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 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 © AMSP

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

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

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

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

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 o  Drug reward o 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) © AMSP