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Impaired Decision Making In Substance Use Disorders

Impaired Decision Making In Substance Use Disorders. Claire Wilcox MD UNM Dept of Psychiatry Alcohol Medical Scholars Program. © AMSP. Case. 55 y.o. male Physician High intelligence Methamphetamine dependent Multiple prior treatments Negative consequences: unemployed

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Impaired Decision Making In Substance Use Disorders

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  1. Impaired Decision Making In Substance Use Disorders Claire Wilcox MD UNM Dept of Psychiatry Alcohol Medical Scholars Program © AMSP

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

  3. This Lecture Will Cover • Neurocognitive aspects • Neurochemical systems • Malfunction in substance use disorder (SUD) • Treatment implications © AMSP

  4. How Are Decisions Made? • Mental process Neurocognitive • Involves 3 stages • Interconnected • Experience-driven © AMSP

  5. Stage 1: Stimulus Assessment • Preference • Valence • Salience • Context © AMSP

  6. Stage 1: Assessment Stage 2: Execution • Action selection • Action performance © AMSP

  7. Stage 3: EFFECT!! • Evaluation/feedback: pros and cons of choice © AMSP

  8. Stage 1: Assessment Stage 2: Execution Stage 3: Effect Stage 3: Learning © AMSP

  9. Stages in the Case • Stage 1 (Assessment) • Saw friend use • Frustrated/stressed • Stage 2 (Execution) • Became obsessed • Unable to fight impulse • Stage 3 (Effect & Learning) • Use pleasure, relief  drug use reinforced © AMSP

  10. Lecture Neurocognitive aspects Neurochemical systems Malfunction in substance use disorder (SUD) Treatment implications © AMSP

  11. Dopamine • Salience • Cost benefit analysis Stage 1: Assessment • Action • Inhibitory control Stage 2: Execution  • ‘High’ • Learning Stage 3: Effect & Learning © AMSP

  12. Glutamate Learning • Stimulus • Preference Stage 1: Assessment Stage 2: Execution Stage 3: Learning © AMSP 12

  13. Noradrenaline Stress response Sympathetic NS CRF release Stage 1:Assessment • Focus on task • Exploration Stage 2: Execution Stage 3: Learning 13 © AMSP

  14. Lecture Neurocognitive aspects Neurochemical systems Malfunction in substance use disorder (SUD) Treatment implications © AMSP

  15. 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 © AMSP

  16. Assessment Deficits  Response to cue Preference,short-term reward/”high” Stress,  cue salience © AMSP

  17. Execution Deficits • Habitual actions favored • Can’t see other options •  Inhibitory control • Can’t hold back © AMSP

  18. Effect/Learning Deficits • Imbalanced reward encoding • First drug use,  reward • Once dependent •  Drug reward • Further drug consumption •  Learning from negative © AMSP

  19. Case • Assessment:  preference for drug • Execution:  inhibitory control • Effect: / response to drug • Learning:  response neg consequence © AMSP

  20. Lecture Neurocognitive aspects Neurochemical systems Malfunction in substance use disorder (SUD) Treatment implications © AMSP

  21. Prevention •  Exposure • Target high-risk • Adolescents • Genetically vulnerable • Cognitive probs (schizophrenia, brain injury) •  Stress reactive (depressed/anxious) © AMSP

  22. Medications  Drug cue effect • Naltrexone (AUDs), opioid blocker •  DA release •  Craving •  Relapse © AMSP

  23. Medications  Negative emotional states  drug craving • Methadone (opioid use disorder) •  Withdrawal/craving •  Brain stress response/  anxiety • Treat co-occurring disorders © AMSP

  24. Medications Cognitive functioninhibitory control • Experimental • Varenicline (Nicotine Use Disorders) • Memantine (Alzheimer’s Disease) © AMSP

  25. Medications  Drug reward • Under development • Cocaine & nicotine vaccines • Abs block drug entry into brain © AMSP

  26. Psychotherapies • Contingency Management Therapy • Reward changes behaviors • Learn abstinence  earn $$$ • Relapse Prevention Therapy • Identify triggers • Learn avoidance © AMSP

  27. This lecture covered • Neurocognitive aspects of decision making • Neurochemical systems • How systems can malfunction in SUD • Treatment implications © AMSP

  28. 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) 28 © AMSP

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