have clarified that the regions involved in self-discipline and long-term priorities function suboptimally among those struggling with substance use disorders.
These cognitive impairments likely develop from drug exposure, but also share common risk factors like genetics, developmental adversity, and mental illness.
Unfortunately, the very abilities critical for recovery like delaying gratification and remembering goals are exactly those areas functioning poorly in addicted individuals trying to get clean.
This sets up a challenging situation where achieving and maintaining abstinence becomes extremely difficult.
Cognition & Addiction Treatment Outcomes
Given the above, an important scientific question is whether targeting cognitive deficits could actually improve real-world treatment outcomes like abstaining from drug use.
Researchers investigated this by analyzing which specific mental capacities tracked long-term success among people undergoing therapy for alcohol, cocaine, opioids, and other addictions.
They found that a battery measuring processing speed and reasoning ability modestly predicted people staying in treatment longer.
However, by far the strongest and most consistent predictor of sustaining abstinence after finishing therapy was performance on tests assessing decision-making and risk/reward information processing.
This aligns with the clinical reality that avoiding relapse hinges on deliberate self-control and evaluating choices according to long-term goals.
Brain Stimulation Shows Potential in Addiction (TMS & tDCS)
Non-invasive techniques for stimulating specific brain areas like transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS) are gaining interest as ways to directly improve cognition and alter craving.
Studies applying these methods have recorded changes in abilities like response inhibition, working memory, and delay discounting among people with substance use disorders.
Corresponding reductions occurred in their craving, drug consumption, and other addiction-related behaviors.
Exactly how stimulation achieves these effects remains unknown.
They could directly modulate the brain circuits regulating craving and cognitive control.
But improved cognition may also play an intermediary role in supporting abstinence.
Larger and longer trials are needed to clarify the techniques’ viability as clinical treatments.
Cognitive Training Targets Automatic and Deliberate Processes
Parallel efforts are ongoing to develop cognitive training programs that target, remediate, and strengthen capacities like memory so people are better equipped to pursue recovery.
Methods differ between bottom-up processes like habitual drug-seeking behaviors versus top-down goal setting and planning.
For example, researchers created a computerized approach called cognitive bias modification that helps alcohol users avoid attentional bias towards images of drinks.
It trains an automatic tendency to shift attention towards alternative rewarding stimuli.
Studies indicate it can reduce measures of alcohol craving and consumption by re-training bottom-up reactions.
In contrast, a method called goal management training focuses on deliberate decision-making by giving step-by-step meta-cognitive strategies.
People learn to “stop” habitual urges, use mindfulness to clarify priorities, set goals aligned with those values, and “check” that behaviors match.
Early research found improved performance on tests of planning abilities and reduced drug use among alcohol and cocaine users who underwent goal management training.
Optimizing these approaches to suit an individual’s cognitive profile may further enhance their impact.
For instance, people with stronger habitual biases benefit more from avoiding alcohol cues, while highly impulsive individuals show greater gains from building self-control skills.
Multi-pronged combinations that address both automatic and deliberate cognition could hypothetically work synergistically.
Medications Target Neurochemical Systems
Pharmacological cognitive enhancers aim to rectify neurochemical imbalances underlying addiction, potentially improving cognition as an intermediary step towards abstinence.
For example, boosting acetylcholine signalling impaired in addiction using Alzheimer’s medications like galantamine improved measures of attention and working memory among people dependent on stimulants.
Similarly, modafinil blocked reuptake of dopamine and norepinephrine.
This well-studied stimulant sharpened numerous cognitive abilities like memory, response inhibition, and decision-making in groups addicted to cocaine, alcohol, and opioids.
Improvements again tracked clinical outcomes like longer abstinence. Intriguingly, people with more severe baseline deficits consistently benefited the most from pharmacological aids.
Methylphenidate used for ADHD also shows initial promise for strengthening cognition and reducing unprescribed stimulant use among those suffering from both disorders.
While highly effective medications like buprenorphine and methadone remain mainstays of opioid recovery, selectively targeting cognitive–motivational dysfunction may boost existing treatment efficacy.
Addressing the Psychological Context in Addiction Recovery
Understanding Individuality
Delving into the personal history and psychological context of individuals with substance use disorders is crucial.
Understanding each person’s unique trajectory into addiction can reveal cognitive patterns that predispose them to substance abuse.
Emotional Regulation Training
Many individuals turn to substances as a means of coping with negative emotions.
Training in emotional regulation could be a critical component of treatment, helping individuals develop healthier coping mechanisms and reducing the cognitive load of emotional distress.
Enhancing Social & Environmental Support
Role of Social Support
Recovery doesn’t occur in isolation.
Strengthening an individual’s social support network can provide external cognitive scaffolding, offering reminders and encouragement, and helping maintain focus on recovery goals.
Changing Environmental Cues
Environmental cues often trigger substance use. Understanding how to alter or avoid these cues can be a crucial strategy in preventing relapse.
This might involve training individuals to recognize and react differently to triggers or altering their environments to reduce exposure.
Using Technology for Better Outcomes
Digital Therapeutics
Mobile apps and online platforms can provide cognitive training exercises, track progress, and offer support.
These tools can be particularly useful for individuals who might not have access to traditional in-person therapy sessions.
Virtual Reality (VR) for Cognitive Training
VR technology can simulate real-world environments and situations, providing a safe space for individuals to practice cognitive skills and coping strategies. This immersive experience could be particularly effective in training attention away from substance-related cues.
Focusing on Physical Health
Exercise and Cognition
Physical exercise has been shown to improve cognitive function and could be integrated into treatment plans.
Regular physical activity might enhance the brain’s plasticity, providing a stronger foundation for cognitive training and recovery.
Nutrition and Brain Health
Research is increasingly linking nutrition to cognitive function and mental health.
Ensuring individuals in recovery are receiving adequate nutrition could support cognitive training efforts and overall brain health.
Long-Term Follow-Up and Continued Care
Ongoing Cognitive Assessments
Regularly assessing cognitive function during and after treatment can help track progress, identify areas needing additional support, and adjust treatment plans accordingly.
Booster Sessions
Just like with many chronic conditions, occasional booster sessions may be necessary to maintain cognitive gains.
These could involve refresher courses in cognitive training or short-term reintroduction of pharmacological support.
Takeaway: Cognition & Addiction Recovery
Expanding the focus to include these additional aspects can provide a more holistic approach to treatment, addressing not only the cognitive deficits associated with substance use disorders but also the broader psychological, social, and environmental factors that influence recovery.
As research continues to unveil the complex interplay between these elements, treatments can become more nuanced, personalized, and ultimately, more effective.
References
- Study: Cognition and addiction
- Authors: Verdejo-Garcia et al. (2019)
